[Internal carotid artery stenosis with repeated ischemic stroke recurrence due to mechanical stimulation by the hyoid bone and thyroid cartilage: a case report].

We present a case of internal carotid artery (ICA) stenosis caused by mechanical stimulation by the hyoid bone (HB) and thyroid cartilage (TC). A 78-year-old man with a history of right ICA stenting four years previously was admitted for abrupt onset of dysarthria and left hemiparesis and diagnosed with ischemic stroke by magnetic resonance imaging. Three-dimensional computed tomographic angiography revealed internal carotid in-stent restenosis. Furthermore, the HB and TC contacted with the right ICA. Treatment involved antiplatelet therapy, partial HB and TC resection, and carotid artery restenting. Posttreatmently, the ICA was restored and stenosis improved. Since restenosis may occur posttreatmently in patients with carotid artery stenosis caused by mechanical stimulation of the HB and TC, it is necessary to consider treatments including not only carotid artery stenting but also partial bone structures resection and carotid endarterectomy.

Fulminant Guillain-Barré syndrome secondary to Campylobacter coli infection: An autopsy case report.

The most common infection preceding Guillain-Barré syndrome (GBS) is Campylobacter jejuni enteritis, although a few patients present with Campylobacter coli. We report a case of C. coli-induced fulminant GBS. A 61-year-old woman presented with bilateral limb weakness. Nerve conduction studies revealed a reduction of amplitude and C. coli was isolated from a fecal specimen, leading to the diagnosis of GBS. Although the patient was immediately administered immunoglobulin, her symptoms rapidly worsened and she died. Peripheral nerve autopsy revealed myelin ovoid, and infiltration of CD68-positive macrophages into nerves. More effective treatments for fulminant GBS need to be developed.

Perfusion abnormality in neuronal intranuclear inclusion disease with stroke-like episode: A case report.

Neuronal intranuclear inclusion disease (NIID) is a slowly progressive neurodegenerative disease. Some patients with NIID occasionally present with acute symptoms. However, its mechanism remains unclear. We report a patient with NIID who presented with a stroke-like episode. Arterial spin labeling magnetic resonance imaging revealed hypoperfusion in the focal cerebral region at the onset while no apparent arterial occlusion was observed. The abnormal perfusion area was normalized 6 days after admission. Therefore, the perfusion abnormality was likely the main cause of acute neurologic deficits in NIID. NIID should be considered in the differential diagnosis of stroke mimics.

Endovascular Coil Embolization for Recurrent Bow Hunter's Stroke.

Bow hunter's stroke is a rare cause of vertebrobasilar infarction. There is no consensus regarding the optimal treatment. We herein report a case of bow hunter's stroke successfully treated by endovascular treatment. A 70-year-old man presented with central vertigo. Magnetic resonance imaging (MRI) showed posterior circulation infarcts. Dynamic angiography revealed thrombus formation and hypoperfusion of the right vertebral artery upon head rotation to the left. Endovascular parent artery occlusion of the right vertebral artery was performed, and there was no recurrence at follow-up MRI. Endovascular parent artery occlusion might be a useful treatment for bow hunter's stroke.

[Mild encephalitis/encephalopathy with a reversible splenial lesion (MERS) with a family history: an adult case].

We present an adult case of mild encephalitis/encephalopathy with a reversible splenial lesion (MERS). A 26-year-old man with a family history of MERS presented to our hospital owing to dysarthria and dysesthesia of the right side of his body. The duration of these symptoms was approximately 4 hours. T2 and diffusion weighted MRI showed high signal intensity lesions in the bilateral deep white matter. On a 3-week follow-up MRI, the lesions had completely disappeared. We attributed this clinical course and image findings to MERS. The patient had experienced similar symptoms at the age of 8 years old. Furthermore, his younger brother showed a similar clinical history and experienced a few recurrence events during the age of 9-16 years old. The mechanism of MERS remains controversial. However, similar to our case, there are some case reports with a family history. In addition, a previous report has confirmed the existence of a heterozygous variant in the myelin regulatory factor gene in patients with MERS. Some genetic factors may induce MERS, especially with extensive white matter lesions.

Subarachnoid hemorrhage due to a craniocervical junction arteriovenous fistula associated with thrombus formation in the internal jugular vein: illustrative case.

BACKGROUND: A craniocervical junction arteriovenous fistula (CCJAVF) is a rare vascular malformation, and its etiology remains unclear. Here, to the best of the authors' knowledge, they present the first case of CCJAVF associated with thrombus formation in the ipsilateral internal jugular vein. OBSERVATIONS: An 80-year-old man presented with a sudden occipital headache. Computed tomography revealed a subarachnoid hemorrhage surrounding the brainstem and upper cervical cord. Digital subtraction angiography showed a CCJAVF fed by the left C2 radiculomeningeal artery with ascending intracranial drainage and epidural plexus. After endovascular treatment, the authors retrospectively found that his ipsilateral internal jugular vein and innominate vein were occluded with a huge thrombus at admission. LESSONS: This case suggested a restricted antegrade venous flow due to thrombus-induced progressive retrograde intracranial drainage causing hemorrhage. Venous hypertension should be considered one of the causes of hemorrhage due to CCJAVF as well as intracranial arteriovenous fistulas.

[Nonrecanalization after mechanical thrombectomy in acute ischemic stroke due to infective endocarditis: an autopsy case].

An 86-year-old man was admitted for the abrupt onset of right hemiparesis and aphasia. DWI revealed the high intensity legion in the left insular cortex, and MRA demonstrated the left middle cerebral artery occlusion. Recanalization of the artery was not achieved after mechanical thrombectomy. The diagnosis of infective endocarditis was made as Enterococcus faecalis was cultured from the blood, and mobile vegetation was detected at the aortic valve by transthoracic echocardiography. The patient died from multiple organ failure at 19 days. Autopsy findings revealed fibrin-rich thrombus in the left middle cerebral artery containing neutrophils and bacteria. At the occluded site, neutrophils had intensively infiltrated into the vessel wall, and endothelial cells had partially disappeared. Moreover, disrupted internal elastic lamina was discovered. These findings could indicate that the thrombus had adhered to the vessel wall. The adhesion of the thrombus and vessel wall could be associated with unsuccessful recanalization after endovascular thrombectomy in patients with ischemic stroke due to infective endocarditis.

Current status of a helicopter transportation system on remote islands for patients undergoing mechanical thrombectomy.

BACKGROUND: Mechanical thrombectomy (MT) is standard treatment for acute ischemic stroke (AIS) with large-vessel occlusion within 6 h of symptom onset to treatment initiation (OTP). Recent trials have extended the therapeutic time window for MT to within 24 h. However, MT treatment remains low in remote areas. Nagasaki Prefecture, Japan has many inhabited islands with no neurointerventionalists. Our hospital on the mainland is a regional hub for eight island hospitals. We evaluated clinical outcomes of MT for patients with AIS on these islands versus on the mainland. METHODS: During 2014-2019, we reviewed consecutive patients with AIS who received MT at our hospital. Patients comprised the Islands group and Mainland group. Patient characteristics and clinical outcomes were compared between groups. RESULTS: We included 91 patients (Islands group: 15 patients, Mainland group: 76 patients). Seven patients (46.7%) in the Islands group versus 43 (56.6%) in the Mainland group achieved favorable outcomes. Successful recanalization was obtained in 11 patients (73.3%) on the islands and 67 (88.2%) on the mainland. The median OTP time in the Islands was 365 min. In both the Islands and Mainland groups, the OTP time and successful recanalization were associated with functional outcome. The modified Rankin Scale (mRS) score at 90 days ≤2 was obtained in two patients and mRS = 3 in four patients among eight patients with OTP time >6 h. CONCLUSIONS: Few patients with AIS on remote islands have received MT. Although patients who underwent MT on the islands had longer OTP, the clinical outcomes were acceptable. OTP time on remote islands must be shortened, as this is related to functional outcome. In some cases with successful recanalization, a favorable outcome can still be obtained even after 6 h. Even if OTP exceeds 6 h, it is desirable to appropriately select patients and actively perform MT.

[Task-shifting Carried out by an Emergency Department's Stroke Hotline and Medical Care Support Conducted by Nurse Practitioners].

Our hospital serves as the main hub for eight remote island hospitals(RIHs)in Nagasaki Prefecture, Japan. The shortage of stroke physicians, which has led to overwork, is a major concern. Several "task-shifting" systems were adopted to avoid physician burnout. First, the emergency department established a hotline system for receiving emergency calls regarding a stroke, and which managed initial care until the stroke physicians arrived(called the Nagasaki Medical Center stroke hotline system: N-SHOT)in 2014. The rt-PA administration rate increased from 3.3% in the Pre-N-SHOT group to 6.7% in the N-SHOT group. Second, the 'isolated islands stroke hotline system(I-SHOT)', with which physicians in RIHs participate in cooperation with N-SHOT, was started in 2017. After I-SHOT was introduced, the number of patients treated with the drip and ship method using teleradiology and 24-h helicopter transportation increased from 20(2010-2016)to 29 cases in 2017-2018. Additionally, new information and communication technology(ICT)using smart devices was introduced into the teleradiology system for task support. Third, on behalf of stroke physicians, nurse practitioners(NP)helped bedridden patients who had been delivered from RIHs and who had received acute treatment, and returned to their islands by helicopter or airplane as transitions of care. N-SHOT is smoothly operated by each hospital department without reducing the quality of the stroke hotline. It has contributed to an increase in rt-PA and mechanical thrombectomy cases; I-SHOT has had the same effect. Task-shifting and task support with N- & I-SHOT, the smooth transfer system by NP, and the new ICT are considered to be useful for reducing the overall burden of stroke physicians.