Carotid ultrasound features of anomalous left vertebral artery originating from the aortic arch proximal to the left subclavian artery.

We present three cases of anomalous origin of the left vertebral artery (LVA) detected during the evaluation of stroke. The VA usually enters the transverse foramen of the sixth cervical vertebra (C6), but an anomalous LVA originating from the aorta frequently enters at a higher level. In our series, ultrasound of the LVA showed entry at C4 in two patients and at C5 in one patient. These findings suggested anomalous LVA origin, and three-dimensional computed tomography demonstrated the LVA arising from the aorta proximal to the left subclavian arteries. Carotid duplex ultrasound is useful for the diagnosis of this anomaly.

Cerebral infarction associated with accessory middle cerebral arteries: two case reports.

We herein present two cases of cerebral infarction in the middle cerebral artery (MCA) territory associated with an accessory middle cerebral artery (AMCA), which is a rare anomalous vessel arising from the anterior cerebral artery that coexists with the main trunk of the MCA. Cerebral infarction occurred in both patients: due to occlusion of the MCA main trunk in one patient and occlusion of the AMCA in the other patient. These cases suggest the importance of recognizing an AMCA when interpreting neuroradiological findings in patients with MCA ischemic stroke, especially in the hyperacute phase.

Hyponatremia upon resumption of paroxetine therapy.

We present a 79-year-old woman with severe hyponatremia secondary to resumption of treatment with paroxetine, a selective serotonin-reuptake inhibitor antidepressant. Confusion and fatigue followed re-initiation of paroxetine after a 3-month hiatus. Hyponatremia, serum hypoosmolality, and urine hyperosmolality strongly suggested the syndrome of inappropriate secretion of antidiuretic hormone. Hyponatremia was quickly resolved after discontinuation of paroxetine and initiation of intravenous normal saline infusion together with oral fluid restriction. This case underscores the importance of monitoring serum sodium in elderly patients taking paroxetine, whether this represents a new prescription or reintroduction of the drug.

Effects of anticoagulation on infarct size and clinical outcome in acute cardioembolic stroke.

Effects of anticoagulation on infarct size and outcome have not been fully elucidated in patients with acute cardioembolic stroke, although the anticoagulation therapy reduces both occurrence and recurrence of ischemic stroke greatly. The authors retrospectively investigated the relationship of anticoagulation intensity to infarct size and outcome. In 104 consecutive patients (mean age 70.8 +/- 10.0 years) who had suffered acute supratentorial cardioembolic infarction or transient ischemic attacks, they analyzed risk factors for atherosclerosis, underlying heart diseases, the infarct size (maximal area) on brain computed tomography, and modified Rankin scale score upon discharge. They compared these clinical data between patients who had received warfarin before the ictus and those who had not. In addition, they investigated the effects of the international normalized ratio (INR) on infarct size and outcome in 19 patients who had been receiving anticoagulant therapy and had measurement of INR within 24 hours after stroke onset. There were 25 patients who had received anticoagulation before the stroke (A/C group) and 79 patients who had not (non-A/C group). The infarct size in the A/C group tended to be smaller than that in the non-A/C group (p = 0.081, Mann-Whitney U test). In the 19 patients who had prior anticoagulation and measurement of INR within 24 hours of stroke onset, large infarcts were seen in 6 of 13 patients with INR < 1.6 and in none of 6 patients with INR > or = 1.6. Poor clinical outcome was observed in 5 patients with INR < 1.6, but in none with INR > or = 1.6. In conclusion, anticoagulant therapy with INR > or = 1.6 appears to effectively prevent a large infarct and poor outcome, even when ischemic stroke dose occurs in patients with an emboligenic heart disease.