Successful Recanalization by Intravenous Thrombolysis in a Patient With Calcified Cerebral Emboli With Major Vessel Occlusion: A Case Report.

A 69-year-old man, with a history of left superficial temporal artery-middle cerebral artery bypass due to cerebral infarction by left internal carotid artery occlusion, was hospitalized with acute right hemispatial neglect and left hemiparesis. Diffusion-weighted imaging showed a high-intensity lesion in the right insular cortex. Although there seemed to be no arterial occlusion in magnetic resonance angiography (MRA), non-contrast computed tomography (CT) on admission showed calcification in the right Sylvian fissure. As hyperacute ischemic stroke within 4.5 hours after onset, we used an intravenous recombinant tissue plasminogen activator, and his symptoms improved. Follow-up MRA revealed recanalization of the right M2 branches with distal migration of calcification. Although calcification was identified on non-contrast CT in the initial assessment, the diagnosis of middle cerebral artery occlusion was missed. Therefore, arterial occlusion should be considered when calcification is observed in the brain sulcus. This case also illustrated that intravenous thrombolysis may be effective even in calcified cerebral emboli with major vessel occlusion.

Amyloid accumulation in cases of suspected comorbid cerebral amyloid angiopathy and isolated cortical venous thrombosis.

BACKGROUND AND AIM: The differentiation of isolated cortical venous thrombosis (ICVT) from cerebral amyloid angiopathy (CAA) can be difficult because both diseases share similar neurological symptoms and imaging findings. N-methyl-11C-2-(4'-methylaminophenyl)-6-hydroxybenzo-thiazole (11C-PiB) positron emission tomography (PET) functions as a diagnostic modality for CAA by detecting amyloid deposition. The present prospective study evaluated amyloid deposition using 11C-PiB-PET in consecutive patients with suspected ICVT. METHOD: This study was a prospective observational study. Patients who attended or were hospitalized between May 2019 and March 2020 were included in the analysis. Consecutive patients who met the criteria for suspicion of ICVT were enrolled in the study, and the clinical course, symptoms, imaging findings (including magnetic resonance imaging), and the 11C-PiB-PET findings of each case were analyzed. RESULTS: The study cohort included four patients (64-82 years of age, all women). In one younger patient, 11C-PiB-PET afforded no findings suggestive of CAA, whereas the remaining three patients exhibited 11C-PiB-PET findings suggestive of CAA. CONCLUSION: Although 11C-PiB-PET would be a reasonable modality for distinguishing ICVT from CAA, especially in younger patients, it might be difficult to differentiate ICVT from CAA in elderly patients because of the potential deposition of amyloid. CLINICAL TRIAL REGISTRATION: URL: https://www.umin.ac.jp/ctr/ Unique identifier: UMIN 000037101.

Thrombolysis for Acute Wake-Up and Unclear-Onset Strokes with Alteplase at 0.6 mg/kg in Clinical Practice: THAWS2 Study.

INTRODUCTION: The aim of this study was to determine the safety and efficacy of intravenous (IV) alteplase at 0.6 mg/kg for patients with acute wake-up or unclear-onset strokes in clinical practice. METHODS: This multicenter observational study enrolled acute ischemic stroke patients with last-known-well time >4.5 h who had mismatch between DWI and FLAIR and were treated with IV alteplase. The safety outcomes were symptomatic intracranial hemorrhage (sICH) after thrombolysis, all-cause deaths, and all adverse events. The efficacy outcomes were favorable outcome defined as an mRS score of 0-1 or recovery to the same mRS score as the premorbid score, complete independence defined as an mRS score of 0-1 at 90 days, and change in NIHSS at 24 h from baseline. RESULTS: Sixty-six patients (35 females; mean age, 74 ± 11 years; premorbid complete independence, 54 [82%]; median NIHSS on admission, 11) were enrolled at 15 hospitals. Two patients (3%) had sICH. Median NIHSS changed from 11 (IQR, 6.75-16.25) at baseline to 5 (3-12.25) at 24 h after alteplase initiation (change, -4.8 ± 8.1). At discharge, 31 patients (47%) had favorable outcome and 29 (44%) had complete independence. None died within 90 days. Twenty-three (35%) also underwent mechanical thrombectomy (no sICH, NIHSS change of -8.5 ± 7.3), of whom 11 (48%) were completely independent at discharge. CONCLUSIONS: In real-world clinical practice, IV alteplase for unclear-onset stroke patients with DWI-FLAIR mismatch provided safe and efficacious outcomes comparable to those in previous trials. Additional mechanical thrombectomy was performed safely in them.

Detection of Atrial Fibrillation Using Insertable Cardiac Monitors in Patients With Cryptogenic Stroke in Japan (the LOOK Study): Protocol for a Prospective Multicenter Observational Study.

BACKGROUND: Paroxysmal atrial fibrillation (AF) is a probable cause of cryptogenic stroke (CS), and its detection and treatment are important for the secondary prevention of stroke. Insertable cardiac monitors (ICMs) are clinically effective in screening for AF and are superior to conventional short-term cardiac monitoring. Japanese guidelines for determining clinical indications for ICMs in CS are stricter than those in Western countries. Differences between Japanese and Western guidelines may impact the detection rate and prediction of AF via ICMs in patients with CS. Available data on Japanese patients are limited to small retrospective studies. Furthermore, additional information about AF detection, including the number of episodes, cumulative episode duration, anticoagulation initiation (type and dose of regimen and time of initiation), rate of catheter ablation, role of atrial cardiomyopathy, and stroke recurrence (time of recurrence and cause of the recurrent event), was not provided in the vast majority of previously published studies. OBJECTIVE: In this study, we aim to identify the proportion and timing of AF detection and risk stratification criteria in patients with CS in real-world settings in Japan. METHODS: This is a multicenter, prospective, observational study that aims to use ICMs to evaluate the proportion, timing, and characteristics of AF detection in patients diagnosed with CS. We will investigate the first detection of AF within the initial 6, 12, and 24 months of follow-up after ICM implantation. Patient characteristics, laboratory data, atrial cardiomyopathy markers, serial magnetic resonance imaging findings at baseline, 6, 12, and 24 months after ICM implantation, electrocardiogram readings, transesophageal echocardiography findings, cognitive status, stroke recurrence, and functional outcomes will be compared between patients with AF and patients without AF. Furthermore, we will obtain additional information regarding the number of AF episodes, duration of cumulative AF episodes, and time of anticoagulation initiation. RESULTS: Study recruitment began in February 2020, and thus far, 213 patients have provided written informed consent and are currently in the follow-up phase. The last recruited participant (May 2021) will have completed the 24-month follow-up in May 2023. The main results are expected to be submitted for publication in 2023. CONCLUSIONS: The findings of this study will help identify AF markers and generate a risk scoring system with a novel and superior screening algorithm for occult AF detection while identifying candidates for ICM implantation and aiding the development of diagnostic criteria for CS in Japan. TRIAL REGISTRATION: UMIN Clinical Trial Registry UMIN000039809; https://tinyurl.com/3jaewe6a. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/39307.

Rapid Evaluation of Large Vessel Occlusion for Mechanical Thrombectomy Using Carotid Duplex Ultrasound.

Objectives This study clarified the usefulness of carotid duplex ultrasound (CDU) in evaluating large vessel occlusion (LVO) in patients with acute stroke planned to be treated with mechanical thrombectomy (MT). Methods This study was single-center, prospective, observational trial. If the ratio of end-diastolic velocity in the common carotid arteries was ≥1.4, or diastolic flow in the affected internal carotid artery (ICA) was absent on CDU, patients were immediately transferred to the angio-suite without additional cerebrovascular imaging. Clinical parameters, including time metrics and outcomes, were evaluated in participants. Patients We enrolled stroke patients with a National Institutes of Health Stroke Scale score ≥6 and Alberta Stroke Program Early CT score ≥6 in whom MT could be initiated within 6 hours of the stroke onset. Results Among 140 patients screened during the study period, 48 were ultimately enrolled. Twenty-seven patients were diagnosed with LVO by CDU alone. CDU offered 83% sensitivity and 82% specificity for identifying the occlusion of the ICA or M1 segment of the middle cerebral artery. Among the 29 total patients treated with MT, 20 (67%) showed a modified Rankin Scale score ≤2 at 90 days. The door-to-puncture time was significantly shorter in patients evaluated by CDU alone (34 minutes) than in those evaluated by magnetic resonance angiography after CDU (47.5 minutes, p<0.001). Conclusion CDU might reduce the time metrics for early initiation of MT with good sensitivity and specificity in identifying LVO.

Evaluation of cholesterol crystals in carotid plaque by dual energy computed tomography.

Cholesterol crystals (CCs) in carotid plaques might be an indicator of vulnerability, although they have not been fully investigated and non-invasive methods of assessment have not been established. This study examines the validity of assessing CCs using dual-energy computed tomography (DECT) that uses X-rays with different tube voltages for imaging, allowing material discrimination. We retrospectively evaluated patients who had undergone preoperative cervical computed tomography angiography and carotid endarterectomy between December 2019 and July 2020. We developed CC-based material decomposition images (MDIs) by scanning CCs crystallized in the laboratory using DECT. We compared the percentage of CCs in stained slides defined by cholesterol clefts with the percentage of CCs displayed by CC-based MDIs. Thirty-seven pathological sections were obtained from 12 patients. Thirty-two sections had CCs; of these, 30 had CCs on CC-based MDIs. CC-based MDIs and pathological specimens showed a strong correlation. Thus, DECT allows the evaluation of CCs in carotid artery plaques.

Identifying large vessel occlusion using the hyperdense artery sign in patients treated with mechanical thrombectomy.

OBJECTIVES: The hyperdense artery sign on non-contrast computed tomography-reconstructed images is useful for identifying large vessel occlusion in acute ischemic stroke. This study aimed to assess its efficacy in patients with large vessel occlusion treated with mechanical thrombectomy. MATERIALS AND METHODS: This retrospective and prospective single-centered study from June 2019 to May 2021 evaluated the use of non-contrast computed tomography-reconstructed images for detecting hyperdense artery sign to identify large vessel occlusion from June 2020 to May 2021. We registered consecutive potential candidates for mechanical thrombectomy due to suspected stroke and assessed the accuracy of hyperdense artery sign on non-contrast computed tomography-reconstructed images for large vessel occlusion in the hyperacute setting. Non-contrast computed tomography images were reconstructed into maximum intensity projection images with iterative reconstruction algorithms to detect hyperdense artery signs. We compared the door-to-puncture time and functional outcome at 90 days before and after employing non-contrast computed tomography-reconstructed images in patients with large vessel occlusion treated with mechanical thrombectomy. RESULTS: The cohort included 82 patients, wherein 47 were treated with mechanical thrombectomy. The sensitivity (96%) and specificity (94%) of hyperdense artery sign on non-contrast computed tomography-reconstructed images for large vessel occlusion were performed. The door-to-puncture time was significantly shortened after using non-contrast computed tomography-reconstructed images (49 versus 28 min, p = 0.001), but the functional outcome at 90 days remained unchanged. CONCLUSIONS: Non-contrast computed tomography-reconstructed images, as a vascular imaging tool for mechanical thrombectomy, can reduce workflow time in hospitals by identifying large vessel occlusion with high sensitivity and specificity.

Effects of tissue plasminogen activator on medium-term functional independence: A propensity score-matched analysis.

This study revealed the effects of tissue plasminogen activator (tPA) on medium-term functional independence in patients with stroke. We retrospectively examined 240 patients from April 2016 to March 2019 and selected 68 who met our criteria. After adjusting the functional status at the onset by propensity score matching, the functional independence measure (FIM) on admission to and discharge from the convalescent rehabilitation wards was compared between the groups classified by the presence or absence of tPA. Twelve pairs were derived by propensity score matching. Upon admission to the convalescent rehabilitation ward, the median score of the FIM was significantly higher in the tPA group than in the non-tPA group (P = .028). Patients in the tPA group had higher median FIM scores at discharge than those in the non-tPA group (P = .060). The difference in the independence level of activities of daily living (ADL) between the groups with and without tPA may gradually decrease with continuous inpatient rehabilitation. However, the tPA group tended to have high levels of independence in ADL at the time of discharge.

Impact of Patency of the Carotid Terminus and Middle Cerebral Artery on Early Clinical Outcomes in Patients with Acute Internal Carotid Artery Occlusion and Mild Symptoms.

INTRODUCTION: Both collateral flow via the internal carotid artery (ICA) terminus (ICT) and initial mild symptoms might be associated with favorable outcomes in patients with acute ICA occlusion (ICAO). This study aimed to address the association between early clinical outcomes and patency of the ICT and middle cerebral artery (MCA) in patients with acute ICAO with mild symptoms. METHODS: Of 1,214 consecutive patients with acute ischemic stroke or transient ischemic attack due to large vessel occlusion, patients with ipsilateral ICAO and initial National Institutes of Health Stroke Scale (NIHSS) score ≤5 were retrospectively enrolled. We examined the associations between clinical factors including patency of the ICT and MCA and recurrence of stroke or early neurological deterioration (REND). Significant early neurological deterioration was defined as increment in NIHSS score ≥1 during hospital stay. RESULTS: Thirteen of the 35 patients who were finally enrolled had REND (37%), and median modified Rankin scale (mRS) score at discharge was 1 (interquartile range, 0-4). Initial NIHSS score (4 vs. 1, p < 0.001) and rates of diabetes mellitus (61.5% vs. 13.6%, p = 0.007), intravenous thrombolysis (IVT) (30.9% vs. 0%, p = 0.014), and mechanical thrombectomy (MT) (23.1% vs. 0%, p = 0.044) were significantly higher in patients with REND rather than in those without. The rate of patent ICT and MCA was comparable between groups. Except for 1 patient who underwent MT promptly after IVT immediately after REND, 3 patients initially treated with IVT deteriorated after the procedure. One patient without patent ICT and MCA did not meet the indications for MT. In 2 other patients with patent ICT and MCA, MT was not initially performed, but was eventually performed because of REND due to thrombus migration, and both were discharged with an mRS score of 5. CONCLUSION: The overall clinical outcomes of patients with acute ICAO with mild symptoms were not depending on the patency of the ICT and MCA, but initial treatment with IVT alone might risk unfavorable outcomes due to thrombus migration in patients with patent ICT and MCA.

A case of ischemic stroke accompanied by multiple arterial dissections associated with Klippel-Feil syndrome.

OBJECTIVES: To describe the case of an ischemic stroke patient with Klippel-Feil syndrome who developed multiple aneurysms and discuss the mechanism of aneurysm development. MATERIALS AND METHODS: A 44-year-old man presented with dizziness, left hemiparesis, and left-sided numbness and was admitted to our department. He developed multiple aneurysms at the bilateral vertebral artery (VA) and bilateral internal carotid artery. RESULTS: We diagnosed the etiology of his brain infarction as an embolic stroke caused by left VA dissection or the large thrombosed aneurysm. Furthermore, we considered that arterial dissection or Hox gene mutation was associated with the development of multiple aneurysms. CONCLUSION: While previous reports have described single aneurysm, this is the first report of multiple aneurysms associated with Klippel-Feil syndrome.

Endovascular Therapy for Acute Stroke with a Large Ischemic Region.

BACKGROUND: Endovascular therapy for acute ischemic stroke is generally avoided when the infarction is large, but the effect of endovascular therapy with medical care as compared with medical care alone for large strokes has not been well studied. METHODS: We conducted a multicenter, open-label, randomized clinical trial in Japan involving patients with occlusion of large cerebral vessels and sizable strokes on imaging, as indicated by an Alberta Stroke Program Early Computed Tomographic Score (ASPECTS) value of 3 to 5 (on a scale from 0 to 10, with lower values indicating larger infarction). Patients were randomly assigned in a 1:1 ratio to receive endovascular therapy with medical care or medical care alone within 6 hours after they were last known to be well or within 24 hours if there was no early change on fluid-attenuated inversion recovery images. Alteplase (0.6 mg per kilogram of body weight) was used when appropriate in both groups. The primary outcome was a modified Rankin scale score of 0 to 3 (on a scale from 0 to 6, with higher scores indicating greater disability) at 90 days. Secondary outcomes included a shift across the range of modified Rankin scale scores toward a better outcome at 90 days and an improvement of at least 8 points in the National Institutes of Health Stroke Scale (NIHSS) score (range, 0 to 42, with higher scores indicating greater deficit) at 48 hours. RESULTS: A total of 203 patients underwent randomization; 101 patients were assigned to the endovascular-therapy group and 102 to the medical-care group. Approximately 27% of patients in each group received alteplase. The percentage of patients with a modified Rankin scale score of 0 to 3 at 90 days was 31.0% in the endovascular-therapy group and 12.7% in the medical-care group (relative risk, 2.43; 95% confidence interval [CI], 1.35 to 4.37; P = 0.002). The ordinal shift across the range of modified Rankin scale scores generally favored endovascular therapy. An improvement of at least 8 points on the NIHSS score at 48 hours was observed in 31.0% of the patients in the endovascular-therapy group and 8.8% of those in the medical-care group (relative risk, 3.51; 95% CI, 1.76 to 7.00), and any intracranial hemorrhage occurred in 58.0% and 31.4%, respectively (P<0.001). CONCLUSIONS: In a trial conducted in Japan, patients with large cerebral infarctions had better functional outcomes with endovascular therapy than with medical care alone but had more intracranial hemorrhages. (Funded by Mihara Cerebrovascular Disorder Research Promotion Fund and the Japanese Society for Neuroendovascular Therapy; RESCUE-Japan LIMIT ClinicalTrials.gov number, NCT03702413.).

Clinical characteristics of patients with lateral medullary infarction who had fatal respiratory failure.

INTRODUCTION: Respiratory failure is a fatal complication of lateral medullary infarction (LMI). However, the clinical characteristics associated with respiratory failure in patients with LMI have not been fully elucidated. We aimed to evaluate the clinical characteristics associated with respiratory failure in patients with LMI. METHODS: Among the 6365 consecutive patients who were admitted to our institute within 7 days of onset of acute ischemic stroke between January 2007 and December 2019, we identified those with acute LMI as verified by magnetic resonance imaging. We evaluated the associations between clinical characteristics and fatal respiratory failure that occurred within 10 days of stroke onset. RESULTS: Of 102 patients with acute LMI, eight had fatal respiratory failure within 10 days of stroke onset. Patients with fatal respiratory failure had a higher premorbid modified Rankin Scale score than did those without (3 vs. 0, p < 0.001), as well as a higher frequency of pulmonary disease (37.5% vs. 2.1%, p = 0.003). Severe dysphagia (100% vs. 30.9%, p < 0.001), dysarthria (100% vs. 56.4%, p = 0.020), ipsilateral hemiparesis (50.0% vs. 5.3%, p = 0.002), and urinary retention (50.0% vs. 2.1%, p < 0.001) were also significantly more common in patients with fatal respiratory failure than in those without. There were no significant differences in infarct locations between patients with fatal respiratory failure and those without. CONCLUSIONS: Assessment of pre-stroke history and monitoring of neurological symptoms that occur during the first 10 days post-stroke onset would be useful for predicting the risk of respiratory failure in patients with acute LMI.

Twenty-Year Change in Severity and Outcome of Ischemic and Hemorrhagic Strokes.

Importance: Whether recent changes in demographic characteristics and therapeutic technologies have altered stroke outcomes remains unknown. Objective: To determine secular changes in initial neurological severity and short-term functional outcomes of patients with acute stroke by sex using a large population. Design, Setting, and Participants: This nationwide, hospital-based, multicenter, prospective registry cohort study used the Japan Stroke Data Bank and included patients who developed acute stroke from January 2000 through December 2019. Patients with stroke, including ischemic and hemorrhagic strokes, who registered within 7 days after symptom onset were studied. Modified Rankin Scale scores were assessed at hospital discharge for all patients. Exposure: Time. Main Outcomes and Measures: Initial severity was assessed by the National Institutes of Health Stroke Scale for ischemic stroke and intracerebral hemorrhage and by the World Federation of Neurological Surgeons grading for subarachnoid hemorrhage. Outcomes were judged as favorable if the modified Rankin Scale score was 0 to 2 and unfavorable if 5 to 6. Results: Of 183 080 patients, 135 266 (53 800 women [39.8%]; median [IQR] age, 74 [66-82] years) developed ischemic stroke, 36 014 (15 365 women [42.7%]; median [IQR] age, 70 [59-79] years) developed intracerebral hemorrhage, and 11 800 (7924 women [67.2%]; median [IQR] age, 64 [53-75] years) developed subarachnoid hemorrhage. In all 3 stroke types, median ages at onset increased, and the National Institutes of Health Stroke Scale and World Federation of Neurological Surgeons scores decreased throughout the 20-year period on multivariable analysis. In ischemic stroke, the proportion of favorable outcomes showed an increase over time after age adjustment (odds ratio [OR], 1.020; 95% CI, 1.015-1.024 for women vs OR, 1.015; 95% CI, 1.011-1.018 for men) but then stagnated, or even decreased in men, on multivariate adjustment including reperfusion therapy (OR, 0.997; 95% CI, 0.991-1.003 for women vs OR, 0.990; 95% CI, 0.985-0.994 for men). Unfavorable outcomes and in-hospital deaths decreased in both sexes. In intracerebral hemorrhage, favorable outcomes decreased in both sexes, and unfavorable outcomes and deaths decreased only in women. In subarachnoid hemorrhage, the proportion of favorable outcomes was unchanged, and that of unfavorable outcomes and deaths decreased in both sexes. Conclusions and Relevance: In this study, functional outcomes improved in patients with ischemic stroke during the past 20 years in both sexes presumably partly owing to the development of acute reperfusion therapy. The outcomes of patients with hemorrhagic stroke did not clearly improve in the same period.

Irreversible Homonymous Hemianopia Associated with Severe Hyperglycemia and Cerebral Hyperperfusion: A Case Report and Literature Review.

A 68-year-old man was admitted to our department because of left incomplete homonymous hemianopia accompanied by hyperglycemia. Both T2-weighted and diffusion-weighted imaging revealed a low signal intensity along the subcortex and high signal intensity along the cortex on the right parietal and occipital lobes. Furthermore, arterial spin labeling and single-photon emission computed tomography showed hyperperfusion at the right parieto-occipital lobe. However, the electroencephalography result was normal. Hyperperfusion improved after controlling the blood glucose levels; nevertheless, homonymous hemianopia remained. We suspect that the irreversible brain damage was attributable to hyperperfusion associated with long-term hyperglycemia.

Association of Admission Hyperglycemia with Clinical Outcomes in Japanese Patients with Acute Large Vessel Occlusion Stroke: A post hoc Analysis of the Recovery by Endovascular Salvage for Cerebral Ultra-Acute Embolism Japan Registry 2.

INTRODUCTION: Admission hyperglycemia is an indicator of poor functional prognosis in acute stroke, but investigations of its prevalence and effects on the outcomes of acute large vessel occlusion in real-world, large-scale studies are limited, especially in Asian population. OBJECTIVE: We aimed to elucidate the relationship between admission hyperglycemia and outcomes in a prospective multicenter registry in Japan. METHODS: We analyzed data from the Recovery by Endovascular Salvage for Cerebral Ultra-Acute Embolism (RESCUE) Japan Registry 2, which was a prospective, multicenter registry that enrolled patients from 46 centers in Japan. Admission hyperglycemia was defined as blood glucose level >140 mg/dL. The relationships between clinical outcomes and admission hyperglycemia were analyzed in all 1,932 assessable patients. A favorable functional outcome, defined as a modified Rankin Scale score of 0-2 at day 90, as well as mortality within 90 days and symptomatic intracranial hemorrhage (SICH) within 72 h, was analyzed. We performed subgroup analyses of the adjusted variables to investigate the association between hyperglycemia and favorable outcome in relation to each variable. RESULTS: Admission hyperglycemia was present in 687 (35.6%) of the assessable patients and in 420 (26.9%) of the 1,561 patients without diabetes. A favorable outcome was significantly less frequent in the hyperglycemia group than in the no-hyperglycemia group (33.2% vs. 47.6%, adjusted odds ratio [OR]: 0.60, 95% confidence interval [CI]: 0.47-0.76). The mortality rates were 12.8% and 6.8% in the hyperglycemia and no-hyperglycemia groups, respectively. The incidence of SICH within 72 h was higher in the hyperglycemia group than in the no-hyperglycemia group (4.4% vs. 1.9%, adjusted OR: 2.54, 95% CI: 1.36-4.82). Hyperglycemia was associated with unfavorable outcomes in almost all subgroups. CONCLUSIONS: Admission hyperglycemia in Japanese patients with large vessel occlusion stroke is associated with an unfavorable functional outcome at 90 days, mortality within 90 days, and the occurrence of SICH within 72 h.

Hypertrophic Pachymeningitis Related Brain Infarction in Synovitis-Acne-Pustulosis-Hyperostosis Osteomyelitis Syndrome.

A 50-year-old woman with a history of synovitis-acne-pustulosis-hyperostosis osteomyelitis (SAPHO) syndrome was admitted for left unilateral neglect, dysarthria, and left hemiparesis. Brain MRI showed multiple infarctions in the territory of the right middle cerebral artery and gadolinium enhancement of the thickened frontotemporal dura mater on the right side. MR angiography showed significant narrowing of the cavernous segment of the right internal carotid artery. The right internal carotid artery stenosis was thought to originate from hypertrophic pachymeningitis associated with SAPHO syndrome. This is the first report of brain infarction due to internal carotid artery stenosis caused by hypertrophic pachymeningitis associated with SAPHO syndrome.

Unilateral chronic pulsatile headache as the single manifestation of anti-MOG antibody-associated unilateral cerebral cortical encephalitis.

Unilateral cerebral cortical encephalitis (UCCE) with myelin oligodendrocyte glycoprotein (MOG)-antibody comprises a new spectrum of disease entities generally presenting seizures. Here, we report a case of a young adult with anti-MOG antibody-associated UCCE who only presented persistent left pulsatile headache. Neurological examination revealed no deficits. Brain MRI showed a fluid-attenuated inversion recovery hyperintense lesion along the swollen left cerebral cortex. The patient was positive for anti-MOG antibodies. We diagnosed him with anti-MOG antibody-associated UCCE. Immediately after the administration of high-dose IV methylprednisolone, the headache diminished. Anti-MOG antibody-associated UCCE is a new differential diagnosis in patients with unilateral chronic pulsatile headache.

Clinical Outcome of Patients With Large Vessel Occlusion and Low National Institutes of Health Stroke Scale Scores: Subanalysis of the RESCUE-Japan Registry 2.

Background and Purpose- The treatment and prognosis of acute large vessel occlusion with mild symptoms have not been sufficiently studied. The present study aimed to investigate the clinical or radiological predictors of clinical outcome in patients with stroke with mild symptoms due to acute large vessel occlusion. Methods- Of 2420 patients with acute large vessel occlusion in the RESCUE-Japan Registry 2 (Recovery by Endovascular Salvage for Cerebral Ultra-Acute Embolism-Japan Registry 2), a multicenter prospective registry in Japan, patients with modified Rankin Scale scores of 0 to 2 before onset and initial National Institutes of Health Stroke Scale (NIHSS) scores of 0 to 5 were examined in post hoc analysis. We examined the clinical and radiological characteristics associated with a favorable outcome (modified Rankin Scale score, 0-2 at 90 days) using multivariate analysis, as well as the factors associated with a favorable outcome in patients treated with endovascular therapy. Results- We analyzed 272 patients (median age, 73 years; median NIHSS score on admission, 3). Eighty-six (31.6%) patients were treated with intravenous recombinant tissue-type plasminogen activator, 54 (19.9%) underwent endovascular therapy, and 208 (76.5%) showed a favorable outcome. In multivariate analysis, age <75 years (odds ratio [OR], 2.42 [95% CI, 1.30-4.50]), initial NIHSS score 0 to 3 (OR, 3.08 [95% CI, 1.59-5.98]), intravenous recombinant tissue-type plasminogen activator (OR, 2. 86 [95% CI, 1.32-6.21]), and blood glucose level ≤140 mg/dL (OR, 2.37 [95% CI, 1.22-4.60]) were independently associated with a favorable outcome. However, endovascular therapy was not associated with a favorable outcome (OR, 1.65 [95% CI, 0.71-3.88]). Among 54 patients treated with endovascular therapy, good reperfusion status was more common in the favorable outcome group (88.6% versus 60.0%; P<0.05). Conclusions- Younger age, lower initial NIHSS score, intravenous recombinant tissue-type plasminogen activator, and absence of hyperglycemia were independently associated with a favorable outcome in patients with acute large vessel occlusion with low NIHSS scores. Registration- URL: https://www.clinicaltrials.gov; Unique identifier: NCT02419794.

Supratentorial infarcts accompanying hiccup.

BACKGROUNDS: The main culprit lesion causing hiccup in patients with ischemic stroke is thought to involve the medulla oblongata, but some cases of hiccups caused by damage to the supratentorial cortex have been reported. The present study aimed to address the clinical and radiological characteristics of acute stroke patients accompanied by hiccups caused by supratentorial lesions. METHOD: We retrospectively studied 5,309 consecutive patients with acute ischemic stroke or transient ischemic attack who were admitted to our institute within 7 days after onset between April 2006 and September 2017. We searched for the term "hiccup" in prospectively collected descriptive datasets and analyzed associations between hiccup and clinical and radiological findings, with particular focus on patients with supratentorial lesions. RESULTS: We finally selected 16 stroke patients accompanied by hiccup. Nine patients had infarcts in the lateral medulla oblongata, and others had supratentorial infarcts (three patients with cortical infarcts, four patients with subcortical infarcts). Moreover, the right hemisphere was frequently damaged in this series (6/7, 86%). CONCLUSIONS: Hiccup could be caused by supratentorial infarcts including the insular cortex, temporal lobe, and subcortex.