Japan will become a full–fledged aged society. The elderly population aged 65 years or over will account for more than 26 percent of the population. One of four people was 65 years old or over. In Japan, the appropriate clinical management is thus important in elderly patients with neuro–infections including meningitides and encephalitides. Bacterial meningitis and encephalitides are lifethreatening neurological emergencies, and early recognition, efficient decision–making, and rapid commencement of therapy can be lifesaving. Empirical therapy should be initiated promptly whenever bacterial meningitis or encephalitides are a probable diagnosis. In this article, elderly patients with bacterial meningitis, Herpes simplex virus encephalitis, Japanese encephalitis, and autoimmune encephalitis are reviewed. Neurologist should be able to recognize the clinical signs and symptoms of these infections and familiarize themselves with a rational diagnostic approach and therapeutic modalities, as early recognition and treatment are key to improving outcomes.

Hypertension is the major risk factor for stroke. In the Hisayama study, the risks of cardiovascular disease increased significantly from the lower range (120–129/80–84 mmHg) of prehypertension in a general Japanese population. Since the clinical trial SPRINT demonstrated that targeting a systolic blood pressure of less than 120mmHg reduced fatal and nonfatal major cardiovascular events, blood pressure goals in patients with hypertension currently tend to be more intensive. However, we should conduct more careful antihypertensive treatment when setting blood pressure target in the elderly or patients with cerebral artery stenosis. The meta–analysis including the majority studies for primary stroke prevention has shown that reducing LDL cholesterol with statins reduces the risk of stroke, therefore statin therapy is recommended for patients with dyslipidemia, especially having diabetes mellitus. Early detection and treatment of atrial fibrillation are valuable prevention for stroke risk reduction in the elderly. Anticoagulation should be considered even for the patients with atrial fibrillation (CHADS2 0 or 1) and other vascular risk factors. Regarding primary prevention of stroke for patients with asymptomatic cerebral atherosclerosis and silent lacunar infarction, intensive management of vascular risk factors such as hypertension and diabetes mellitus is the most important treatment for stroke prevention, and antiplatelet therapy should be taken into considered only in patients with high risk of ischemic stroke.

It is also essential to educate and enlighten the knowledge of stroke risk factors and warning signs to the general public.

Stroke is the fourth most common cause of death in Japan and a significant cause of chronic disability. Delayed hospital arrival has been considered as the most significant prehospital barrier to acute stroke management. In order to reduce the time from stroke onset to arrival at the hospital, patients need to recognize stroke symptoms immediately, activate medical services, and emergency medical services (EMS) play critical roles in reducing prehospital delays and ensuring timely stroke treatment. Prehospital delay between stroke onset and hospital arrival is an ongoing problem. A widely held assumption that public stroke education by mass media, school education, helps potentially to increase public awareness of stroke warning signs will lead to earlier recognition, activation of EMS, and reduced prehospital delay. A variety of prehospital stroke scale and protocol have been developed to assist EMS to improve prehospital care and the accuracy of diagnosis of stroke. Public stroke campaigns should not only inform the public about stroke symptoms in order to ensure people act appropriately, but should also focus on increasing public awareness about the fact that an effective treatment exists. EMS education program, community outreach, and standardized protocols for acute stroke is warranted.

The effectiveness of mechanical thrombectomy in acute ischemic stroke due to large vessel occlusion was established by several randomized controlled trials published in 2015. Further, the effectiveness of reperfusion therapy in stroke patients with unknown time of onset has been reported since 2018. The evolution of reperfusion therapies for acute ischemic stroke has resulted from not only new technologies but also the rapid patient selection with imaging diagnosis. The neurologist should acquire latest knowledges of diagnosis and reperfusion therapy for acute stroke to relieve a lot of patients from disability.

Most of the stroke patients are transferred to the rehabilitation hospital after the acute treatment to get more concentrated and effective rehabilitation in the recovery period (convalescence). It is quite important to select and decide the second facility to experience qualified but fulfilling rehabilitation as well as to make utmost recovery after stroke. When the patients move to the convalescent ward from the acute one within 2 months after the ictus, maximum period of 6 months eligible for the rehabilitation will be approved to them. In this article, typical profile of stroke rehabilitation is disclosed in each stage of acute, convalescent and maintenance phase after stroke.

For the secondary prevention of stroke, the strict control of risk factors and the appropriate prescription of antithrombotic agents are necessary. The blood pressure level target for secondary stroke prevention is <140/90mmHg, but more strict control, i.e., <130/80mmHg as the target, is recommended for hemorrhagic stroke patients and for ischemic stroke patients with antithrombotic agents. In the control of dyslipidemia, PCSK9 inhibitors are expected to prevent the recurrence of stroke in ischemic stroke patients. Probucol has a strong anti–oxidative effect for LDL cholesterol. The recent PICASSO trial revealed significant efficacy of probucol in ischemic stroke patients who are at high risk of hemorrhage. The combination of antiplatelet therapy with cilostazol (CSPS.com) is effective in the secondary prevention of stroke among noncardiogenic ischemic stroke patients. Clinical trials have shown that in patients with atrial fibrillation, the Watchman left atrial appendage closure device is more effective than medical treatment using warfarin. A patent foramen ovale (PFO) closure device showed efficiency in cryptogenic ischemic stroke patients with a PFO.

Introduction :

Levodopa carbidopa intestinal gel (LCIG) was approved for advanced Parkinson's disease (PD).

We performed LCIG therapy in patients with advanced PD.

The effect and problem including the plasma levodopa level in continues LCIG infusion were studied.

Method :

Six PD patients treated with LCIG were included in this study. Pharmacokinetics, efficacy and adverse events were assessed.

Results :

Compared with baseline, LCIG decreased off time. The degree of fluctuation of levodopa plasma concentrations were small while continues LCIG infusion.

In spite of the constant plasma levodopa, one of the 6 cases presented motor fluctuations.

Intersubject variability of levodopa plasma concentrations were present. And the plasma levodopa level of the same patient fluctuated among the days.

Therefore, there was no strict correlation between LCIG dosing rate and plasma concentration of levodopa, when compared with intravenous levodopa infusion.

The dosing rate of levodopa was adjusted according to the plasma levodopa concentration in one case.

Conclusion :

The monitoring of the levodopa plasma cncentrations is useful for determination of dosing rate.

A 71–year–old man, who was taking azathioprine (50mg/day) because of ulcerative colitis, was admitted to the hospital because of sudden onset of dysarthria followed by pharyngeal discomfort on August 4. Neurological examination revealed atrophy of the tongue and deviation of the tongue to the left, suggesting the left hypoglossal nerve palsy. Gadolinium–enhanced 3D T1–weighted magnetic resonance imaging showed a mass lesion at the left hypoglossal canal. Computerized tomography showed an abscess with calcification extending to the parapharyngeal space from the tonsils. Serum levels of β–D glucan were slightly elevated (7.5pg/dL), and the test result for serum Aspergillus antigen was positive. Clinical characteristics and imaging features improved after antifungal treatment with liposomal amphotericin B. The patient was finally diagnosed as having invasive aspergillosis, which might invade into the hypoglossal canal from the tonsils through the pharyngeal space. Therefore, careful investigations of the parapharyngeal space and nasal sinuses are recommended when a fungal infection in the skull base is strongly suspected.

A 25–year–old female suddenly developed paraparesis and bowel bladder dysfunction. Magnetic resonance imaging (MRI) at the onset revealed longitudinally extensive lesions (LETM) at the vertebral height of Th5–Th10, centrally located within the spinal cord. She was treated with intravenous methylprednisolone therapy, followed by oral prednisolone (PSL) of 40mg/day for 2 weeks. Her symptoms completely resolved, and did not show any relapses for 10 years in the absence of PSL. However, 6 months after oral contraceptive therapy was initiated at the age of 34, she developed a clinical relapse. The attack caused paraparesis, bowel bladder dysfunction, and sensory disturbances of the lower limbs. Lumbar MRI revealed centrally located swollen lesion at the vertebral height of Th10–Th11. Laboratory blood tests were negative for both anti–aquaporin–4, and anti–myelin oligodendrocyte glycoprotein antibodies. She was treated with intravenous methylprednisolone therapy, and her neurological symptoms completely resolved. She was started on oral PSL of 15mg/day. LETM is the core feature of neuromyelitis optica spectrum disorders (NMOSD). Despite the fact that for the fulfillment of NMOSD diagnostic criteria announced in 2015, 2 core symptoms are required, the centrally located lesions of the spinal cord is a typical characteristic suggesting NMOSD. Moreover, in contrast to the favorable effect of oral contraceptive therapy on multiple sclerosis, autoantibody–mediated disease such as systemic lupus erythematosus, is well known to be exacerbated. Our case is unique in that after 10 years of remission, she suddenly presented a clinical relapse after the induction of oral contraceptive therapy. This report highlights the possibility that oral contraceptive therapy may induce relapse of seronegative LETM.