Background and Purpose: We examined the effect of early enteral immunonutrition (EEIN) on various clinical parameters and outcomes in acute stroke critical patients. Methods: Acute stroke patients with impaired consciousness were enrolled for the study. The patients were divided into three groups; 54 patients admitted in July 2004–March 2007 before starting early enteral nutrition (EEN) practice, as the control group; 53 in October 2009–March 2011 with EEN, as group A; and 53 in January 2013–March 2014 with EEIN, as group B. They were retrospectively assessed for fecal property, rate of infectious complication including pneumonia, in-hospital periods, and 3-month clinical outcomes. Results: Compared to the control group, groups A and B had significantly shorter median fasting periods (control; 8.7 days, A; 1.5 days, B; 1.8 days), more favorable nutritional status, enteral environment aggravation (watery diarrhea) rates (control; 42.6%, A; 1.9%, B; 1.9%), lower infectious complication rates (control; 85.2%, A; 66.0%, B; 35.8%), lower pneumonia rates (control; 74.1%, A; 50.9%, B; 15.1%), lower amounts (dosage days per patient) of antibiotic agents (control; 14.8 days, A; 9.2 days, B; 3.3 days), shorter median in-hospital periods (control; 30.5 days, A; 23.0 days, B; 23.0 days), and more favorable 3-month mortality rates (control; 20.4%, A; 3.8%, B; 1.9%). Group B showed significantly lower incidence of infection (pneumonia) than group A. Conclusions: EEN in the acute phase of a stroke can translate into improved clinical outcomes. It is also suggested that EEIN could minimize the risk of infectious complications such as pneumonia.

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Background and Purpose: The number of elderly patients with aneurysmal subarachnoid hemorrhage (SAH) has been increasing because of the rapid aging of society and the increasing incidence rate of SAH with age. We often have difficulty to make decision to perform surgery and optimal treatment method for these patients because they have higher surgical risks and their functional prognosis is also poor. The aim of this study was to reveal the clinical features and treatment outcomes of these patients. Methods: We retrospectively analyzed 47 patients, ≥80 years, out of 162 consecutive patients with aneurysmal SAH between April 2009 and December 2015. Results: The average age was 85.0 years, and the proportion of women (89%) was greater than men. Severe cases with World Federation of Neurosurgical Societies (WFNS) grade IV and V on admission accounted for 70% of all cases. The aneurysms were located in the anterior circulation in 95%. Twenty-two patients were treated for ruptured aneurysms with either surgical clipping or endovascular coiling. Favorable outcomes were achieved in 6% and the rate of mortality was 43%. Favorable outcomes in patients received surgical intervention tended to be associated with ≤84 years of age and lower WFNS grade (I–II). Conclusion: Although the treatment outcome in elderly patients with aneurysmal SAH is poor, radical treatment should be considered if the WFNS grade is low, and they are in a good preoperative general condition and are relatively independent in their daily living activities.

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A 44-year-old woman with a history of migraine presented with lower abdominal pain in early August 2012. Blood examination revealed severe anemia (hemoglobin 4.7 g/dl), and she was diagnosed with uterine cancer. After a transfusion and administration of an oral iron preparation, her anemia improved. Quasi-extensive total hysterectomy and bilateral salpingo-oophorectomy were performed in late September. She was admitted for a severe headache in late October. Magnetic resonance imaging revealed findings indicative of posterior reversible encephalopathy syndrome. Repeated headaches spreading from posterior to anterior occurred after hospitalization. A thunderclap headache occurred the moment she came in contact with hot water while taking a shower on day 6 after admission. She was sedated because she developed generalized convulsion and restlessness. Brain computed tomography (CT) showed left temporal lobe hemorrhage, and reversible cerebral vasoconstriction syndrome (RCVS) was considered. Her headache improved after the administration of 240 mg/day verapamil. Three-dimensional CT angiography revealed broad cerebral vasoconstrictions on day 12 after admission. This condition resolved on day 69, and she was diagnosed with RCVS. In addition to correction of anemia, estrogen deficiency due to surgery for uterine cancer may cause RCVS.

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We report the case of a 73-year-old man who developed bilateral vertebral artery dissection after a craniocervical contusion. He fell into a side ditch, and suffered bruising on the head and neck. He was diagnosed with a sixth cervical vertebral fracture, cerebellar infarction, and bilateral vertebral artery dissection, and was treated conservatively. The location of the left vertebral artery dissection coincided with the region where the vertebral artery entered into the transverse foramen. We speculated that the deviation of the cervical vertebral body caused by the fracture led to left vertebral artery dissection. Regarding the right vertebral artery, we speculated that the hyperextension of the right vertebral artery caused by the forcible hit led to dissection, and subsequently an occlusion of the right vertebral artery. This case highlights bilateral vertebral artery dissection caused by trauma. The possibility of underlying vertebral artery injury should be kept in mind in patients with craniocervical trauma.

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We report a rare case of oculomotor nerve palsy caused by vertical sandwich-like compression, which is being pinched between the internal carotid-posterior communicating artery (IC-PC) aneurysm and tortuous parent artery. A 76-year-old female with a past history of the aneurysmal coiling against subarachnoid hemorrhage admitted at our hospital because of gradual worsening of her ptosis on the right. Magnetic resonance imaging of the head did not reveal any ischemic stroke on the midbrain, however, a carotid angiogram newly demonstrated an unruptured saccular aneurysm at the origin of the IC-PC junction. During surgical clipping of the aneurysm, it became clear that the tortuous parent artery at the supraclinoid portion of the internal carotid artery (ICA) had been directly compressing right oculomotor nerve, and the IC-PC aneurysm was located below the inferior aspect of the nerve, with resulting upward displacement of the oculomotor nerve. As a result of clipping of the aneurysmal neck, the supraclinoid ICA was just medially displaced and straightened up by the clip-head. Vertical sandwich-like compression of the oculomotor nerve was then released by above procedures. Though newly formed aneurysmal compression at IC-PC junction was typically considered to be the main reason for oculomotor nerve palsy, it was judged that tortuous supraclinoid ICA might contribute to the tendency to manifest as oculomotor nerve palsy under local surrounding background.

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We describe simultaneous acute ischemic stroke and acute myocardial infarction in a 66-year-old woman who was presented at the emergency room with sudden left hemiparesis. A neurological examination revealed dysarthria, left hemiparesis, and left hemi-hypoesthesia. Imaging findings revealed acute ischemic stroke and acute myocardial infarction with congestive heart failure. Immediate intravenous tissue plasminogen activator (t-PA) improved both the acute ischemic stroke and the acute myocardial infarction. Previous reports about treating simultaneous acute ischemic stroke and acute myocardial infarction with intravenous t-PA did not indicate the prognosis of the patients. However, intravenous t-PA might be valuable for such situations.

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A 52-year-old male was presented with left hemiparesis. Magnetic resonance imaging revealed right frontal lobe infarction. Computed tomography and digital subtraction angiography revealed a large partial thrombosed aneurysm of the distal right anterior cerebral artery and occlusion of the right pericallosal artery. Operation views showed the mechanical obstruction of right pericallosal artery induced by mass effect of the thrombosed aneurysm. The aneurysm was dome-clipped, and the residual neck was coated 23 days after admission. The patient is doing well 6 months after operation, and the residual neck regrowth is not recognized, but careful follow-up must be necessary in future.

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A 45-year-old woman was presented to our hospital for severe pharyngalgia and neck pain with fever. The CT angiography revealed the presence of the giant extracranial internal carotid artery (ICA) aneurysm at the time of admission. The MRI revealed abnormal intensity suggestive of abscess formation in the pharyngeal area. Endovascular parent artery occlusion was performed on Day 2. Postoperative evaluation was performed by transoral carotid ultrasonography (TOCU) to obtain image guidance for puncture and drainage the abscess. The ICA and the giant aneurysm were completely thrombosed, and the drainage of abscess was performed with high safety on the basis of the TOCU findings. Although endovascular treatment for extracranial infectious ICA aneurysm has not been well established, our case suggests that the treatment with guidance of TOCU appears effective.

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