The aim of this study was to investigate the frequency of left ventricular diastolic dysfunction (LVDD) in non-cardioembolic stroke patients and the factors associated with moderate to severe LVDD. We retrospectively enrolled 100 patients with non-cardioembolic stroke within 7 days of onset between September 2015 and June 2017. Diastolic function was assessed using transthoracic echocardiography, and patients were classified as normal, impaired relaxation (mild), pseudonormal (moderate), and restrictive filling pattern (severe). LVDD was evident in 70 patients, and moderate to severe LVDD was in 10 patients. The median brain natriuretic peptide (BNP) level was significantly higher in the presence group than in the absence group (26.9 vs. 96.8 pg/ml, P=0.0009). Multivariate logistic regression analysis showed that the plasma BNP was the only independent factor associated with moderate to severe LVDD (odds ratio 8.12; 95% confidence interval 1.162–56.67, P=0.035). Most of the non-cardioembolic stroke patients had LVDD, and we should consider the presence of moderate to severe LVDD when BNP is over 80 pg/ml.
Background and Purpose: Detection of atrial fibrillation (AF) after cryptogenic stroke (CS) has therapeutic implications. We assessed the initial treatment outcome using insertable cardiac monitors in CS. Methods: We included 15 patients with CS who underwent insertable cardiac monitor placement from December 2016 to November 2017 at our hospital. AF was determined by performing screening tests such as 12-lead electrocardiogram (ECG), Holter ECG, and continued electrocardiographic monitoring for 3 days. Transesophageal echocardiogram was essential to diagnose CS. We analyzed the parameters of AF and the time at which AF was first detected within 1 year. Results: There were 10 (66%) male patients, and the median age was 68 (interquartile range, 60–76) years. The parameters of AF were not outliers. The detection rate of AF at 12 months was 40%. The median time from onset of stroke to device insertion was 18 (range, 12–29) days, and the median time from device insertion to first AF episode detection was 22 (range, 7–108) days. Conclusion: The detection rate of AF in our hospital was higher than that in previous reports.
Background and purpose: Previous randomized trials using a stent retriever for acute stroke showed that endovascular thrombectomy had clinical efficacy. This study retrospectively examined recanalization therapy after the use of a stent retriever and analyzed factors associated with unsuccessful recanalization. Materials and methods: A total of 55 patients (mean age: 73 years) were divided into the recanalization and non-recanalization groups, and the effective recanalization rate (thrombolysis in cerebral infarction grades 2b and 3), complications, symptomatic intracerebral hemorrhage, optimal outcome (Modified Rankin Scale score 0–2), and prognosis at 3 months after treatment were assessed. Data from the non-recanalization group were used to examine factors associated with unsuccessful recanalization. Results: Effective recanalization was achieved in 48 of 55 cases (87%), and optimal outcome was achieved in 33 cases (60%). Seven of 55 cases (13%) did not achieve successful recanalization. Causes of failure were determined in five internal carotid artery (ICA) and two middle cerebral artery (MCA) occlusion cases. Multiple procedure attempts and prolonged procedure times were considered as the factors for failure in cases involving the ICA. In cases involving the MCA, inadequate stent retriever deployment due to tortuous vascular structure was the presumptive factor. Conclusion: Although stent retrievers can achieve good results in acute stroke, a complicated procedure and prolonged procedure time were associated with unsuccessful recanalization in ICA occlusion cases, and tortuous vascular structure was a contributory factor in MCA occlusion cases.
Background and Purpose: In the diagnosis of internal carotid artery stenosis (ICS), measurement of peak systolic velocity (PSV) is useful. However, some patients with calcified lesions do not meet the diagnostic criteria. We examined the effects of calcification on the diagnosis of ICS based on PSV. Methods: The subjects were 150 consecutive patients (mean age: 73 years, male: 114) who underwent carotid CT angiography (CTA) and carotid ultrasonography from September 2014 to August 2015. Among the 300 blood vessels of the subjects, those other than carotid arteries with occlusion, post-endarterectomy or stenting were examined. Regarding calcification, the subjects were divided into the calcification group, which exhibited ≥50% perivascular calcification, and the control group, which exhibited <50% calcification, based on CT transverse images. The CTA stenosis rate based on PSV diagnosis was compared between the two groups. Results: In the analysis of 81 blood vessels in the calcification group and 166 blood vessels in the control group, the correlation coefficients of the stenosis rate and PSV were 0.81 and 0.87, respectively. The sensitivity/specificity to detect NASCET stenosis rate of 70% or more with PSV of 200 cm/sec was 90%/75% and 100%/90% in the calcification and control groups, respectively. The calcification group included false-negative subjects for whom observation of the inner cavity was difficult, and false-positive subjects who showed low stenosis rate and PSV>200 cm/sec. Conclusion: Although PSV is a useful marker, even for calcified lesions, the diagnostic accuracy may be affected by cases in which evaluation of the inner cavity is difficult and by those with increased PSV and a low stenosis rate.
A 56-year-old woman experienced a sudden episode of severe headache and left motor weakness. Her past medical history is untreated hypertension. On admission, a CT scan revealed convexal subarachnoid hemorrhage. Brain diffusion-weighted MR images revealed infarction at the same region as the territory of right anterior cerebral artery. Cerebral angiography showed multifocal segmental vasoconstriction of anterior and posterior cerebral arteries. During conservative treatment including calcium antagonist and cilostazol, new neurological deficit was not observed. However, segmental stenosis of the anterior cerebral artery improved once, and then progressed. MR angiography showed that the stenosis was almost completely relieved 2 weeks after onset of severe headache. Her left hemiparesis had completely recovered on the fourth week after the onset. She was diagnosed with reversible cerebral vasoconstriction syndrome (RCVS) by the radiographical findings and clinical courses. We should mind that RCVS exhibited both subarachnoid hemorrhage and cerebral infarction at an early onset.
We reported a case of 66-year-old right handed woman who showed geographical mislocation due to the right caudate infarction. She complained that she was at home which was reconstructed quite the same as her room in the hospital. Her compliment was observed only from the night to early in the morning. But, in the day-time, she recognized that she was at the room of the hospital. She remembered and could explain her compliments as it was in the next day. We supposed that her symptom could be regarded as geographical mislocation, because her misidentification could not be explained only by the delirium and/or visual cognitive impairment. As the mechanism of this case, we considered that her geographical mislocation was caused by the dysfunction of frontal and limbic system due to the right caudate infarction.
Delayed obstructive hydrocephalus after intraventricular hemorrhage is rare. We report two patients with intraventricular hemorrhage who experienced the delayed development of obstructive hydrocephalus. Case 1: A 63-year-old man developed left putaminal hemorrhage, intraventricular hemorrhage (IVH) and was admitted to the hospital. We selected a conservative treatment. However, 3 days after his consciousness sudden deteriorate due to acute hydrocephalus was caused by the obstruction of aqueduct hematoma clot. We emergently performed external ventricular drainage (EVD). Case 2: A 62-year-old man developed left thalamic hemorrhage, IVH and acute obstructive hydrocephalus and was admitted to the hospital. EVD was performed for hydrocephalus. After 3 days, his consciousness was improved and CT scan showed wash-out of IVH. However, four days after his consciousness sudden deteriorate due to acute hydrocephalus was caused by the obstruction of aqueduct hematoma clot. We emergently reperformed EVD. The majority of patient with IVH required EVD within 24 hours from last known normal, but the patient who required EVD thereafter 48 hours was rare. It is important to be aware of these scenarios if CT scan showed hematoma in the third ventricle even if it is a little.
Segmental arterial mediolysis (SAM) produces dissecting aneurysms due to the segmental melting of the tunica media. Although SAM is known to cause rupture of abdominal aneurysms, the aneurysms simultaneously occur and multiply in various arterial systems, particularly in cerebral arteries. In addition, large thrombotic cerebral aneurysms may become an embolism; however, reports that small aneurysms have become embolic sources were limited. We encountered a case of intra-abdominal bleeding caused by SAM in the cerebral embolism, which caused the small thrombotic aneurysm in the internal carotid artery (ICA)-the anterior choroidal artery (AchA) bifurcation. An 80-year-old woman developed right limb paralysis, and magnetic resonance imaging (MRI) revealed a 3-mm aneurysm at the left ICA-AchA bifurcation and infarction at the left AchA region. An aneurysm morphologically changed with the magnetic resonance angiography (MRA) over time, and in the contrast high-resolution MRI, the inner side of the nodule was observed to be clotted. Small infarction also occurred in the left middle cerebral artery and was determined as embolism from a thrombotic small aneurysm. Sudden abdominal bleeding occurred on the seventh day of hospitalization; angiography revealed pseudoaneurysm extravasation and left omental artery expansion, which was diagnosed as SAM. Even a small aneurysm became thrombotic and embolic. The contrast MRI on the vascular wall of an aneurysm seems to indicate minute vessel wall damage, and SAM was thought to be involved in the clotting mechanism of a small aneurysm.
In the endovascular therapy for acute ischemic stroke, time to re-perfusion is crucial to get a good outcome for acute ischemic stroke. Therefore, a rapidly examination is desired. On the other hand, there are reports referring a few patients with acute type A aortic dissection were judged as an acute ischemic stroke. Hence, type A aortic dissection should be assessed in correctly on pre-endovascular therapy. The brain imaging with 3 Tesla MRI is a common technique to diagnose an acute ischemic stroke with high sensitivity. However, it was difficult to assess chest aortic artery with a fast scan on 3 Tesla in general. The main reason of this problem is the artifact caused by B1 inhomogeneity. We developed a new MRA sequence using saturation effect to overcome this artifact. We applied this sequence for 169 patients who suspected acute ischemic stroke, and experienced two patients with type A aortic dissection. The symptoms suggesting acute type A aortic dissection were not observed before the examination in both cases. We report that two clinical cases who demonstrated the efficacy of new chest MRA sequence to estimate aortic dissection rapidly.
Percutaneous endoscopic gastrostomy (PEG) is frequently difficult in stroke patients with VP shunts, due to complications such as shunt infection, obstruction and migration. It is important to determine an optimum abdominal position for PEG catheter insertion. In such case, real-time 3D reconstruction CT-gastrography guided PEG is a useful method.