Background : The purpose of this study was to investigate the usefulness of an ultrasonographic method for examination of dysphagia in stroke patients based on evaluation of tongue movement during the swallowing process. Methods : Nineteen patients with acute stroke (13men, 76.1 ± 6.5years) in whom dysphagia was proven by videofluoroscopic examination of swallowing (VF) were eligible for inclusion in the tongue and oral function test with ultrasonography (TOFU) study. Sixteen age- and sex-matched individuals (11men, 73.4 ± 6.1years) served as controls. In the TOFU study, a patient was required to swallow saliva in the 30-degree head-up position. The tongue surface was visible as a bright narrow line on an M-mode image. We recorded the velocity of the tongue downward and upward movement (Vd and Vu) and the distance from the caudally falling to the cranially raised position (D). Results : Vu of patients with dysphagia was significantly slower than that of control subjects (44.7 ± 11.1mm/s vs. 70.4 ± 13.4min/s, p<0.001), and D of patients was shorter than that of control subjects (11.4 ± 3.4mm vs. 14.7 ± 3.0min, p = 0.002). Vd showed no significant association. Conclusions : These preliminary results suggest that TOFU is an accurate method for bedside evaluation of dysphagia in acute stroke patients.
Cervical internal carotid artery dissection causes ischemic stroke in young patients. There is no evidence to clearly indicate whether antithrombotic therapy is effective in such patients. We treated two patients who suffered ischemic events due to cervical internal carotid artery dissection. Both patients underwent transcranial Doppler (TCD) monitoring of the ipsilateral middle cerebral artery. No high-intensity transient signals (HITS) were detected in either case. Therefore we did not perform antithrombotic therapy and there was no recurrence. TCD monitoring may indicate whether antithrombotic therapy is necessary or not.
We report an 84-year-old woman who underwent carotid artery stenting because of asymptomatic carotid artery stenosis. Perioperative monitoring by three-dimensional ultrasonography (US) revealed more than 80% stenosis in the right carotid artery. The patient initially had transient ischemic attacks manifested by dizziness and vertigo, and was diagnosed by carotid artery US at the brain dock. As intravascular treatment, carotid artery stenting was performed using the Angioguard XP filter protection device and Precise stent. Three-dimensiona] us and three-dimensional reconstruction of color Doppler sonography (CDS) enabled examination of carotid artery blood flow prior to surgery, as well as blood flow in the stent, and conditions of the grafted stent after surgery. Intravascular images, such as plaque shift or subacute thrombosis, were visualized in three spatial dimensions by a combination of three-dimensional US and standard two-dimensional US, indicating their benefit for the evaluation of intra-stent blood flow. On the other hand, two-dimensional US showed better performance in terms of plaque diagnosis, specifically for evaluation of the morphology and properties of plaques, than three-dimensional US. Further improvements in three-dimensional US including CDS systems are anticipated.
A case of bow hunter's stroke with anomalies of the craniocervical junction is reported. The patient, a 22-year-old man, was admitted to our hospital complaining of neck pain, dizziness and gait unsteadiness. The symptoms appeared a day after he had turned his neck to an extreme extent during sleep. Diffusion-weighted MRI demonstrated acute cerebral infarction in the area supplied by the left posterior inferior cerebellar artery. Plain X-ray of the skull and neck and cervical CT revealed anomalies of the craniocervical junction, including basilar impression, atlanto-axial dislocation and atlanto-occipital assimilation. Carotid ultrasonography showed normal flow in the right vertebral artery (VA) in the midline neck position. However, end-diastolic flow of the right VA disappeared when the head was turned 80 degrees to the left. Cerebral angiography also revealed obstruction of the right VA at the C1－2level on rotation of the head 80 degrees to the left. The left VA appeared hypoplastic. An instrumented posterior occipitocervical fusion was performed. Postoperative ultrasound examination revealed recovery of right VA flow on head rotation to the left. This case demonstrated the usefulness of carotid ultrasonography with head rotation for diagnosis of bow hunter's stroke.
Pulmonary embolism (PE) is a potentially fatal perioperative complication, and ultrasonographic diagnosis of venous thromboembolism (VTE) in the lower limbs is essential for hemiplegic patients undergoing craniotomy. Prophylactic management of PE includes the use of elastic stockings, intermittent pneumatic compression, and administration of heparin, which carries a potential risk of intracranial bleeding. It is well known that low-molecular-weight heparin (LMWH) carries a lower risk of bleeding and has higher bioavailability than heparin. We describe two patients in whom VTE was diagnosed before elective craniotomy. Case 1 was a 67-year-old woman with a ring-enhanced lesion in the right motor cortex. Lower limb venous ultrasound (LVUS) demonstrated a venous thrombus in her left leg. She was administered LMWH (dalteparin) perioperatively, and underwent open craniotomy without pulmonary accident. Case 2 was a 72-year-old man with idiopathic encephalitis. Although open brain biopsy was planned. LVUS revealed a thrombus in the left soleus vein. He was treated sequentially with heparin, LMWH (enoxaparin) and warfarin, and the thrombus changed to an organized clot 4 weeks later. These cases suggest that if no intracranial bleeding is evident by CT on the day after craniotomy, LMWH is effective for prevention of PE in the perioperative period.