Background: Suspected pulmonary arteriovenous fistula (PAVF) on transesophageal echocardiography (TEE) is sometimes difficult to prove with examinations such as contrast-enhanced (CE) CT.
Methods: Clinical features were investigated in 19 patients with ischemic stroke (14 men; mean age, 60.8 y) with suspected PAVF on TEE but unproven on further examinations. Patients with atrial fibrillation, aortic atherosclerosis, ipsilateral carotid or intracranial stenosis and other risks of stroke such as vasculopathies, hypercoagulable states, or hematologic disorders were excluded.
Results: The infarct region was in the territory of the unilateral middle cerebral artery in 12 cases, bilateral in 1 case, posterior cerebral artery in 1 case, vertebrobasilar artery in 2 cases, internal carotid artery in 1 case, and undetermined in 2 cases. CECT was performed in 17 cases (including 3D CT reconstruction in 7 cases), ventilation/perfusion lung scintigraphy in 1 case, and CE-MRI in 1 case. Modified Rankin Scale (mRS) scores at discharge were 0, 1, 2 and 3 in 7, 6, 1 and 4 cases, respectively, and 4 in a case complicated by Wernicke's encephalopathy. In 2 cases in which PAVF was proven on CECT, the mRS scores were 2 and 5.
Conclusion: Patients with unproven PAVF tended to have better outcomes than those with proven PAVF. Patients with unproven PAVF may have small PAVFs or shunts unrelated to stroke that still require comprehensive treatment due to other risks and pathologies.

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Purpose: Hereditary motor and sensory neuropathy with proximal predominance (HMSN-P) presents with progressive weakness and atrophy of the proximal limbs and truncal muscles, although the literature has reported marked sparing of the bulbar muscles, distinguishing this pathology from amyotrophic lateral sclerosis (ALS). We sought to clarify whether involvement of the bulbar muscles is present in advanced cases of HMSN-P.
Method: We conducted thorough clinical electrophysiological and ultrasonographic examinations in four patients with advanced HMSN-P. We evaluated the presence of fasciculation of the tongue on ultrasonography and fibrillation/positive sharp waves on needle electromyography.
Result: Mean age and disease duration were 69 years and 29 years, respectively. All patients showed near-complete paralysis of all four extremities. Three patients required mechanical ventilation. All four patients revealed tongue atrophy. Although none showed fasciculation of the tongue on visual examination or needle electromyography, ultrasonography detected fasciculation in two patients. Conversely, the two patients without fasciculation showed signs of active denervation on needle electromyography.
Conclusion: This study found evidence of cranial nerve involvement in patients with advanced HMSN-P, but the extent of involvement was much milder than that in ALS. In our patient series, the rate of detecting denervation of the lingual muscles improved with complementary use of both electromyography and ultrasonography.

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We describe the complexity of oscillating thrombus (OT) pathology determined by carotid ultrasonography (US) in one patient with cardioembolic stroke and in another with idiopathic carotid artery dissection. The OT disappeared over time under B-mode US observation in both patients. However, Doppler flow evaluation revealed occlusion indicating the absence of internal carotid artery recanalization. Oscillating thrombus is a rare and specific finding, and follow up by carotid US is useful for observation. Further information about OT is required.

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Cervical carotid artery evaluation is central to the treatment of carotid stenosis, and is usually performed using MRI, magnetic resonance angiography (MRA), 3-dimensional CT angiography (3D-TA), and carotid ultrasonography. Carotid ultrasonography is a non-invasive, easily repeated method that can also allow real-time intraoperative monitoring. We can accurately determine the location of a carotid lesion using ultrasound navigation. The positions of the cervical vertebrae from C3 to C7 are confirmed before and after carotid evaluation. Using this system, we place marks on real-time images that act as guides to lesion location. We defined this technique as the “ vertebral level measurement method”. We evaluated whether the technique was effective in a stroke patient with a carotid lesion and an allergy to iodine. The case involved a 69-year-old man with cerebral infarction. Carotid ultrasonography revealed a severe and vulnerable stenotic plaque in the right cervical carotid artery. Cerebral angiography or percutaneous carotid angioplasty could not be performed due to the iodine allergy, but carotid endarterectomy (CEA) needed to be performed. Using the “ vertebral level measurement method”, we performed an evaluation similar to preoperative angiography. CEA was then successfully completed without contrast examination. This method appears extremely helpful.

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