A case of polyneuropathy associated with diabetic ketoacidosis in new-onset type 1 diabetes

Although diabetic peripheral neuropathy is the most common diabetic microangiopathic complication, several other neuropathy syndromes can occur in the context of diabetes. We describe a rare case of polyneuropathy associated with diabetic ketoacidosis in a patient with new‐onset type 1 diabetes. A 42‐year‐old man with diabetic ketoacidosis was admitted to our hospital with complications of respiratory and renal failure requiring mechanical ventilation and hemodialysis, respectively. After diabetic ketoacidosis improved from the critical state, he developed upper‐ and lower‐limb paralysis with sensory disturbances and pain, as well as right facial paralysis, left recurrent nerve paralysis, and left hypoglossal nerve paralysis. Autonomic nerve function was also impaired. As the pathophysiology, prevention, and treatment of polyneuropathy associated with diabetic ketoacidosis are unclear, the neurologic function of patients with diabetic ketoacidosis should be closely monitored.

Clinical features and efficacy of reperfusion therapy in minor ischemic stroke patients with atrial fibrillation

The efficacy of reperfusion therapy (RT) using intravenous infusion of recombinant tissue plasminogen activator and/or endovascular therapy for minor ischemic stroke (MIS) has not yet been established. The present study aimed to elucidate the clinical features of MIS patients with atrial fibrillation (AF) and examine whether they could be potential candidates for RT. Data of MIS patients, defined as those with a score ≤ 5 on the National Institute of Health Stroke Scale, were extracted from patients admitted to our hospital between 2006 and 2018, and clinical characteristics were compared between the AF and non-AF groups. Thereafter, the impact of RT on outcomes in the AF- group was evaluated using the modified Rankin scale (mRS) score 3 months after onset and compared to that of standard medical therapy (SMT) using propensity score matching (PSM). Of 10,483 stroke patients, 3003 were shortlisted, and 457 AF patients and 2546 non-AF patients were finally selected. Patients in the AF group had more RT (13.3% vs. 5.7%, p < 0.001) than those in the non-AF group. Using PSM, 53 patients each were extracted from the AF-RT and AF-SMT groups. The frequencies of mRS = 0 or 1 for the AF-RT and AF-SMT groups were 69.8% and 64.2% (p = 0.536), respectively, with a significant difference in mRS = 0 (56.5% vs. 34.0%, p = 0.019). The present study found that MIS patients with AF underwent more RT than those without AF and that RT compared favorably with SMT for them; further study is warranted to examine whether these patients could be good candidates for RT.

Efficacy of the Insertion-support Guiding Catheter in Approaching Intracranial or Craniocervical Lesions in Patients with the Difficulty of Extracranial Trans-arterial Access

Objective

We aimed to investigate the efficacy of the insertion-support guiding catheter (ISGC) for approaching target lesions during endovascular therapy in patients with severe atherosclerotic or tortuous arteries.

Case Presentations

The ISGC is an 8 Fr, JB2 shape, stiff-type, short guiding catheter. We used ISGC for 52 patients between April 2007 and March 2018, microcatheters or therapeutic devices were delivered to target lesions via ISGC in 46 (88.4%) of the 52 patients, and none of them developed associated complications. Herein, we present three representative cases.

Conclusions

An ISGC is useful for vascular intervention in patients with atherosclerotic or tortuous arteries.

Acute Prevertebral Abscesses Caused by Bacterial-infected Traumatic Tooth Fractures

We report a case of acute prevertebral abscess caused by traumatic tooth fractures in a 77-year-old Japanese man. After being transferred to our hospital the patient was initially diagnosed with a neck hematoma; however, blood culture showed Streptococcus parasanguinis, an oral bacterium, and an MRI examination suggested prevertebral abscesses. Tooth fractures, severe periodontitis, and peri-implantitis with Streptococcus parasanguinis were observed. Antibiotics were administered and fractured teeth were extracted. The patient's condition then gradually improved. We concluded that bacteremia caused by traumatic tooth fractures induced the acute prevertebral abscesses.

Multidisciplinary clinical approach by sharing oral examination information to treat a diabetes patient with dysgeusia

Taste alteration is one of the complications of severe diabetes. It is important in diabetes treatment to assess taste alteration and perform dietary counseling, therapeutic exercise, and oral care. In this case, multidisciplinary clinical approach by medical staff was successful for a severely diabetic patient with dysgeusia.

Abstract TP18: Impact of Reperfusion Therapy on Short-Term Outcome in Patients With Mild Acute Ischemic Stroke

Purposes: The efficacy of reperfusion therapies (RT), including both intravenous recombinant tissue plasminogen activator (iv rt-PA) and any endovascular therapy (EVT) for mild acute ischemic stroke (AIS), is yet to be established. The present study aimed to evaluate the impact of RT on mild AIS patients outcome compared with non-RT.

Methods: Of all 9775 AIS patients admitted in our hospital between 2006 and 2017, those patients with values of 0-1 on the modified Rankin Scale (mRS) prior to the onset of AIS and of ≤ 10 on the National Institute of Health Stroke Scale (NIHSS) just before the therapy was started were selected. Of these, RT patients and comparable non-RT patients were selected using propensity score matching. The RT group included patients with iv rt-PA and any EVT (local arterial infusion of Urokinase, percutaneous transluminal angioplasty, Merci retriever, Penumbra system, and any stent retriever). The primary outcome was mRS 0-1 at three months after the onset, which was defined as an excellent outcome. Subgroup analysis for patients with NIHSS ≤ 5, 6-10, small vessel occlusion (SVO), and non-SVO was also performed.

Results: Of the selected 3089 patients, we constructed the 526 (263 each) propensity score-matched patients cohort. The propensity score-matched RT patients consisted of 135 solely iv rt-PA, 109 EVT, and 19 both. The non-RT patients had a median age of 72 compared to 73 years for the RT patients and the median NIHSS was 5 in both patient groups. The frequencies of excellent outcome in RT and non-RT patients did not differ significantly with 57.8 % and 52.1 %, respectively. The odds ratio and 95 % confidence interval (CI) of RT patients for an excellent outcome was 1.26 (0.89-1.78). In the subgroup analysis, odds ratios of patients with NIHSS ≤ 5, NIHSS 6-10, SVO, and non-SVO were 0.97 (0.61-1.56), 1.75 (1.01-3.03), 1.24 (0.57-2.70), and 1.27 (0.86-1.86), respectively.

Conclusion: The present study found an excellent outcome of RT only in patients with NIHSS 6-10. Further studies may be warranted to investigate the efficacy of RT for patients with mildest AIS (NIHSS ≤ 5).

[Reversible cerebral vasoconstriction syndrome: a clinical study of 11 cases]

This study reports eleven cases of reversible cerebral vasospasm syndrome (RCVS). Of the 11 patients, two were males and nine were females, with the average age of 47.9 ± 14.1 years. Many of these patients were young. The rates of severe, intractable and pulsative headache, generalized convulsions, and motor hemiparesis were 64%, 27%, and 36%, respectively. As complications of intracerebral lesions in the early stage of disease onset, convexal subarachnoid hemorrhage, lobar intracerebral hemorrhage, and posterior reversible encephalopathy syndrome were observed in 63%, 9%, and 45% of cases, respectively. Cerebral infarction occurred in 45% of cases at around 1-3 weeks after onset. Improvement of cerebral vasoconstriction was recognized in several cases from about the first month of onset. The post-partum period, migraine, transfusion, rapid amelioration for anemia, renal failure, bathing, and cerebrovascular dissection were suspected as disease triggers. Abnormally high blood pressure at onset was confirmed in 55% of cases. It is important to analyze the pathophysiology of RCVS associated with these triggers from the viewpoint of the breakdown of the blood-brain barrier.

[Transient, recurrent, white matter lesions in X-linked Charcot-Marie-Tooth disease with heterozygote mutation of GJB1 gene: case report of a female patient]

A 32-year-old woman showed transient central type facial nerve palsy and bulbar symptoms. Brain MRI revealed high intensity signals in the cerebral white matter, splenium of corpus callosum, and posterior limb of internal capsule. Two elder brothers of the patient had distal dominant peripheral neuropathies in four limbs. In this family, the point mutation of GJB1 gene, encoding connexin 32, was revealed and X-linked Charcot-Marie-Tooth disease (CMTX1) was diagnosed. The presented case was a heterozygote of this mutation. She showed severe transient central nervous system (CNS) symptoms and subclinical demyelinating peripheral neuropathy. The CNS symptoms and alterations of brain images were very similar among three siblings. There are many reports on male patients with CMTX1 who show associated CN symptoms, but female patients are very rare. There has been no previous report of a CMTX1 patient similar to the patient presented here. The trigger factors have been recognized at the onset of transient CN symptoms in these cases. The prevention of these factors is important for the management of such patients.

[Rapidly deteriorated lobar intracerebral hemorrhages: possible association of varicella zoster virus-vasculopathy]

A 75-year-old man having dementia and lifestyle related diseases developed a lobar intracerebral hemorrhage (LICH) in the left parietal and a small cerebellar infarction in the left occipital lobe. Many micro bleeds (MB) due to cerebral amyloid angiopathy (CAA) in the subcortical areas and multiple vascular stenosis were also found by MRI and MRA. He developed herpes zoster in his buttocks on day 6 of hospitalization and complicated with varicella zoster virus (VZV) meningitis with positive for VZV-DNA in the cerebrospinal fluid. Subsequently, LICHs occurred in the left frontal lobe and in the right parietal lobe for a short period of time and died on the day 18. We speculated that the repeating hemorrhages was primarily caused by VZV vasculopathy and additionally the subcortical MBs increased the hemorrhagic risk. The relationship between VZV vasculopathy and CAA should be studied in the future.

[Clinical, epidemiological, and etiological studies of adult aseptic meningitis: a report of 12 cases of herpes simplex meningitis, and a comparison with cases of herpes simplex encephalitis]

We treated 437 cases of adult aseptic meningitis and 12 cases (including 2 recurrent patients; age, 31.8 ± 8.9 years; 7 females) of herpes simplex meningitis from 2004 to 2016. The incidence rate of adult herpes simplex meningitis in the cases with aseptic meningitis was 2.7%. One patient was admitted during treatment of genital herpes, but no association was observed between genital herpes and herpes simplex meningitis in the other cases. The diagnoses were confirmed in all cases as the cerebrospinal fluid (CSF) was positive for herpes simplex virus (HSV)-DNA. For diagnosis confirmation, the DNA test was useful after 2-7 days following initial disease onset. Among other types of aseptic meningitis, the patients with herpes simplex meningitis showed relatively high white blood cell counts and relatively high CSF protein and high CSF cell counts. CSF cells showed mononuclear cell dominance from the initial stage of the disease. During same period, we also experienced 12 cases of herpes simplex encephalitis and 21 cases of non-hepatic acute limbic encephalitis. Notably, the patients with herpes simplex meningitis were younger and their CSF protein and cells counts were higher than those of the patients with herpes simplex encephalitis.

Abstract TP19: Impact of Revascularization Therapy on Patient Outcome by the Severity of Acute Ischemic Stroke

Background and Purpose: It has not fully investigated whether the benefit from revascularization therapy for patients with mild acute ischemic stroke (AIS) can overweigh the risk. The aim of this study was to investigate the impact of revascularization therapy on patient outcome as related to the severity of the stroke.

Methods: From our hospital’s stroke database from January 2006 to March 2017, we extracted data for patients with AIS. Eligible criteria for the patients were: modified Rankin Scale (mRS) of 0 or 1 before onset, admitted less than 24 hours after onset, and followed up for at least 3 months. Revascularization therapy included intravenous tissue plasminogen activator; endovascular therapy (intra-arterial urokinase infusion, percutaneous transluminal angioplasty, emergent carotid artery stenting, and thrombectomy); and carotid endarterectomy performed within 14 days from onset.

Patients were divided into 4 groups based on the severity using the National Institutes of Health Stroke Scale (NIHSS) on admission : Group 1 = 0-4, Group 2 = 5-9, Group 3 = 10-19, and Group 4=20-. We defined a good outcome as mRS score of 0-1 at 3 months after onset. The odds ratio of a good outcome was computed among 4 groups, adjusting for age and sex.

Results: We extracted data for 3275 patients with AIS (71.3 years, 65.1% men). Of these, 17.9% received revascularization therapy of any type. This was distributed across the 4 NIHSS groups as follows: 6.1% of Group 1 (n=2193), 27.1% of Group 2 (n=527), 56.4% of Group 3 (n=298), and 55.6% of Group 4 (n=257). The odds ratios (95% confidence interval) of treatment for good outcome in group 1 to 4 were 0.42 (0.29-0.62), 1.15 (0.78-1.72), 2.80 (1.60-4.90), and 4.40 (1.79-10.82), respectively. Group 1 was further divided into 5 subgroups by each NIHSS scores of 0-4. The odds ratios for each subgroup (NIHSS scores 0, 1, 2, 3, and 4) were 0.20 (0.07-0.61), 0.28 (0.11-0.69), 0.27 (0.11-0.69), 0.93 (0.43-2.03), and 0.88 (0.42-1.85), respectively.

Conclusions: Approximately half of the patients with NIHSS score of ≥10 received revascularization therapy and had significant benefit. However, revascularization therapy for patients with mild AIS (specifically NIHSS scores of 0, 1, or 2) could be rather harmful.

[A case of optic perineuritis-A literature review of Japanese cases and clinical problems]

A 64-year-old woman was admitted to our hospital owing to decreased visual acuity and visual field defect. She had a similar history of decreased visual acuity and received steroid therapy 10 years ago. Brain MRI revealed gadolinium-enhancement in the sheath of the optic nerve, called "tram-track" and "doughnut" signs. Optic perineuritis (OPN) was diagnosed on the basis of her clinical manifestations, which improved on treatment with high-dose methylprednisolone (mPSL). However, clinical manifestations relapsed 10 days post-discharge; hence, she was re-admitted. She was re-administered high-dose mPSL and subsequent oral administration of prednisolone. She had no relapse or recurrence for the last 2 years. We reviewed studies involving Japanese patients with OPN, including 17 idiopathic and 14 secondary cases and found that 43% of patients had recurrences and 30% of patients had poor outcome including severe residuals of visual acuity. Secondary OPN occurred owing to various diseases manifesting generalized systematic inflammation. Timely and suitable treatment was very important for clinical favorable outcomes in OPN.

Serum 1,5-Anhydroglucitol: Risk Factor of Acute Ischemic Stroke and Transient Ischemic Attack in Well-Controlled Diabetes

BACKGROUND

Serum 1,5-anhydroglucitol (1,5-AG) levels are a measure that provides information on daily glycemic variations. We evaluated whether 1,5-AG could be a possible marker of acute ischemic stroke (AIS) or transient ischemic attacks (TIA) in patients with diabetes mellitus (DM).

METHODS

We retrospectively reviewed electronic medical records of 5,294 AIS/TIA patients. Of the 5,294, 1,898 had diabetes and in 1,246, serum 1,5-AG levels were measured (group S). Group S was divided into 2 subgroups: hemoglobin A1c (HbA1c) <7% (S-low) and >7% (S-high). As controls, 394 outpatients with diabetes (group C) without AIS/TIA were likewise divided into subgroups, C-low and C-high according to HbA1c level. In each HbA1c subgroup, the association between serum 1,5-AG (≥14 vs. <14 µg/mL) and stroke was examined using multivariable logistic regression (MLR) with stepwise variable selection. In model 1, the OR and 95% CI was examined adjusted for age and gender. Known risk factors for stroke; hypertension, dyslipidemia, alcohol consumption, smoking, and estimated glomerular filtration rate were included in model 2.

RESULTS

Overall, serum 1,5-AG levels were lower in group S than in group C. Serum 1,5-AG levels were low in subgroups S-high and C-high, showing no differences in mean values. However, mean serum 1,5-AG levels in S-low was statistically lower than that in C-low. MLR analysis showed that the OR for low (<14 µg/mL) 1,5-AG for stroke was statistically significant only in well-controlled diabetes (OR [95% CI] 2.19 [1.54-3.10]) in model 1 and (2.26 [1.56-3.28]) model 2.

CONCLUSIONS

Low serum 1,5-AG levels could be a possible marker for AIS/TIA risk in patients with well-controlled DM.

[Clinical, epidemiological and etiological studies of adult aseptic meningitis: Report of 11 cases with varicella zoster virus meningitis]

We treated 11 cases (52.7 ± 14.9 years, all male) with varicella zoster virus (VZV) meningitis and 437 cases with adult aseptic meningitis from 2004 to 2016. The incidence rate of adult VZV meningitis in the cases with aseptic meningitis was 2.5%. Herpes zoster infections are reported to have occurred frequently in summer and autumn. VZV meningitis also occurred frequently in the similar seasons, in our patients. The diagnoses were confirmed in 9 cases with positive VZV-DNA in the cerebrospinal fluid and in 2 cases with high VZV-IgG indexes (> 2.0). For diagnosis confirmation, the former test was useful for cases within a week of disease onset, and the latter index was useful for cases after a week of disease onset. Zoster preceded the meningitis in 8 cases, while the meningitis preceded zoster in 1 case, and 2 cases did not have zoster (zoster sine herpete). Two patients were carriers of the hepatitis B virus, 1 patient was administered an influenza vaccine 4 days before the onset of meningitis, and 1 patient was orally administered prednisolone for 2 years, for treatment. Their immunological activities might have been suppressed. The neurological complications included trigeminal neuralgia, facial palsy (Ramsay Hunt syndrome), glossopharyngeal neuralgia, and Elsberg syndrome. Because the diseases in some patients can become severe, they require careful treatment.

The evaluation of brain perfusion SPECT using an easy Z-score imaging system in the mild cognitive impairment subjects with brain amyloid-β deposition

OBJECTIVE

The analysis of ⁹⁹mTc-ECD single-photon emission computed tomography (SPECT) images using the easy Z-score imaging system (eZIS) program is useful for the diagnosis of early AD in daily medical practice. However, it remains unclear whether eZIS analysis can identify the amnestic mild cognitive impairment (MCI) subjects with brain amyloid-β deposition. The aim of this study was to evaluate the usefulness of an eZIS analysis for predicting amnestic MCI subjects with brain amyloid β deposition.

PATIENTS AND METHODS

Twenty-three subjects with MCI (10 men and 13 women, mean age; 74.2 years) underwent brain perfusion SPECT and ¹¹C-Pittsburgh Compound B positron emission tomography (PiB-PET). MCI subjects were divided into PiB-positive and PiB-negative subgroups. SPECT data was analyzed using the Specific Volume of interest Analysis of the eZIS program. Three indicators (severity, extent, and ratio) were calculated automatically and compared between the two subgroups.

RESULTS

Five of 12 (41.7%) subjects in the PiB-positive subgroup and three of 11 (27.3%) subjects in the PiB-negative subgroup showed the abnormal value for each indicator. The frequency of subjects with abnormal ratio values was significantly higher in the PiB-positive subgroup compared to the PiB-negative subgroup (p=0.02), whereas that of subjects with abnormal values in severity and extent did not differ among the two subgroups. In particular, all subjects in the PiB-negative subgroup showed normal ratio values. Moreover, the subjects with abnormal values on two indicators, including ratio, or on all three indicators, showed PiB-positive.

CONCLUSION

The analysis of brain perfusion SPECT using an eZIS program cannot identify the amnestic MCI subjects with brain amyloid-β deposition. However, abnormal three indicators or normal ratio values may be helpful SPECT findings for predicting the results of PiB-PET in the amnestic MCI subjects.

Vascular Risk Factors and Internal Jugular Venous Flow in Transient Global Amnesia: A Study of 165 Japanese Patients

BACKGROUND

The etiology of transient global amnesia (TGA) remains unclear. We studied the pathophysiology of TGA in 165 Japanese patients.

SUBJECTS AND METHODS

TGA was diagnosed in hospitalized patients from 2004 to 2015. We analyzed clinical characteristics, magnetic resonance imaging findings, and maximum intima-media thickness of the common carotid artery, and the reflux of internal jugular venous (IJV) flow by ultrasonography, and statistically compared patients with TGA with age-matched and sex-matched patients who have had a transient ischemic attack (TIA), small-vessel occlusion (SVO), and normal controls (each group, N = 165).

RESULTS

Patients with TGA showed lower prevalence of vascular risk factors than patients with TIA and SVO did. Eleven patients (6.7%) had 2 episodes of TAG, but specific clinical variables could not be recognized in these patients. The maximum intima-media thickness was significantly thinner in TGA (1.1 ± .7 mm) than in SVO (1.6 ± .9 mm; P = .001). The percentages of cases whose IJV flow reflux was increased by Valsalva maneuver showed no difference (P = .573) between TGA (26.0 %) and SVO (29.4%). MR diffusion-weighted imaging yielded small hyperintense signals in the hippocampus in 64 of 90 (71.1%) patients between 24 and 72 hours. Potential precipitating specific factors or events before the attacks could be recognized in 40 cases (24.2%) of 165 patients.

CONCLUSION

Arterial ischemia and IJV flow reflux might not contribute to TGA pathophysiology. The vulnerability of the hippocampus to physical or emotional stress might be suspected as an underlying mechanism in some patients with TGA.

Abstract WP370: Cerebral Microbleeds Play an Important Role in Turning Recurrent Stroke Towards Intracranial Hemorrhage in Patients With First-ever Ischemic Stroke/Transient Ischemic Attack

Background and Purpose: After ischemic stroke (IS) or transient ischemic attack (TIA), use of an antithrombotic agent to prevent recurrence is mandatory. However, antithrombotic agents rarely cause intracranial hemorrhage (ICH), frequently resulting in worse outcomes than recurrent IS. Cerebral microbleeds (CMBs) have been reported as a useful marker for finding ICH-prone patients. This retrospective study aimed to investigate the significance of CMB in the development of ICH in first-ever IS/TIA patients.

Methods: The data source was our consecutive patient registry between 2005 and 2015. Patients with stroke/TIA admitted to our hospital more than twice (first as first-ever IS/TIA and second or later as recurrent IS/TIA or ICH) and underwent head MRI including T2*-weighted imaging on the first admission were extracted. Clinical characteristics including use of antithrombotic therapy and distribution of CMB on the first and second admissions were compared between recurrent IS/TIA and ICH groups. Distribution of CMB was divided into deep, lobar, or both.

Results: In total, 708 IS/TIA patients (second stroke: 640 IS/TIA; 68 ICH) were extracted. The ICH group showed a longer period until second stroke (1,062 days vs. 817 days, p=0.022) and higher mean NIHSS score (14.8 vs. 6.1, p<0.001) on second admission than the IS/TIA group. On first admission, the ICH group had a higher frequency of CMB (72.1% vs. 49.5%, p<0.001) and lower frequency of cardioembolism (14.7% vs. 25.8%, p=0.044) than the IS/TIA group. About half of hemorrhages occurred in similar locations of the CMB depicted on first admission. A higher frequency of ICH was observed in patients with deep CMB (11.3% vs. 5.6%, p=0.022) or both deep and lobar CMBs (17.4% vs. 5.6%, p<0.001) than in those without CMB. Use of anticoagulants was a significant risk factor for transition from first IS/TIA to second ICH (odds ratio [95% confidence interval]: 3.75 [1.30-10.8], adjusted by sex, age, type of first stroke, and CMB location).

Conclusions: This study found IS/TIA patients with CMB are at high risk of ICH compared to patients without CMB. Preventive antithrombotic treatment particularly use of anticoagulants for CI/TIA patients with CMB should be provided under careful monitoring for the risk of hemorrhage.

Induction of Genes Expressed in Endothelial Cells of the Corpus Callosum in the Chronic Cerebral Hypoperfusion Rat Model

BACKGROUND

Cerebrovascular white matter lesions (WMLs) are associated with cognitive impairment in patients with subcortical vascular dementia. We performed a comprehensive gene expression analysis to elucidate genes associated with WML development in a chronic cerebral hypoperfusion rat model.

METHODS

Brains of rats with bilateral carotid ligation (2VO, n = 10) and sham-operated rats (n = 5-10/group) were removed on days 1, 7, or 28 after surgery. Total RNA isolated from the corpus callosum was evaluated by microarray analysis and quantitative reverse transcription-polymerase chain reaction.

RESULTS

On days 7 and 28, WMLs exhibited histologic changes. On day 7, 16 genes were differentially expressed between groups. mRNA levels of Ptprb, Kcnj8, Crispld2, Bcl6b, and Gja5 were differentially expressed in 2VO rats on day 7, but then returned to normal, whereas mRNA levels of Vwf and Trappc6a were upregulated after day 7. Immunohistochemistry showed that GJA5 and vWF were detected in endothelial cells, KCNJ8 in endothelial cells and astrocytes, CRISPLD2 in neurons and astrocytes, and TRAPPC6A in neurons.

CONCLUSION

Our findings indicate novel genes that may be associated with WML development in the chronic cerebral hypoperfusion rat model, and suggest an important role of neurovascular dysfunction in the pathophysiology.

[Cerebral venous sinus thrombosis associated with hyperhomocysteinemia due to combined deficiencies of folate and vitamin B12]

A 63-year-old man was admitted to our hospital because of convulsive seizures. Radiological examinations revealed cerebral venous sinus thrombosis in the anterior part of the superior sagittal sinus. He had marked hyperhomocysteinemia (93.5 nmol/ml) due to combined deficiencies of folate and vitamin B12. He was T/T homozygous for methylene tetrahydrofolate reductase C677T polymorphism. He received a supplement therapy of vitamins. First, he was administered folate orally. After 3 months, the serum level of homocysteine decreased to 22.6 nmol/ml (an 86% reduction), but was still above the normal level. Next, an additional supplement therapy of vitamin B12 lowered the homocysteine level to normal (12.3 nmol/ml) after 4 months. These results showed that the increase of homocysteine levels in this patient was mainly caused by the deficiency of folate. Additionally, acquired risk factors like vitamin deficiencies increased the level of serum homocysteine to almost 100 nmol/ml.

Evaluation of regional cerebral blood flow in Alzheimer's disease patients with subclinical hypothyroidism

BACKGROUND

This study examined regional cerebral blood flow (rCBF) in Alzheimer's disease (AD) patients with and without subclinical hypothyroidism (SCH).

METHODS

Eleven AD patients with SCH and 141 AD patients without SCH underwent brain perfusion single photon emission computed tomography (SPECT). The SPECT data were analyzed by statistical parametric mapping (SPM8) and FineSRT.

RESULTS

AD patients with SCH showed a significantly decreased rCBF mainly in the temporal lobe and thalamus, whereas those without SCH showed a significantly decreased rCBF in the parietotemporal lobe and cingulate gyrus as well as the frontal lobe.

CONCLUSION

Our findings suggest that SCH may affect cerebral perfusion in regions associated with the memory function.

Relationship between white matter lesions and regional cerebral blood flow changes during longitudinal follow up in Alzheimer's disease

AIM

The aim of the present study was to evaluate the relationship between baseline white matter lesions (WML) and changes in regional cerebral blood flow during longitudinal follow up of patients with Alzheimer's disease (AD).

METHODS

A total of 38 patients with AD were included in the study (16 men, 22 women; mean age 77.8 years). All patients were evaluated using the Mini-Mental State Examination and brain perfusion single-photon emission computed tomography at baseline with an approximately 2-year follow up. The patients were divided into two subgroups according to the presence of WML on magnetic resonance imaging. Single-photon emission computed tomography data were analyzed using a voxel-by-voxel group analysis with Statistical Parametric Mapping 8 and region of interest analysis using FineSRT. Changes in Mini-Mental State Examination scores and regional cerebral blood flow were analyzed using the Wilcoxon signed-rank test.

RESULTS

Mean Mini-Mental State Examination scores in AD patients with WML significantly decreased from 19.4 ± 4.8 to 15.5 ± 6.5 (P = 0.003). Statistical Parametric Mapping 8 and FineSRT analysis showed more severe and widespread regional cerebral blood flow reduction, mainly in the frontal and mesial temporal regions in AD patients with WML compared with those without WML.

CONCLUSION

Baseline WML could predict a rapid progression of cognitive and brain functional impairment during longitudinal follow up in AD. Geriatr Gerontol Int 2016; 16: 836-842.