Rho-kinase ROCK inhibitors reduce oligomeric tau protein

Neurofibrillary tangles, one of the pathological hallmarks of Alzheimer's disease, consist of highly phosphorylated tau proteins. Tau protein binds to microtubules and is best known for its role in regulating microtubule dynamics. However, if tau protein is phosphorylated by activated major tau kinases, including glycogen synthase kinase 3β or cyclin-dependent kinase 5, or inactivated tau phosphatase, including protein phosphatase 2A, its affinity for microtubules is reduced, and the free tau is believed to aggregate, thereby forming neurofibrillary tangles. We previously reported that pitavastatin decreases the total and phosphorylated tau protein using a cellular model of tauopathy. The reduction of tau was considered to be due to Rho-associated coiled-coil protein kinase (ROCK) inhibition by pitavastatin. ROCK plays important roles to organize the actin cytoskeleton, an expected therapeutic target of human disorders. Several ROCK inhibitors are clinically applied to prevent vasospasm postsubarachnoid hemorrhage (fasudil) and for the treatment of glaucoma (ripasudil). We have examined the effects of ROCK inhibitors (H1152, Y-27632, and fasudil [HA-1077]) on tau protein phosphorylation in detail. A human neuroblastoma cell line (M1C cells) that expresses wild-type tau protein (4R0N) by tetracycline-off (TetOff) induction, primary cultured mouse neurons, and a mouse model of tauopathy (rTG4510 line) were used. The levels of phosphorylated tau and caspase-cleaved tau were reduced by the ROCK inhibitors. Oligomeric tau levels were also reduced by ROCK inhibitors. After ROCK inhibitor treatment, glycogen synthase kinase 3β, cyclin-dependent kinase 5, and caspase were inactivated, protein phosphatase 2A was activated, and the levels of IFN-γ were reduced. ROCK inhibitors activated autophagy and proteasome pathways, which are considered important for the degradation of tau protein. Collectively, these results suggest that ROCK inhibitors represent a viable therapeutic route to reduce the pathogenic forms of tau protein in tauopathies, including Alzheimer's disease.

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.

Clinical Assay of Serum SCC-Ag in Urothelial Cancers

Serum squamous cell carcinoma related antigen (SCC-Ag) values were determined in 86 patients with urothelial cancers. Mean + standard deviation for serum SCC-Ag. was 3.4 ± 0.98 ng/ml and positive values (> 2.0 ng/ml) were found in 27%. Neither pathological stage nor cell grade of the urothelial cancer showed any relation to serum SCC-Ag. Serum SCC-Ag. changed parallel to the clinical course. These results suggest that, as there is no specific tumor marker in urothelial cancer, serum SCC-Ag. may be a useful aid in diagnosing cancer and monitoring these patients. Used together with another non-specific marker, an increase in the accuracy of diagnosis of these malignancies can be expected.

[A case of various illusion, and hallucination caused by occipital lobe infarction]

A 70-year-old right-handed man noticed that the right side of the screen on his television displayed a time lag compared to the other side. For five days before admission, he had characteristic polyopia, visual photopia, and complex hallucination. Upon neurological examination, he showed no abnormal findings except for right homonymous hemianopia. MRI showed acute infarction of the occipital gyri and part of the lingual gyrus in the left occipital lobe. After admission, he experienced various visual hallucinations and visual illusions, including metamorphopsia and micropia, many times. They gradually disappeared after 2 months. Various hallucination was caused by the release of visual information, and illusion was thought to be due to integration failure of visual information. The appearance of complex hallucination in the blind visual field is known due to the damage of the region on the left occipital gyrus. However, the cases with various symptoms such as visual photopia and micropsia are rare.

[Guillain-Barré syndrome associated with acute hepatitis A-A case report and literature review]

A 44-year-old female developed acute hepatitis A (HA) 5 weeks after ingesting raw oysters. She developed ascending motor weakness, bilateral peripheral facial nerve palsy, and bulbar symptoms. A diagnosis of demyelinating Guillain-Barré syndrome (GBS) was made on the basis of her clinical manifestations and the results of a nerve conduction study. The patient showed improvement following combination treatment with intravascular immunoglobulin and high dose methylprednisolone. No antibodies against specific gangliosides, sulfated glucuronyl paragloboside (SGPG), or sulfatide were detected. HA virus (HAV) RNA was isolated from her serum and its full-length genome sequence was determined. It revealed a homology of 99.9% or more with HAV genotype IA (HAV-IA) of the 2014 outbreak. No mutant virus RNA was detected.

[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.

[Guillain-Barré syndrome following cytomegalovirus infection with increased level of antibody against moesin-a case report]

A 28-year-old man noticed sensory disturbance in the distal parts of his four extremities and muscle weakness of his hands two weeks after cytomegalovirus (CMV) infection. He had splenomegaly, impairment of hepatic function and peripheral neuropathy with decreased tendon reflexes. Protein-cell dissociation was observed in the cerebrospinal fluid, and the nerve conduction study (NCS) showed the changes due to demyelination. Intravenous immunoglobulin therapy was performed for 5 days after the diagnosis of Guillain-Barré syndrome. He did not show any severe symptoms such as bulbar palsy and was discharged on day 16. Anti-GM2 and anti-GalNAc-GD1a IgM antibodies were detected and acute inflammatory demyelinating polyneuropathy following the CMV infection was confirmed. NCS showed the abnormal changes were normalized after 4 months. The levels of antibodies against moesin, which is a protein existing in trace amounts in node of Ranvier, were increased. However, the antibodies were not detected 4 months after therapy. These changes were well correlated to his clinical course.

[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.

[CADASIL with cysteine-sparing NOTCH3 mutation manifesting as dissociated progression between cognitive impairment and brain image findings in 3 years: A case report]

A 55-year-old man with no history of stroke or migraine presented to the clinic with cognitive impairment and depression that had been experiencing for two years. Neurological examination showed bilateral pyramidal signs, and impairments in cognition and attention. Brain MRI revealed multiple lacunar lesions and microbleeds in the deep cerebral white matter, subcortical regions, and brainstem, as well as diffuse white matter hyperintensities without anterior temporal pole involvement. Cerebral single-photon emission computed tomography (SPECT) revealed bilateral hypoperfusion in the basal ganglia. Gene analysis revealed an arginine-to-proline missense mutation in the NOTCH3 gene at codon 75. The patient was administered lomerizine (10 mg/day), but the patient's cognitive impairment and cerebral atrophy continued to worsen. Follow-up testing with MRI three years after his initial diagnosis revealed similar lacunar infarctions, cerebral microbleeds, and diffuse white matter hyperintensities to those observed three years earlier. However, MRI scans revealed signs of increased cerebral blood flow. Together, these findings suggest that the patient's cognitive impairments may have been caused by pathogenesis in the cerebral cortex.

[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.

[Trigeminal Herpes Zoster Presenting with High-intensity Signals for the Spinal Trigeminal Nucleus and Tract on Diffusion-weighted Image: A Case Report of Stroke Mimic]

A 50-year-old woman was admitted to our hospital with dysesthesia on the right upper portion of her face and a headache. Diffusion-weighted brain magnetic resonance imaging (MRI) revealed high-intensity signals in the dorsolateral portion of the medulla oblongata. She was diagnosed with lateral medullary infarction and was intravenously treated with sodium ozagrel. On the second day of hospitalization, she had nausea and vomiting and showed nystagmus to all directions, suggesting damage to the vestibular nucleus. These manifestations coincided with partial symptoms of lateral medullary syndrome. On the third day of hospitalization, a rash appeared on the region of skin innervated by the first and second branches of the right trigeminal nerve. A reevaluation of the MRI findings indicated the presence of a lesion of the right spinal trigeminal nucleus and tract. She was treated with acyclovir for 14 days, and was discharged without any residual symptoms. Varicella zoster virus-DNA was detected in her cerebrospinal fluid. This disease mimics the presentation of a stroke and is important for differential diagnosis. (Received August 1, 2017; Accepted September 14, 2017; Published February 1, 2018).

[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.

[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.

[Anti-myelin oligodendrocyte glycoprotein (MOG) antibody-positive varicella-zoster virus myelitis presenting as longitudinally extensive transverse myelitis: a case report]

A 69-year-old man was admitted to our hospital because of disturbed consciousness and gait disturbance. He had herpes zoster (HZ) in his left thigh 10 days before admission, and motor paresis of four extremities developed. A dark red rash was observed in his left buttock and thigh (L2-3 region), which was also scattered in the right lower leg, chest wall, and both upper extremities. Brain MRI showed no lesions of demyelinating plaques. Spine MRI showed no abnormal signals in the lumbar region; however, high signals in the spinal cord from the bottom of the medulla oblongata to the upper (Th 2) thoracic region were observed. High signals were observed mainly in the central white matter. These lesions might correspond to longitudinally extensive transverse myelitis (LETM). Cerebrospinal fluid (CSF) showed increased protein and cell counts of lymphocytes and was positive for varicella-zoster virus (VZV)-DNA. His serum sample tested negative for anti-aquaporin (AQP)4 antibody but positive for anti-myelin oligodendrocyte glycoprotein (MOG) antibody (cell-based assay). Disseminated HZ was suspected on the basis of the widely scattered rash, and damage to the both lungs and liver. This is the first report of HZ-associated LETM with a high titer anti-MOG antibodies. Our case showed that HZ may trigger anti-MOG-IgG positive myelitis.

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.

[Retraction:Adult-onset leukoencephalopathy with axonal spheroids and pigmented glia: A case presented brain calcification and corpus callosum atrophy from over 10 years before the onset of dementia]

This article was retracted by author’s request.

[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.

[Auditory agnosia associated with bilateral putaminal hemorrhage: A case report of clinical course of recovery]

A 45-year-old right-handed man with a past history (10 years) of putaminal hemorrage presented with auditory agnosia associated with left putaminal hemorrhage. It was suspected that the auditory agnosia was due to bilateral damage in the acoustic radiations. Generalized auditory agnosia, verbal and non-verbal (music and environmental), was diagnosed by neuropsychological examinations. It improved 4 months after the onset. However, the clinical assessment of attention remained poor. The cognition for speech sounds improved slowly, but once it started to improve, the progress of improvement was rapid. Subsequently, the cognition for music sounds also improved, while the recovery of the cognition for environmental sounds remained delayed. There was a dissociation in recovery between these cognitions. He was able to return to work a year after the onset. We also reviewed the literature for cases with auditory agnosia and discuss their course of recovery in this report.

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.

Adult-onset neuronal intranuclear inclusion disease presented transient global amnesia-a case report

A 65-year-old man had a transient amnesia for about 3 hours. Similar symptoms appeared three years ago. He did not manifest dementia, cerebellar ataxia and involuntary movements. Peripheral neuropathy was observed by the neurophysiological examinations. Diffusion weighted image showed high intensity signal in the area of the corticomedullary junction of the frontal to parietal lobes and immunohistochemical studies of biopsied skin revealed many intranuclear inclusion bodies. Adult-onset neuronal intranuclear inclusion disease was diagnosed. As there was no similar member in his family, he was a sporadic case. Clinical characteristics of his amnesia was fulfilled with the criteria of transient global amnesia (TGA). The transient disturbance of limbic system was suspected.

Foreign accent syndrome caused by the left precentral infarction-a case report

A 57-year-old right-handed man was admitted to our hospital because of right facial paresis and acute-onset dysarthria. He presented with non-fluent aphasia. His aphasia gradually improved, but he started speaking with a strange accent and intonation from the fifth hospital day. He was diagnosed with foreign accent syndrome (FAS), which lasted for 2 months. MRI revealed ischemic infarction with edema in the superior, middle, and inferior parts of the left precentral gyrus. One year later, MRI revealed old, small infarct lesions in the left precentral gyrus, middle frontal gyrus, and postcentral gyrus. We suspected that FAS developed because of disturbance of prosody in the speaking network on improving his aphasia. His meticulous character was probably influenced on developing FAS. The responsible lesions possibly were those in the reversible parts of the left precentral gyrus with edema on acute stage.

[Adult-Onset Neuronal Intranuclear Inclusion Disease in Two Female Siblings]

Neuronal intranuclear inclusion disease (NIID) in two adult siblings (both women, aged 76 and 68 years) is reported on here. The elder sister had a resting tremor and bradykinesia at age 66 years, and treatment with L-DOPA was initiated(L-3, 4-dihydroxyphenylalanine). Three years later, she showed a frozen gait that was associated with the medication wearing off. The clinical manifestations did not improve with the administration of antiparkinson drugs. Six years later, she showed impaired cognitive functions, which had occured gradually, and she began to take donepezil. At age 76, she was diagnosed with NIID based on a skin biopsy. The younger sister exhibited peculiar behaviors at age 62 years, and showed impaired cognitive function 4 years later. At age 68 years, she died because of an accident in the bath tub. In both cases, diffusion-weighted magnetic resonance imaging (DWI) showed high-intensity signals in the U fiber area of the corticomedullary junction. These signals began in the frontal lobe at the initial stages of the disease, and extended to the parietal and temporal lobes at later stages. High-intensity signal areas were detected in the deep white matter in T2-weighted and fluid-attenuated inversion recovery (FLAIR) images in the elder sister. The histological examination via a skin biopsy was useful in diagnosing NIID. (Received August 18, 2016; Accepted December 8, 2016; Published March 1, 2017).

[Acute encephalopathy due to angel's trumpet intoxication: A case report and literature review]

We report two cases (a married couple) of intoxication due to angel's trumpet ingestion. Case 1: A 71-year-old woman was found lying unconscious on the sofa at home and was brought to our hospital by ambulance. She showed mydriatic anisocoria, and an intracerebral lesion was suspected. However, the brain magnetic resonance imaging showed no abnormal lesion and acute encephalopathy of unknown cause was diagnosed. Case 2: A 68-year-old man (husband of the patient of Case 1) showed alteration of consciousness with agitation and was admitted to our hospital on the next day. He also had slight mydriasis. As his manifestations were similar to those of his wife, we studied their medical history again. We found that they mistook the roots of angel's trumpet for burdock and cooked and ate them. This intoxication causes characteristic encephalopathy with altered consciousness and mydriasis. In the case of anisocoria or mild mydriasis, the diagnosis is difficult sometimes. The intoxication occurred within a family; this was a clue to the correct diagnosis. Severe cases exhibit pyramidal signs and symptoms or convulsion, and deaths have been reported. Angel's trumpet intoxication is an important neurological emergency.

Ability of the Ankle Brachial Index and Brachial-Ankle Pulse Wave Velocity to Predict the 3-Month Outcome in Patients with Non-Cardioembolic Stroke

Aim: Both the ankle brachial index (ABI) and brachial-ankle pulse wave velocity (baPWV) are surrogates for atherosclerosis. In this study, we aimed to evaluate the ability of ABI and baPWV to predict stroke outcome in patients with first-ever non-cardioembolic stroke.

Methods: This study included consecutive patients with first-ever non-cardioembolic stroke admitted within 1 week after onset to Ota Memorial Hospital between January 2011 and December 2013. Baseline characteristics and National Institutes of Health stroke scale scores at admission were noted. ABI and baPWV were evaluated within 5 days of admission. The patients were categorized according to ABI (cut-off 0.9) and baPWV (cut-off 1870 cm/s) determined using the receiver operation curve for poor outcome. Clinical outcomes were defined based on the modified Rankin scale (mRS) scores 3 months after stroke onset as good (0 and 1) or poor (2–6).

Results: A total of 861 patients were available for evaluation. ABI < 0.9 and baPWV > 1870 cm/s were associated with poor outcome in the univariate analysis (p < 0.001 and p < 0.001, respectively). After adjusting for factors that showed differences between groups, ABI < 0.9 was associated with poor outcome. Among patients with ABI ≥ 0.9, higher baPWV showed a slight association with poor outcome after adjustment [odds ratio 1.46 (95% CI 0.95–2.27)].

Conclusion: Our study suggests that the stroke outcome can be predicted using ABI and to an extent using baPWV when ABI ≥ 0.9 in patients with non-cardioembolic stroke.

[Clinical Manifestations of Spinal Epidural Hematoma-Stroke Mimic and Pitfalls in Diagnosis]

Clinical manifestations of spinal epidural hematoma are presented, and the cases mimicking acute ischemic stroke have been reviewed from the literature. Many reports described the cases of spinal epidural hematoma with acute hemiparesis mimicking ischemic stroke in which intravenous thrombolytic treatment with recombinant tissue plasminogen activator was considered. A correct diagnosis of acute ischemic stroke must be made within 4.5 hours from the onset of symptoms, a relatively short window period. A spinal epidural hematoma is a potentially important stroke mimic in a wide variety of conditions that mimic a stroke. The literature review and discussion will emphasize allowing the distinction between these hemiparetic presentation of spinal epidural hematoma and acute ischemic stroke. A spinal epidural hematoma should be considered in the differential diagnosis of patients with acute onset of hemiparesis when associated with neck pain and signs of Horner's syndrome and Brown-Sēquard syndrome.

Abstract WP367: Volume of Intracerebral Hemorrhage Varies According to the Kind of Anticoagulant: Direct Oral Anticoagulants vs Warfarin

Background and Hypothesis: The effectiveness and safety of anticoagulants, which are widely used for preventing stroke recurrence, in stroke prevention is well established, they rarely cause severe adverse events, such as intracerebral hemorrhage (ICH). Direct oral anticoagulants (DOACs) have recently become an option for anticoagulation therapy. The incidence of hemorrhagic events in patients under DOAC therapy has been investigated in several studies, but it is unclear whether the severity of a hemorrhagic event is influenced by the use of DOACs. We hypothesized that the severity of ICH is different in patients under warfarin versus those under DOAC therapy.

Method: We retrospectively reviewed medical records and computed tomography images of patients with ICH who were treated at our hospital during April 2011-May 2016. Patients’ clinical characteristics and ICH volume and location were compared between warfarin- and DOAC-treated patients.

Result: Of the 1147 patients with ICH, 114 patients were taking anticoagulants on admission. Eighty-nine patients (78.1%) received warfarin, whereas 25 (21.9%) received DOACs. The following DOACs were used: dabigatran (two patients), rivaroxaban (10 patients), apixaban (12 patients), and edoxaban (one patients). Median ICH volume was significantly lesser in DOAC-treated patients than in warfarin-treated patients [8.1 (range, 0.05-160) ml vs 15.9 (range, 0.1-119) ml, respectively; p = 0.048). A significant correlation between ICH volume and HAS-BLED score was found only in the DOACs group (ρ= 0.560 p = 0.004) but not in the warfarin group (ρ= 0.025 p = 0.822). We found two patients with an ICH volume of >150 mL in the DOACs group. Their HAS-BLED score was 3, and they had experienced multiple stroke events (three or six times).

Conclusion: ICH volume was lesser in DOAC-treated patients than in warfarin-treated patients. We also found that HAS-BLED can be a predictor of ICH volume in DOAC-treated patients.

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.

[Hypogeusia and High Signals in the Nuclei of the Solitary Tract on MRI due to Varicella-Zoster Virus Infection: A Case Report]

A 63-year-old man noticed hypogeusia after presenting hiccups for several days. He was serologically diagnosed with varicella-zoster virus (VZV) infection, but had no skin lesions typical of herpes (zoster sine herpete). Hypogeusia was confirmed by electrogustometry and the filter-paper disk method, which showed damage in the areas innervated by the cord of tympanum, glossopharyngeal nerve, and greater petrosal nerve. High signals in the nuclei of the solitary tract of the medulla oblongata and the enhancement of the bilateral intracranial segments of the cranial nerve IX and X complex were observed by magnetic resonance imaging (MRI). The signal changes in the nuclei of the solitary tract on MRI were seen for more than 2 months, and hypogeusia lasted for more than 7 months. Hypogeusia caused by VZV infection has rarely been reported; however, similar cases could have gone undiagnosed or underdiagnosed in patients with idiopathic hypogeusia. (Received August 18, 2016; Accepted September 29, 2016; Published February 1, 2017).

Lateral geniculate body presenting only hemorrhage homonymous hemianopia-A case report

We report a case of a 55-year-old man who developed acute-onset narrowing of his visual field. He showed right homonymous hemianopsia without any other neurological symptoms and signs. Brain CT and MRI showed localized hemorrhage (about 1.6 ml) in the left lateral geniculate body (LGB). A cerebral angiography showed no vascular anomalies of cerebral vessels, and the left anterior choroidal artery and left lateral posterior choroidal artery could be visualized well. He had hypertension, polycythemia and dyslipidemia and was a habitual smoker and an alcoholic. In the literature, various kinds of visual field defects including hemianopsia, upper quadrant hemianopsia, lower quadrant hemianopsia, and horizontal sectoranopia have been reported in eight cases of LGB hemorrhage. Localized LGB hemorrhage was found in only one case out of 2,763 cerebral hemorrhage patients enrolled in our stroke registry for 11 years from 2005 to 2016. Localized hemorrhage of LGB very rarely occurred.

Clinicopathological features of adult-onset neuronal intranuclear inclusion disease

Neuronal intranuclear inclusion disease (NIID) is a slowly progressive neurodegenerative disease characterized by eosinophilic hyaline intranuclear inclusions in the central and peripheral nervous system, and also in the visceral organs. NIID has been considered to be a heterogeneous disease because of the highly variable clinical manifestations, and ante-mortem diagnosis has been difficult. However, since we reported the usefulness of skin biopsy for the diagnosis of NIID, the number of NIID diagnoses has increased, in particular adult-onset NIID. In this study, we studied 57 cases of adult-onset NIID and described their clinical and pathological features. We analysed both NIID cases diagnosed by post-mortem dissection and by ante-mortem skin biopsy based on the presence of characteristic eosinophilic, hyaline and ubiquitin-positive intanuclear inclusion: 38 sporadic cases and 19 familial cases, from six families. In the sporadic NIID cases with onset age from 51 to 76, dementia was the most prominent initial symptom (94.7%) as designated 'dementia dominant group', followed by miosis, ataxia and unconsciousness. Muscle weakness and sensory disturbance were also observed. It was observed that, in familial NIID cases with onset age less than 40 years, muscle weakness was seen most frequently (100%), as designated 'limb weakness group', followed by sensory disturbance, miosis, bladder dysfunction, and dementia. In familial cases with more than 40 years of onset age, dementia was most prominent (100%). Elevated cerebrospinal fluid protein and abnormal nerve conduction were frequently observed in both sporadic and familial NIID cases. Head magnetic resonance imaging showed high intensity signal in corticomedullary junction in diffusion-weighted image in both sporadic and familial NIID cases, a strong clue to the diagnosis. All of the dementia dominant cases presented with this type of leukoencephalopathy on head magnetic resonance imaging. Both sporadic and familial NIID cases presented with a decline in Mini-Mental State Examination and Frontal Assessment Battery scores. Based on these clinicopathological features, we proposed a diagnosis flow chart of adult-onset NIID. Our study suggested that the prevalence rate of adult-onset NIID may be higher than previously thought, and that NIID may be underdiagnosed. We should take NIID into account for differential diagnosis of leukoencephalopathy and neuropathy.

[Pneumococcal meningitis with accompanying severe hearing loss: 3D-FLAIR imaging of the inner ear and treatment]

A 66-year-old man was admitted to our hospital because of unconsciousness. He was diagnosed with pneumococcal meningitis and treated with a combination of antibiotics (meropenem hydrate), dexamethasone, and intravenous immunoglobulin. Although he gradually regained consciousness, he started showing signs of hearing disturbance. Measurement of auditory brainstem response revealed severe sensorineural hearing loss. The patient then underwent three-dimensional fluid-attenuated inversion recovery magnetic resonance imaging, which revealed increased signals in the cochlea and the vestibuum, and their enhancement after gadolinium administration. This enhancement was still observed on images of the inner ear acquired on the 52nd hospital day. These findings suggested that the change of content in the lymph and the damage to the blood-labyrinth barrier was caused and aggravated by an immune response. Recent studies have shown that an MyD88-dependent immune response contributes to hearing loss in an experimental mouse model of pneumococcal meningitis. The patient was administered steroid pulse and hyperbaric oxygen therapies for improving the hearing deficit, but these therapies were discontinued because of the aggravation of hepatitis B and diabetes mellitus, which he had developed previously.

[Dementia with Lewy bodies presenting marked tongue protrusion and bite due to lingual dystonia: A case report]

We report the patient of a 53-year-old woman who developed subacute-onset marked tonge protrusion and bite. She was diagnosed as dementia with Lewy bodies (DLB) from the clinical features including progressive cognitive decline, visual hallucinations, parkinsonism, and severe insomnia and depression, and the radiological finding of low dopamine transported uptake in basal ganglia by Dat SCAN and low blood circulation in occipital lobe of cerebrum. The patient received 600 mg doses of levodopa for over a year, followed by rotigotine and ropinirole with a rapid increase of dosage. It is believed that these treatments stimulated and sensitized dopamine D1 receptors, thereby inducing lingual dystonia. Furthermore, the patient demonstrated dyspnea and attacks of apnea caused by the closure of bilateral vocal cords due to laryngeal dyskinesia. After initiation of the neuroleptic, olanzapine, for a short duration, the high dose of levodopa overlapped with neuroleptic sensitivity, suggesting DOPA-induced dystonia and dyskinesia. This interaction can sometimes lead to lethal adverse events, and must be considered very important when treating patients with DLB.

Cerebral venous sinus thrombosis in the patient with multiple sclerosis associated with congenital antithrombin deficiency

We report the case of a 25-year-old man with multiple sclerosis (MS) who had severe headache and unconsciousness. He suffered from optic neuritis that had started at age 6. From the age of 12 years, he had suffered from multiple sclerosis (MS) cerebral lesions that relapsed three times over for 5 years. At age 25, he showed a new lesion in the cerebellar cortex, suggesting an exacerbation of the MS. However, magnetic resonance imaging findings the next day showed cerebral venous sinus thrombosis. His laboratory findings showed low antithrombin activity. Genetic analysis revealed a single-base substitution (C>T) at the codon 359 (Arg to STOP) in the 5th exon portion of the antithrombin gene, heterozygote. In the literature review, 17 cases of multiple sclerosis associated with cerebral venous sinus thrombosis, which occurred after the lumbar puncture and the treatment with high-dose methylpredonisolone in 11 of these cases. In our case, antithrombin deficiency, hyperhomocystinemia, infection, and lumbar puncture were suggested as the risk factors.

[Intracerebral hemorrhage associated with nephrotic syndrome-Prevalemce and clinical characteristics]

Of the 11,161 cases of stroke observed for over 9 years, 21 cases in which both levels of serum albumin and cholesterol were < 3 g/dl and > 250 mg/dl, respectively, were identified. Out of these 21 cases, cases of severe proteinuria, i.e., nephrotic syndrome were selected. These included 10 cases of arterial ischemic thrombosis, 2 cases of cerebral venous sinus thrombosis, and 4 cases of intracerebral hemorrhage. The incidence of intracerebral hemorrhage associated with nephrotic syndrome was 0.18% of total stroke or 0.036% intracerebral hemorrhage. Nephrotic syndrome essentially induced a hypercoagulable state. The 4 cases with intracerebral hemorrhage associated with nephrotic syndrome, however, had strong risk factors for intracerebral hemorrhage, suggesting that they overcame the risk for thrombophilia. The diseases associated with the nephrotic syndrome were diabetic nephropathy and amyloidosis in 3 cases and in 1 case, respectively. The nephrotic syndrome tends to be associated with a risk for venous or arterial thrombosis. In addition, we must pay attention to intracerebral hemorrhage associated with nephrotic syndrome in cases of stroke.

Brain Natriuretic Peptide and Particular Left Ventricle Segment Asynergy Associated with Cardioembolic Stroke from Old Myocardial Infarction

BACKGROUND

It is important to determine the usage of anticoagulants by defining the actual risk of cardioembolic stroke in patients with old myocardial infarction. In the present study, we aimed to more precisely evaluate the risks of each segment associated with cardioembolic stroke using a 16-segment model. The usage of the plasma brain natriuretic peptide (BNP) associated with cardioembolic stroke was also evaluated in comparison with a left ventricle ejection fraction less than 40%.

METHODS

There were a total of 190 ischemic stroke patients who had premorbid myocardial infarction. The study included a total of 143 ischemic stroke patients with old myocardial infarction who were available for evaluation and excluded patients with atrial fibrillation or acute myocardial infarction. Their left ventricle wall motion abnormality and the level of plasma BNP at their admission were analyzed.

RESULTS

Hypertension and a plasma BNP level of 206.9 pg/mL or higher, determined from the receiver operating characteristic curve, were independently associated with cardioembolic stroke (χ(2) = 35.6, R(2) = .30, P < .001). Adjusting for these factors, statistically independent high risk was observed at the basal-inferior, basal-inferolateral, mid-anterior, mid-anteroseptal, apical-anterior, and apical-septal left ventricles.

CONCLUSION

High plasma BNP levels and left ventricular wall motion abnormalities in the segments perfused with left anterior descending coronary artery or right coronary artery show a high risk for cardioembolic stroke in patients with old myocardial infarction. Considering these factors, it could be possible to more precisely define the risk of cardioembolic stroke and to perform appropriate antithrombotic treatments in old myocardial infarction patients.

Abstract TP62: The Incidence of Post-treatment Cerebral Microbleeds After Combined Therapy of Endovascular Thrombectomy and tPA

Introduction: Cerebral microbleeds (CMBs) are considered as a risk factor for stroke. The incidence of post-tPA microbleeds have been reported in recent studies, however, it is not clear that whether hybrid procedure (the combination of tPA and endovascular thrombectomy) for ischemic stroke would increase risk of post-treatment CMBs more than treatment with tPA or endovascular thrombectomy alone. Objective of this study is to compare the incidence of post-treatment CMBs and symptomatic exraischemic hemorrhage by treatments: hybrid procedure, tPA alone, and endovascular thrombectomy alone.

Hypothesis: Combined therapy of endovascular thrombectomy and tPA for ischemic stroke have higher incidence of post-treatment CMBs than tPA or endovascular thrombectomy alone.

Methods: We retrospectively reviewed pre- and post-T2*-weighted MRI of ischemic stroke patients who received above treatments in our hospital during 2010 to 2014. The presence and number of CMBs were assessed according to the Brain Observer Microbleeds Scale. We compared the number of pre-treatment CMBs, incidence of newly-occurred post-treatment CMBs and symptomatic extraischemic hemorrhage within a year after treatments among hybrid procedure, tPA alone, and endovascular thrombectomy alone.

Results: A total of 147 (hybrid procedure n=17, tPA alone n=90, endovascular thrombectomy alone n=40) patients’ pre- and post-treatment MRIs were reviewed. The average number of pre- treatment CMBs was 1.4±4.0 and there was no difference among treatments. The incidence of post-treatment CMBs was significantly higher in hybrid procedure (n=5, 29.4%) and tPA alone (n=18, 20.0%) than endovascular thrombectomy (n=1, 2.5%). However, there was no difference between hybrid procedure and tPA alone. Symptomatic extraischemic hemorrhage was found only one patient who received endovascular thrombectomy alone.

Conclusion: The incidence of CMBs after treatments was increased in treatments using tPA. However, there was no difference in post-treatment incidence between hybrid procedure and tPA alone. This result suggests that additional thrombectomy after tPA would not increase the risk of CMBs.

Abstract TP208: 1,5-anhydro-d-glucitol as a Predictor of Cerebral Infarction in Patients With Glycated Hemoglobin A1c-based Good Diabetes Control

Introduction: Current guidelines set the goal of diabetes control to a glycated hemoglobin A1c (HbA1c) level of <7% in order to prevent macrovascular events. However, we often experience diabetes patients with cerebral infarction (CI), even though their HbA1c level is well-controlled. A reason for this disparity between the diabetes control status and CI onset may be the limitation of HbA1c as a diabetes control indicator. HbA1c reflects the mean blood glucose level over the past 2-3 months. Therefore, with HbA1c, we cannot evaluate short-term blood glucose control and glycemic variability, which are reported as risk factors for CI. Measurement of 1,5-anhydro-D-glucitol (1,5AG) allows the evaluation of these factors.

Hypothesis: 1,5AG can be used to evaluate the risk of CI in patients with well-controlled diabetes.

Methods: We retrospectively reviewed the medical records of 1169 patients with diabetes who received treatment for CI at our hospital between 2009 and 2014. These patients were divided into the following two groups according to their HbA1c-based diabetes control status: a CI-low group (HbA1c <7%, n=549) and a CI-high group (HbA1c ≧7%, n=620). We also included a non-CI group of 394 diabetes patients without CI (control group), and these patients were further divided into the following two groups in the same manner: a nonCI-low group (n=199) and a nonCI-high group (n=195). The 1,5AG levels were compared between the CI-low and nonCI-low groups, and the CI-high and nonCI-high groups.

Results: There was no difference in the 1,5AG level between the CI-high and nonCI-high groups (8.8±7.3% vs. 8.9±7.1%, p=0.83). However, the 1,5AG level was significantly lower in the CI-low group than in the nonCI-low group (12.5±8.1% vs. 15.2±8.8%, p<0.001). This difference remained significant after adjusting for age and sex.

Conclusion: The results of this study show that short-term glycemic control and glycemic variability have a significant relationship with existing CI especially in patients with good diabetes control. The 1,5AG level may be a surrogate measure of the risk of CI in patients with HbA1c levels that indicate good diabetes control.