High incidence of acute kidney injury in extracorporeal resuscitation, Leading to poor prognosis

Background

Extracorporeal membrane oxygenation (ECMO) patients have a high incidence of acute kidney injury (AKI). Extracorporeal cardiopulmonary resuscitation (ECPR) patients are more likely to develop AKI than ECMO patients because of serious injury during cardiac arrest (CA).

Objectives

This study aims to assess the occurrence and outcomes of AKI in ECPR and ECMO, and to identify specific risk factors and clinical implications of AKI in ECPR.

Methods

This is a retrospective observational study from a single tertiary care hospital in Gwangju, Korea. Adults (≥18 years) who received ECMO with cardiac etiology in the emergency and inpatient departments from January 2015 to December 2021 were included. The patients (n = 169) were divided into two groups, ECPR and ECMO without CA, and the occurrence of AKI was investigated. The primary outcome of the study was in-hospital mortality, and the secondary outcomes were six-month cerebral performance category (CPC) and AKI during hospitalization.

Results

The incidence of AKI was significantly higher with ECPR (67.5 %) than with ECMO without CA (38.4 %). ECPR was statistically significant for Expire (adjusted OR (aOR) 2.45, 95 % CI 1.28-4.66) and Poor CPC (2.59, 1.32-5.09). AKI was also statistically significant for Expire (6.69, 3.37-13.29) and Poor CPC (5.45, 2.73-10.88). AKI was the determining factor for the outcomes of ECPR (p = 0.01).

Conclusions

ECPR patients are more likely to develop AKI than ECMO without CA patients. In ECPR patients, AKI leads to poor outcomes. Therefore, clinicians should be careful not to develop AKI in ECPR patients.

The association between lactate to albumin ratio and outcomes at early phase in patients with traumatic brain injury

BACKGROUND

The majority of traumatic brain injury (TBI) cases result in death in the early phase; predicting short-term progno-sis of affected patients is necessary to prevent this. This study aimed to examine the association between the lactate-to-albumin ratio (LAR) on admission and outcomes in the early phase of TBI.

METHODS

This retrospective observational study included patients with TBI who visited our emergency department between January 2018 and December 2020. TBI was considered as an head abbreviated injury scale (AIS) score of 3 or higher and other AIS of 2 or lower. The primary and secondary outcomes were 24-h mortality and massive transfusion (MT), respectively.

RESULTS

In total, 460 patients were included. The 24-h mortality was 12.6% (n=28) and MT was performed in 31 (6.7%) patients. In the multivariable analysis, LAR was associated with 24-h mortality (odds ratio [OR], 2.021; 95% confidence interval [CI], 1.301-3.139) and MT (OR, 1.898; 95% CI, 1.288-2.797). The areas under the curve of LAR for 24-h mortality and MT were 0.805 (95% CI, 0.766-0.841) and 0.735 (95% CI, 0.693-0.775), respectively.

CONCLUSION

LAR was associated with early-phase outcomes in patients with TBI, including 24-h mortality and MT. LAR may help predict these outcomes within 24 h in patients with TBI.

The Association Between Induction Rate and Neurologic Outcome in Patients Undergoing Targeted Temperature Management at 33°C

To determine the association between the induction rate and 6-month neurologic outcomes in out-of-hospital cardiac arrest (OHCA) survivors who underwent targeted temperature management (TTM). This retrospective observational study analyzed data prospectively collected from adult comatose OHCA survivors treated with TTM at the Chonnam National University Hospital in Gwangju, Korea, between October 2015 and December 2020. We measured the core body temperature (BT) through an esophageal probe and recorded it every 5 minutes throughout TTM. Induction time was defined as the elapsed time between the initiation of TTM and the achievement of target BT of 33°C. We calculated the induction rate as the change of BT divided by induction time. The primary outcome was a poor 6-month neurologic outcome, defined as cerebral performance category 3-5. Of the OHCA survivors, 218 patients were included, and 137 (62.8%) patients had a poor neurologic outcome. Patients with a poor neurologic outcome had lower BT at the initiation of TTM, shorter induction time, and higher induction rate than those with good neurologic outcomes. After adjusting for confounders, induction time (odds ratio [OR] 0.995; 95% confidence interval [CI], 0.992-0.999) and induction rate (OR 2.362; 95% CI, 1.178-4.734) were independently associated with poor neurologic outcome. BT at TTM initiation was not associated with a poor neurologic outcome. Induction rate was independently associated with a poor neurologic outcome in OHCA survivors who underwent TTM at 33°C.

Association Between Procalcitonin Level at 72 Hours After Cardiac Arrest and Neurological Outcomes in Cardiac Arrest Survivors

The association between procalcitonin (PCT) level measured 72 hours after cardiac arrest (CA) and neurological outcomes is unknown. We aimed to examine the association of serial PCT levels up to 72 hours with neurological outcomes in patients who underwent targeted temperature management (TTM) after CA. This retrospective observational study included adult comatose patients with CA undergoing TTM (33℃ for 24 hours) at the Chonnam National University Hospital in Gwangju, Korea, between January 2018 and December 2020. PCT levels were measured at admission and at 24, 48, and 72 hours after CA. The presence of early-onset infections (within 7 days after CA) was confirmed by reviewing clinical, radiological, and microbiological data. The primary outcome was poor neurological outcomes at 6 months and was defined by cerebral performance category 3-5. Among the CA survivors, 118 were included and 67 (56.8%) had poor neurological outcomes. The PCT level at 72 hours in the poor outcome group (3.01 [0.88-12.71]) was higher than that in good outcome group (0.56 [0.18-1.32]). The multivariate analysis revealed that the PCT level at 72 hours (adjusted odds ratio 1.241; 95% confidence interval, 1.059-1.455) was independently associated with poor neurological outcomes, showed good performance for poor outcomes (area under the receiver operating characteristic curve of 0.823), and was not associated with early-onset infections. The PCT level at 72 hours after CA can be helpful in predicting prognosis, and it did not correlate with early-onset infections in the study.

Heat loss augmented by extracorporeal circulation is associated with overcooling in cardiac arrest survivors who underwent targeted temperature management

We investigated the association of extracorporeal circuit-based devices with temperature management and neurological outcome in out-of-hospital cardiac arrest survivors who underwent targeted temperature management. Patients with extracorporeal membrane oxygenation and/or continuous renal replacement therapy were classified as the extracorporeal group. We calculated the cooling rate during the induction period and time-weighted core temperatures (TWCT) during the maintenance period. We defined the sum of TWCT above or below 33 °C as positive and negative TWCT, respectively, and the sum of TWCT above 33.5 °C or below 32.5 °C as undercooling or overcooling, respectively. The primary outcome was the negative TWCT. The secondary outcomes were positive TWCT, cooling rate, undercooling, overcooling, and poor neurological outcomes, defined as Cerebral Performance Category 3–5. Among 235 patients, 150 (63.8%) had poor neurological outcomes and 52 (22.1%) were assigned to the extracorporeal group. The extracorporeal group (β, 0.307; p < 0.001) had increased negative TWCT, rapid cooling rate (1.77 °C/h [1.22–4.20] vs. 1.24 °C/h [0.77–1.79]; p = 0.005), lower positive TWCT (33.4 °C∙min [24.9–46.2] vs. 54.6 °C∙min [29.9–87.0]), and higher overcooling (5.01 °C min [0.00–10.08] vs. 0.33 °C min [0.00–3.78]). However, the neurological outcome was not associated with the use of extracorporeal devices (odds ratio, 1.675; 95% confidence interval, 0.685–4.094).

Water Temperature Variability Is Associated with Neurologic Outcomes in Out-of-Hospital Cardiac Arrest Survivors Who Underwent Targeted Temperature Management at 33°C

We examined the association between variability in body temperature (BT) and water temperature (WT) during the maintenance period of targeted temperature management (TTM) and neurologic outcomes in out-of-hospital cardiac arrest (OHCA) survivors. Adult (≥18 years), comatose OHCA survivors who underwent TTM at 33°C between October 2015 and December 2019 were included. We collected data on BT and WT recorded every minute during the TTM maintenance period. Temperature variability was measured as the standard deviation of BT and WT during the 33°C maintenance period. The primary outcome was a poor neurologic outcome, defined as a cerebral performance category scale 3-5 at 6 months. Of the 154 included patients, 96 (62.3%) had poor outcomes. The BT variability in the poor outcome group was lower than that in the good outcome group (0.16°C [0.13-0.27°C] vs. 0.13°C [0.11-0.18°C]). In addition, the WT variability during the maintenance period in the poor outcome group was lower than that in the good outcome group (2.24°C [1.80-3.96°C] vs. 1.77°C [1.26-2.32°C]). In the multivariate analysis, WT variability (odds ratio 0.508; 95% confidence interval, 0.295-0.874; p = 0.014) was independently associated with poor neurologic outcome. BT variability and cooling beyond 33.0°C ± 1.0°C were not associated with poor neurologic outcomes. WT variability during the maintenance period was independently associated with neurologic outcomes in OHCA survivors who underwent TTM at 33°C. In addition, overcooling or undercooling during the maintenance period was not associated with neurologic outcomes.

Coagulopathy after snake envenomation in South Korea

OBJECTIVE

This retrospective study investigated the nature and severity of venom-induced consumption coagulopathy (VICC) and determined the clotting factors involved in VICC in patients after envenomation by South Korea's snakes. Additionally, we studied the effectiveness of antivenom for the treatment of VICC after envenomation.

METHODS

Included patients were divided into three groups according to the severity of VICC (no VICC, partial VICC, and complete VICC). Data, including changes in coagulation parameters during hospitalization and clotting factors at presentation, were collected and analyzed.

RESULTS

One hundred nineteen patients who presented at our emergency department within 3 h after snake envenomation were included. VICC developed in 34 patients (27 patients with partial VICC and 7 patients with complete VICC). Two of 34 patients with VICC required blood transfusions. Five patients with complete VICC had an undetectable fibrinogen concentration at presentation. Three patients with complete VICC had an unmeasurable INR and aPTT within 24 h. The median times of the most extreme values were 10 h for INR, 12 h for aPTT, and 16 h for fibrinogen after presentation in the VICC group. The D-dimer concentration peaked at a median of 63.5 h after presentation. The activities of factors II and X were significantly reduced in the complete VICC group (factor II: 88 (84-99.3)% in the non-VICC group vs. 69 (49.5-83.5)% in the complete VICC group; factor X:94 (83-102) in the non-VICC group vs. 70 (66.5-79.8)% in the complete VICC group), while there was no difference in factor V activity at presentation. The time from bite to first antivenom administration did not correlate with the time course and most extreme concentrations for fibrinogen and D-dimer within the VICC groups.

DISCUSSION AND CONCLUSION

VICC occurs in approximately one-quarter of snakebite patients in South Korea; however, VICC itself does not appear to lead to clinical deterioration. Fibrinogen is an early diagnostic maker for complete VICC. Clotting factors II and X are involved in VICC. Future investigations should explore the mechanism of VICC from Korean snakebites and the effect of antivenom on VICC.

Risk factors outperform intracranial large artery stenosis predicting unfavorable outcomes in patients with stroke

Background

This study examined how intracranial large artery stenosis (ILAS), symptomatic and asymptomatic ILAS, and risk factors affect unfavorable outcome events after medical treatment in routine clinical practice.

Methods

This was a 24-month prospective observational study of consecutively recruited stroke patients. All participants underwent magnetic resonance angiography, and their clinical characteristics were assessed. Outcome events were vascular outcome, recurrent stroke, and death. Cox regression analyses were performed to identify potential factors associated with an unfavorable outcome, which included demographic and clinical characteristics, the risk factors, and stenosis status.

Results

The analysis included 686 patients; among them, 371 were assessed as ILAS negative, 231 as symptomatic ILAS, and 84 as asymptomatic ILAS. Body mass index (p < .05), hypertension (p = .01), and old infarction (p = .047) were factors relating to vascular outcomes. Hypertension was the only factor for recurrent stroke (p = .035). Poor glomerular filtration rate (< 30 mL/min/1.73 m²) (p = .011) and baseline National Institutes of Health Stroke Scale scores (p < .001) were significant predictors of death.

Conclusions

This study extended previous results from clinical trials to a community-based cohort study by concurrently looking at the presence/absence of stenosis and a symptomatic/asymptomatic stenotic artery. Substantiated risk factors rather than the stenosis status were predominant determinants of adverse outcome. Although the degree of stenosis is often an indicator for treatment, we suggest risk factors, such as hypertension and renal dysfunction, should be monitored and intensively treated.

A potential role for skeletal muscle caveolin-1 as an insulin sensitivity modulator in ageing-dependent non-obese type 2 diabetes: studies in a new mouse model

AIMS/HYPOTHESIS

Type 2 diabetes mellitus is a common age-dependent disease. We discovered that male offspring of non-diabetic C57BL/6 and DBA/2 mice, called JYD mice, develop type 2 diabetes when they grow old. JYD mice show characteristics of insulin resistance, hyperglycaemia and hyperinsulinaemia in old age without obesity. We postulated that the mechanism of age-dependent type 2 diabetes in this model relates to caveolin-1 status in skeletal muscle, which appears to regulate insulin sensitivity in the mice.

METHODS

We compared insulin sensitivity in aged C57BL/6 and JYD mice using glucose and insulin tolerance tests and (18)F-fluorodeoxyglucose positron emission tomography. We also determined insulin signalling molecules and caveolin proteins using western blotting, and altered caveolin-1 levels in skeletal muscle of C57BL/6 and JYD mice using viral vector systems, to examine the effect of this on insulin sensitivity.

RESULTS

In 30-week-old C57BL/6 and JYD mice, the basal levels of IRS-1, Akt and peroxisome proliferator-activated receptor-gamma decreased, as did insulin-stimulated phosphorylation of Akt and insulin receptor beta. However, caveolin-1 was only increased about twofold in 30-week-old JYD mice as compared with 3-week-old mice, whereas an eightfold increase was seen in C57BL/6 mice. Downregulation of caveolin-1 production in C57BL/6 mice caused severe impairment of glucose and insulin tolerance. Upregulation of caveolin-1 in aged diabetic JYD mice significantly improved insulin sensitivity with a concomitant increase of glucose uptake in the skeletal muscle.

CONCLUSIONS/INTERPRETATION

The level of skeletal muscle caveolin-1 is correlated with the progression of age-dependent type 2 diabetes in JYD mice.

Failure of stress-induced downregulation of Bcl-2 contributes to apoptosis resistance in senescent human diploid fibroblasts

We previously reported that senescent human diploid fibroblasts (HDFs) are resistant to apoptosis induced by H(2)O(2) and staurosporine. We report here that senescent HDFs are resistant to thapsigargin-induced apoptosis as well. These agonists caused the reductions in mitochondrial membrane potential (MMP) and in the apoptosis inhibitory protein (B-cell lymphoma) only in young HDFs but not in senescent HDFs. In addition, downregulation of Bcl-2 increased the sensitivity of senescent HDFs to apoptosis induction, suggesting the significant role of Bcl-2 in apoptosis resistance of the senescent HDFs. We further found that P-cAMP response element-binding protein (CREB), a positive regulator of Bcl-2, decreased in stress-induced apoptosis of young HDFs but not in senescent HDFs, and that Bcl-2 was markedly reduced in CREB small interfering RNA (siRNA), transfected senescent HDFs. In addition, activity of protein phosphatase 2A (PP2A), which dephosphorylates p-CREB, significantly increased in young HDFs but not in senescent HDFs treated with H(2)O(2), staurosporine or thapsigargin. Taken together, these results suggest that failure of stress-induced downregulation of Bcl-2 underlies resistance of senescent HDFs to apoptosis.

Role of Src-specific phosphorylation site on focal adhesion kinase for senescence-associated apoptosis resistance

A decreased apoptotic response toward noxious stress is an issuing characteristic of the aging phenotype. Hydrogen peroxide or staurosporine induced apoptosis readily in young cells but not in senescent cells. We showed that focal adhesion kinase (FAK) expression and its phosphorylation at Tyr397, autophosphorylation site for focal adhesion formation, and Tyr577, Src-dependent phosphorylation site, were both increased in senescent cells. Moreover, FAK was inactivated proteolytically by apoptotic stimuli in young cells, but not in senescent cells. In addition, senescent cells whose FAK expression was downregulated by siRNA showed the increased level of apoptosis by staurosporine treatment via caspase-3 activation but not by hydrogen peroxide treatment. Interestingly dephosphorylation at Tyr577 of FAK by PP2 treatment, Src-family kinase inhibitor, induced the apoptosis by staurosporine in senescent cells but dephosphorylation at Tyr397 by downregulation of caveolin-1 was not affected. These data suggest that FAK might differently regulate apoptosis and focal adhesion formation through site-specific tyrosine phosphorylation in senescent cells.

Occurrence and characteristics of enterohemorrhagic Escherichia coli O157 in calves associated with diarrhoea

Little is known of the association of enterohemorrhagic Escherichia coli O157:H7/NM (EHEC O157) with disease in naturally infected calves, although cattle have been known as a major source for EHEC O157 outbreaks in humans. In this study, we investigated the occurrence of EHEC O157 in calves associated with/without diarrhoea to examine if EHEC O157 is involved in calf diarrhoea and to characterize the isolates. Four hundred and ninety eight diarrhoeic and non-diarrhoeic young calves from 115 different farms were examined. Of 244 diarrhoeic calves, 24 (9.8%) were positive for EHEC O157, and of 254 non-diarrhoeic calves, 7 (2.8%) were positive. EHEC O157 was recovered from 12/76 (15.79%) of diarrhoeic calves less than 2-week-old, and no EHEC O157 was detected in this age group of non-diarrhoeic calves. This implicates EHEC O157 as a possible cause of the disease in naturally infected neonatal calves. The occurrence of EHEC O157 was relatively lower in the older calves (aged older than 8 weeks) and no significant difference was found in the occurrence rates between these diarrhoeic and non-diarrhoeic calves. PCR analysis of virulence markers revealed that the isolates carried various virulence genes such as Ehly, eae, stx1 and stx2, which underlines the potential importance of these attributes for the infection, colonization and possible pathogenesis of calf diarrhoea.

Myxoma attached to both atrial and ventricular sides of the mitral valve: report of a case and review of 31 cases of mitral myxoma

We report for the first time upon a case of myxoma that involved both atrial and ventricular sides of the anterior mitral valve leaflet. Electron beam tomography (EBT) showed that the tumor was attached to both the atrial and ventricular sides of the mitral valve, while echocardiography did not. EBT also diagnosed dynamic obstruction of left ventricular outflow tract caused by the tumor.

CT and MR findings of primary cardiac lymphoma: report upon 2 cases and review

Although primary cardiac lymphoma was a near fatal disease in the past, recent advances in imaging diagnosis and chemotherapy have dramatically improved survival. We describe the CT and MR findings of primary cardiac lymphoma in two immunocompetent subjects who recovered after chemotherapy. The primary cardiac lymphomas manifested as a poorly enhancing mass on CT, relatively hyperintense on a T2-weighted image and a heterogeneously enhanced mass on contrast-enhanced MR. The tumor also showed a predilection for right heart chambers and contiguous infiltration along adjacent structures.

Efficacy of MRI in complicated congenital heart disease with visceral heterotaxy syndrome

PURPOSE

The authors' goal was to assess the diagnostic accuracy and clinical effect of MRI compared with echocardiography and catheterization in the evaluation of cardiac defects with situs ambiguous.

METHOD

Twenty-two patients with visceral heterotaxy syndrome were included.

RESULTS

Because situs determined by the relation between the pulmonary artery and bronchi showed most predominantly a tendency toward lateralization, this was regarded as the standard reference of situs determination. For the purpose of this study, patients were classified as having right isomerism (n = 13) or left isomerism groups (n = 9). MRI has several advantages compared with echocardiography or cardiac angiography for examining patients with situs ambiguous. (1) The bronchial, pulmonary arterial, and splenic situs can be readily determined, and discrepancies (n = 2) can be assessed easily. (2) Venoatrial connections are adequately imaged. In particular, all types of total and partial anomalous pulmonary venous return are delineated, regardless of whether restrictions of pulmonary blood flow or pulmonary venous obstructions are involved (n = 4). The courses of vertical veins were easily identified, and the prearterial position was revealed in only one of seven right isomerisms with total anomalous pulmonary venous return. The drain pattern of the hepatic vein can be visualized using three-dimensional spatial information and is useful for total cavopulmonary connection design. (3) Associated complicated cardiac anomalies, particularly the size or peripheral stenosis of the pulmonary arteries, may be evaluated, and this information is useful for palliative shunt operations.

CONCLUSION

Because of its wide field of view and imaging, which is not restricted by associated anomalies, a thorough understanding of the cardiovascular anatomy of the situs ambiguous can be achieved using MRI, which is of considerable value in the surgical correction of this complicated anomaly. MRI can obviate or facilitate catheterization in these critically ill patients.

Purification and partial characterization of a novel glucanhydrolase from Lipomyces starkeyi KSM 22 and its use for inhibition of insoluble glucan formation

A novel glucanhydrolase from a mutant of Lipomyces starkeyi ATCC 74054 was purified. The single protein (100 kDa) showed either dextranolytic or amylolytic activity. We referred to the glucanhydrolase as a DXAMase. The DXAMase was produced in a starch medium and it was 3.75-fold more active for hydrolysis of the purified insoluble-glucan of Streptococcus mutans than Penicillium funiculosum dextranase. Aggregation of S. mutans cells with dextran and adherence to glass were eliminated by incubating with the DXAMase. The addition of DXAMase (0.1 IU/ml) to the mutansucrase reaction digest with sucrose reduced the formation of insoluble-glucan about 80%. Also the DXAMase (0.5 IU/ml) removed 80% of the pre-formed sucrose-dependent adherent film. These in vitro properties of L. starkeyi KSM 22 DXAMase are desirable for its application as a dental plaque control agent.

Retroperitoneal multilocular bronchogenic cyst adjacent to adrenal gland

Bronchogenic cysts are generally found in the mediastinum, particularly posterior to the carina, but they rarely occur in such unusual sites as the skin, subcutaneous tissue, pericardium, and even the retroperitoneum. A 30-year-old Korean man underwent surgery to remove a cystic adrenal mass incidentally discovered during routine physical checkup. At surgery, it proved to be a multilocular cyst located in the retroperitoneum adjacent to the left adrenal gland. Microscopically, the cyst was lined by respiratory epithelium over connective tissue with submucous glands, cartilage and smooth muscle, thereby histologically confirming bronchogenic cyst. This is the first reported case of retroperitoneal bronchogenic cyst in an adult without other congenital anomalies in Korea.

Chronic inorganic mercury induced peripheral neuropathy

We report the clinical features, electrophysiological studies, and morphometric analysis of sural nerve pathology in a patient with polyneuropathy due to inorganic mercury intoxication. He developed slowly progressive generalized paralysis of all limbs after 3 months ingestion of herb drugs which contained mercuric sulfate. Electrophysiologic studies revealed axonal polyneuropathy involving both motor and sensory fibers. Sural nerve biopsy demonstrated axonal degeneration with demyelination and a predominant loss of large myelinated fibers. His muscle strength showed only mild improvement after 2 years' follow-up. We concluded that inorganic mercury exposure may induce severe axonal sensorimotor polyneuropathy in humans and that neurological deficits may persist in severe cases.

Lacunar infarctions presenting as memory loss and mental changes: four cases report

Impairment of higher cortical functions is usually not considered as a typical presentation of lacunar infarction. However, a small discrete lesion at strategically important locations may produce memory loss and mental changes. We report 4 patients with lacunar infarctions manifested as acute amnesia and mental changes. One patient had left thalamic infarction, one had left capsular genu infarction, one had right capsular genu infarction, and one had left capsular genu infarction extending to the ipsilateral thalamus. The mental and memory impairment was transient in one patient but was persistent in the other 3 patients. Our report reconfirms that a lacunar infarction can cause impairment of higher cortical functions.

Mixed meningococcal and tuberculous meningitis

Meningococcal meningitis is one of the most common bacterial infections of the meninges worldwide, and tuberculous infection is the most common cause of chronic meningitis in Taiwan. However, mixed meningococcal and tuberculous meningitis is rare. We describe a 27-year-old woman with a case of culture-proven meningococcal and tuberculous meningitis verified by polymerase chain reaction on a cerebrospinal fluid specimen. The patient was initially treated with intravenous antibiotics including penicillin G and chloramphenicol. Though the patient responded well to therapy initially, her subsequent clinical deterioration was finally controlled by long-term antituberculous medications.

Carotid floating plaques associated with multiple cerebral embolic strokes. Case reports

The authors describe 2 patients with multiple cerebral infarcts and hemorrhagic transformation caused by artery-to-artery emboli. Ulcerated plaques with free-floating thrombus adherent to the plaque were detected at the carotid bifurcation by duplex sonography. No other embolic source could be found. One patient developed an occipital infarction due to carotid emboli passing through a fetal-type posterior communicating artery. Both patients recovered well without recurrence of stroke or transient ischemic attack with antiplatelet treatment only. Follow-up carotid duplex sonography showed disappearance of floating thrombus in 1 patient and consolidation of the lesion in the other.

Coexistence of cerebral venous sinus and internal carotid artery thrombosis associated with exogenous sex hormones. A case report

A forty-six year-old premenopausal woman developed headache, nausea and vomiting, left hemiparesis and seizure two days after parenteral use of progesterone and estradiol. Diabetes mellitus (DM) was found during admission. Computed tomography showed a hemorrhagic infarct in the right frontal lobe and increased density in the superior sagittal sinus (SSS). Left carotid angiography found occlusion of the left internal carotid artery (ICA). Right carotid angiograms failed to show the SSS and inferior sagittal sinus, suggestive of venous sinus thrombosis. Coexistence of the cerebral artery and the venous sinus occlusion has been described infrequently. In this case, the authors postulate that the use of estradiol and progesterone and the underlying DM increased vascular thrombogenicity, which provided a common denominator for thrombosis of both the ICA and the venous sinus.

Clinical features and carotid duplex sonography in patients with carotid transient ischemic attacks

BACKGROUND

Transient ischemic attack (TIA) is recognized as a precursor of cerebral infarction. It is prompted by an embolism from extracranial carotid artery disease. However, extracranial carotid disease is less prevalent in Chinese patients. Non-invasive duplex sonography has been used for initial screening for extracranial carotid artery disease.

METHODS

One hundred and twenty-seven consecutive patients with carotid TIA were divided into two groups according to sonographic results, Group I: < or = 50%, and Group II: > 50% stenosis of the carotid artery. The two groups were compared for the clinical manifestations, risk factors, brain computed tomography (CT) findings and subsequent stroke. An age and sex-matched group of patients with lacunar stroke was also collected from the same neurosonological data bank for further comparative analysis.

RESULTS

The mean age at onset was 59 +/- 12 (mean SD) years. Hypertension was the most common risk factor. The most common symptom was transient focal motor deficit (73%) with or without other complaints. Eighty-two percent of the TIA episodes were less than one hour in duration. In Group I, there were 114 patients (90%) with stenosis < or = 50% ipsilateral to the symptomatic side. Group II included only 13 patients (10%) with the ipsilateral carotid artery stenosis > 50%. Mean age was older and cigarette smoking was more common in Group II (p < 0.05). Otherwise, no significant difference was noted between the two groups in initial characteristics of TIAs, risk factors, brain CT findings or subsequent stroke. Further, there was no statistical significant difference between the TIA and lacunar stroke groups in the degree of carotid stenosis.

CONCLUSIONS

Hypertension was the most common risk factor for carotid TIAs. The prevalence of extracranial carotid artery disease was low in Chinese patients with carotid TIAs. The severity of the carotid artery was not predictive of recurrence of TIA or of subsequent stroke. There was no significant difference between patients with TIA and with lacunar stroke in sonographic findings of extracranial carotid arteries.

Transcranial color-coded sonography in normal Chinese adults and its clinical applications

We have performed transcranial color-coded sonography to 150 normal adults. Through the temporal, orbital and foraminal windows, by using a 2 MHz pulsed-wave transducer, we were able to directly insonate the brain parenchyma, and to obtain color-coded Doppler vascular imagings and flow velocities of the intracranial basal cerebral arteries. There was no significant difference of blood flow velocities and resistance index between the right and left hemispheres. The mean velocities was highest in the middle cerebral artery and lowest in the ophthalmic artery while which had the highest resistance index. Female had higher mean velocity in basilar artery. The mean velocity, peak systolic velocity, as well as end diastolic velocity decreased significantly with age in middle cerebral artery, anterior cerebral artery and basilar artery. Four illustrative cases with abnormal findings were presented to compare with normal control. Some pitfalls in ultrasonography were also described.

Common carotid artery occlusion: evaluation with duplex sonography

PURPOSE

To demonstrate the efficacy of carotid duplex ultrasound to diagnose common carotid artery occlusion (CCAO) and to define the clinical features of CCAO.

METHODS

We reviewed 5400 carotid duplex ultrasonograms obtained over a 7-year period for suspected carotid artery disease. In cases of CCAO, medical records were reviewed.

RESULTS

Thirteen cases (0.24%) of CCAO were diagnosed by carotid duplex ultrasonography, including five cases of isolated CCAO. Seven cases were proved by cerebral angiography. Cerebral angiography failed to demonstrate patent internal carotid arteries in two cases of isolated CCAO. Mean age of onset was 67 +/- 9 years. The main clinical presentation was stroke in nine cases (69%). The most common vascular risk factors were hypertension (62%) and heart diseases (54%). Three patients had a history of radiation therapy to the neck. Two of five patients with isolated CCAO had major stroke, with good recovery in one, whereas five of eight patients with CCAO had major stroke; among them, only one had good recovery.

CONCLUSION

Patients with isolated CCAO may have a better outcome than patients with CCAO. Duplex sonography, particularly with color-coded flow imaging, provides an accurate examination to define the patency of the arteries distal to the carotid bifurcation. The clinical features of CCAO are similar to those of internal carotid artery occlusion except for the low prevalence of CCAO.

Ginseng-associated cerebral arteritis

We report a 28-year-old woman who had a severe headache after ingesting a large quantity of ethanol-extracted ginseng. Cerebral angiograms showed "beading" appearance in the anterior and posterior cerebral and superior cerebellar arteries, consistent with cerebral arteritis. The close temporal association between intake of ginseng and cerebral arteries suggests a causal relationship.

Cerebral arteritis associated with oral use of phenylpropanolamine: report of a case

Phenylpropanolamine (PPA) is the major ingredient of many over-the-counter cold remedies and diet pills. Use or abuse of PPA may cause hemorrhagic stroke or cerebral vasculitis similar to the clinical and angiographic picture associated with amphetamine use or abuse. We report a 32-year-old Taiwanese women who developed sudden onset of severe headache, nausea and vomiting on the seventh day of oral ingestion of 75 mg PPA per day. Cerebral angiograms showed multiple areas of alternating focal constriction and dilatation ("beading" appearance) in the anterior and posterior cerebral arteries consistent with cerebral arteritis. This case should alert medical practitioners to the potential hazards of over-the-counter drugs like PPA.

MRI diagnosis of spinal cord infarction: report of a case

A 62-year-old diabetic women developed acute quadriparesis. Her first symptom was clumsiness of the right limbs, which was followed shortly after by quadriparesis with severe left-sided symptoms. Sensory examination showed pinprick and thermal sensation deficits below the left T6 and right T8 dermatomes. An intramedullary infarction in the cervical cord at C5 to C6 levels was demonstrated by serial magnetic resonance imaging (MRI) studies with Gadolinium-DTPA (Gd-DTPA) enhancement. Based on the findings from this patient and 20 patients with spinal cord infarction reported in the literature, it was concluded that spinal cord infarct lesions are characterized by negative Gd-DTPA enhancement at the acute and chronic stages and positive enhancement at the subacute stage, 1 to 4 weeks after the onset of infarction.

Carotid duplex and transcranial color-coded sonography in evaluation of carotid-cavernous sinus fistulas

We performed carotid duplex and transcranial color-coded sonography in three patients with traumatic and one patient with spontaneous carotid-cavernous fistulas. High flow and low resistance were detected by carotid Doppler imaging in the extracranial internal carotid artery in three cases and in the external carotid artery in one case. The fistula could be demonstrated directly as heterogenous color flashes with turbulent flow by transcranial color-coded sonography through the orbital or temporal window. The transorbital approach showed that the ophthalmic venous flow was normal or to-and-fro bidirectional in patients without proptosis and was retrograde, away from the cavernous sinus with arteriolization in patients with proptosis. Combination of carotid duplex and transcranial color-coded sonography provides a noninvasive method for more accurate hemodynamic study of cerebral circulation and direct imaging of CCF.

Carotid ultrasonographic findings in intracranial internal carotid artery occlusion

Five cases of unilateral intracranial internal carotid artery (ICA) occlusion received both carotid angiographic and ultrasonographic studies. The Doppler examination showed that the resistive index (RI) of the common carotid artery (CCA) and ICA was higher but the peak systolic velocity was lower on the diseased side as compared with the normal side. Absence of the diastolic phase was found in the CCA flow in 2 cases and in the ICA flow in 3 cases on the diseased side. The mean CCA flow volume on the diseased side (271 +/- 82 mL/min) was half or less than that on the normal side (680 +/- 86 mL/min) (P < 0.01). The flow volume of the diseased ICA (49 +/- 20 mL/min) was markedly lower than that of the normal side (344 +/- 49 mL/min) (P < 0.01) and was also less than that of the ipsilateral external carotid artery (ECA) (129 +/- 43 mL/min). The Doppler ophthalmic artery flow all showed a forward direction. The authors propose that the following extracranial carotid ultrasonographic findings may be helpful in the prediction of intracranial carotid artery occlusion: (1) diminished frequencies, increased RI, and a more than 50% reduction of flow volume in the CCA as compared with the opposite side; (2) diminished frequencies to loss of the diastolic phase, a more than 50% reduction of the flow volume, and reversed ICA/ECA flow volume in the ICA as compared with the opposite side; and (3) a forward Doppler ophthalmic artery flow.

Forward Doppler ophthalmic artery flow in patients with extracranial carotid artery occlusion--a case report

The authors report 2 cases of common carotid artery (CCA) occlusion and 4 cases of extracranial internal carotid artery (ICA) occlusion with forward Doppler ophthalmic artery flow. The compression test during Doppler study showed that the ophthalmic artery flow was reduced to zero when compressed contralateral to the CCA in 1 case of CCA occlusion and when compressed ipsilateral to the CCA in all 4 cases of ICA occlusion. The angiograms showed that in the 2 cases of CCA occlusion, 1 had the ophthalmic artery originating from the anterior communicating artery, and the other had subclavian steal syndrome with a reversed vertebral flow. In 3 of the 4 cases of ICA occlusion, the ophthalmic artery was found to originate from the ipsilateral middle meningeal artery. Their findings suggest that in cases of extracranial carotid artery occlusion, the forward ophthalmic artery flow is supplied from the contralateral CCA in cases of CCA occlusion and from the branches of the ipsilateral external carotid artery in cases of ICA occlusion, and the vertebrobasilar system plays a less important role.

Sudden bilateral hearing impairment in vertebrobasilar occlusive disease

BACKGROUND

Bilateral hearing impairment is rare in vertebrobasilar occlusive disease.

SUMMARY OF COMMENT

Between 1986 and 1991, we encountered seven patients (four men, three women; median age, 61 years; range, 46-71 years) who had sudden bilateral hearing impairment among 503 patients with vertebrobasilar occlusive disease. The main initial neurological symptoms were sudden bilateral hearing impairment, tinnitus, and vertigo. Acute labyrinthitis or Ménière's disease was the initial diagnosis until subsequent brain stem or cerebellar signs appeared. Brain stem auditory evoked potentials were abnormal bilaterally in six patients but had unilateral attenuation of the IV-V complex in the remaining one patient. Computed tomographic scans in all six patients showed multiple hypodense lesions in the brain stem and the cerebellum. Cerebral angiography showed complete occlusion on both vertebral arteries in one patient, occlusion on the left with small caliber on the right in another, and severe stenosis on both sides in a third. There was no opacification of internal auditory arteries in these three patients. The remaining patient had arteriosclerotic changes with faint opacification of the bilateral internal auditory arteries. Five patients had a poor prognosis, with locked-in state in four and severe truncal ataxia in one.

CONCLUSIONS

We conclude that sudden bilateral hearing impairment in vertebrobasilar occlusive disease is more common than previously recognized and that it may indicate a grave prognosis.

Correlation between sonographic and angiographic findings of extracranial carotid artery disease

Comparison between sonographic and angiographic findings of the extracranial carotid arteries were made in 68 patients. We used a Diasonic Duplex Ultrasonograph (DRF 400) which combined a real-time B-mode imaging system and a pulsed-wave Doppler spectral analyser. Continuous-wave Doppler was also used to determine ophthalmic artery flow direction. The findings were classified into four categories: (1) normal or less than 10% stenosis, (2) 10-49% stenosis, (3) 50-99% stenosis, (4) and total occlusion. The agreement between the two tests was 0.53 which meant fair agreement beyond chance by Kappa statistics. When angiograms were used as gold standard, the sensitivity of duplex sonography was above 80% in all categories of stenosis, and the overall accuracy and specificity were above 90% in those stenosis greater than 50% and occlusion. We conclude that duplex sonography, a reproducible noninvasive test, is a safe and cost-efficient screening method which can provide a good correlation with angiograms in detecting extracranial carotid artery disease.

Comparison between carotid duplex sonography and angiography in the diagnosis of extracranial internal carotid artery occlusion

To determine the diagnostic accuracy of extracranial internal carotid artery (ICA) occlusion by carotid duplex sonography and ophthalmic flow direction, we compared both carotid sonograms and angiograms in 82 cases of ischemic cerebrovascular disease. A total of 157 carotid arteries were available for comparison. The overall diagnostic accuracy of ICA occlusion by duplex scanning was 96% (sensitivity, 83%; specificity, 98%; positive predictive value, 91%), by ophthalmic flow examination, 95% (sensitivity, 79%; specificity, 98%; positive predictive value 86%), and by combined study, 98% (sensitivity, 96%; specificity, 98%; positive predictive value 92%). We recommend that the ophthalmic flow examination should be used in combination with other sonographic methods in detecting extracranial carotid artery disease. The combined study gives higher diagnostic accuracy than the single method. When an occlusion or a tight stenosis is uncertain on carotid sonograms, color Doppler or angiography is indicated for further confirmation.

Primary medullary hemorrhage: report of a case

A 40-year-old normotensive man suddenly developed dizziness, vomiting, hoarseness and swallowing disturbance. Neurologic examinations showed bilaterally decreased palatal elevation and gag reflex, upbeat nystagmus and gait ataxia. The diagnosis of medullary hemorrhage was first established by computed tomography (CT). Magnetic resonance imaging study further showed a hematoma in the paramedial medulla oblongata extending dorsorostrally to the pontomedullary junction. It gave the precise anatomic boundary of the intramedullary hematoma and was well correlated with the clinical findings. This patient's subsequent prognosis was good with gradual improvement of the clinical signs and symptoms. A follow-up CT scan showed resolution of the hematoma, and the prognosis was consistent with a good neurologic recovery.

[Primary mesencephalic hemorrhage: report of four cases]

Spontaneous intracerebral hemorrhage rarely occurs in the mesencephalon (midbrain), though thalamic or pontine hemorrhage may extend into that location. The neurologic manifestations and outcome in patients with primary mesencephalic hemorrhage (PMH) are different from those with thalamic or pontine hemorrhage. We report 4 patients (2 men and 2 women) with nontraumatic and non-neoplastic hemorrhages confined to the mesencephalon. One young patient, a 37-year-old woman, had no detectable risk factors for stroke, and her cerebral angiogram was normal. The other 3 elderly patients (73-85 years of age) all had a history of hypertension. The neurologic manifestations of patients with PMH are characterized by disturbance of ocular movements and cerebellar signs. Two patients with tegmental hematoma showed Claude's syndrome, i.e., ipsilateral oculomotor palsy and contralateral cerebellar signs. One patient with a small central midbrain hematoma showed bilateral oculomotor palsy. Another patient with a relatively large central midbrain hematoma presented with bilateral ptosis, bilateral internuclear ophthalmoplegia, upward gaze palsy, and bilateral cerebellar signs. The prognosis after conservative treatment for our patients with PMH was good.

CT, somatosensory and brainstem auditory evoked potentials in the early prediction of functional outcome in putaminal hemorrhage

The CT and median somatosensory and brainstem auditory evoked potentials (SEP and BAEP) were studied in 80 patients with spontaneous putaminal hemorrhage for their values in the early prediction of functional outcome. The CT scan was performed within 2 days and EPs within a week after the onset of symptoms. The activities of daily living was assessed at 6 months. Patients with good functional recovery had the following findings: 1) the hemorrhage had not involved the thalamus or the posterior limb of the internal capsule; 2) the SEPs were normal or had prolonged central conduction time; and 3) the BAEP was normal. When the cortical SEPs were absent, the majority of patients were moderately or severely disabled. Attenuation or absence of BAEP wave V always forecast a grave prognosis. It is concluded that the combined use of CT, SEP and BAEP is an objective and reliable method for the early prediction of functional outcome in patients with putaminal hemorrhage.

The prognostic value of blood glucose in patients with acute stroke

We prospectively studied levels of blood glucose and glycohemoglobin, and their correlations with types, severity, and prognosis of stroke in 37 patients with brain infarction (BI) and 35 patients with brain hemorrhage (BH). We found that in the BH group, patients with an elevated glucose level due to stress, diabetes, or both, had a lower consciousness level on admission, larger hematoma size, higher incidence of rupture into the ventricles, and a worse 1-month outcome than patients with a normal glucose level (p less than 0.05). In patients with BI, however, no significant difference was found as related to levels of glucose, though a difference in 6-month mortality between stress hyperglycemic and normoglycemic patients (p less than 0.05) was found. We conclude that an elevated glucose level is associated with a worse clinical condition, larger hematoma size, higher incidence of rupture into the ventricles, and worse outcome in patients with BH. However, it seems to be the severity of the stroke, not the hyperglycemia, that causes the poor outcome. Hyperglycemia may be an epiphenomenon of stroke severity.

Secondary prevention of ischemic stroke with low dose acetylsalicylic acid

In order to evaluate the efficacy of low dose acetylsalicylic acid (ASA) for the secondary prevention of ischemic stroke, this cooperative multicenter clinical trial was conducted on a non-blind basis. Patients having a first transient ischemic attack (TIA), reversible ischemic neurological deficit (RIND) or completed ischemic stroke were eligible for this trial. A total of 590 patients including 47 cases of TIA, 23 cases of RIND and 520 cases of completed stroke entered this study. These patients were allocated by the time of admission to one of the following 5 trial regimens: (1) vasodilators having no known inhibitory effect on platelet function (control group), (2) dipyridamole (DP) 50 mg 3 times a day (DP group), (3) ASA 300 mg once a day (ASA 300 mg group), (4) ASA 300 mg once in combination with DP 50 mg 3 times a day (ASADP group), and (5) ASA 100 mg once a day (ASA1 group). No difference in effect between the control and DP groups was observed, nor between the ASA 300 mg and ASADP groups. Therefore, we combined the control and DP groups to make a non-ASA group, and joined the ASA 300 mg and ASADP groups to make an ASA3 group. The differences in the cumulative event-free rate appeared to be significant between the non-ASA group and the ASA3 group and also between the non-ASA group and the ASA1 group. But the frequency distribution of age, territory of stroke, diabetes mellitus, cardiac disease, hematological disease and hyperuricemia were significantly different among these 3 study groups. We thus included these covariates in the Cox's proportional hazard model to control their possible confounding effects.(ABSTRACT TRUNCATED AT 250 WORDS)

Intracranial hemorrhage in patients with polycystic kidney disease

To emphasize the important association of polycystic kidney disease and hypertensive cerebral hemorrhage, a registry of 900 consecutive cases of hemorrhagic stroke was reviewed. Eleven patients (1.2%) had intracranial hemorrhage (eight had hypertensive cerebral hemorrhage and the other three had aneurysmal subarachnoid hemorrhage) found to be associated with polycystic kidney disease. These 11 patients also accounted for 11% of the 98 cases of polycystic kidney disease during the 28-month study period. As verified by computed tomography, parenchymal hemorrhage occurred mainly in the putamen and the thalamus, the usual sites for hypertensive cerebral hemorrhage. One patient with cerebral hemorrhage was autopsied and one was studied angiographically, but in neither patient was an intracranial aneurysm identified. In the patients with polycystic kidney disease and intracranial hemorrhage, hypertension had been inadequately treated or even undetected; therefore, I emphasize early detection and more effective control of hypertension in patients with polycystic kidney disease for prophylaxis against hemorrhagic cerebrovascular events.

Guillain-Barré syndrome associated with acute delta hepatitis virus superinfection

We describe a patient with the clinical characteristics of Guillain-Barré syndrome, including progressive ascending paresis; cerebrospinal fluid albumino-cytological dissociation; polyphasic small evoked potential, with prolonged latency and slow motor nerve conduction velocity; and active denervation pattern on electromyography, in association with acute delta hepatitis virus superinfection. The patient recovered from Guillain-Barré syndrome but developed chronic active delta hepatitis.

Intracranial phycomycosis: case reports

Cerebral phycomycosis is a rare disease. We describe two patients with unusual features of focal intracranial phycomycosis: a diabetic patient with chronic epidural abscess and a healthy individual with an isolated intracerebral abscess. Biopsy established the diagnosis in both patients. Treatment was successful in the patient with intracerebral abscess.

Pituitary apoplexy with intracerebral hemorrhage simulating rupture of an anterior cerebral artery aneurysm

Pituitary apoplexy presenting with intracerebral hemorrhage into the left frontal lobe and lateral ventricle, simulating an anterior cerebral artery aneurysm rupture, is reported. No other cases of intracerebral hemorrhage caused by pituitary apoplexy have been found in a review of the English literature.

Moyamoya disease in Taiwan

Moyamoya disease occurring in Chinese has been inadequately described. Here we report 13 cases of this disease identified by review of 3,200 cerebral angiograms performed between August 1979 and March 1986. Nine were males and four were females; there were 12 adults (aged 34-51 years) and one child (aged 11 years). All had hemorrhagic strokes with one exception, a patient with an occipital infarction. Intraventricular hemorrhage was noted by computed tomography in 10; five of these emanated from the caudate nucleus. A localized hematoma without intraventricular hemorrhage was found in two. All 13 angiograms had smokelike basal anastomoses with various degrees of stenosis or occlusion of the anterior portion of the circle of Willis; the involvement was bilateral in 12 and unilateral in one. Aneurysms were found in two patients, one in the anterior communicating artery and the other in the left anterior choroidal artery. Eleven patients recovered from the initial stroke, but two died with recurrent hemorrhage. This series differs from the series reported in Japan by the predominance of adult males. The high incidence of intraventricular hemorrhage and intracerebral hematoma is not in keeping with the previous Chinese series, in which subarachnoid hemorrhage was suspected to be the major clinical manifestation.