Characteristics of Ischemic Versus Hemorrhagic Stroke in Patients Receiving Oral Anticoagulants: Results of the PASTA Study

Objective Limited data exist regarding the comparative detailed clinical characteristics of patients with ischemic stroke (IS)/transient ischemic attack (TIA) and intracerebral hemorrhage (ICH) receiving oral anticoagulants (OACs). Methods The prospective analysis of stroke patients taking oral anticoagulants (PASTA) registry, a multicenter registry of 1,043 stroke patients receiving OACs [vitamin K antagonists (VKAs) or non-vitamin K antagonist oral anticoagulant (NOACs)] across 25 medical institutions throughout Japan, was used. Univariate and multivariable analyses were used to analyze differences in clinical characteristics between IS/TIA and ICH patients with atrial fibrillation (AF) who were registered in the PASTA registry. Results There was no significant differences in cardiovascular risk factors, such as hypertension, diabetes mellitus, dyslipidemia, smoking, or alcohol consumption (all p>0.05), between IS/TIA and ICH among both NOAC and VKA users. Cerebral microbleeds (CMBs) [odds ratio (OR), 4.77; p<0.0001] were independently associated with ICH, and high brain natriuretic peptide/N-terminal pro B-type natriuretic peptide levels (OR, 1.89; p=0.0390) were independently associated with IS/TIA among NOAC users. A history of ICH (OR, 13.59; p=0.0279) and the high prothrombin time-international normalized ratio (PT-INR) (OR, 1.17; p<0.0001) were independently associated with ICH, and a history of IS/TIA (OR, 3.37; 95% CI, 1.34-8.49; p=0.0101) and high D-dimer levels (OR, 2.47; 95% CI, 1.05-5.82; p=0.0377) were independently associated with IS/TIA among VKA users. Conclusion The presence of CMBs, a history of stroke, natriuretic peptide and D-dimer levels, and PT-INR may be useful for risk stratification of either IS/TIA or ICH development in patients with AF receiving OACs.

Generative image transformer (GIT): unsupervised continuous image generative and transformable model for [123I]FP-CIT SPECT images

OBJECTIVE

Recently, generative adversarial networks began to be actively studied in the field of medical imaging. These models are used for augmenting the variation of images to improve the accuracy of computer-aided diagnosis. In this paper, we propose an alternative new image generative model based on transformer decoder blocks and verify the performance of our model in generating SPECT images that have characteristics of Parkinson's disease patients.

METHODS

Firstly, we proposed a new model architecture that is based on a transformer decoder block and is extended to generate slice images. From few superior slices of 3D volume, our model generates the rest of the inferior slices sequentially. Our model was trained by using [¹²³I]FP-CIT SPECT images of Parkinson's disease patients that originated from the Parkinson's Progression Marker Initiative database. Pixel values of SPECT images were normalized by the specific/nonspecific binding ratio (SNBR). After training the model, we generated [¹²³I]FP-CIT SPECT images. The transformation of images of the healthy control case SPECT images into PD-like images was also performed. Generated images were visually inspected and evaluated using the mean absolute value and asymmetric index.

RESULTS

Our model was successfully generated and transformed into PD-like SPECT images. The mean absolute SNBR was mostly less than 0.15 in absolute value. The variation of the obtained dataset images was confirmed by the analysis of the asymmetric index.

CONCLUSIONS

These results showed the potential ability of our new generative approach for SPECT images that the generative model based on the transformer realized both generation and transformation by a single model.

Abstract P659: Pre-Stroke Chads 2 Scores Should Be Associated With Onset Severity and Functional Outcome in Acute Stroke Patients With Atrial Fibrillation During Oral Anticoagulants: A Sub-Analysis of PASTA Registry Study

Background and Purpose: The impact of CHADS 2 score on neurological severity in patients with stroke during oral anticoagulant (OAC) has not yet been elucidated. We investigated the association between pre-stroke CHADS 2 score and severity on admission and functional outcome in acute cardioembolic stroke due to AF during OAC.

Methods: We conducted an investigator-initiated, multicenter, prospective, observational cohort study, PASTA registry. One thousand forty-three patients with transient ischemic attack, ischemic stroke, and ICH who were taking OACs were prospectively enrolled in 25 medical institutions throughout Japan. We compared the clinical characteristics including severity onset and discharge outcome between low CHADS 2 score group (<2), and high CHADS 2 score group (≥2) in patients with cardioembolic stroke due to AF.

Result: A total of 548 patients (237 women; median age 80 [quartiles 74-85] years) were enrolled. Of these, there were 76 patients (14%) in low CHADS 2 group and 472 (86%) in high CHADS 2 score group (Fig A). Along with increase of pre-stroke CHADS 2 score, NIHSS score was gradually increased (Fig B). Low CHADS 2 score group was associate with good outcome than high CHADS 2 group (p<0.001, Fig C). Age (p<0.001), male (p<0.001), pre-stroke CHADS 2 score (p<0.001), and initial NIHSS score (p<0.001) were significantly higher in non-excellent outcome (mRS≥2) group than excellent outcome group (mRS<2). In contrast, creatinine clearance and body weight were higher in excellent outcome group (Both p<0.001). Multivariate logistic regression analysis indicated that high pre-stroke CHADS 2 score independently associated with higher NIHSS score (NIHSS score≥6; OR 1.55, 95%CI 1.02-2.36, p=0.041) and non-excellent outcome (OR 1.94, 95%CI 1.01-3.80, p=0.047).

Conclusion: The present study suggests that the pre-stroke CHADS 2 score should be useful for the prediction of clinical outcomes in patients with cardioembolic stroke due to AF even taking OAC.

Quantitative Evaluation of 18F-Flutemetamol PET in Patients With Cognitive Impairment and Suspected Alzheimer's Disease: A Multicenter Study

Background: In clinical practice, equivocal findings are inevitable in visual interpretation of whether amyloid positron emission tomography (PET) is positive or negative. It is therefore necessary to establish a more objective quantitative evaluation method for determining the indication for disease-modifying drugs currently under development.

Aims: We aimed to determine cutoffs for positivity in quantitative analysis of ¹⁸F-flutemetamol PET in patients with cognitive impairment and suspected Alzheimer's disease (AD). We also evaluated the clinical efficacy of amyloid PET in the diagnosis of AD. This study was registered in the Japan Registry of Clinical Trials (jRCTs, 031180321).

Methods: Ninety-three patients suspected of having AD underwent ¹⁸F-flutemetamol PET in seven institutions. A PET image for each patient was visually assessed and dichotomously rated as either amyloid-positive or amyloid-negative by two board-certified nuclear medicine physicians. If the two readers obtained different interpretations, the visual rating was rerun until they reached consensus. The PET images were quantitatively analyzed using the standardized uptake value ratio (SUVR) and standardized Centiloid (CL) scale with the whole cerebellum as a reference area.

Results: Visual interpretation obtained 61 positive and 32 negative PET scans. Receiver operating characteristic analysis determined the best agreement of quantitative assessments and visual interpretation of PET scans to have an area under curve of 0.982 at an SUVR of 1.13 and a CL of 16. Using these cutoff values, there was high agreement between the two approaches (kappa = 0.88). Five discordant cases had SUVR and CL values ranging from 1.00 to 1.22 and from 1 to 26, respectively. In these discordant cases, either diffuse or mildly focal elevation of cortical activity confused visual interpretation. The amyloid PET outcome significantly altered the diagnosis of AD (χ² = 51.3, p < 0.0001). PET imaging elevated the proportions of the very high likelihood category from 20.4 to 46.2% and the very low likelihood category from 0 to 22.6%.

Conclusion: Quantitative analysis of amyloid PET using ¹⁸F-flutemetamol can objectively evaluate amyloid positivity using the determined cutoffs for SUVR and CL. Moreover, amyloid PET may have added value over the standard diagnostic workup in dementia patients with cognitive impairment and suspected AD.

Early Cognitive Impairment after Minor Stroke: Associated Factors and Functional Outcome

OBJECTIVES

Evaluation of cognitive status is not performed routinely in the acute stroke setting. This study aimed to evaluate the frequency of early cognitive impairment in patients with minor ischemic stroke, analyze the factors associated with early cognitive impairment, and assess functional outcomes.

METHODS

In this prospective study, 112 consecutive patients with acute minor ischemic stroke were enrolled. Neuroimages were assessed for semiquantitative evaluation of brain atrophy and small vessel disease (SVD) markers. Cognitive performance was measured within 5 days of onset using Montreal Cognitive Assessment (MoCA) scores. Functional outcome analyses were adjusted for demographic variables, premorbid cognitive status, education level, vascular risk factors, neuroimaging characteristics, stroke severity, and MoCA scores.

RESULTS

The median MoCA score was 22, and 63% of patients had cognitive impairment. Factors independently associated with cognitive impairment were education (odds ratios [OR], .79; confidence intervals [CI], .63-.99), smoking (OR, .26; 95%CI, .073-.89), and temporal horn atrophy (OR, 4.73; 95% CI, 1.66-13.49). Factors independently associated with poor functional outcome were total MoCA score (OR, .78; 95%CI, .62-.95) and the sum of 4 MoCA subscores (visuospatial/executive, attention, language, and orientation; OR, .72; 95%CI, .53-.92). The cutoff value of the sum of 4 MoCA subscores for predicting poor outcome was 13 points with 76.5% sensitivity and 81.1% specificity.

CONCLUSIONS

Early cognitive impairment was common after minor ischemic stroke and was associated with preexisting temporal horn atrophy but not SVD markers. The sum of 4 MoCA subscores was useful in predicting the functional outcome.

Genetically fused charged peptides induce rapid crystallization of proteins

We utilized electrostatic interaction to induce rapid crystallization of streptavidin. Simply mixing streptavidins possessing either a positively or negatively charged peptide at their C-terminus generated diffraction-quality crystals in a few hours. We modified the streptavidin crystals with fluorescent molecules using biotin, demonstrating the concept of protein crystals as functional biomaterials.

Early Cognitive Assessment Following Acute Stroke: Feasibility and Comparison between Mini-Mental State Examination and Montreal Cognitive Assessment

OBJECTIVES

Cognitive assessment is not performed routinely in the acute stroke setting. We investigated factors associated with cognitive impairment and the differences between the Mini-Mental State Examination (MMSE) and Montreal Cognitive Assessment (MoCA) scores in patients with acute stroke.

METHODS

In this prospective study, 881 consecutive patients (median age, 73 years) with acute stroke were enrolled. Clinical characteristics, such as education, vascular risk factors, premorbid cognitive status using the Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE), and stroke severity, were assessed. Cognitive performance was measured using MMSE and MoCA within 5 days of stroke onset.

RESULTS

Both MMSE and MoCA were feasible in 621 (70.5%) patients. Factors independently associated with nonfeasibility were age (odds ratio [OR]: 1.05; 95% confidence interval [CI]: 1.02-1.08), IQCODE score (OR: 1.02; 95%CI: 1.00-1.04), and National Institutes of Health Stroke Scale (NIHSS) score (OR, 1.16; 95%CI, 1.12-1.20). Impaired MoCA (with a cut-off <26/30) performance was observed in 544 of 621 (87.6%) patients. Factors independently associated with cognitive impairment were age (OR: 1.06; 95%CI: 1.03-1.10) and NIHSS score (OR: 1.34; 95%CI: 1.14-1.57). Eighty percent of patients with normal MMSE scores had an impaired MoCA score (MMSE-MoCA mismatch). The differences were highest in the visuospatial (94.8% versus 65.3%; P < .0001), recall (76.6% versus 35.6%; P < .0001), abstraction (82.5% versus 49.8%; P < .0001), and language (72.3% versus 65.9%; P < .0001) domains between the normal MMSE and MoCA group and MMSE-MoCA mismatch group.

CONCLUSIONS

The MoCA can be particularly useful in patients with cognitive deficits undetectable on the MMSE in the acute stroke phase.

Negative-FLAIR vascular hyperintensities serve as a marker of no recanalization during hospitalization in acute stroke

BACKGROUND

Since acute fluid-attenuated inversion recovery vascular hyperintensity (FVH) is indicative of disordered blood flow, FVH is considered a marker of acute major arterial occlusion. Conversely, the role of the absence of FVH (negative-FVH) remains unknown.

METHODS

Consecutive stroke patients were studied via magnetic resonance angiography, within 24 h of onset and major arterial occlusion. All patients were examined using serial angiography to evaluate the presence of recanalization. Patients were classified into negative-FVH and positive-FVH groups.

RESULTS

A total of 72 patients (49 [68%] male patients, aged 76 [66-83] years) were enrolled. Ten patients were allocated to the negative-FVH group and 62 to the positive-FVH group. Initial National Institutes of Health Stroke Scale (NIHSS) score was 4 (2-8) in the negative-FVH group and 10 (4-21) in the positive-FVH group (p = 0.012). Recanalization was achieved in 1 (10%) of the 10 patients in the negative-FVH group and in 49 (79%) of the 62 patients in the positive-FVH group during hospitalization (p < 0.001). Patients with recanalization were older (p = 0.023), had higher NIHSS score (p = 0.008), were admitted earlier (p = 0.014), exhibited a higher prevalence of atrial fibrillation (p = 0.010) and anterior circulation occlusion (p = 0.021), and were more frequently treated with hyperacute recanalization therapy (p = 0.004). Multivariate regression analysis demonstrated that negative-FVH (odds ratio 0.087, 95% confidential interval [0.008-0.988], p = 0.049) was a negative independent factor associated with recanalization during hospitalization.

CONCLUSIONS

In conclusion, negative-FVH in acute stroke was associated with lack of recanalization during hospitalization.

Accurate etiology diagnosis in patients with stroke and atrial fibrillation: A role for brain natriuretic peptide

BACKGROUND

Atrial fibrillation (AF) is the leading cause of cardioembolic stroke (CES), and patients with stroke and AF are frequently assumed to have CES. However, strokes presumably due to atherosclerotic pathophysiologies in large or small vessels can also occur in patients with AF. The aims of the present study were to clarify the prevalence of and factors related to a non-cardioembolic etiology in acute stroke patients with AF.

METHODS

From March 2011 through May 2017, consecutive acute ischemic stroke patients with AF were retrospectively recruited. The concomitant presence of non-cardioembolic features (small vessel occlusion [SVO] or large artery atherosclerosis [LAA]) on imaging was evaluated. The frequency of and factors associated with co-existing SVO/LAA features were assessed.

RESULTS

A total of 560 consecutive patients with AF and acute stroke (237 women; median age 78 [IQR 71-85] years; NIHSS score 9 [3-20]) were enrolled. Of these, 42 (7.5%) had co-existing SVO/LAA features. Multivariable logistic regression analysis showed that the brain natriuretic peptide level (BNP, OR 0.78, p = .030 per 100 pg/mL increase) was independently and negatively associated with co-existing SVO/LAA features and receiver operating characteristic curve analysis revealed the practical cut-off BNP value was 130 pg/mL (sensitivity 54% and specificity 68%).

CONCLUSION

SVO/LAA features were found in 7.5% of acute stroke patients with AF. A relatively low BNP level on admission was independently associated with co-existing SVO/LAA features. Thorough examination for a more appropriate etiology may be particularly necessary in acute stroke patients with AF and a relatively low BNP level.

Prior Direct Oral Anticoagulant Therapy is Related to Small Infarct Volume and No Major Artery Occlusion in Patients With Stroke and Non-Valvular Atrial Fibrillation

Background The aims of the present study were to investigate the relationships between prior direct oral anticoagulant ( DOAC ) therapy and infarct volume and the site of arterial occlusion in patients with acute ischemic stroke and non-valvular atrial fibrillation. Methods and Results From March 2011 through November 2016, consecutive patients with acute ischemic stroke in the middle cerebral artery territory and non-valvular atrial fibrillation were recruited. The infarct volume was assessed semi-automatically using initial diffusion-weighted imaging, and the arterial occlusion site was evaluated on magnetic resonance angiography. The effect of prior DOAC treatment on the site of arterial occlusion was assessed by multivariate ordinal logistic regression analysis. A total of 330 patients (149 women; median age 79 [quartiles 71-86] years; median National Institutes of Health Stroke Scale score 11 [4-21]) were enrolled. Of these, 239 were on no anticoagulant, 40 were undertreated with a vitamin K antagonist ( VKA ), 22 were sufficiently treated with VKA ( PT - INR ≥1.6), and 29 were on a DOAC before the acute ischemic stroke. The infarct volume on admission differed among the groups (median 14.5 [2.0-59.8] cm3 in patients with no anticoagulation, 24.8 [2.1-63.0] in undertreated VKA , 1.3 [0.3-13.5] in sufficient VKA , and 2.3 [0.5-21.0] in DOAC , P=0.001). Multivariate analysis showed that prior DOAC treatment was independently and negatively associated with more proximal artery occlusion (odds ratio [OR] 0.34, P=0.015), compared with no anticoagulant. Conclusions DOAC treatment before the event was associated with smaller infarct volume and decreased risk of greater proximal artery occlusion in acute ischemic stroke patients with non-valvular atrial fibrillation, compared with no anticoagulation.

In Hyperacute Recanalization Therapy, Early Hospital Arrival Improves Outcome in Patients with Large Artery Occlusion

BACKGROUND

It is unknown whether the effect of onset---to-door (OTD) time on clinical outcomes differs between -patients with and without large artery occlusion (LAO) who undergo hyperacute recanalization therapy.

METHODS

Hyperacute recanalization therapy includes intravenous thrombolysis tissue-plasminogen activator (tPA), and endovascular therapy (EVT). Favorable clinical outcome was defined as modified Rankin Scale of ≤2 at discharge.

RESULTS

Among 164 patients, 117 (71%) patients received tPA, 86 (52%) received EVT, and 39 (24%) received tPA and EVT. One hundred and fifteen patients (70%) were classified into the LAO group and 49 (30%) into the non-LAO group. In the total cohort, multivariate regression analysis showed OTD time (OR 0.809 [95% CI 0.693-0.944], p = 0.007) was an independent factor related to the favorable outcome. Similarly, among patients with LAO, OTD was an independent negative factor for the favorable outcome (0.779 [0.646-0.940], p = 0.009). On the contrary, OTD was not associated with the favorable outcome (1.5 [0.7-2.5] vs. 1.7 [1.1-3.2], p = 0.155) in patients without LAO. This was confirmed with multivariate regression analysis, which did not show OTD to be an independent factor for the favorable outcome (0.900 [0.656-1.236], p = 0.516).

CONCLUSION

The effect of early hospital arrival on clinical outcome differed between patients with and without LAO.

MRI scout images can detect the acute intracerebral hemorrhage on CT

INTRODUCTION

Magnetic resonance imaging (MRI) has recently emerged as a first-line tool for investigating acute stroke. However, MRI requires long scan times, which could be detrimental for severe stroke patients with a large intracerebral hemorrhage (ICH). MRI scout images, which are taken prior to a study to determine the range of subsequent images, can be used to rapidly screen the whole brain. We examined whether MRI scout imaging can detect ICHs observed by computed tomography (CT).

METHODS

Between September 2014 and March 2016, consecutive acute ICH patients who underwent both MRI scout and CT imaging in the acute setting were studied. ICHs on MRI scout images were defined as space-occupying lesions. Two neurologists independently assessed the scout images. We investigated whether ICHs on CT scans can be detected on MRI scout images and the characteristics of ICHs not detected by MRI scout images.

RESULTS

One hundred and forty-eight ICH patients (median age, 68 [interquartile range, 59-77] years; 99 [67%] males; median National Institutes of Health Stroke Scale score, 11 [4-17]) were enrolled. Among these, 138 (93%) patients were diagnosed as having ICH by MRI scout imaging (positive group), and 10 (7%) patients were not (negative group). The bleeding volume was 9.3 [4.5-22.4] ml in the positive group and 1.0 [0.4-2.0] ml in the negative group (p < .001). The cut-off value of bleeding volume calculated from the receiver operating characteristic curve was 2.0 ml. Regarding ICH lesions, 4 (44%) of the 9 pontine hemorrhages were detected on MRI scout images, whereas 134 (96%) of the 139 other hemorrhages were diagnosed (p < .001).

CONCLUSIONS

We diagnosed >90% of ICHs using MRI scout images. Low levels of ICH and pontine hemorrhaging might be difficult to detect using MRI scout imaging.

Abstract WP195: Current Status of Reperfusion Therapy and Functional Outcome in Acute Ischemic Stroke Patients With Non-Valvular Atrial Fibrillation: a Single-Center, Six-Year Experience of Consecutive 546 Patients

Background: The concept and tools of oral anticoagulation (OAC) therapy for preventing stroke in patients with non-valvular atrial fibrillation (NVAF) and their use as part of an acute treatment regimen in patients experiencing large-vessel occlusive stroke have grossly changed in the last 10 years. The aim of this study was therefore to evaluate the changes in reperfusion therapy and the clinical outcomes in acute ischemic stroke (AIS) patients with NVAF during a six-year time period.

Methods: From March 2011 to March 2017, consecutive patients with AIS with NVAF who were admitted to our department were retrospectively analyzed. Patients were divided into three groups according to the year of their initial visit: 2011-2012 (n=136), 2013-2014 (n=206), and 2015-2016 (n=204). Reperfusion therapy including intravenous thrombolysis and endovascular therapy, and functional outcome, were compared between the three time periods.

Results: The rate of reperfusion therapy increased steadily from 19.9% in 2011-2012 to 42.7% in 2015-2016 ( P < 0.0001). Parenchymal hematoma (PH) occurrence increased slightly from 5.9% in 2011-2012 to 9.8% in 2015-2016, but there was no significant difference ( P = 0.4301). Although there was no difference with respect to National Institutes of Health Stroke Scale (NIHSS) score at admission between the 2011-2012 and 2015-2016 groups (8 vs. 7, P = 0.3926), and CHA 2 DS 2 -VASc score was significantly higher in 2015-2016 compared with in 2011-2012 (4 vs 3, P = 0.0062), and discharge NIHSS score in 2015-2016 was significantly lower compared with that in 2011-2012 (2 vs. 4; P = 0.0093). The percentage of modified Rankin Scale 0-1 upon discharge was significantly higher in patients treated with reperfusion therapy than in those who were treated without it, among moderate-severe stroke patients (initial NIHSS ≥ 8) (15.4 vs. 2.8%, P = 0.0002). Moreover, hospital mortality rate significantly decreased from 11.0% in 2011-2012 to 3.4% in 2015-2016 ( P = 0.0167).

Conclusions: According to the six-year trend, the use of reperfusion therapy increased steadily and this increase appears to be factor in improvement of functional outcome and mortality in patients with AIS with NVAF.

Age-Related Decrease in Male Extra-Striatal Adenosine A1 Receptors Measured 11C-MPDX PET

Adenosine A₁ receptors (A₁Rs) are widely distributed throughout the entire human brain, while adenosine A_2A receptors (A_2ARs) are present in dopamine-rich areas of the brain, such as the basal ganglia. A past study using autoradiography reported a reduced binding ability of A₁R in the striatum of old rats. We developed positron emission tomography (PET) ligands for mapping the adenosine receptors and we successfully visualized the A₁Rs using 8-dicyclopropylmethyl-1-¹¹C-methyl-3-propylxanthine (¹¹C-MPDX). We previously reported that the density of A₁Rs decreased with age in the human striatum, although we could not observe an age-related change in A_2ARs. The aim of this study was to investigate the age-related change of the density of A₁Rs in the thalamus and cerebral cortices of healthy participants using ¹¹C-MPDX PET. We recruited eight young (22.0 ± 1.7 years) and nine elderly healthy male volunteers (65.7 ± 8.0 years). A dynamic series of decay-corrected PET scans was performed for 60 min starting with the injection of ¹¹C-MPDX. We placed the circular regions of interest of 10 mm in diameter in ¹¹C-MPDX PET images. The values for the binding potential (BP_ND) of ¹¹C-MPDX in the thalamus, and frontal, temporal, occipital, and parietal cortices were calculated using a graphical analysis, wherein the reference region was the cerebellum. BP_ND of ¹¹C-MPDX was significantly lower in elderly participants than young participants in the thalamus, and frontal, temporal, occipital, and parietal cortices. In the human brain, we could observe the age-related decrease in the distribution of A₁Rs.

Acute Poststroke Depression Is Associated with Thalamic Lesions and Clinical Outcomes: A Case-Control Study

BACKGROUND

We investigated the role of acute-phase stroke lesions and patient characteristics in poststroke depression (PSD) and its effect on the clinical outcome.

PATIENTS AND METHODS

Five and 30 days after admission, 175 patients self-reported their depressive symptoms on the Patient Health Questionnaire-9. We compared the clinical characteristics and outcomes in patients with (n = 41) and without PSD (n = 134). Stroke severity was assessed with the National Institutes of Health Stroke Scale (NIHSS); the modified Rankin Scale (mRS) was used to determine the functional outcome.

RESULTS

There was no significant difference between patients with and without PSD in the age, gender ratio, lesion side, and the history of hypertension, diabetes mellitus, alcohol and tobacco use, and previous stroke. Thalamic lesions were significantly associated with PSD (P = .03), although there was no significant difference in both the NIHSS score and the final mRS score of patients with thalamic lesions. Backward stepwise logistic regression analysis showed that a higher NIHSS score and thalamic lesions were independent predictors of PSD. Total hospitalization was significantly longer in patients with PSD. At the time of admission, the NIHSS score was significantly higher in patients who developed moderate to severe PSD than in those with mild PSD or without PSD.

CONCLUSIONS

PSD in the acute phase was associated with thalamic lesions and severe stroke. Hospitalization was significantly longer in patients with PSD and their functional disability was more severe, suggesting that PSD played a role in the unsatisfactory results of poststroke rehabilitation.

Low Free Triiodothyronine at Admission Predicts Poststroke Infection

BACKGROUND

Poststroke infection (PSI) is common and is usually associated with a severe prognosis. We investigated the association between PSI and thyroid hormones, which are critical to immune regulation, in patients with acute stroke.

METHODS

We retrospectively enrolled 520 consecutive patients with acute ischemic stroke (326 men; age, 71.9 ± 13.2 years) admitted to our department between September 2014 and June 2016. The impact of serum thyroid hormone levels measured at admission (thyroid-stimulating hormone [TSH], free triiodothyronine [FT3], and free thyroxine [FT4]) on the PSI was evaluated using multivariate logistic regression analysis.

RESULTS

We diagnosed 107 patients (20.6%; pneumonia, 65; urinary tract infection, 19; others, 23) with PSIs. While age (P <.001), body mass index (P = .0012), preadmission modified Rankin scale score (P = .0001), National Institutes of Health Stroke Scale score on admission (P <.001), admission FT3 level (P <.001), atrial fibrillation (P <.001), and ischemic heart disease (P = .0451) were significantly associated with PSI, we found no relationship among TSH levels, FT4 levels, and PSI occurrence. After multivariate adjustment, patients with PSIs were more frequently in the Q1 quartile (≤2.25 pg/mL) than in the Q2 (2.26-2.55 pg/mL; P = .0251), Q3 (2.56-2.89 pg/mL; P = .0007), or Q4 (≥2.90 pg/mL; P = .0010) quartiles of FT3 levels. Moreover, low FT3 levels (<2.29 pg/mL) were independently associated with PSI occurrence (P = .0013).

CONCLUSIONS

Low FT3 levels at admission are independently associated with PSI occurrence.

The Prevalence of and Factors Related to Vascular Hyperintensity on T1-Weighted Imaging in Acute Ischemic Stroke

BACKGROUND

Thrombus visualization in patients with acute ischemic stroke has been detected and reported using various imaging modalities. T1-weighted imaging (T1-WI) can depict thrombi as hyperintense signals within vessels. Moreover, in addition to thrombi, T1-WI hyperintensities in arteries may suggest arterial dissection. However, the frequency of and factors related to the T1-hyperintense vessel sign (T1-HVS) are not fully known. The aim of this study was to clarify the prevalence of and related factors for the T1-HVS in patients with acute ischemic stroke.

METHODS

From September 2014 through December 2015, consecutive acute ischemic stroke patients who were admitted to our stroke unit within 7 days from symptom onset were retrospectively recruited from the prospective registry. A T1-HVS was defined as the presence of a hyperintense signal, with intensity higher than surrounding brain, within the vessel lumen. Moreover, T1-HVSs were separated into filled T1-HVSs (hyperintensity fills whole vessel lumen) and non-filled T1-HVSs. The frequency of the T1-HVS and the timing of emersion and the relationship between the presence of the T1-HVS and arterial occlusion were assessed.

RESULTS

A total of 399 patients (139 women; median age 73 years; National Institutes of Health Stroke Scale score 3) were enrolled in the present study. Of these, 327 (82%) patients had T1-WI on admission. Two hundred and sixty-seven (67%) subjects had at least one follow-up T1-WI (median 6 days after admission), and 134 (34%) cases had ≥2 follow-up T1-WI examinations. The T1-HVS was observed in 18 patients during admission; therefore, the frequency of the T1-HVS in acute ischemic stroke patients was 4.5% (95% CI 2.5-6.5%). All but one (94%) of the T1-HVSs were first observed on follow-up imaging, and the median number of days from onset to T1-HVS appearance was 9. For patients having initial major artery occlusion and follow-up MRI (n = 95), sensitivity and specificity of the T1-HVS for persistent arterial occlusion on follow-up MR angiography were 22 and 100%, respectively. T1-HVS persisted for a few months and then normalized. Although there were no significant differences between filled and non-filled T1-HVS, more patients with non-filled T1-HVS had arterial dissection (43%) than those with filled T1-HVS (9%, p = 0.245).

CONCLUSION

The T1-HVS was observed in 4.5% of acute ischemic stroke patients. T1-HVSs appeared in the subacute phase in arteries with persistent occlusion and remained for a few months.

Abstract TP237: In Hyperacute Recanalization Therapy, Early Hospital Arrival Should Improve Outcome in Patients With Large Artery Occlusion but Not Without It

Introduction: Early hospital arrival form symptom onset has been related to the good outcome. However, it has been unknown whether in hyperacute recanalization therapy, early hospital arrival improves outcome in patients with and without large artery occlusion (LAO). We evaluated the association of onset-to-door (OTD) time with clinical outcome after hyperacute recanalization therapy in patients with and without LAO.

Methods: Consecutive stroke patients treated using hyperacute recanalization therapy including intravenous thrombolysis using tissue-plasminogen activator (tPA) and endovascular therapy (EVT) were studied. Good outcome was defined as mRS ≤2 at hospital discharge. All patients were divided into patient with and without LAO.

Results: From 2014 September to 2016 July, 129 (median age, 73 [64-82] years; 86 [67%] males) patients were analyzed. tPA alone was administered in 65 (50%) patients, EVT alone in 33 (26%), and tPA and EVT in 31 (24%). At discharge, 67 (52%) patients achieved the good outcome. Ninety-one patients (71%) were classified into the LAO group and 38 (29%) were into the non-LAO group. The OTD was similar between the LAO and the non-LAO groups (1.57 [0.87-3.42] h vs. 1.38 [0.76-2.68], p=0.420). Forty-six (51%) patients in the LAO and 21 (55%) patients in the non-LAO groups had good outcome (p=0.701). Regarding patients with LAO, age, OTD, and NIHSS score were significantly associated with good outcome (p=0.021, 0.014, and 0.001). Multivariate regression analysis also showed the OTD was the independent negative factor for good outcome (OR 0.77, 95%CI: 0.65-0.91, p=0.003). On the other hand, when we analyzed patients without LAO, OTD and NIHSS score were also significantly associated with good outcome (p=0.009, and 0.004). However, multivariate regression analysis did not show the OTD was the independent factor for good outcome (OR 0.83, 95%CI: 0.58-1.18, p=0.299). Only NIHSS score was independently related to it (OR 0.80, 95%CI: 0.67-0.96, p=0.018).

Conclusion: Impact of early hospital arrival on clinical outcome after hyperacute recanalization therapy differed between patients with and without LAO. In hyperacute recanalization therapy, early hospital arrival should improve outcome in patients with LAO but not without it.

Abstract TP200: Urinary Albumin/creatinine Ratio Should Be Associated With White Matter Lesion Severity in First-ever Stroke Patients

Background and purpose: White matter lesion (WML) is an indicator of small vessel disease, however, the underlying pathological mechanisms has not been fully understood. In recent years, experimental and epidemiological studies have suggested that chronic kidney disease (CKD) is associated with endothelial dysfunction; thereby, a CKD state may initiate small vessel damage. Our aim was to investigate the association of estimated glomerular filtration rate (eGFR), urinary albumin/creatinine ratio (UACR), and WML in first-ever stroke patients.

Methods: We retrospectively enrolled 284 consecutive patients (177 male; median age 72 years) admitted to our stroke center between May 2010 and January 2012. eGFR and UACR measurements were performed on admission. WML were assessed using the Fazekas classification. Severe WML was defined as Fazekas gradings of 2 or higher. The impact of the eGFR and UACR on WML was evaluated using multiple logistic regression analysis. Separate analyses were conducted according to severe WML and trichotomized eGFR level [60 mL/min ≤ eGFR (reference), 45 mL/min ≤ eGFR < 60 mL/min, and eGFR < 45 mL/min)] and UACR level [UACR < 30.0 mg/g creatinine (reference), 30.0 mg/g creatinine ≤ UACR < 300 mg/g creatinine, and 300 mg/g creatinine ≤ UACR].

Results: According to the Fazekas gradings, 91 patients (32.0%) had scale 0; 90 patients (31.7%), scale 1; 59 patients (20.8%), stage 2; and 44 patients (15.5%), scale 3. Age ( P < 0.0001), sex ( P = 0.0094), eGFR ( P = 0.0173), UACR ( P = 0.0001), hypertension ( P = 0.0436), and brain natriuretic peptide ( P = 0.0354) were significantly associated with severe WML. On multivariable logistic regression analysis, high UACR (≥ 39.6 mg/g creatinine), but not low eGFR (≤ 74 mL/min/1.73 m 2 ), was independently associated with severe WML. In comparisons between trichotomized UACR level, severe WML were more frequent in UACR ≥ 300 mg/g creatinine group than in UACR < 30.0 mg/g creatinine group after multivariate adjustment (OR, 2.25; 95% CI, 1.04-5.00; P = 0.039). On the other hand, there was no significant association with trichotomized eGFR level and severe WML (OR, 1.51; 95% CI, 0.62-3.77; P = 0.3672).

Conclusions: Our data suggest that a high UACR, but not eGFR, is independently associated with severe WML.

Abstract TP323: Prevalence And Clinical Character Of Cortical Superficial Siderosis In Stroke Patient

Background and purpose: Cortical superficial siderosis (CSS) is a neuroimaging marker of cerebral amyloid angiopathy and has been associated with a high risk for intracerebral hemorrhage. However, CSS in acute stroke patients have not been fully investigated. The aim of this study was to assess the prevalence of CSS in both ischemic and hemorrhagic stroke patients. Furthermore, we aimed to assess the relation between CSS and clinical or radiologic characteristics.

Methods: From September 2014 through June 2016, consecutive acute ischemic and hemorrhagic stroke patients who were admitted to our department within 7 days from symptom onset were retrospectively recruited from the prospective registry. CSS was defined as a homogeneous curvilinear signal intensity (black) on T2*-GRE sequences in the superficial layers of the cerebral cortex, within the subarachnoid space, away from at least three sulci of the hematoma with no corresponding signal hyperintensity on FLAIR sequences, to exclude potential hemorrhagic mimics. We analyzed the association between CSS and the topographic distribution of cerebral microbleeds (MBs), white matter lesions plus cardiovascular risk factors.

Results: A total of 680 patients (530 ischemic stroke and 150 hemorrhagic stroke; median age 71 years) were enrolled in the present study. CSS was detected in 6 patients (1.1 %) with ischemic stroke and 7 patients (4.7%) with hemorrhagic stroke ( P < 0.0001). CSS are associated with previous stroke ( P = 0.0234), hemorrhagic stroke ( P < 0.0001), white matter lesions ( P = 0.0105), and lobar and non-lobar MBs (both P < 0.0001), but no relationship between age, sex, cardiovascular risk factors and CSS were found. On multivariable logistic regression analysis, high lobar MBs (≥ 2; odds ratio [OR], 74.39; 95% confidence interval [CI], 10.24-1553.25; P < 0.0001) and hemorrhagic stroke (OR, 4.30; 95% CI, 1.12-18.14; P = 0.0336) were independently associated with the presence of CSS.

Conclusions: Our results suggest that CSS occurs with high prevalence in hemorrhagic stroke patients and is associated with lobar MBs, while the association between CSS and age, sex and cardiovascular risk factors were not observed.

Abstract WP209: Plasma Brain Natriuretic Peptide Should be a Predictor for 3-Month Mortality in Non-Cardioembolic Stroke

Background: Plasma brain natriuretic peptide (BNP) is primarily released from the ventricular myocardium and is a biomarker of cardioembolic stroke. Previous studies have shown that elevated plasma BNP level predicts short and long term mortality in cardioembolic stroke. However, the relationship between BNP and mortality in non-cardioembolic stroke has not been fully examined. The present study tested the hypothesis that admission plasma BNP level can serve as a marker of 3-month mortality in non-cardioembolic stroke.

Methods: From a prospective stroke registry, we examined acute non-cardioembolic stroke patients within 7 days after symptom onset who measured plasma BNP on admission from September 2014 to March 2016. We divided all patients into the non-survivors and the survivors within 3 month of non-cardioembolic stroke, and compared clinical characteristics between the two groups. The factors associated with 3-month mortality were investigated by multivariate logistic regression analysis.

Results: Three hundred and one patients (198 males, 71 [61-80] years old) were enrolled in the study. Thirteen patients (3.8%) died within 3 month of non-cardioembolic stroke. There were no significant differences in male (61.5% vs. 66.0%, P=0.769), age (71 years old vs. 68 years old, P=0.450), hypertension (61.5% vs. 65.6%, P=0.771), diabetes (15.4% vs. 28.7%, P=0.525), dyslipidemia (30.8% vs. 43.4%, P=0.409), and smoking (61.5% vs. 50.0%, P=0.573) between the non-survivors and the survivors. The NIHSS score was significantly higher in the non-survivors than in the survivors (15 vs. 2, P<0.001). The plasma BNP was significantly higher in the group of non-survivors than in the group of survivors (85 pg/ml vs. 31 pg/ml, p =0.005). A cut off plasma BNP level of 65.0 pg/ml could predict death within 3 month of non-cardioembolic stroke. Multivariate logistic regression analysis showed that a plasma BNP level of >65.0 pg/ml (odds ratio [OR] 6.49; 95% confidence interval [CI], 1.79-23.56, P=0.04) was independently associated with 3-month mortality in non-cardioembolic stroke.

Conclusions: A high plasma BNP level on admission should be a predictor for 3-month mortality in non-cadioembolic stroke.

Abstract TP161: Low Free Triiodothyronine on Admission Should Be Associated With Post-stroke Infection in Acute Stroke Patients

Background and purpose: Post-stroke infection (PSI) is a common and it is associated with a severe prognosis. Recent studies have shown that thyroid hormones play critical roles in the immune system regulation. However, association between PSI and thyroid hormone have not been fully elucidated. We therefore investigated the impact of thyroid hormone on PSI in acute stroke patients.

Methods: We retrospectively enrolled 520 consecutive patients with acute ischemic stroke (326 male, 71.9 ± 13.2 years) admitted to our department between September 2014 and June 2016. Serum thyroid stimulating hormone (TSH), free triiodothyronine (FT3), and free thyroxine (FT4) were evaluated upon admission. PSI was defined as infection occurring during hospitalization. The impact of the thyroid hormone on PSI was evaluated using multiple logistic regression analysis. Separate analyses were conducted according to PSI and quartile serum FT3 concentration.

Results: PSI was diagnosed in 107 patients (20.6 %). The most common infection was pneumonia with the prevalence of 65 patients (60.7 %), followed by urinary tract infection recorded in 19 patients (17.8 %). Age ( P < 0.001), body mass index ( P = 0.0044), pre-admission mRS ( P = 0.002), NIHSS score on admission ( P < 0.001), admission FT3 (2.63 ± 0.49 pg/mL vs. 2.24 ± 0.66 pg/mL, P < 0.001), and cardio-embolic stroke ( P < 0.001) were significantly associated with PSI, but no relationship between TSH (2.84 ± 8.12 mIU/L vs. 2.20 ± 1.45 mIU/L, P = 0.4610), FT4 (1.22 ± 0.21 ng/dL vs. 1.21 ± 0.28 ng/dL, P = 0.1478), and PSI were found. On multivariable logistic regression analysis, low FT3 (< 2.29 pg/mL; odds ratio [OR], 2.96; 95% confidence interval [CI], 1.61- 5.45; P = 0.0005) and high admission NIHSS score (≥ 9 points, OR, 7.65; 95% CI, 4.10-14.73; P <0.0001) were independently associated with PSI. In comparisons between PSI and FT3 quartiles (Q1 [≤ 2.25 pg/mL], Q2 [2.26-2.55 pg/mL], Q3 [2.56-2.89 pg/mL], Q4 [≥ 2.90 pg/mL]), patients with PSI were significantly more frequent in Q1 than in Q2, Q3, and Q4 after multivariate adjustment.

Conclusions: Our results showed that a low FT3 at admission should be associated with PSI in acute ischemic stroke patients.

Long-term observation of lateral medullary infarction due to vertebral artery dissection assessed with multimodal neuroimaging

A 33-year-old man presented with a lateral medullary infarction, vertigo, and nausea. At the time of hospital admission, he had Wallenberg syndrome. Although initial magnetic resonance imaging showed no abnormalities, subsequent diffusion-weighted magnetic resonance imaging showed a high-intensity area in the right lateral medulla oblongata. The right vertebral artery was shown to be dilated on basi-parallel anatomical scanning but to be stenosed on magnetic resonance angiography (MRA). Cerebral angiography 7 days after onset showed the "pearl and string sign" in the right vertebral artery. Follow-up MRA showed gradual improvement of the stenosis in the right vertebral artery. Multiple neuroimaging studies, such as MRA, basi-parallel anatomical scanning, 3-dimensional computed tomographic angiography, and cerebral angiography, should be performed soon after onset in suspected cases of cerebral artery dissection. In addition, serial imaging examinations increase diagnostic accuracy, and the medical history and neurological examination are important.

Thrombolysis, Complete Recanalization, Diffusion Reversal, and Luxury Perfusion in Hyperacute Stroke

A 59-year old man was admitted to our stroke care unit 1.8 hours after onset of cardioembolic stroke. Administration of issue-plasminogen activator achieved complete recanalization, and his lesion on diffusion-weighted imaging (DWI) disappeared and single photon emission computed tomography showed luxury perfusion. DWI reversal and luxury perfusion were sometimes observed in hyperacute stroke patients, especially timely reperfusion was achieved. However, the relationships between DWI reversal and luxury perfusion were not well known. Transient DWI reversal may be associated with luxury perfusion in patients treated with t-PA, via early complete recanalization achieved by thrombolysis.

Pharmacokinetics of Levodopa before and after Gastrointestinal Resection in Parkinson's Disease

Introduction

Levodopa (LD) is important in the clinical treatment of Parkinson's disease (PD), and the changes of its pharmacokinetics may affect the clinical outcome. LD is mainly absorbed in the upper intestine; thus, the pharmacokinetics of LD may change after gastrointestinal operation. Here, we present the case of a patient who underwent resection of the intestine and compared his LD pharmacokinetics before and after resection.

Case Presentation

A 72-year-old Japanese male PD patient developed jaundice and was diagnosed with cholangiocarcinoma. Pancreaticoduodenectomy was performed and part of the stomach, total duodenum, and part of the jejunum were resected. The patient had been treated with LD, and his pharmacokinetics was checked twice at the age of 68 years. Because LD is absorbed in the duodenum and jejunum, we checked his pharmacokinetics again after the operation. The results before the operation were almost similar; however, in comparison, the area under the curve and peak drug concentration was reduced, and the time-to-peak drug concentration and elimination halftime were elongated after the operation.

Conclusion

Physicians must pay attention to the change of LD pharmacokinetics after gastrointestinal operation.

The potentially protective effect of donepezil in Alzheimer's disease

BACKGROUND/AIMS

Donepezil is an acetylcholinesterase inhibitor used to treat Alzheimer's disease (AD). In this study, we used a voxel-based specific regional analysis system for AD (VSRAD) to analyze the hippocampal volume and to assess the pharmacologic effects of donepezil as a disease modifier.

METHODS

A total of 185 AD patients underwent MRI, 120 (43 men and 77 women, 77.8 ± 7.1 years) without and 65 (29 men and 36 women, 78.4 ± 6.0 years) with donepezil treatment. VSRAD was compared in both groups and against a database of 80 normal subjects. The Z-score was used to assess the degree of hippocampal atrophy.

RESULTS

No significant difference between the groups was found for age, sex, or Z-scores, but a significant difference was found for mean Mini-Mental State Examination (MMSE) scores (p = 0.02, Student's t test). Single regression analysis showed no significant association between Z-scores and MMSE scores in the treated group (p = 0.494), but a significant association in the untreated group (p = 0.001) was observed. This implies that the MMSE score becomes lower when the Z-score is higher in the untreated group, whereas there is no significant trend in the treated group.

CONCLUSION

Donepezil affects the relationship between hippocampal volume and cognitive function and may therefore have a pharmacologic effect as a disease modifier.

Efficacy of tracheostomy for central alveolar hypoventilation syndrome caused by lateral medullary infarction

Central alveolar hypoventilation syndrome (CAHS) is a rare and potentially fatal condition. However, respiratory care for patients with CAHS caused by lateral medullary infarction (CAHS-LMI) remains an important unsolved problem. We describe 2 patients with CAHS-LMI and review the case reports for 17 previously described patients. Patient 1 was a 78-year-old man who was referred to our hospital because of dizziness. After admission, Wallenberg syndrome developed. Magnetic resonance imaging showed left LMI. He had hypercapnia and respiratory acidosis the next afternoon and temporarily received mechanical ventilation. A tracheotomy was performed on the 12th hospital day, and the patient was weaned from the ventilator on the 18th hospital day. Patient 2 was 72-year-old man who was referred to our hospital because of dizziness and gait disturbance. Wallenberg syndrome was diagnosed after admission, and magnetic resonance imaging showed right LMI. His consciousness deteriorated, and hypercapnia developed on the ninth hospital day. The patient received ventilatory support, and a tracheotomy was performed on the 12th hospital day. He was weaned from the ventilator by the 16th hospital day. Consistent with our findings, most previously reported cases of CAHS-LMI were initially associated with mild symptoms, which subsequently worsened. Five of the 19 patients (26.3%) died within 1 month after onset, and 7 patients (36.8%) died within 1 year. Tracheotomy was performed in 12 patients, 2 of whom died 1 month after onset (16.7%); another patient died of chronic renal failure after 2 years. Tracheotomy seemed to be an effective procedure in patients with CAHS-LMI. We speculate that tracheotomy assists alveolar ventilation by reducing dead space ventilation. Closure of the tracheotomy should, therefore, be avoided in patients with CAHS-LMI, even if respiratory status is good.

Test-retest variability of adenosine A2A binding in the human brain with (11)C-TMSX and PET

Background

The goal of the present study was to evaluate the reproducibility of cerebral adenosine A_2A receptor (A_2AR) quantification using ¹¹C-TMSX and PET in a test-retest study.

Methods

Five healthy volunteers were studied twice. The test-retest variability was assessed for distribution volume (V_T) and binding potential relative to non-displaceable uptake (BP_ND) based on either metabolite-corrected arterial blood sampling or a reference region. The cerebral cortex and centrum semiovale were used as candidate reference regions.

Results

Test-retest variability of V_T was good in all regions (6% to 13%). In the putamen, BP_ND using the centrum semiovale displayed a lower test-retest variability (3%) than that of BP_ND using the cerebral cortex as a reference region (5%). The noninvasive method showed a higher or similar level of test-retest reproducibility compared to the invasive method.

Conclusions

Binding reproducibility is sufficient to use ¹¹C-TMSX as a tool to measure the change in A_2AR in the human brain.

Electronic supplementary material

The online version of this article (doi:10.1186/s13550-014-0076-9) contains supplementary material, which is available to authorized users.

Loss of GluN2A-containing NMDA receptors impairs extra-dimensional set-shifting

Glutamate neurotransmission via the N-methyl-D-aspartate receptor (NMDAR) is thought to mediate the synaptic plasticity underlying learning and memory formation. There is increasing evidence that deficits in NMDAR function are involved in the pathophysiology of cognitive dysfunction seen in neuropsychiatric disorders and addiction. NMDAR subunits confer different physiological properties to the receptor, interact with distinct intracellular postsynaptic scaffolding and signaling molecules, and are differentially expressed during development. Despite these known differences, the relative contribution of individual subunit composition to synaptic plasticity and learning is not fully elucidated. We have previously shown that constitutive deletion of GluN2A subunit in the mouse impairs discrimination and re-learning phase of reversal when exemplars are complex picture stimuli, but spares acquisition and extinction of non-discriminative visually cued instrumental response. To investigate the role of GluN2A containing NMDARs in executive control, we tested GluN2A knockout (GluN2A(KO) ), heterozygous (GluN2A(HET) ) and wild-type (WT) littermates on an attentional set-shifting task using species-specific stimulus dimensions. To further explore the nature of deficits in this model, mice were tested on a visual discrimination reversal paradigm using simplified rotational stimuli. GluN2A(KO) were not impaired on discrimination or reversal problems when tactile or olfactory stimuli were used, or when visual stimuli were sufficiently easy to discriminate. GluN2A(KO) showed a specific and significant impairment in ventromedial prefrontal cortex-mediated set-shifting. Together these results support a role for GluN2A containing NMDAR in modulating executive control that can be masked by overlapping deficits in attentional processes during high task demands.

Hemothorax after the intravenous administration of tissue plasminogen activator in a patient with acute ischemic stroke and rib fractures

A 79-year-old man experienced sudden-onset left hemiparesis and disturbance of consciousness. Diffusion-weighted magnetic resonance imaging showed an acute ischemic stroke in the territory of the right middle cerebral artery. He underwent systemic thrombolysis via the intravenous administration of tissue plasminogen activator (t-PA). Chest radiography and computed tomography performed the following day showed severe hemothorax with atelectasis of the left lung and multiple rib fractures; the initial chest radiogram had revealed rib fractures but we did not recognize them at the time. Conservative treatment with the placement of chest tubes was successful, and the patient recovered without further deterioration. Although systemic thrombolysis with t-PA is an accepted treatment for acute cerebral ischemic stroke, posttreatment intracranial hemorrhage has a negative effect on prognosis. Extracranial bleeding is a rare complication, and our search of the literature found no reports of hemothorax after treatment with t-PA in patients with cerebral ischemic stroke. We have reported a rare case of severe hemothorax after systemic thrombolysis with t-PA. This important complication indicates the need to rule out thoracic trauma with radiography and computed tomography of the chest.

Aortic arch atherosclerosis in ischaemic stroke of unknown origin affects prognosis

Background

Cerebral infarction of unknown origin at admission accounts for half of all cerebral infarction cases in some institutions. However, the factors associated with cerebral infarction prognosis have not been sufficiently examined. Here, we investigated whether aortic arch plaques (AAPs) on transoesophageal echocardiography (TOE) were associated with the prognosis of cerebral infarction of unknown origin at admission.

Methods

Of 571 patients who were hospitalised between June 2009 and September 2011, 149 (age: 67 ± 14 years; 95 men) with cerebral infarctions of unknown origin at admission underwent TOE and were enrolled in this study. We examined their clinical characteristics, the incidence of intermittent atrial fibrillation detected on 24-hour electrocardiography, and the echographic findings of the carotid artery in the hospital. A poor prognostic outcome was defined as a modified Rankin Scale score of ≥3 after 90 days.

Results

In all, 110 patients (74%) showed good prognoses and 39 patients (26%) showed poor outcomes. A National Institutes of Health Stroke Scale score of >6 on admission [odds ratio (OR) = 6.77; 95% confidence interval (CI): 2.59-18.8; p < 0.001] and AAPs of ≥4 mm (OR = 2.75; 95% CI: 1.19-6.91; p = 0.024) showed significant associations with a poor prognosis of cerebral infarction of unknown origin at admission.

Conclusions

Thick AAPs could be a factor in the prediction of a poor prognosis of cerebral infarction of unknown origin at admission. The establishment of international standards for aortogenic brain embolisms is required. Future prospective studies should examine cerebral infarctions of unknown origin.

Prospective assessment of concomitant lumbar and chronic subdural hematoma: is migration from the intracranial space involved in their manifestation?

Object

Spinal subdural hematomas (SDHs) are rare and some are concomitant with intracranial SDH. Their pathogenesis and etiology remain to be elucidated although their migration from the intracranial space has been suggested. The authors postulated that if migration plays a major role, patients with intracranial SDH may harbor asymptomatic lumbar SDH. The authors performed a prospective study on the incidence of spinal SDH in patients with intracranial SDH to determine whether migration is a key factor in their concomitance.

Methods

The authors evaluated lumbar MR images obtained in 168 patients (125 males, 43 females, mean age 75.6 years) with intracranial chronic SDH to identify cases of concomitant lumbar SDH. In all cases, the lumbar MRI studies were performed within the 1st week after surgical irrigation of the intracranial SDH.

Results

Of the 168 patients, 2 (1.2%) harbored a concomitant lumbar SDH; both had a history of trauma to both the head and the hip and/or lumbar area. One was an 83-year-old man with prostate cancer and myelodysplastic syndrome who suffered trauma to his head and lumbar area in a fall from his bed. The other was a 70-year-old man who had hit his head and lumbar area in a fall. Neither patient manifested neurological deficits and their hematomas disappeared under observation. None of the patients with concomitant lumbar SDH had sustained head trauma only, indicating that trauma to the hip or lumbar region is significantly related to the concomitance of SDH (p < 0.05).

Conclusions

As the incidence of concomitant lumbar and intracranial chronic SDH is rare and both patients in this study had sustained a direct impact to the head and hips, the authors suggest that the major mechanism underlying their concomitant SDH was double trauma. Another possible explanation is hemorrhagic diathesis and low CSF syndrome.

Relative risk values of age, acrolein, IL-6 and CRP as markers of periventricular hyperintensities: a cross-sectional study

OBJECTIVE

Brain white matter hyperintensities can be divided into periventricular hyperintensity (PVH) and deep-and-subcortical white matter hyperintensity (DSWMH); the former contributes more to cognitive dysfunction and infarction risk. We conducted the present investigation to define the relationship between PVH and DSWMH.

DESIGN

Cross-sectional study.

SETTING

University hospital.

PARTICIPANTS

We prospectively enrolled 228 healthy Japanese volunteers with relative risk values (RRVs) >0.5.

PRIMARY OUTCOME MEASURES

We investigated whether it is possible to use the RRV to predict PVH and DSWMH.

RESULTS

Among 228 volunteers, 103 (45.1%) and 157 (68.8%) exhibited PVH and DSWMH, respectively. Age, body mass index and PVH were significant independent determinants of RRV. A significant OR for PVH was noted in the highest RRV tertile compared with the lowest, after adjusting for potential confounding factors. A significant OR for high predicted PVH risk was found for RRV levels as well.

CONCLUSIONS

Elevated RRV levels were significantly associated with increased predicted PVH, suggesting that measuring the plasma protein-conjugated acrolein, interleukin 6 and C reactive protein levels may be useful for identifying Japanese at high risk for PVH.

Multiple Vascular Accidents Including Rupture of a Sinus of Valsalva Aneurysm, a Minor Ischemic Stroke and Intracranial Arterial Anomaly in a Patient with Systemic Congenital Abnormalities: A Case Report

A 39-year-old man with a history of rupture of a sinus of Valsalva aneurysm experienced an ischemic stroke. Although the patient presented left-sided hemiparesis for a week, no abnormal signals were indicated on diffusion-weighted imaging with repeated magnetic resonance scans. Carotid ultrasound and cerebral angiography were conducted, and they revealed hypoplasty of the left internal carotid artery with a low-lying carotid bifurcation at the level of the C6 vertebra. In addition, he was diagnosed with intellectual disabilities, evaluated by the Wechsler Adult Intelligence Scale-III, and congenital velopharyngeal insufficiency. We herein present the first report of a patient with cardio-cerebrovascular abnormalities, intellectual disabilities, and an otorhinolaryngological abnormality.