An autopsy case of progressive multifocal leukoencephalopathy after rituximab therapy for malignant lymphoma

Progressive multifocal leukoencephalopathy (PML) is a rare fatal demyelinating disease of the central nervous system caused by reactivation of the JC virus (JCV), which is named after the initials of the patient from whom the virus was first isolated. JCV is highly prevalent worldwide, infects humans in early childhood, and the infection persists throughout the course of life in latent form. The present paper deals with the second autopsy case report of rituximab-associated PML in Japan. A 63-year-old woman who had undergone chemotherapy for non-Hodgkin lymphoma developed progressive dysarthria and cerebellar ataxia. Head magnetic resonance imaging (MRI) revealed small, scattered, hyperintense areas in the midbrain, pons and thalamus, and the patient was first diagnosed as having cerebral infarction. Follow-up MRI showed tendency toward cerebellar atrophy and multiple system atrophy cerebellar type was suggested, which we concluded must have coincidentally occurred. It was challenging to perform biopsy due to the location of the foci and the patient's condition. Twelve months later she died of aspiration pneumonia caused by the bulbar lesion. At autopsy, the histological examination suggested the presence of demyelinating foci with numerous foamy macrophages. In the foci, oligodendrocytes with enlarged ground-glass like nuclei were found in a scattered manner and astrocytes with bizarre nuclei were also detected. These findings verified the case as PML. The first diagnosis of cerebral infarction was later withdrawn, although appropriate disorders were not recalled even after testing with various antibodies. The rate of PML development tends to increase after treatment with molecular-targeted therapies, which directly or indirectly attenuate the cellular-mediated immune system. Various novel molecular-targeted and immunosuppressive drugs have been released on the market; the cases of PML have consequently increased. Accordingly, pathologists should keep this disease in mind in the differential diagnosis when neural symptoms newly emerge in patients who are treated with these drugs.

Improvement and Aggravation of Spontaneous Unruptured Vertebral Artery Dissection

Background

Intracranial vertebral artery dissection (VAD) is a well-recognized cause of stroke in young and middle-aged individuals, especially in Asian populations. However, a long-term natural course remains unclear. We investigated the long-term time course of VAD using imaging findings to examine the rate and predisposing factors for improvement.

Methods

We registered 56 consecutive patients (40 males; mean age, 51.8 ± 10.7 years) with acute spontaneous VAD and retrospectively investigated neuroimaging and clinical course within 1 month and at 3 months ± 2 weeks, 6 months ± 2 weeks, and 12 months ± 2 weeks after onset to ascertain predisposing factors and time course for improvement.

Results

The most common presenting symptoms were headache and/or posterior neck pain, seen in 41 patients (73%). Magnetic resonance imaging showed brainstem and/or cerebellum infarction in only 32 patients (57%). Of the 56 VADs, 16 (28%) presented with pearl and string sign, 5 (9%) with pearl sign, 15 (27%) with string sign, and 20 (36%) with occlusion sign. VAD occurred on the dominant side in 20 patients and on the nondominant side in the other 36 patients. The pearl and string sign was more frequently noted on the dominant side than on the nondominant side (50 vs. 17%, p = 0.008). On the other hand, occlusion occurred more often on the nondominant side than on the dominant side (47 vs. 15%, p = 0.016). Furthermore, the pearl and string sign was more frequently seen in the improvement group (41 vs. 15%, p = 0.028), whereas the occlusion sign was evident more frequently in the nonimprovement group (21 vs. 52%, p = 0.015). Follow-up neuroimaging evaluation was performed at 1 and 3 months in 91% each, and at 6 and 12 months in 82% each. VAD aggravation was identified within 1 month after onset in 14%, while VAD improvement was seen in 14, 38, 50, and 52% at each period, mainly within 6 months after onset. Older patients and current smoking were negatively associated with VAD improvement.

Conclusions

VAD improvement primarily occurs within 6 months after onset, and VAD aggravation within 1 month. It seems that older patients and current smoking are negative predictors of VAD improvement as risk factors, and as image findings, the pearl and string sign is a positive predictor and occlusion a negative predictor.

[Repeated Cerebellar Hemorrhage Related to Rivaroxaban and Apixaban: A Case Report]

We report a case of repeated cerebral hemorrhage associated with administration of rivaroxaban and apixaban. A 74-year-old man had undergone catheter ablation for non-valvular paroxysmal atrial fibrillation in 2 years prior. Warfarin treatment was continued after successful catheter ablation, and was then changed to rivaroxaban in 1 year prior. Three months later, he developed subcortical cerebral hemorrhage in the right occipital lobe and pharmacotherapy was changed to apixaban. At the current presentation, he complained of headache and left visual field defect, and was admitted to our hospital. Computed tomography of the head revealed recurrent hematoma at the same site as the previous hemorrhagic lesion. Administration of apixaban was subsequently stopped. Magnetic resonance imaging of the head revealed no vascular anomalies around the hemorrhagic lesion, except for two microbleeds in the left cerebral cortex, suggesting amyloid angiopathy. We report the current case from the perspective of whether anticoagulation should be continued after successful catheter ablation, and whether anticoagulation is appropriate in patients with microbleed signals in the cerebral cortex.

Impact of Metformin on the Severity and Outcomes of Acute Ischemic Stroke in Patients with Type 2 Diabetes Mellitus

BACKGROUND

Diabetes mellitus (DM) is a major risk factor for cardiovascular disease. Metformin therapy reportedly decreases the risk of stroke, but the associations between metformin treatment and neurological severity or patient prognosis have not been investigated in clinical studies. This study evaluated the effects of metformin on stroke severity and outcomes in acute ischemic stroke patients with type 2 DM.

METHODS

We examined 355 stroke patients with type 2 DM without severe renal impairment or prestroke impairment of activities of daily living who were admitted to Kyushu Medical Center between April 2010 and September 2014. Neurological severity was assessed according to the National Institutes of Health Stroke Scale (NIHSS) score on admission. Mild neurological severity was defined as an NIHSS score lower than 3 on admission, and favorable functional outcome was defined as a modified Rankin Scale score of 2 or lower at discharge.

RESULTS

On logistic regression analysis with adjustments for multiple confounding factors, pretreatment with metformin was independently associated with mild neurological symptoms (odds ratio [OR], 2.12; 95% confidence interval [CI], 1.09-4.10; P = .026). In contrast, functional outcomes showed no significant associations. Nevertheless, a benefit of prior metformin use was observed in patients with a prior history of stroke (OR, 11.3; P = .046) and in patients after excluding those with mild stroke severity (OR, 5.64; P = .042).

CONCLUSIONS

Administration of metformin in DM patients prior to stroke onset may be associated with reduced neurological severity and improved acute-phase therapy outcomes.

Safety and Management of Antithrombotic Therapy with Intra-Arterial Catheter Procedures

OBJECTIVE

Intravascular catheter procedures are often performed in patients undergoing antithrombotic therapy. However, methods for the management of antithrombotic agents in the perioperative period are currently unclear. Therefore, the safety and management of antithrombotic agents in these patients were investigated.

METHODS

A prospective, multicenter, observational study [Management of Antithrombotic Agents During Surgery or Medical Procedures with Bleeding (MARK study)] at 58 National Hospital Organization institutions in Japan was performed. 1,040 patients were enrolled in the MARK study and underwent an intravascular catheter procedure. For all participants, the details of the procedure, method of perioperative management of antithrombotic agents, and occurrence of thrombosis, embolism, and bleeding complications during the study period were investigated.

RESULTS

The use of antithrombotic agents was continued in 1,017 patients (98%, continuation group) and discontinued in the other 23 (2%, discontinuation group). Continuation of the antithrombotic agents did not have a significant effect on the overall occurrence of thromboembolism [hazard ratio (HR), 0.15; p=0.08] or bleeding events (HR, 0.19; p=0.12). However, the overall adverse event risk was significantly lower in the continuation group than in the discontinuation group (HR, 0.18; p=0.03).

CONCLUSION

It is both safe and appropriate to perform intravascular catheter procedures in patients continuing with antithrombotic therapy.

Abstract T P157: The Impact of Estimated Glomerular Filtration Rate on a Recurrence of Ischemic Stroke: The Fukuoka Stroke Registry

Introduction: Although chronic kidney disease has been shown as a risk factor for stroke recurrence in several studies, there are few reports about the impact of the degree of estimated glomerular filtration rate (eGFR) on recurrence.

Hypothesis: There is a trend that hazard ratio of stroke recurrence was lower in the higher group of eGFR while higher in the lower group. We aimed to determine the influence of eGFR grade on stroke recurrence.

Methods: We enrolled 5101 consecutive patients who were hospitalized in stroke centers within seven days of onset from June 2007 to May 2012. The clinical characteristics of patients were assessed on admission, and the clinical course of all patients was followed subsequently. Patients were divided into three groups based on the level of eGFR; E1 (eGFR < 30 ml/min/1.73 m 2 ), E2 (30 ≤ eGFR < 60), E3 (60 ≤ eGFR). In these groups, we performed Multivariate Cox proportional hazards analyses to determine the influence of eGFR grade on stroke recurrence.

Results: Of all patients, 5028 (2998 males, 74 ± 12 years of age) cases with ischemic stroke were investigated in the present study. Six hundred twenty-nine patients (13%) suffered a recurrence of ischemic stroke during the follow-up period (680 ± 387 days). The Kaplan-Meier method revealed the cumulative recurrence rates of ischemic stroke in three groups of patients were significantly different, as shown in figure (E1 vs. E2, E1 vs. E3, p < 0.0001 by the log-rank test). On Cox proportional analysis with adjustments for multiple confounding factors, E2 (hazard ratio [HR] 1.27, 95% confidence interval [CI] 1.06 to 1.52, p = 0.0115) and E3 ([HR] 1.95, 95% [CI] 1.48 to 2.52, p < 0.0001) groups were at greater risk of stroke recurrence compared with the E1 group.

Conclusions: There is the significant relationship between a level of eGFR and a recurrence of ischemic stroke. In the stroke patients who have lower eGFR, the risk of a recurrence more increases.

Abstract T P160: Are Severity and Outcome of Ischemic Stroke With Paroxysmal Atrial Fiblliration Different From Those With Chronic Atrial Fibrillation?

Background and Purpose: Previous studies indicated that incidence of ischemic stroke did not differ between patients with paroxysmal atrial fibrillation (PAF) and those with chronic atrial fibrillation (CAF). However, it has been under dispute whether severity and outcome of ischemic stroke in patients with PAF differ from those with CAF. Then, we compared them between ischemic stroke patients with PAF and those with CAF.

Methods: We obtained data from the medical records of 372 consecutive patients admitted to our hospital, who had acute ischemic stroke with atrial fibrillation, from January, 2008, to December, 2012.We compared neurological severities (NIH stroke scale scores) on admission and discharge, functional outcome evaluated by modified Rankin scale, (mRS) on discharge between patients with PAF and those with CAF.

Results: Of 372 patients, 123 patients had PAF (men 62.6%, 78.0 +- 10.0 years old) and 249 patients (men 62.1%, 77.9 +- 9.5 years old) had CAF. There were no significant differences in NIH stroke scale on admission between the PAF group (media 5 with IQR 2-14) and the CAF group (6, 2-16)(P=0.2772). NIH stroke scale scores (1, 0-8.75, vs. 2, 0-10, p=0.1549) and mRS(2, 1-4, vs. 3, 1-4, p=0.2105) on discharge did not differ between the two groups, either. After adjustment for age, sex, modified Rankin scale before admission, diabetes, hypertension, dyslipidemia, there was no significant difference in mRS at discharge between the two groups. (P=0.1416).

Conclusion: It seems that the severity and outcome of ischemic stroke with PAF are not different from those with CAF.

[Neurological deterioration within 30 days of ischemic stroke with spontaneous cervicocranial artery dissection]

The objective of this study was to identify the clinical features associated with neurological deterioration within 30 days of ischemic stroke patients with spontaneous cevicocranial dissection (SCCD) and clarify the effect on outcomes. We retrospectively identified 18 patients with SCCD (1.6%, 3 women, 52 ± 16 years old) among 1,112 patients with acute ischemic stroke within 7 days after onset. Of the 18 patients, 13 (72%) had vertebrobasilar arterial dissection. Neurological deterioration was present in 4 patients (22%), and 2 patients (11%) died. All of them became worse within 3 days after onset. Their initial blood pressures were high. All of them had dominant side vertebral artery or basilar artery dissection. Subarachnoid hemorrahage (SAH) were not seen although the agressive anticoagulant therapy were performed except for a case who had aneurysmal change. The patients with neurological deterioration had poor outcome, but the patients without neurological deterioration had good outcome. Recurrent ischemic event or SAH did not occurred in 3 months if they had not neurological deterioration. When we see acute stroke patients with dissection at the dominant side vertebral artery or the basilar artery, we should observe carefully for neurological deterioration especially within three days of onset.

Acute thrombocytopenia after initiating anticoagulation with rivaroxaban

A 75-year-old man with paroxysmal atrial fibrillation developed a traumatic intracranial hemorrhage during warfarin treatment. The administration of warfarin was stopped and rivaroxaban therapy, a novel oral anticoagulant (NOAC), was started. Immediately, his platelet count decreased to 3.7×10(4) /μL. The platelet count recovered rapidly after cessation of rivaroxaban administration. Development of thrombocytopenia and its rapid recovery was observed again after another administration, and subsequent cessation, of the drug. A diagnosis of rivaroxaban-induced thrombocytopenia was made. The incidence of thrombocytopenia due to NOACs is rare. Careful attention to thrombocytopenia, which is associated with a higher risk for life-threatening bleeding, is therefore necessary during treatment with NOACs.

Recombinant tissue-type plasminogen activator (rt-PA) therapy in an acute stroke patient taking dabigatran etexilate: a case report and literature review

Whether recombinant tissue-type plasminogen activator (rt-PA) therapy can be administered in acute stroke patients treated with dabigatran remains controversial. We administered rt-PA (0.6 mg/kg) in an acute stroke patient treated with dabigatran (110 mg bid) whose activated partial thromboplastin time (APTT) was 37.1 seconds 113 minutes after onset, 10 hours after the last dose of dabigatran. His symptoms improved from the National Institute of Health Stroke Scale score of 10 to 1 after treatment without hemorrhagic complications. The administration of rt-PA therapy is feasible in acute stroke patients on dabigatran when taking into account the APTT and time from the last dose.

Increase in the Size of an Intracardiac Thrombus during Dabigatran Therapy (110 mg b.i.d.) in an Acute Cardioembolic Stroke Patient

We report a case of atrial fibrillation in a patient in whom a mobile thrombus in the left atrial appendage increased in size after low-dose dabigatran therapy. A 74-year-old man was admitted to our hospital because of sudden onset of right hemiplasia and dysarthria. On admission, his National Institutes of Health Stroke Scale score was three. Axial diffusion-weighted magnetic resonance images and magnetic resonance angiography images showed hyperintense signals in the left front-parietal cerebral cortex without any intracranial stenotic lesions, and acute cardioembolic stroke associated with nonvalvular atrial fibrillation was diagnosed. Transesophageal echocardiography revealed a mobile thrombosis (1.0 × 2.2 cm) in the left atrial appendage, and dabigatran therapy (110 mg b.i.d.) was initiated to prevent stroke recurrence. Transesophageal echocardiography performed 6 days later revealed that the size of the thrombus had increased to 1.5 × 3.0 cm. Medication was changed to warfarin, and the thrombosis subsequently decreased in size. The patient did not have a recurrent stroke and was discharged with a National Institutes of Health Stroke Scale score of zero. This case demonstrates that low-dose dabigatran may not be effective in reducing the size of a thrombus.

Antegrade internal carotid artery collateral flow and cerebral blood flow in patients with common carotid artery occlusion

OBJECTIVES

To determine the incidence of antegrade internal carotid artery collateral flow in patients with common carotid artery occlusion, which artery supplies blood to the internal carotid artery, and whether the flow affects regional cerebral blood flow in the middle cerebral artery territory.

METHODS

We determined the incidence of antegrade internal carotid artery collateral flow and identified its arterial origins using carotid sonography in 10 patients with common carotid artery occlusion and evaluated middle cerebral artery territory regional cerebral blood flow by single-photon emission computed tomography in these patients and 30 age- and sex-matched patients with internal carotid artery occlusion.

RESULTS

Six (60%) of the 10 patients with common carotid artery occlusion had antegrade internal carotid artery collateral flow, which was supplied through the carotid bifurcation from retrograde flow of the external carotid artery in 5 and by a small artery directly into the internal carotid artery in 1. The regional cerebral blood flow ipsilateral to the occlusion at rest was higher in patients with common carotid artery occlusion than those with internal carotid artery occlusion (mean ± SD, 40.4 ± 8.5 versus 34.3 ± 6.2 mL/100 g/min; P = .02). The regional cerebral blood flow was significantly higher in the 6 patients with antegrade internal carotid artery flow than those with internal carotid artery occlusion at rest (42.2 ± 7.2 versus 34.3 ± 6.2 mL/100 g/min; P = .02) but not in the other 4 patients without antegrade internal carotid artery flow.

CONCLUSIONS

Antegrade collateral internal carotid artery flow was found in 60% of patients with common carotid artery occlusion and was mainly supplied by retrograde external carotid artery flow. It contributes to maintenance of middle cerebral artery territory regional cerebral blood flow.

Selective Occipital Artery Sonography for Dural Arteriovenous Fistulas

Carotid duplex sonography is a useful method for evaluation of dural arteriovenous fistulas. The resistance index of the external carotid artery has been reported to correlate with the efficacy of treatment and recurrence or aggravation of dural arteriovenous fistulas. Herein, we describe a case of dural arteriovenous fistulas mainly supplied by the occipital artery and show that the resistance index of the occipital artery was more sensitive than that of the external carotid artery. To the best of our knowledge, this is the first report to describe the feasibility of occipital artery detection by carotid duplex sonography and clinical application of the resistance index of the occipital artery for dural arteriovenous fistulas.

Abstract 3278: Aortic Arch Complicated Lesion is Strongly Associated with Recurrence of Ischemic Stroke

Background: Aortic arch plaque is a risk factor for ischemic stroke. The aim of this study was to identify whether aortic arch plaque is also a risk factor for recurrence of ischemic stroke.

Methods: We performed transesophageal echocardiography for source of emboli in 452 acute stroke patients between 2002 January and 2010 July. We investigated age, gender, incidence of atrial fibrillation, antithrombotic therapy, diabetes mellitus, hypertension, dyslipidemia, history of ischemic heart disease, history of peripheral artery disease, smoking, and transesophageal echocardiographic findings, such as spontaneous echo contrast in the left atrium, patent foramen ovale, and aortic atheroma ≥4.0 mm(complicated plaque). We compared these clinical findings between patients with the first ever stroke and those with recurrent stroke by univariate and multivariate analysis.

Results: We developed 383 patients with the first ever stroke and 69 patients who had recurrent stroke. Univariate analysis demonstrated that age(66.8±12.1 VS 71.4±9.9, p<0.05), antithrombotic therapy(21% VS 70%, p<0.05, 97 with antiplatelet, 23 with anticoagulation, 9 with both), diabetes mellitus(25% VS 41%, p<0.05), history of ischemic heart disease(9% VS 20%, p<0.05), history of peripheral artery disease(3% VS 7%, p<0.05), smoking(29% VS 14%, p<0.05) and aortic atheroma > or =4.0 mm(40% VS 61%, p<0.05) were associated with recurrence of ischemic stroke. Multivariate analysis showed that antithrombotic therapy (OR 7.55, 95%CI 4.29-13.66) and aortic atheroma > or =4.0 mm (OR 1.83, 95%CI 1.04-3.26) were independently associated with recurrence of ischemic stroke.

Conclusions: Aortic atheroma > or =4.0 mm seems to associate with reccurence of ischemic stroke regardless of antithrombotic therapy.

Outcomes associated with carotid pseudo-occlusion

PURPOSE

We tested the hypothesis that patients with carotid pseudo-occlusion (PO) have a different prognosis from those with carotid artery stenosis (CS) without PO.

MATERIALS AND METHODS

500 patients were examined for CS by cerebral angiography; those with severe CS ≥ 70% (CS group) or with PO (PO group) were enrolled in this study. The primary endpoint was defined as the combined endpoint of the occurrence of stroke, myocardial infarction, or death. Patients without any events were censored at 60 months. We followed patients for the occurrence and date of primary endpoints and compared clinical characteristics and outcomes between the PO group and the CS group.

RESULTS

We enrolled 337 patients (281 men, 56 women, mean age: 70.4 years, mean follow-up period: 32.0 months), of whom 303 (89.9%) were allocated to the CS group while 34 (10.1%) were allocated to the PO group. The rate of diabetes mellitus in the PO group (55.9%) tended to be higher than in the CS group (39.9%). According to Kaplan-Meier analysis, the PO group suffered from the primary outcome more frequently than the CS group. The occurrence of the primary outcome was also associated with older age, peripheral arterial disease and a history of myocardial infarction. Multivariate analysis indicated that patients in the PO group had a significantly poorer outcome compared with those in the CS group (p = 0.013).

CONCLUSION

Patients in the PO group more frequently had neurological and cardiac events or died compared with those in the CS group.

[Left to right ratio of transcranial color-coded sonography for monitoring hyperperfusion syndrome after carotid artery stenting: a case report]

Hyperperfusion syndrome is a significant complication after carotid endarterectomy (CEA) or carotid artery stenting (CAS). A few reports have shown that an increase in the ratio of mean flow velocity (MFV) of the middle cerebral artery (MCA) of the affected side by transcranial color-coded sonography (TCCS) is useful for the evaluation of hyperperfusion after CEA or CAS. We report a case of hyperperfusion syndrome after CAS in which not only the increased ratio of the affected side based on preoperative mean flow velocity, but also the left to right ratio (L/R ratio) was useful for monitoring hyperperfusion. A 48-year-old man was admitted to our hospital because of cerebral infarction of the right internal carotid artery (ICA) due to stenosis of the right ICA at origin. The preoperative L/R ratio of MFV of the MCA by TCCS was 0.58. We performed CAS and the patient then developed hyperperfusion syndrome with epilepsy and was intubated under the management of strict blood control. We performed TCCS daily and the patient was extubated when the L/R ratio of MFV of the MCA decreased to 1.1 from a maximum of 2.6, although the increased ratio of MFV of the MCA of the affected side was still higher than 1.4. The patient went home without any complications from hyperperfusion. When there is preoperative laterality of cerebral blood flow, the L/R ratio of MFV by TCCS can be useful for monitoring hyperperfusion after CEA or CAS.

Two case reports of inherited antithrombin deficiency: a novel frameshift mutation and a large deletion including all seven exons detected using two methods

An inherited antithrombin deficiency is an autosomal dominant thrombotic disorder. We identified two pedigrees of inherited type I antithrombin deficiency and two responsible mutations in each. A novel 21-22delAA appeared to have caused a frameshift with a premature termination at amino acid +63 in one patient and a large deletion including all seven exons was identified by multiplex ligation-dependent probe amplification in the other. Some asymptomatic relatives of the second patient had the same mutation. The present findings support the value of using more than one method of gene analysis and of studying the families of probands with inherited thrombotic disorders.

Prognosis of medical treatment for Japanese patients with carotid stenosis

PURPOSE

This study was designed to determine whether, among Japanese patients receiving medical treatment for carotid stenosis, symptomatic carotid stenosis was more strongly associated with subsequent neurological events than asymptomatic carotid stenosis.

METHODS

We consecutively registered Japanese patients with carotid stenosis of 50% or more as evaluated by digital subtraction angiography who were treated medically. We reviewed medical records regarding previous neurological events as well as other stroke risk factors and underlying diseases at admission. We monitored the occurrence and date of stroke and death after the first evaluation. We also attempted to obtain information from patients or their family members by means of a questionnaire or telephone survey.

RESULTS

Among 67 patients with carotid stenosis of 50% or more who were treated medically, follow-up was completed in 62 subjects (56 men, 6 women; median age, 72 years; mean follow-up period, 37.3 months). The number of patients with subsequent stroke with symptomatic carotid stenosis was five, while that with asymptomatic stenosis was four. A significantly higher rate of subsequent stroke was observed in patients with symptomatic carotid stenosis compared with those with asymptomatic stenosis (p=0.012). Cox proportional hazards model indicated that symptomatic carotid stenosis was significantly correlated with future neurologic events (p=0.019).

CONCLUSION

In a Japanese population with carotid stenosis treated medically, symptomatic carotid stenosis is associated with future stroke more frequently than asymptomatic carotid stenosis.

[Association of location of deep venous thrombosis and d-dimer value in acute intracerebral hemorrhage]

AIM

We investigated the association of the presence and the location of deep venous thrombosis (DVT) with D-dimer value in acute intracerebral hemorrhage (ICH).

METHODS

We analyzed the data regarding DVT in patients with ICH. Based on an ultrasonographic examination 2 weeks after the occurrence of ICH, the patients were divided according to the presence/absence and the location of DVT, i.e. no evidence of DVT (n-DVT), calf DVT (c-DVT), and proximal DVT (p-DVT). D-dimer value was measured 2 weeks later and compared among the groups.

RESULTS

The numbers of patients with n-DVT, c-DVT and p-DVT were 27, 19, and 2, respectively. Univariate analysis indicated that D-dimer values were significantly different between patients with n-DVT and c-DVT and between patients with n-DVT and p-DVT (p<0.05, respectively). The cut-off value for estimating the presence of DVT and p-DVT was 3.9 µg/mL and 18.5 µg/mL, respectively.

CONCLUSION

D-dimer value assessment after 2 weeks may be associated with the presence and the location of DVT in patients with ICH.

Correlation between the degree of left subclavian artery stenosis and the left vertebral artery waveform by pulse Doppler ultrasonography

BACKGROUND

Development of retrograde blood flow may be observed in the vertebral artery and is associated with progressive ipsilateral proximal subclavian or innominate artery stenosis. The subclavian steal phenomenon is more prevalent in the left subclavian artery (LSA). The purpose of this study was to analyze the correlation between the degree of LSA stenosis and pulse Doppler waveforms of the left vertebral artery (LVA).

METHODS

A retrospective analysis of LVA waveforms was performed in 22 cases with LSA proximal stenosis before the origin of the LVA in conventional angiograms. The degree of LSA stenosis was classified into 5 groups (<50, 50-59, 60-69, 70-89, 90-100%). Pulse Doppler waveforms of the LVA were also classified into 5 subtypes depending on the depth of the mid-systolic notch representing retrograde blood flow (normal, mid-systolic notch, retrograde flow smaller than antegrade flow, retrograde flow larger than antegrade flow, retrograde flow without antegrade flow).

RESULTS

A statistically significant correlation (R(2) = 0.646, p < 0.0001) was found between the degree of LSA stenosis and the LVA waveform.

CONCLUSIONS

The pattern analysis of LVA pulse Doppler waveforms seems to be useful in determining the degree of LSA stenosis.

Morphological classification of mobile plaques and their association with early recurrence of stroke

BACKGROUND

The present study investigated the frequency and morphological characteristics of carotid mobile plaques and examined the relationship between carotid mobile plaques and recurrent strokes.

METHODS

The study included 94 consecutive acute stroke patients with large-artery atherosclerosis associated with extracranial carotid stenosis. We investigated the presence of mobile plaques by carotid ultrasonography and classified patients into two groups (mobile group and non-mobile group). We compared backgrounds, MRI and ultrasonographic findings, neurological severity on admission and at discharge, and the rate of early recurrent stroke between both groups.

RESULTS

Mobile plaques were detected in 12 patients (12.8%). There were four types of mobile plaques: (1) the jellyfish-type plaque, in which the fibrous cap fluctuated like a jellyfish; (2) the streaming-band-type plaque, in which the string attached to the plaque was swaying; (3) the mobile-thrombus-type plaque, in which a mobile mass was attached to the plaque surface, and (4) the fluctuating-ulcer-type plaque, which contained a mobile substance in the plaque ulcer. Although National Institutes of Health Stroke Scale (NIHSS) scores on admission were less severe in the mobile group than in the non-mobile group (median 1 vs. 4, respectively; p = 0.004), the rate of early recurrent stroke was significantly higher in the mobile group than in the non-mobile group (33.3 vs. 7.3%, respectively; p = 0.022). There were no significant differences in NIHSS scores at discharge between groups.

CONCLUSIONS

Morphologically, several types of mobile plaques were detected in consecutive patients with acute stroke associated with carotid stenosis. Mobile plaques are strongly associated with an early recurrence of stroke.

[A case of brain infarction and thoracic aortic dissection without chest nor back pain diagnosed by carotid duplex ultrasonography]

A 63-year-old man was admitted because of sudden transient consciousness disturbance and left-side hemiparesis 110 minutes after the onset. Typical symptoms of aortic dissection, such as chest pain, back pain, neck pain, laterality of blood pressure or hypotension were not found. Brain magnetic resonance imaging (MRI) showed multiple acute brain infarction of the right middle cerebral artery territory. Carotid duplex ultrasonography demonstrated a subintimal dissection with a false channel of the right common carotid artery (CCA) and the right internal carotid artery (ICA). Thoracoabdominal computed tomographic (CT) scan demonstrated the false lumen in ascending and descending thoracic aorta. Cervical CT scan showed a dissection with a false channel of the right CCA. Intravenous administration of recombinant tissue plasminogen activator (rt-PA) is a contraindicant therapy in patients of brain infarction with aortic dissection. Thus our patient showed thoracic aortic dissection with extension of the dissection toward the right internal carotid artery. And the patient complained of neither the pain in the chest, the back nor the neck. So we emphasize the necessity of carotid duplex ultrasonography examination before intravenous administration of rt-PA in the treatment of the cerebral infarction, regardless of having chest pain, back pain, neck pain or not.

[Case with multiple brain infarcts due to calcified emboli from a calcified atheroma of the innominate artery]

A 75-year-old-woman was admitted to our hospital because of acute brain infarction with symptoms of vertigo, conjugate deviation of the eyes, speech disturbances, left hemiparesis, and right limb ataxia. On admission, diffusion-weighted MR imaging revealed a high-intensity area in the right internal carotid artery (ICA) and vertebrobasilar (VB) territories. MRA showed normal intracranial arteries. Ultrasonography with a sector probe (2MHz) showed a mobile mass with an acoustic echo in the innominate artery. Contrast-enhanced computed tomography showed a calcified mass in the innominate artery. Despite full-dose antithrombotic therapy, recurrent attacks could not be prevented. Replacement of the innominate artery was performed by cardiac surgeons, and a ruptured calcified plaque was found in the innominate artery. Subsequent, computed tomography of the brain showed calcified emboli in the right ICA and VB territories. Arterial ultrasonography appears to be very useful in evaluating the innominate artery. On finding calcified emboli, an embolic source should be searched for in the aorta, heart valves, and the innominate artery. When infarcts with calcified emboli are found only in the right ICA and VB territories, the innominate artery should be explored by ultrasonography for the presence of a calcified atheroma.

Polymorphisms in the lymphotoxin alpha gene and the risk of ischemic stroke in the Japanese population. The Fukuoka Stroke Registry and the Hisayama Study

BACKGROUND AND PURPOSE

Lymphotoxin alpha (LTA), one of the tumor necrosis factor family proteins, is an important proinflammatory cytokine and appears to play a putative role in the inflammatory process of atherosclerosis. Recent genetic studies have suggested that variations in the gene encoding LTA, which affect its expression and biological function, may contribute to the development of vascular diseases. We conducted a case-control study to clarify the association of LTA gene polymorphisms with ischemic stroke in a large Japanese population.

METHODS

Genotyping for LTA A252G and C804A polymorphisms was achieved by a rapid-cycle polymerase chain reaction and melting curve analysis using fluorescent probes in 1,044 incident cases of ischemic stroke recruited from the Fukuoka Stroke Registry and 1,044 age- and sex-matched control subjects recruited from the Hisayama Study.

RESULTS

The overall distribution of allele and genotype for each polymorphism was similar between stroke patients and control subjects. The allele frequencies of 252G and 804A were slightly lower in stroke patients than in control subjects; however, conditional logistic regression analysis adjusted for potential risk factors found no association between the risk of ischemic stroke and either polymorphism. In terms of stroke subtype, we also found no association of these polymorphisms with any subtypes of ischemic stroke.

CONCLUSIONS

Neither the A252G nor C804A polymorphism of the LTA gene was associated with stroke overall and any subtypes of ischemic stroke in the Japanese population.

NAD(P)H oxidase p22phoxC242T polymorphism and ischemic stroke in Japan: the Fukuoka Stroke Registry and the Hisayama study

The C242T polymorphism of p22phox, a component of NAD(P)H oxidase, may have an impact on cardiovascular diseases; however, the association between this polymorphism and brain infarction is not fully understood. Here, we investigate the relationship between the C242T polymorphism and brain infarction in Japan. We recruited 1055 patients with brain infarction and 1055 control subjects. A chi-squared test revealed that the T-allele frequency was lower in patients with cardioembolic infarction (5.6%) than in control subjects (11.0%, P < 0.001); however, allele frequencies in patients with lacunar and atherothrombotic infarction (11.2%) were not significantly different from those in control subjects (11.0%). A multivariate-adjusted conditional logistic regression analysis also revealed no association between CT + TT genotype, and lacunar and atherothrombotic infarction (odds ratio = 0.97, 95% confidence interval: 0.72-1.32). To investigate the functional effects of the C242T polymorphism, we examined superoxide production in COS-7 cells cotransfected with Nox4 and p22phox of each genotype. The superoxide-producing activity in those cells expressing p22phox with the T allele was not significantly different from that in cells expressing p22phox with the C allele. The present results suggest that the p22phox C242T polymorphism may have a protective effect against cardioembolic infarction, but is not related to lacunar and atherothrombotic infarction in Japan.

[A case of spinal cord infarction caused by cervical disc herniation]

A 40-year-old previously healthy female was diagnosed with acute progressive paraparesis. Neurological examination revealed bilateral four-limb weakness predominant in the distal part of the upper limbs and superficial sensory impairment below the cervical region. T2-weighted image on MRI showed an area of hyperintensity in the gray matter of the cervical cord with disc herniation at the C4/C5 vertebral level. Laboratory investigation showed no evidence of infections, autoimmune, inflammatory, or neoplastic causes. A follow-up MRI study 3 days after admission showed that the region of hyperintensity was had enlarged without contrast enhancement. Spinal angiography was performed 21 days after admission and demonstrated that the anterior spinal artery originated from the fourth segment of the left vertebral artery and occluded at the level of C4/C5, which coincided with the location of disc herniation. We hypothesized that she developed anterior spinal artery syndrome which caused disc herniation. Although we frequently encountered disc herniation, there are few cases developed spinal cord infarction. We discuss the etiology and pathogenetic relation between disc herniation and spinal cord infarction.

[A case of the spontaneous dissection of the bilateral internal carotid arteries diagnosed by the transoral carotid ultrasonography (TOCU)]

A 56-year-old-man was admitted to our hospital because of acute brain infarction with symptoms of consciousness disturbance and left hemiparesis. After admission, the symptoms disappeared rapidly. MRI diffusion-weighted image on day one revealed high intensity area at the right insular cortex and MRA showed stenosis of the right middle cerebral artery. MRA on the next day demonstrated that the stenotic lesion improved, but another stenosis appeared at the petrous portion of the right internal carotid artery (ICA). Brain angiography on day eight showed improvement of the stenosis of the right ICA petrous portion and stenosis of bilateral ICAs extracranial distal portion. The transoral carotid ultrasonography (TOCU) on day nine showed clearly true lumen and false lumen at the bilateral extracranial distal ICAs, which indicated spontaneous dissection of the bilateral extracranial distal ICAs. TOCU seems very useful in evaluating the extracranial carotid arterial dissection.

Quantitative analysis of neurofibrillary pathology in a general population to reappraise neuropathological criteria for senile dementia of the neurofibrillary tangle type (tangle-only dementia): the Hisayama Study

Senile dementia of the neurofibrillary tangle type (SD-NFT) is characterized by numerous neurofibrillary tangles (NFT) in the hippocampal region and the absence or minimal presence of senile plaques throughout the brain. We analyzed 207 demented subjects and 68 non-demented subjects autopsied in the Hisayama study to investigate the clinicopathological aspects of SD-NFF in the general Japanese population. The prevalence of SD-NFT in the consecutive autopsy cases was 8/207 (3.9%), comprising three men and five women. The average age at onset and death was 83.8 +/- 6.8 (mean +/- SD; standard deviation) and 88.1 +/- 7.6 years, respectively. A mild memory disturbance preceded a decrease in the ability to undertake the activities of daily living and the diagnosis of dementia. Focal cerebral symptoms, such as aphasia and paralysis, did not appear during the disease course of any subject. Gross examination of the brains showed moderate to severe diffuse cerebral atrophy with brain weight loss (mean +/- SD; standard deviation: 1118.1 +/- 124.0 g). Histologically, there were abundant NFT and neuropil threads predominantly in or limited to the limbic cortex. The density of NFT in the CA1/subiculum in SD-NFT was much higher than the densities in the other hippocampal regions. The average density of NFT in CA1 in SD-NFT subjects was 115.4 per 100 x field (range 23-247), that in Alzheimer disease (AD) subjects was 80.1 (range 1-227), and that in non-demented elderly subjects was 37.2 (range 0-203). Although many previous papers have reported that the densities of NFT in the limbic system in SD-NFT were significantly higher than those in AD, there was considerable overlap of NFT densities in CA1 among the non-demented elderly, AD subjects and SD-NFT subjects.

C-Reactive Protein and Risk of First-Ever Ischemic and Hemorrhagic Stroke in a General Japanese Population

Background and Purpose— The role of high-sensitivity C-reactive protein (hsCRP) in the development of stroke is not clearly understood. We investigated the relationship between serum hsCRP levels and stroke occurrence in a general Japanese population.

Methods— We followed 2692 subjects ≥40 years of age for 12 years. The relative risks and 95% CIs for ischemic and hemorrhagic stroke occurrence were calculated according to the hsCRP quintiles.

Results— During the follow-up, 129 first-ever ischemic and 59 hemorrhagic strokes occurred. In men, the age-adjusted incidence of ischemic stroke significantly increased with elevated serum hsCRP levels; the difference between the first and fifth quintiles was statistically significant (1.4 versus 6.6 per 1000 person-years; P =0.02). This association remained significant even after adjustment for other confounding factors, such as age, systolic blood pressure, ECG abnormalities, diabetes, body mass index, total cholesterol, high-density lipoprotein cholesterol, smoking habits, alcohol intake, and regular exercise (adjusted relative risks, 3.11; 95% CI, 1.04 to 9.32; P =0.04). However, such associations were not observed for ischemic stroke in women or in hemorrhagic stroke in either sex. Among male subjects who were both in the fifth hsCRP level and had hypertension, diabetes, obesity, hypercholesterolemia, or a smoking habit, the risk of ischemic stroke was extremely increased, even after adjustment for other risk factors.

Conclusions— Our findings suggest that elevated serum hsCRP levels are an independent risk factor for future ischemic stroke in Japanese men and that the coexistence of a high hsCRP level with another risk factor extremely increases the risk of ischemic stroke.

Elevated C-reactive protein is a predictor of the development of diabetes in a general Japanese population: the Hisayama Study

OBJECTIVE

We examined the association between high-sensitivity C-reactive protein (CRP) levels and the development of diabetes in a general Japanese population.

RESEARCH DESIGN AND METHODS

A total of 1,759 Japanese subjects, aged 40-79 years and without diabetes (according to American Diabetes Association fasting criteria), were stratified into three groups according to CRP tertiles by sex and followed up prospectively for a mean of 9.0 years.

RESULTS

During the follow-up, 131 subjects (67 men and 64 women) developed diabetes. In both sexes, the age-adjusted cumulative incidence of diabetes increased significantly as the tertiles of CRP levels increased. In multivariate analyses, the risk of developing diabetes was significantly higher in the highest CRP tertile than in the lowest after adjustment for a number of confounding factors (odds ratio 2.63 [95% CI 1.23-5.65] for men and 2.25 [1.01-5.01] for women). In stratified analyses, this CRP-diabetes association was stronger in subjects without obesity or other risk factors related to insulin resistance and in nondrinking subjects.

CONCLUSIONS

Our findings suggest that elevated CRP concentration is a significant predictor of diabetes in the general Japanese population, independent of obesity and insulin resistance.

Chronic kidney disease and cardiovascular disease in a general Japanese population: the Hisayama Study

BACKGROUND

Chronic kidney disease has been shown to be an independent risk factor for cardiovascular disease in high-risk populations. However, this relationship is inconclusive in community-based populations.

METHODS

To clarify this issue, we followed 2634 community-dwelling individuals without cardiovascular disease, aged 40 years or older, for 12 years and examined the relationship between chronic kidney disease and the incidence of cardiovascular disease.

RESULTS

During the follow-up period, 99 subjects (56 men and 43 women) experienced coronary heart disease, 137 subjects (60 men and 77 women) ischemic stroke, and 60 subjects (26 men and 34 women) hemorrhagic stroke. In men, the age-adjusted incidence of coronary heart disease was significantly higher in subjects with chronic kidney disease than in those without it (6.2 vs. 2.9 per 1000 person-years) (P < 0.05), but such a relationship was not observed with ischemic stroke. In contrast, in women, the age-adjusted incidence of ischemic stroke was significantly higher in subjects with chronic kidney disease than in those without it (3.4 vs. 2.5) (P < 0.05), while that of coronary heart disease was not. Chronic kidney disease was not found to be associated with the incidence of hemorrhagic stroke. In multivariate analysis, even after adjustments for traditional and nontraditional cardiovascular disease risk factors, chronic kidney disease was found to be an independent risk factor for the occurrence of coronary heart disease in men [hazard ratio (HR), 2.26; 95% CI, 1.06-4.79], and for the occurrence of ischemic stroke in women (HR, 1.91; 95% CI, 1.15-3.15).

CONCLUSION

Our findings suggest that chronic kidney disease is an independent risk factor for the occurrence of cardiovascular disease in the general Japanese population.

Intracerebroventricular injection of tumor necrosis factor-alpha induces thermal hyperalgesia in rats

To investigate the role of tumor necrosis factor-alpha (TNF-alpha) in the brain in nociception, we injected recombinant human TNF-alpha (rhTNF-alpha; 1 pg-10 ng/rat) into the lateral cerebroventricle (LVC) in rats and observed the changes in paw withdrawal latency to radiant heat by using the plantar test for 90 min after injection. LCV injections of TNF-alpha at doses of 10 pg, 100 pg and 1 ng reduced paw withdrawal latency, showing a maximal response at a dose of 10 pg which peaked 60 min after injection. TNF-alpha at doses of 1 pg and 10 ng had no effect on nociception during the test period. The TNF-alpha (10 pg)-induced reduction in paw withdrawal latency was blocked by simultaneous injection of diclofenac (1 ng), a cyclooxygenase inhibitor, or interleukin-1 receptor antagonist (IL-1 ra, 10 ng). LCV injection of neither diclofenac (1 ng) nor IL-1 ra (10 ng) had any effect on nociception by itself. The results suggest that TNF-alpha in the brain induces thermal hyperalgesia and that the brain TNF-alpha-induced hyperalgesia is mediated by the central action of interleukin-1 and activation of the cyclooxygenase pathway of the arachidonate.