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Background: When severe aortic stenosis (AS) is concomitant with carotid stenosis, carotid artery stenting (CAS) will become a high-risk procedure because baroreceptor reflex-induced bradycardia and hypotension may cause irreversible circulatory collapse. When carotid stenosis-related misery perfusion is present, the risk of cerebral hyperperfusion syndrome increases after carotid revascularization. We report a case of severe carotid disease concomitant with severe AS successfully treated by a combination of staged angioplasty (SAP) and transcatheter aortic valve implantation (TAVI). Case Description: An 86-year-old man presented with transient deterioration of mental status and sluggish responsiveness continuous from the previous day. Magnetic resonance imaging of the brain revealed a right putaminal infarction, occlusion of the right internal carotid artery (ICA), and severe stenosis of the left ICA. Severe AS was diagnosed and single-photon emission computed tomography showed misery perfusion at the bilateral ICA territories. We performed a staged treatment consisting of SAP for the left carotid stenosis and TAVI. A first-stage carotid angioplasty was performed, followed by TAVI 2 weeks later and second-stage CAS 1 week after that. There were no apparent periprocedural complications throughout the clinical course. Conclusion: Combining SAP and TAVI may be an effective treatment option for severe carotid stenosis with misery perfusion concomitant with severe AS.

Cortical damage in areas such as the frontal lobe is reported in amyotrophic lateral sclerosis (ALS). However, aside from executive dysfunction, the pathological significance of this cortical damage has yet to be clarified. The present study investigated the effects of cortical damage on vestibular function in ALS.Subjects comprised 18 ALS patients and 18 age- and sex-matched healthy controls. Cold air caloric stimulation was performed in all subjects to induce vestibular nystagmus, which was analysed to evaluate vestibular function. Visual suppression testing to investigate the suppressive effects of visual stimuli on vestibular nystagmus was expressed as suppression rate (SR, %). Executive function was tested using the frontal assessment battery (FAB).Suppression rate and FAB score were significantly lower in the ALS group than in the control group (p 0.01 each). A positive correlation was also observed between SR and FAB score (R = 0.65, p = 0.023).Visual suppression testing showed significant damage to the central nervous system vestibular control mechanisms, which utilize visual information in the ALS group and a positive correlation between SR and FAB score suggest a relationship between frontal lobe damage and impaired vestibular control. A simple vestibular function test may be useful as a tool to objectively monitor the progression of cerebral lesions in ALS.

CLIPPERS (chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids) is an inflammatory central nervous system disorder that gives rise to brainstem symptoms such as diplopia and articulatory disorders. It shows characteristic "salt-and-pepper" enhancing brainstem lesions on magnetic resonance imaging (MRI) scans. We present an unusual case of CLIPPERS, in which a 29-year-old man initially presented with a seizure. Brain MRI revealed faint open-ring enhancements in the right frontal lobe, and a brain biopsy was performed to make a definitive diagnosis. Immunohistological tests showed perivascular infiltration by primarily CD3- and CD20-positive cells, albeit including a few CD68-positive cells, which confirmed a diagnosis of CLIPPERS. Both the symptoms and the MRI findings were markedly improved by 3 courses of steroid (methylprednisolone) pulse therapy, followed by oral steroid (prednisolone) administration. This case shows that CLIPPERS can present as a phenotype of cortical lesions and seizures as the first signs. A brain biopsy should therefore be actively carried out for differential diagnosis, especially when other, cortically based inflammatory disorders are suspected.