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A 79-year-old-man with a clinical history of type 2 diabetes and hypertension was admitted to our hospital for recurrent right hemiparesis. He was referred to our department with left internal carotid artery stenosis. Cerebral angiography with a slight contrast agent revealed NASCET 86% stenosis at the left internal carotid bifurcation. Although no neurological deficit was observed, he had a renal dysfunction with an estimated glomerular filtration rate of 32.2 ml/min/1.73 m

Barre-Lieou syndrome (BLS) is a manifestation of various autonomic and secondary symptoms including muscle stiffness, tinnitus, dizziness, and pain in various body parts. Although considered to be caused by hyperactivation of the autonomic nervous system due to trauma, there is currently no firmly established etiology or evidence on the treatment and clinical features of BLS. We retrospectively examined the clinical features of BLS and evaluated the efficacy of trazodone (TZD) for its treatment. We conducted a retrospective analysis of the data of 20 consecutive cases with suspected BLS who were treated in our hospital between 2016 and 2019. BLS symptoms were rated on a 10-point scale, and two groups were defined, that is, a mild-BLS group (BLS scores, 1-5) and a severe-BLS group (BLS scores, 6-10). Univariate analysis of patient factors was performed. The BLS score was 6.0 ± 1.7, and the maximum TZD dose was 80 ± 34 mg/day; nine patients (45%) were TZD free, and no TZD side effects were observed, while all patients had a good clinical outcome. There were significant differences between the mild-BLS and severe-BLS groups in the period from injury to diagnosis (p = 0.015), chest/back pain (p < 0.001), constipation (p = 0.001), and maximum TZD dose (p = 0.008). BLS involves posttraumatic autonomic symptoms accompanied by depression and insomnia. The sympathetic hypersensitivity theory could explain its etiology. TZD could effectively and safely treat BLS, and early diagnosis and treatment can contribute toward good clinical outcomes. Enhanced recognition and understanding of this disease are warranted.

Background: Patients with both nonrheumatoid retro-odontoid pseudotumors (ROPTs) and congenital craniocervical junction (CCJ) abnormalities are rare. Here, a 73-year-old female presented with neck pain and myelopathy due to MR-documented ROPT with intramedullary hyperintensity at the CCJ warranting an occipital-cervical fusion. Case Description: A 73-year-old female originally developed occipitalgia and became quadriparetic within the subsequent 7 months. The cervical MR showed a ROPT with intramedullary hyperintensity at the CCJ. Further, the CT demonstrated C1 occipitalization and a congenital C2-3 fusion without radiological instability. After she underwent an occipito-C2 fusion, her symptoms improved. Conclusion: For patients with C1 occipitalization and a Klippel-Feil syndrome, ROPT may occur due to loading of C1-2 complex. These patients typically favorably respond to occipito-C2 fusion.

Primary central nervous system lymphoma (PCNSL) is a rare malignant tumor of the central nervous system. It is associated with poor prognosis. Early diagnosis and subsequent planning of adequate treatment strategy are relevant to improve survival and reduce neurological deficit. Specifically, there are no reports of successful endoscopic biopsy for PCNSL of the corpus callosum in the splenium with bilateral visuomotor ataxia. An 74-year-old woman presented to our hospital with anorexia, depression and ataxia beginning six months earlier. Head computed tomography and magnetic resonance imaging showed malignant tumor suspected in the corpus callosum. Endoscopic biopsy was performed via the low parieatal approach, suspecting GBM or PCNSL. She had no new postoperative neurological deficits and was pathologically diagnosed with diffuse large B-cell lymphoma (DLBCL). She is currently undergoing radiation chemotherapy with a modified Rankin Scale score of 2. Regarding preoperative symptoms, ataxia was considered to be bilateral visuomotor ataxia caused by damage to the corpus callosum in the splenium, and anorexia and depression were considered symptoms of the surrounding limbic system. Delay in the diagnosis of PCNSL can lead to a poor prognosis. Visuomotor ataxia should also consider the potential for the corpus callosum in the splenium lesion, including PCNSL, and appropriate imaging and pathological diagnosis with endoscopic biopsy can contribute to a good clinical outcome.

Barré-Lièou syndrome is a manifestation of various autonomic and secondary symptoms, such as muscle stiffness, tinnitus, dizziness, and pain in the head, neck, eyes, throat, ears, chest, and back. While thought to be caused by hyperactivation of the autonomic nervous system due to trauma, there is currently no firmly established etiology. This, and the nonspecific nature of many of its symptoms, presents a challenge both for clinicians, who must provide a correct diagnosis and patients, who are often misdiagnosed or faced with undue scrutiny from insurance companies. Here, we present two cases of Barré-Lièou syndrome, focusing on the processes leading to diagnosis, treatment, and problems encountered. Case 1 involves a 68-year-old woman whose head computed tomography (CT) scan revealed no abnormalities following a car accident. Approximately 10 months after her initial injury, Barré-Lièou syndrome was suspected because of autonomic symptoms that developed over time. She was prescribed an α-blocker, and 9 months later, her symptoms subsided. Case 2 was a 69-year-old woman who presented with bruising to the right chest and right knee after colliding with a car while riding her bicycle. One month later, Barré-Lièou syndrome was suspected because of her autonomic symptoms. She was prescribed an α-blocker, and 17 months later, her symptoms subsided. Because of the characteristic autonomic and secondary symptoms described above and a positive response to α-blockers, Barré-Lièou syndrome was suspected in both cases. We believe reporting cases will aid in the understanding of this disease and help patients obtain positive outcomes.

We present a case of a patient with drug-induced hypersensitivity syndrome (DIHS) caused by salazosulfapyridine combined with syndrome of inappropriate secretion of antidiuretic hormone (SIADH) caused by interstitial pneumonia (IP). A 67-year-old man with a past history of rheumatism (RA) presented with right hemiparalysis and aphasia as the chief complaints. A diagnosis of left embolic cerebral infarction following trial therapy for RA based on computed tomography findings was made, and external decompression was performed. Salazosulfapyridine was newly started on day 7. Dabigatran was started on day 37. On day 41, the patient developed fever. On day 42, edema and erythema appeared on his face, and erythema and rash appeared on his trunk and extremities, with gradual transition to erythroderma. The drug eruption was initially attributed to the dabigatran. Various symptoms of organ dysfunction (enteritis, myocarditis, interstitial pneumonia, hepatic disorder, stomatitis, and others) then appeared and persisted; hence, a diagnosis of DIHS associated with human herpes virus 6 and cytomegalovirus infection induced by salazosulfapyridine was suggested, and the oral administration of salazosulfapyridine was discontinued on day 53. Hyponatremia was observed in association with exacerbation of IP. Due to low serum osmotic pressure and prompt improvement of the serum sodium level by fluid restriction, the SIADH was attributed to IP. In this case, steroid pulse therapy followed by gradual decrease therapy prevented worsening of the condition.

There are few reports of pituitary adenomas (PA) mimicking dementia. Delay in disease diagnosis and treatment may result in poor clinical outcome. We experienced a rare case where endoscopic transsphenoidal surgery (eTSS) effectively treated a gonadotroph adenoma mimicking dementia and report on literature considerations. We report the case of a 72-year-old man with chief complaints of cognitive decline, bradykinesia, anorexia, dressing apraxia, and vigor decline over several months. He was admitted to our hospital for scrutiny in a disoriented state. Blood tests showed hyponatremia and thyroid hormone depression. Magnetic resonance imaging showed a pituitary tumor, and preoperative endocrine stress tests showed reduced reactivities of growth hormone, adrenocorticotropic hormone/cortisol, and luteinizing hormone/follicle-stimulating hormone. Symptomatic pituitary adenoma was suspected, and eTSS was performed. The permanent pathological diagnosis was of gonadotroph adenoma. Postoperatively, the hyponatremia, cognitive decline, movement retardation, loss of appetite, dressing apraxia, and limb edema markedly improved. The patient was discharged under hydrocortisone 15 mg/day administration without complications. The endocrine stress test performed 2 months postoperatively showed secondary hypoadrenocorticism, while the other endocrine functions had normalized. No recurrence had occurred by 30 months postoperatively; the medication of hydrocortisone was gradually discontinued and the patient at the time was still being followed as an outpatient with modified Rankin Scale score 0. Secondary hypothyroidism and secondary hypoadrenocorticism due to the pituitary tumor primarily caused the condition. It is important to consider PA in the differential diagnosis of dementia, and early diagnosis and treatment can contribute to a patient's good clinical outcome.

Aspirin–clopidogrel dual antiplatelet therapy and a proton-pump inhibitor are used worldwide to prevent thromboembolism and peptic ulceration in patients undergoing neurointervention. We performed VerifyNow assays (Accumetrics, San Diego, CA, USA) to retrospectively examine the relationship between the effectiveness of antiplatelet agents and different proton-pump inhibitor types. Sixty-four patients with unruptured intracranial aneurysm scheduled for neurointervention received aspirin–clopidogrel dual antiplatelet therapy plus the proton-pump inhibitor lansoprazole (n = 34) or esomeprazole (n = 30). A low response to aspirin and clopidogrel was defined in terms of aspirin reaction units > 550 and P2Y12 reaction units ≥ 230, respectively, by VerifyNow assay. The characteristics, response to antiplatelet therapy, and clinical outcomes were compared in patients treated with lansoprazole or esomeprazole. The preoperative mean VerifyNow aspirin reaction units and P2Y12 reaction units were 466.0 ± 67.3 and 205.0 ± 67.6, respectively. The mean aspirin reaction unit value was 482.0 ± 64.1 in the lansoprazole group, and 461.5 ± 70.9 in the esomeprazole group (p = 0.77). The mean P2Y12 reaction unit was 220.0 ± 64.4 in the lansoprazole group, and 174.5 ± 65.0 in the esomeprazole group; there was a significant difference in the clopidogrel response of patient treated with lansoprazole or esomeprazole (p = 0.005). Our VerifyNow assay results suggest that when on lansoprazole fewer patients achieved the therapeutic goal and required extra therapy before neurointervention.

Paroxysmal sympathetic hyperactivity (PSH) is a clinical condition characterized by abnormal paroxysmal surges in sympathetic nervous system activity. PSH is known to occur after severe head injury and hypoxic encephalopathy. Cases of PSH that develop after stroke have been reported worldwide; however, PSH is not commonly reported in the field of stroke research in Japan. Some studies have suggested that gabapentin may improve the symptoms of PSH. To our knowledge, this is the first case report demonstrating the efficacy of trazodone for the treatment of PSH that developed after thalamic hemorrhage. A 45-year-old woman presented to our clinic with headache and paralysis of the left side of her body after experiencing right thalamic hemorrhage; a conservative treatment was initiated at our hospital. Immediately upon hospitalization, she developed high fever, tachycardia, tachypnea, constipation, and overactive bladder and had breathing difficulties. Blood sampling revealed elevated levels of myocardial escape enzymes; however, coronary angiography did not show any significant stenosis or occlusion. The patient's symptoms improved after the administration of trazodone. She was diagnosed with catecholamine cardiomyopathy associated with PSH after intracranial hemorrhage and was subsequently transferred to a recovery and rehabilitation hospital unit where the oral administration of trazodone continued. Prolonged PSH contributes significantly to the impairment of daily activities in patients with stroke; therefore, early diagnosis and treatment are critical. Here, we report on the efficacy of trazodone as an effective treatment option for improving clinical outcomes and reducing the stay in the stroke care unit.

Background Cranial artery dolichoectasia is characterized by dilated, elongated, and tortuous cranial arteries. Dolichoectasia and dolichoectatic aneurysm—particularly of the internal carotid arteries (ICAs)—are rare but can lead to stroke. We report a case of suspected recurrent acute cerebral infarction and dolichoectatic aneurysm of the left ICA combined with right dolichoectatic aneurysm, vertebrobasilar dolichoectasia, and atrial fibrillation. Case Description An 80-year-old man experienced 3 days of recurrent aphasia episodes. He had a history of atrial fibrillation and hypertension. Neurologic findings indicated Wernicke aphasia. Magnetic resonance imaging showed acute cerebral infarction in the left temporal and parietal lobes. Magnetic resonance angiography and cerebral angiography showed dolichoectatic aneurysms in the C1-2 portion of the bilateral ICAs and vertebrobasilar dolichoectasia. Possible diagnoses included convulsion, cardioembolic infarction, atherothrombotic cerebral infarction, and acute ischemic stroke associated with the dolichoectatic aneurysm of the left ICA. Oral antiplatelet drugs, direct oral anticoagulants, and anticonvulsants were administered. Nine months after initial hospitalization, the patient had a recurrence of acute ischemic stroke and was rehospitalized. He was treated with a new direct oral anticoagulant, clopidogrel, statins, and ethyl icosapentate. At 2 years after initial hospitalization, he has had no recurrence of stroke, has a modified Rankin Scale score of 2, and is currently being followed as an outpatient. Conclusions A direct oral anticoagulant (edoxaban) and clopidogrel were effective for suspected recurrent acute ischemic stroke associated with dolichoectatic aneurysm of the ICA combined with contralateral dolichoectatic aneurysm, vertebrobasilar dolichoectasia, and atrial fibrillation.

Background Intracranial pseudoaneurysm is a rare complication of endoscopic endonasal surgery. Herein, we describe 2-staged stent-assisted coil embolization for posterior communicating artery pseudoaneurysm after endoscopic endonasal surgery for pituitary adenoma. Case Description A 68-year-old man had a history of severe adult growth hormone secretion deficiency, requiring growth hormone replacement therapy; secondary adrenocortical hypofunction; hyperthyroidism; hypertension; constipation; glaucoma; and hyperuricemia. Five years ago, after initial endoscopic transsphenoidal surgery for pituitary adenoma, he was hospitalized for reoperation. Posterior communicating artery injury was observed during second endoscopic transsphenoidal surgery, and pressure hemostasis was performed using a hemostatic preparation. Immediately post surgery, a localized subarachnoid hemorrhage was observed. Sudden-onset impaired consciousness and respiratory disturbances ensued on postoperative day 7, and computed tomography of the head was performed. Recurrent subarachnoid hemorrhage was confirmed, and acute hydrocephalus secondary to third ventricular blockage was identified. Cerebral angiography was performed after urgent bilateral cerebral ventricular drainage under general anesthesia. A pseudoaneurysm was identified in the left posterior communicating artery, and coil embolization was performed. Six weeks post surgery, a low-profile visualized intraluminal stent called an LVIS Jr. stent was placed in the posterior communicating artery. Recurrence of the aneurysm was not detected 6 months post surgery. He underwent lumboperitoneal shunting for secondary normal pressure hydrocephalus after dual antiplatelet therapy discontinuation and is being followed up as an outpatient with a modified Rankin scale score of 2 ten months post surgery. Conclusions Two-staged stent-assisted coil embolization using a low-profile visualized intraluminal stent was effective for a posterior communicating artery pseudoaneurysm occurring after posterior communicating artery injury following endoscopic transsphenoidal surgery for follicle-stimulating hormone-producing pituitary adenoma.

Purpose: In this retrospective study, we investigated the status and validity of endoscopic transsphenoidal surgery (eTSS) for pituitary incidentalomas (PIs) as well as the value of basing the indication for surgery on the PI guidelines. Methods: Patients who underwent eTSS at Fukuoka University Chikushi Hospital between 2012 and 2018 were divided into the PI group and the non-PI group in accordance with the PI guideline of the Endocrine Society and their clinicopathological characteristics and outcomes were compared and analyzed. Results: A total of 59 patients were enrolled, with 35 patients in the PI group and 24 patients in the non-PI group. The diagnoses in the PI group were of non-functioning pituitary adenoma (NFPA) (n = 12, 34%), gonadotropin-producing pituitary adenoma (n = 8, 23%), Rathke cleft cyst (n = 7, 20%), meningioma (n = 4, 11%), and growth hormone-producing pituitary adenoma (n = 3, 9%); those in the non-PI group were of NFPA (n = 6, 25%), gonadotropin-producing pituitary adenoma (n = 3, 13%), Rathke cleft cyst (n = 3, 13%), growth hormone-producing pituitary adenoma (n = 3, 13%), and prolactin producing pituitary adenoma (n = 3, 13%). Regarding the preoperative factors, 1 patient in the PI group with panhypopituitarism was diagnosed with pituitary apoplexy (pure infarction) of an NFPA. The rates of postoperative anterior pituitary hormonal deficiencies (14% vs 46%, P = .015), residual tumor size (2 ± 5 vs 6 ± 7 mm, P = .008), and reoperation (n = 0, 0% vs n = 5, 21%, P = .005) were significantly different between the PI and non-PI groups. Conclusions: This study showed that, postoperatively, the incidence of anterior pituitary hormonal deficiencies was lower in the PI than in the non-PI group, although it was comparable between the 2 groups before the operation. The patients in the PI group also had smaller residual tumors and a lower risk of reoperation than those in non-PI group. PIs could have a better postoperative clinical outcome than non-PIs when the indication for eTSS is based on preoperative scrutiny according to the PI guidelines and eTSS is performed by an experienced pituitary surgeon. Hence, more aggressive scrutiny and treatment for PIs might be desirable.

Paroxysmal sympathetic hyperactivity (PSH) is a clinical condition characterized by abnormal paroxysmal surges in sympathetic nervous system activity. PSH is known to occur after severe head injury and hypoxic encephalopathy. Cases of PSH that develop after stroke have been reported worldwide; however, PSH is not commonly reported in the field of stroke research in Japan. Some studies have suggested that gabapentin may improve the symptoms of PSH. To our knowledge, this is the first case report demonstrating the efficacy of trazodone for the treatment of PSH that developed after temporal subcortical hemorrhage. A 49-year-old woman presented to our clinic with mild confusion and sensory aphasia after experiencing left temporal subcortical hemorrhage; a conservative treatment was initiated at our hospital. Immediately upon hospitalization, she developed prolonged consciousness disorder, high fever, tachycardia, malignant hypertension, tachypnea, constipation, and overactive bladder. The patient's symptoms improved after the administration of trazodone. She was diagnosed with PSH after intracranial hemorrhage and was subsequently transferred to a recovery and rehabilitation hospital unit where the oral administration of trazodone continued. Prolonged PSH contributes significantly to the impairment of daily activities in patients with stroke; therefore, early diagnosis and treatment are critical. Here, we report on the efficacy of trazodone as an effective treatment option for improving clinical outcomes and reducing the stay in the stroke care unit.

Takotsubo syndrome (TTS) is often preceded by emotional or physical stress. Epileptic seizures have been described in more than 100 TTS cases. Due to the lack of typical symptoms, seizure-induced TTS can be overlooked. Here, we describe a rare case where TTS induced by non-convulsive status epilepticus (NCSE) was diagnosed early and successfully treated. An 82-year-old man presented to our hospital with confusion, anorexia, aphagia, and abnormal behavior beginning a few days earlier. Head computed tomography and magnetic resonance imaging did not show any structural abnormalities. Upon hospitalization, blood sampling revealed elevated levels of myocardial escape enzymes; however, cardiac ultrasonography showed apical asystole, and emergency coronary angiography did not show any significant stenosis or occlusion. The patient's symptoms improved after the administration of antiepileptic drugs consisting of diazepam, fosphenytoin, and levetiracetam. On day 2 of hospitalization, an electroencephalogram showed high amplitude slow waves in the left cerebral hemisphere and NCSE-induced TTS was diagnosed. The patient was discharged after 2 weeks with a modified Rankin Scale score of 0 and continuing oral administration of levetiracetam. Delay in the diagnosis of NCSE-induced TTS can lead to a poor prognosis. Early diagnosis and treatment for NCSE and NCSE-induced TTS may result in favorable outcomes for the patient.

Background The periprocedural administration of dual antiplatelet therapy has been recommended in patients treated by carotid artery stenting. However, some patients with concurrent disease have been prescribed anticoagulants. We compared the post-operative incidence of hemorrhagic and thromboembolic events in two patient groups treated by different regimens of multi-antithrombotic agents. Methods As our 31 patients had a history of nonvalvular atrial fibrillation, they had received anticoagulants; they were also treated with aspirin and clopidogrel before carotid artery stenting. The prior anticoagulant therapy was continued in 17 patients and they received vitamin K antagonist plus dual antiplatelet therapy after the procedure (group 1). Other 14 patients underwent direct oral anticoagulant plus aspirin or clopidogrel (group 2). Post-procedural hemorrhagic and thromboembolic events were compared between two groups. Results Carotid artery stenting was angiographically successful in all patients. Complications were encountered in two group 1 patients. Post-operative image revealed a silent subarachnoid hemorrhage in one. The other presented with superior mesenteric artery occlusion 6 months after the procedure. No hemorrhagic or thromboembolic events occurred in group 2. Conclusion We concluded that the administration of a direct oral anticoagulant plus an antiplatelet agent reduced the risk for periprocedural hemorrhagic and embolic events in patients with concurrent nonvalvular atrial fibrillation who underwent carotid artery stenting.

We investigated the safety and efficacy of consciousness sedation with dexmedetomidine (DEX) during the endovascular treatment of patients with acute cerebral infarction. Between April 2014 and November 2016, 38 stroke patients underwent endovascular thrombectomy (EVT) under local anesthesia and DEX consciousness sedation. The continuous intravenous administration of low-dose DEX (0.3-0.4 μg/kg/h) was started before entering the operating room. Patients not completely immobilized received an iv bolus of pentazocine (PTZ) and/or DEX (0.5-0.6 μg/kg/h). EVT was performed using a stent retriever and/or direct thrombo-aspiration. DEX sedation was stopped as soon as the operation was finished. A stent retriever was used in 8 (21.1%), direct thrombo-aspiration in 10 (26.3%), a stent retriever plus thrombo-aspiration in 14 (36.8%), and other devices in 6 patients (15.8%). Reperfusion exceeding 50% (thrombolysis in cerebral infarction >2b) was obtained in 30 patients (78.9%). DEX sedation alone immobilized 24 patients (63.2%), 14 (36.8%) required the additional injection of DEX or PTZ when EVT devices were navigated to the lesion. The administration of DEX and PTZ elicited no significant respiratory depression or cardiac dysfunction interfering with the procedures. Consciousness sedation by DEX was effective during the endovascular treatment of acute stroke patients. Under DEX sedation and the injection of PTZ, EVT was possible without significantly changing the patients' vital signs.

Background and Purpose Because magnetic resonance imaging (MRI) focuses on the morphological characteristics of carotid artery plaques, its diagnostic value with respect to plaque vulnerability is limited. We examined the correlation between N e -(carboxymethyl)lysine (CML), a main chemical structure of advanced glycation end-products, and the vulnerability of plaques visualized on MRI scans. Materials and Methods We enrolled 43 patients who had undergone carotid artery stenting (CAS) for carotid artery stenosis; all underwent MRI studies, including black-blood MRI and diffusion-weighted imaging (DWI). The signal intensity ratio (SIR) of plaques to adjacent sternocleidomastoid muscle (P/M) on T1- and T2-weighted images (T1WI, T2WI) was calculated. Protein samples were extracted from debris trapped by a filter device. The concentrations of CML and myeloperoxidase (MPO) were measured by solid-phase enzyme-linked immunosorbent assay. Results The patients were classified into 2 groups based on their SIR-P/M on T1WI and T2WI scans. We observed a higher incidence of post-CAS DWI lesions in patients with a higher than a lower SIR-P/M on T1WI; the CML and MPO concentrations in their CAS debris were also higher. No such differences were seen in patients with a higher or lower SIR-P/M on T2WI scans. The concentration of CML in CAS debris correlated independently with the SIR-P/M on T1WI of the carotid plaques, and was related to the concentration of MPO in CAS debris. Conclusions Our findings suggest CML as a candidate molecular imaging probe for the identification of vulnerable plaques.

We report a case of rapidly progressing primary high-grade B-cell lymphoma of the central nervous system withic-Myc/itranslocation and Bcl-2 protein expression that resulted in the patient's death 45 days after the onset of convulsions. Further, we provide a literature review. CASE:A 74-year-old man was admitted to our hospital for convulsions. Magnetic resonance imaging on admission showed tumorous lesions at the left temporoparietal junction. An open biopsy was performed promptly. The patient was diagnosed with primary high-grade B-cell lymphoma of the central nervous system withic-Myc/itranslocation and Bcl-2 protein expression(50%). The tumor showed rapid progression postoperatively. The patient did not respond to steroids and died 45 days after the onset of convulsions. CONCLUSION:Theic-Myc/itranslocation, showing a strong c-Myc protein positivity, and co-expression of the Bcl-2 protein were poor prognostic factors for the tumor.

We describe a rare case of neurovascular compression syndrome (NVCS) of the brain stem and opsoclonus-myoclonus syndrome (OMS) complicated with vestibular paroxysmia (VP) and autonomic symptoms. Moreover, we discuss the case with respect to the available information in medical literature. A 36-year-old man with vertigo and nausea had difficulty standing, and was transported by an ambulance to our hospital. He had VP, opsoclonus, cervical myoclonus, anxiety, and restless legs syndrome. Magnetic resonance imaging at hospitalization showed that the dolichoectatic vertebral artery was in contact with the postero-lateral side of the pontomedullary junction. He was diagnosed with NVCS of the brain stem (most likely of the input to the vestibular nucleus) associated with contact with the dolichoectatic vertebral artery. Combination therapy using multiple antiepileptic drugs, such as low-dose carbamazepine, clonazepam, and lacosamide, improved his clinical symptoms. He was finally able to walk and was discharged on day 42 after admission. He is being routinely followed-up since then. Further research is needed to confirm the validity of the combination therapy.

We report a case of cerebral amyloid angiopathy(CAA)-related subarachnoid hemorrhage(SAH)with Parkinson's disease dementia(PDD), along with a literature review. CASE: A 67-year-old woman with a history of Parkinson's disease was diagnosed with SAH(World Federation of Neurosurgical Societies grade I). The plain head CT performed on admission, revealed an atypical hematoma distribution. Blood sampling, MRI and cerebral angiography revealed no vascular abnormalities, meningitis, encephalitis, or primary angiitis of the central nervous system. MRI performed on the third day after admission confirmed the presence of bilateral cortical or subcortical hemorrhage in the parietal lobe, with amyloid-related imaging abnormalities. A preliminary diagnosis of CAA was made, based on the Boston criteria. She was also diagnosed with PDD, based on the cognitive decline during hospitalization. CONCLUSION: Stroke related with CAA, as seen in SAH, may contribute to cognitive decline and the progression of lesions in PDD.

We describe a surgical case of aseptic meningitis and secondary hypophysitis due to rupture of a Rathke's cleft cyst(RCC)and report on literature considerations.A 36-year-old woman with a past history of menstrual irregularity who had been taking a low-dose contraceptive for five years visited our hospital. She had discomfort in her right eye four years earlier. A waxy nodule observed on MRI was diagnosed to be an asymptomatic RCC. She experienced periodic headaches and retrobulbar pain without any prior history. MRI showed dural thickening on gadolinium-T1-weighted(GdT1)imaging, disappearance of the waxy nodule on T1/T2-weighted imaging, signal change of the cyst contents, and suspected cerebrospinal fluid in the pre-pontine cistern. Aseptic meningitis or hemorrhagic adenoma due to RCC rupture was suspected, and endoscopic transsphenoidal surgery was performed on day 26. The pathological results indicated that the ruptured RCC had resulted in aseptic meningitis and secondary hypophysitis.If the rupture of an RCC is suspected and subsequent secondary hypophysitis and optic neuritis are observed, early diagnosis and surgery with informed consent are essential. This is because of the high risk for panhypopituitarism with vision loss and visual field disturbance.

Background Postoperative cerebral embolism after left upper lobectomy caused by a thrombus in the pulmonary vein stump (PVS) is a serious complication. However, it is unclear whether cerebral embolism can develop after other types of lobectomy. We present 2 cases of revascularization for in-hospital acute ischemic stroke after video-assisted thoracic surgery (VATS). Case Description Patient 1 is a 71-year-old man with a history of hypertension and dyslipidemia. VATS was performed for lung cancer in the left upper lobe. On day 0 after VATS, he developed an acute ischemic stroke (left M3 occlusion). Revascularization was performed, and TICI 2b was obtained. He was transferred to a recovery rehabilitation hospital with a modified Rankin Scale score of 3. No ischemic or hemorrhagic stroke was observed 12 months postoperatively. Patient 2 is a 76-year-old man who had a history of hypertension. VATS was performed for metastatic lung cancer in the left lower lobe. On day 6 after VATS, he developed an acute ischemic stroke (left M1 occlusion). Revascularization was performed and TICI 3 was obtained. He was transferred to a recovery rehabilitation hospital with a modified Rankin Scale score of 1. No ischemic or hemorrhagic stroke was observed 13 months postoperatively. Conclusions Postoperative PVS thrombosis causes embolisms, and dabigatran has been effective in preventing postoperative recurrences. Further study of preventive and perioperative management is necessary.

Background No reports have evaluated collateral circulation using simpler measures involving magnetic resonance imaging. Because an anterior communicating artery (A-com) is important in collateral circulation, we investigated whether the presence of an A-com affected the clinical revascularization outcomes in acute ischemic stroke (AIS) in the anterior circulation. Methods The present retrospective study included 73 patients who had undergone continuous administration of recombinant tissue plasminogen activator and revascularization for AIS in the anterior circulation from April 2014 to September 2018. The presence of an A-com was evaluated using preoperative time-of-flight magnetic resonance angiography. The patient characteristics and clinical outcomes were compared, and we investigated the influence of the presence or absence of an A-com on these clinical outcomes. The clinical outcomes were analyzed using multiple logistic regression. Results The clinical outcomes did not significantly correlate with age, sex, or occlusion location but did significantly correlate with the preoperative National Institute of Health stroke scale score, diffusion-weighted Alberta Stroke Program early computed tomography score, reperfusion >50% (thrombolysis in cerebral infarction grade >2b), and onset to recanalization time. The presence of an A-com correlated significantly with good clinical outcomes (modified Rankin scale score 0–3; P = 0.0081) and reduced mortality (P = 0.03). Multiple logistic regression predicted for significantly good clinical outcomes with the presence of an A-com (odds ratio, 17.03; 95% confidence interval, 1.85–157.10; P = 0.012). Conclusions The presence of an A-com on preoperative time-of-flight magnetic resonance angiography is a good prognostic factor for revascularization in patients with anterior circulation AIS, confirms collateral circulation, and allows for faster and safer endovascular treatment.

Background Acromegaly caused by Rathke cleft cyst (RCC) mimicking a plurihormonal pituitary adenoma (PA) is rare. Case Description We report a 71-year-old woman who presented with hyperhidrosis in 2013. Magnetic resonance imaging performed in April 2018 revealed that the patient had a pituitary tumor, and she was referred to our hospital. She presented with an acromegaly-like appearance with mild hypertrophy at her limb extremities. Preoperative blood tests, magnetic resonance imaging, and an endocrine tolerance test indicated that the patient's symptoms satisfied the diagnostic criteria for acromegaly, with a suspected diagnosis of an RCC and growth hormone (GH)-producing PA. Endoscopic transsphenoidal surgery (eTSS) was performed. Permanent pathologic diagnosis showed an RCC mimicking a plurihormonal PA, which was confirmed via immunohistochemistry. Blood sampling 2 months post surgery showed reduced GH (0.41 ng/mL) and increased insulin-like growth factor-1 (IGF-1) (356 ng/mL) levels. In addition, a postoperative endocrine tolerance test revealed a parasitic reaction of GH and secondary adrenocortical hypofunction. No RCC recurrence was found, and the GH (0.32 ng/mL) and previously increased IGF-1 (169 ng/mL) levels were normalized 12 months after eTSS. Conclusions We reported a rare case of acromegaly caused by RCC mimicking a plurihormonal PA. This case suggests that inflammation associated with RCC might be involved in the development of adenomatous cells. Postoperative clinical symptoms and elevated fibrinogen and IGF-1 levels later improved. This outcome suggested that the transient increase in IGF-1 2 months after surgery might reflect RCC-induced inflammation.

Background Black-blood magnetic resonance imaging (BB-MRI) is useful for the characterization and assessment of carotid artery plaques. The plaque-to-muscle signal intensity (SI) ratio (plaque/muscle ratio [PMR]) is used widely to evaluate plaques. However, the correlation between the PMR and the T1 relaxation time needs to be determined. We measured the T1 relaxation time of carotid plaques using T1 mapping and compared the results with the PMR on BB-MRI scans. Methods Between April 2014 and July 2015, 20 patients with carotid artery stenosis were treated by carotid artery stenting. All patients underwent preoperative magnetic resonance plaque imaging. The ratio of the plaque SI to the sternocleidomastoid muscle was calculated on T1-weighted BB-MRI scans. T1 mapping was performed in the region where the vessel was narrowest using the inversion recovery technique. The T1 relaxation time was recorded to determine whether there was a correlation with the PMR. Results The plaque T1 value was 577.3 ± 143.2 milliseconds; the PMR value obtained on BB-MRI scans was 1.23 ± .27. There was a statistically significant decrease in the T1 value as the PMR increased ( P Conclusions As the T1 relaxation time was well correlated with the PMR on BB-MRI scans, the evaluation of vulnerable plaques using the PMR was reliable and convenient.

We investigated the angiographic findings and the clinical outcomes after carotid artery stenting (CAS) using two different, eccentric filter embolic protection devices (EPDs). Between July 2010 and August 2015, 175 CAS procedures were performed using a self-expandable closed-cell stent and a simple eccentric filter EPD (FilterWire EZ in 86 and Spider FX in 89 procedures). The angiographic findings (i.e., flow impairment and vasospasm) at the level of EPDs, neurologic events, and post-operative imaging results were compared between the FilterWire EZ and the Spider FX groups. The CAS was angiographically successful in all 175 procedures. However, the angiographs were obtained immediately after CAS-detected flow impairment in the distal internal carotid artery (ICA) in 11 (6.3%) and ICA spasms at the level of the EPD in 40 cases (22.9%). The incidence of these complications was higher with FilterWire EZ than Spider FX (ICA flow impairment of 10.5% vs. 2.2%, P = 0.03; vasospasm 30.2% vs. 15.7%, P = 0.03). There were nine neurologic events (5.1%); five patients were presented with transient ischemic attacks, three had minor strokes, and one had a major stroke. New MRI lesions were seen in 25 (29.1%) FilterWire-group and in 36 (40.4%) Spider-group patients. The neurologic events and new MRI lesions were not associated with the type of EPD used. Although the ICA flow impairment may result in neurologic events, there was no significant association between the FilterWire EZ and the Spider FX CAS with respect to the incidence of neurologic events by the prompt treatment such as catheter aspiration.

A 93-year-old woman incurred a head bruise 5 days prior to presentation, and head CT revealed right subacute subdural hematoma. As she was on direct oral anti-coagulant(DOAC)treatment for non-valvular atrial fibrillation(NVAF), the DOAC administration was stopped temporarily to prevent an increase in the size of the hematoma. Dabigatran treatment was initiated after the confirmation of no change in hematoma size and the follow-up CT revealed a reduction in the hematoma. However, left upper limb paresis occurred on day 12 of dabigatran treatment and head CT revealed the onset of right chronic subdural hematoma. Emergency burr hole surgery was performed after intravenous administration of idarucizumab to neutralize the dabigatran. Her neurologic symptoms improved after the operation and no recurrence of subdural hematoma was observed even after dabigatran treatment was resumed. Dabigatran could be administered relatively safely, even for subacute intracranial hemorrhage complicated with NVAF, suggesting the possibility of the prevention of ischemic stroke. Moreover, even when intracranial hemorrhage recurred, the prompt neutralizing effect of idarucizumab, a dabigatran-specific neutralizing agent, was useful in the surgical intervention and perioperative management.

Stent-assisted coil embolization (SACE) is used to address wide-necked or complex aneurysms. However, periprocedural and/or late in-stent thrombosis (IST) elicit neurological events. We investigated the incidence and timed the development of acute IST during SACE with braided- or laser-cut stents in a retrospective study. Between May 2013 and April 2018, we evaluated 11 ISTs that occurred in the course of 185 SACE procedures (self-expandable laser-cut stent, n = 128; braided stent, n = 57). The onset of IST was measured from the time of stent placement. All 11 patients with IST were treated with anticoagulants and underwent hypertension induction. Post-procedural neurological events due to IST were also recorded. The implantation of a laser-cut stent elicited IST in 5 of 128 patients (3.9%); braided stent placements resulted in IST in 6 of 57 patients (10.5%) (P = 0.1). The mean stent diameter was significantly smaller in patients with-IST than without IST (3.0 ± 0.9 mm vs. 4.5 ± 0.7 mm, P = 0.007). The mean interval between stent placement and IST onset was 19 ± 7.7 min; it was significantly earlier for braided- than laser-cut stents (17.5 ± 4.1 min vs. 29.0 ± 4.8 min, P = 0.006). All ISTs were resolved during the procedure. Three patients experienced postoperative neurologic events. We recommend the meticulous and prolonged monitoring of images after stent placement because delayed intraoperative IST can occur especially when laser-cut stents are used.

Background Endovascular therapy has been shown to be effective in patients with acute cerebral large‐vessel occlusion, but real‐world efficacies are unknown. Methods and Results We conducted a prospective registry at 46 centers between October 2014 and January 2017. Eligible patients were those who were aged 20 years or older, with acute cerebral large‐vessel occlusion, and who were hospitalized within 24 hours of the onset. We enrolled both consecutive patients who were treated with or without endovascular therapy. Endovascular therapy included thrombectomy, balloon angioplasty, stenting, local fibrinolysis, and piercing. The primary outcome was a favorable outcome as defined by a modified Rankin Scale of 0 to 2 at 90 days after onset. Secondary outcomes were modified Rankin Scale of 0 to 1 and mortality. Safety outcomes were intracerebral hemorrhage or a recurrence of ischemic stroke. We constructed the 2242 (1121 each) propensity score–matched patients cohort based on a propensity score for endovascular therapy and estimated the adjusted odds ratio, followed by sensitivity analyses on original 2399 (1278 in endovascular therapy versus 1121 in no endovascular therapy) patients. In the propensity score–matched cohort, favorable outcomes were observed in 35.3% and 30.7% of patients in the endovascular therapy and no endovascular therapy groups, respectively ( P= 0.02). The adjusted odds ratio for the favorable outcome was 1.44 (95% confidence interval, 1.10–1.86, P =0.007). The efficacy of endovascular therapy in achieving favorable outcomes did not differ between our subgroups and in the sensitivity analyses. Conclusions Endovascular therapy decreased disabilities at 90 days in real‐world patients with acute cerebral large‐vessel occlusion. Clinical Trial Registration URL: http://www.clinicaltrials.gov . Unique identifier: NCT02419794.

Background Stent-assisted coil embolization is effective for intracranial aneurysms, especially wide-necked aneurysms; however, the optimal antiplatelet regimens for ischemic events that develop after coil embolization have not yet been established. We aimed to determine the onset time of such postoperative ischemic events and the relationship between these events and antiplatelet therapy. Methods We performed coil embolization using a vascular reconstruction stent for 43 cases of intracranial aneurysms and evaluated the incidence of postoperative ischemic events in these cases. Results Nine patients showed postoperative ischemic events during the follow-up period (13 ± 7 months). Two patients developed cerebral infarction within 24 hours. Five patients developed transient ischemic attack within 40 days while they were receiving dual antiplatelet therapy. In addition, 1 patient showed cerebral infarction 143 days postoperatively during single antiplatelet therapy, and a case of transient visual disturbance was reported 191 days postoperatively (49 days after antiplatelet therapy had been discontinued). We increased the number of antiplatelet agents in 4 of these patients. The other 5 patients were under strict observation with dual antiplatelet therapy. All these patients were shifted to single antiplatelet therapy 3-13 months postoperatively. No recurrence of ischemic events was noted. Conclusions Postoperative ischemic events are most likely to occur within 40 days postoperatively. For patients with postoperative ischemic events, additional ischemic events can be prevented by increasing the number of antiplatelet agents; subsequently, they can be shifted to single antiplatelet therapy after the risk of recurrence has decreased.

An 87-year-old man presented with extracranial vertebral artery (VA) occlusion and progressive vertebrobasilar ischemia despite maximal medical management. Cerebral angiography showed left proximal VA occlusion, termination of the right VA at the ipsilateral posterior inferior cerebellar artery, and hypoplastic bilateral posterior communicating arteries. Although the stump of the left VA ostium was not visualized, the distal patent artery was reconstituted via muscular branches from the left subclavian artery (SCA). Endovascular angioplasty with a stent for left VA occlusion was performed. The non-visualized VA ostium was extrapolated from the computed tomography angiography findings of the distal patent VA and the partial calcification of the SCA. The occluded VA was penetrated by the guide wire and revascularized by balloon angioplasty with the stent using the support of a snare wire inserted via the left brachial artery for stabilization of the guide catheter. This treatment resulted in resolution of the severe neurological findings.

Because magnetic resonance imaging (MRI) focuses on the morphological characteristics of carotid artery plaques, its diagnostic value with respect to plaque vulnerability is limited. We examined the correlation between NWe enrolled 43 patients who had undergone carotid artery stenting (CAS) for carotid artery stenosis; all underwent MRI studies, including black-blood MRI and diffusion-weighted imaging (DWI). The signal intensity ratio (SIR) of plaques to adjacent sternocleidomastoid muscle (P/M) on T1- and T2-weighted images (T1WI, T2WI) was calculated. Protein samples were extracted from debris trapped by a filter device. The concentrations of CML and myeloperoxidase (MPO) were measured by solid-phase enzyme-linked immunosorbent assay.The patients were classified into 2 groups based on their SIR-P/M on T1WI and T2WI scans. We observed a higher incidence of post-CAS DWI lesions in patients with a higher than a lower SIR-P/M on T1WI; the CML and MPO concentrations in their CAS debris were also higher. No such differences were seen in patients with a higher or lower SIR-P/M on T2WI scans. The concentration of CML in CAS debris correlated independently with the SIR-P/M on T1WI of the carotid plaques, and was related to the concentration of MPO in CAS debris.Our findings suggest CML as a candidate molecular imaging probe for the identification of vulnerable plaques.