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Central nervous system (CNS) infections are often suspected in adult patients with fever-associated seizures. However, it is unclear whether lumbar puncture (LP) is routinely required in patients with fever-associated seizures. This study aimed to examine the prevalence of meningitis and encephalitis in adult patients with fever-associated seizures and to evaluate whether LP is routinely required.We retrospectively studied patients aged ≥16 years who presented to the emergency department with complaints of seizures and fever above 37.5 °C who were admitted to the hospital between January 2017 and December 2019. LP was performed when the emergency physician suspected meningitis or encephalitis. Neurologists assessed patients with normal cerebrospinal fluid (CSF) findings and those admitted without LP after hospitalization. A neurologist confirmed the diagnoses of meningitis and encephalitis.The study included 148 patients. Ninety-seven patients (65.5%) were male, and the median age was 60 years. LP was performed in 105 patients (70.9%), and 14 (13.4%) had CSF pleocytosis. Meningitis and encephalitis were diagnosed in nine patients (6.1%), of whom four (2.8%) had CNS infections. Patients diagnosed with meningitis and encephalitis were more likely to have Glasgow Coma Scale13 (P = 0.03) and less likely to have a history of seizures or epilepsy (P = 0.04) and had higher C-reactive protein levels than the other patients (P = 0.02).The prevalence of meningitis or encephalitis is relatively low in adult patients with fever-associated seizures. Lumbar puncture is considered unnecessary to be performed routinely, but its indication should be carefully considered with reference to the clinical course, comorbidities, and blood tests. Further validation studies with larger sample sizes are needed to confirm the findings of this study.

We herein report a 48-year-old woman receiving eribulin mesylate for breast cancer who presented with gait disorder, distal limb paresthesia, and weakness progressing monthly. A nerve conduction study indicated demyelination with multifocal conduction block. Considering the immune-mediated pathology of her condition, she was administered intravenous immunoglobulin. Her neurological symptoms improved promptly after intravenous immunoglobulin therapy and eribulin withdrawal. Furthermore, the limb myokymia seen at the time of admission disappeared. Her symptoms continued to improve without additional treatment. We conclude that eribulin was a rare cause of demyelinating neuropathy with multifocal conduction block derived from immune-mediated pathology.

パーキンソン病発症には、α-シヌクレイン（αSyn）と呼ばれる蛋白質の線維状異常凝集体（アミロイド線維）形成が密接に関連する。疾病発症の分子機構解明には、αSynのアミロイド線維形成機構、特に凝集開始機構の解明が不可欠である。αSynは天然変性蛋白質であるため、単量体のふるまいが凝集開始に直結している。特定の構造を持たない変性状態の蛋白質のふるまいの特徴づけには、構造分布や構造の揺らぎ（ダイナミクス）そのものを明らかにする「非構造生物学」を構築しなければならない。筆者らは、小角散乱及び中性子準弾性散乱を組み合わせて、天然変性蛋白質の構造・ダイナミクス解析を行う新しい手法を開発した。この手法を用いてαSyn単量体のふるまいを調べ、αSynのアミノ酸主鎖のセグメント運動が重要であることを示した。本稿では、このαSynの「非構造生物学」を紹介すると共に、この手法の発展可能性について議論する。

Coronavirus disease 2019 (COVID-19) patients have been increasingly reported to develop various neurological manifestations. We herein present a rare case of bilateral facial nerve palsy in a patient that occurred 5 weeks after the onset of coronavirus disease 2019. The patient had no motor or sensory deficits in his extremities, and there were no other diseases that may have resulted in bilateral facial palsy. Based on these findings, we concluded that the facial palsy in this case may have been triggered by coronavirus disease 2019.

BackgroundPersistent hypotension (PH) after carotid artery stenting (CAS) is a relatively common complication; however, it is unclear which patients are more likely to experience this phenomenon. Recently, lower left atrial (LA) volume was associated with vasovagal syncope, which has a similar neurological mechanism to hypotension after CAS. This study aimed to investigate whether LA volume can predict PH after CAS.MethodsThis single center retrospective analysis used data from 316 patients who had undergone CAS between March 2013 and February 2021. After the exclusion of urgent CAS, 212 procedures (202 patients) with transthoracic echocardiograms were included. The procedures were divided among two groups according to the presence or absence of PH for more than 1 hour after CAS.ResultsThe mean age of the patients was 73.0±7.5 years. PH was observed during 52 (24.5%) procedures. The PH group exhibited a lower LA volume index (LAVI) than the no-PH group (29.7±9.1 vs 37.7±12.5 mL/m2, respectively; p2 (sensitivity 0.750, specificity 0.625). Multiple logistic regression analysis showed that LAVI 2 was an independent predictor for PH after CAS (OR 4.950, 95% CI 2.190 to 11.200; pConclusionsA lower LA volume can predict PH after CAS, and preoperative hydration may prevent PH after CAS.

Clock proteins maintain constant enzymatic activity regardless of temperature, even though thermal fluctuation is accelerated as temperature increases. We investigated temperature influences on the dynamics of KaiC, a temperature-compensated ATPase in the cyanobacterial circadian clock system, using quasielastic neutron scattering. The frequency of picosecond to sub-nanosecond incoherent local motions in KaiC was accelerated by a factor of only 1.2 by increasing the temperature by 10°C. This temperature insensitivity of the local motions was not necessarily unique to KaiC, but confirmed also for a series of temperature-sensitive mutants of KaiC and proteins other than clock-related proteins. Rather, the dynamics associated with the temperature-compensatory nature of the reaction- and system-level was found in global diffusional motions, which was suggested to regulate the temperature dependence of ATPase activity and dephosphorylation process presumably through changes in the hexamer conformation of KaiC. The spatiotemporal scale at which cross-scale causality of the temperature sensitivity is established is finite, and extends down to picosecond to sub-nanosecond dynamics only in a very limited part of KaiC, not in its entire part.

Anemia is a frequently observed condition, but its clinical impact on large vessel occlusion (LVO) remains unclear. We examined the association between anemic status on admission and clinical outcomes of LVO in a real-world setting.We conducted a post-hoc analysis of the RESCUE-Japan Registry 2, a nationwide registry which enrolled 2408 consecutive patients with LVO who were admitted within 24 h of onset. The patients were classified into anemia (11 g/dL) and no-anemia (≥11 g/dL) groups according to their hemoglobin level on admission. The primary outcome was defined as a modified Rankin Scale of 0-2 at day 90.Among the 2373 patients with available baseline hemoglobin data, 307 (13.0%) were classified in the anemia group. Anemia was associated with a lower likelihood of the primary outcome (adjusted odds ratio [OR]: 0.68; 95% confidence interval [CI]: 0.47-0.98) and higher mortality within 90 days (adjusted OR: 1.48; 95% CI: 1.01-2.17). Subgroup analyses showed that the likelihood of achieving the primary outcome between the two groups was different between men and women (P for interaction = 0.049), those with Alberta Stroke Program Early CT Score (ASPECTS)6 and ASPECTS ≥6 (P for interaction = 0.02), and those with National Institute of Health Stroke Scale (NIHSS) ≥16 and NIHSS 16 (P for interaction = 0.005).Anemic state on admission was associated with poorer clinical outcomes of LVO in real-world clinical practice. The effects of anemic status were larger in LVO patients with lower NIHSS or higher ASPECTS.

Hen egg-white lysozyme (HEWL) is an enzymatic protein with two acidic amino acids, Glu35 and Asp52, in its active site. Glu35 acts as a proton donor to the substrate and Asp52 interacts with the positively charged substrate, suggesting different protonation states of these residues. However, neutron crystallographic studies thus far have not provided a consistent picture of the protonation states of these residues. Only one study succeeded in observing the active protonation states of Glu35 and Asp52 in the triclinic crystal system. However, their active states in the most widely studied tetragonal crystal system are still unknown. The application of the D/H contrast technique in neutron crystallography improves the ability to locate exchangeable D/H atoms in proteins. In the present study, D2O and H2O solvent crystals were prepared. Each neutron data set was collected for only five days by combining a time-of-flight diffractometer (iBIX) and the spallation neutron source at the Japan Proton Accelerator Research Complex. The D/H contrast map provided better visualization of the D/H atoms in HEWL than the conventional neutron scattering length density map. The neutron D/H contrast map demonstrated the alternative protonation of the OE1 and OE2 atoms in the carboxyl group of Glu35. This alternative protonation occurs in the absence of a substrate, where high selectivity of the protonation site does not occur. In this case, only the OE1—HE1 bond attacks the substrate in an equilibrium between OE1—HE1 and OE2—HE2, or the H+ ion of the OE2—HE2 bond moves to the OE1 atom just before or after substrate binding to initiate the catalytic reaction. In contrast, the carboxyl group of Asp52 is not protonated. Protonation of the carboxyl group was not observed for other Asp and Glu residues. These results are consistent with results from NMR spectroscopy and explain the protonation states at the active site in the apo form of HEWL.

The impact of prior antiplatelet therapy (APT) on clinical outcomes of endovascular therapy (EVT) for large vessel occlusion (LVO) on clinical outcomes is uncertain. We explored the associations between prior APT and in-hospital and 90-day outcomes in a real-world setting.The RESCUE-Japan Registry 2 is a physician-initiated registry of 2408 consecutive patients with acute LVO admitted to hospital within 24 h of stroke onset. We compared 1281 patients who received EVT with and without APT before stroke onset (APT group and No-APT group) in terms of intracranial hemorrhage (ICH) within 72 h after the onset, successful recanalization after EVT, and the modified Rankin Scale (mRS) score 0-2 at 90 days were also evaluated. Among the 254 patients (19.8%) in the APT group, 68 (27%) patients presented any ICH and 265 (26%) patients in the No-APT group (adjusted odds ratio [OR], 1.04; 95% confidence interval [CI], 0.71-1.53). The incidence of symptomatic ICH and successful recanalization were also similar between the APT and No-APT groups. The adjusted ORs of the APT group for mRS of 0-2 and death were 0.93 (95% CI, 0.62-1.41) and 0.59 (95% CI, 0.3-1.19), respectively. In patients with an onset to door time ≥ 180 min, any ICH tended to be more prevalent in the APT group than in their counterparts (P for interaction = 0.008).The risk of ICH after EVT was not different between patients with and without APT before EVT for acute LVO.

Miliary brain metastasis is a rare form of metastasis commonly associated with advanced stages of cancer. In this article, we report a case of a 38-year-old male with solitary progression of miliary brain metastasis originating from stage 4 EML-ALK-positive lung adenocarcinoma. Multiple brain lesions were first detected upon the patient's inclusion in a brigatinib clinical trial. The brain lesions dissipated, and the lung and bone lesions decreased in size after starting the brigatinib therapy; however, the brain lesions later increased in number. A biopsy revealed miliary brain metastasis of lung adenocarcinoma. The patient was successfully treated with whole brain therapy, in addition to brigatinib. This case suggests that it is possible for an isolated miliary brain metastasis to occur during the effective suppression of systemic cancer progression. Whole brain radiotherapy while continuing effective systemic therapy is a good strategy for such patients.

A 53-year-old woman was admitted to the hospital because she developed headache and malaise 3 months prior to her arrival, followed by gait disturbance, abnormal behavior, and hallucinations. On admission, she was stupor and showed left hemispatial neglect, and brain MRI showed extensive FLAIR high-signal lesions with contrast enhancement in the bilateral periventricular white matter, and CSF examination showed pleocytosis and elevated protein. A stereotactic brain biopsy was performed from the right temporal lobe lesion, and pathological findings demonstrated a perivascular inflammatory cell infiltrate. After the administration of intravenous methylprednisolone followed by oral prednisolone, she recovered almost completely within three months and the abnormal MRI findings disappeared. Anti-glial fibrillary acidic protein (GFAP) antibody in the cerebrospinal fluid turned out to be positive, then the diagnosis of autoimmune GFAP astrocytopathy was made. Reports of this disease are still rare, and we report this case because of its slowly progressive course and pathological evaluation by brain biopsy.

Objective Various neurological manifestations have been increasingly reported in coronavirus disease 2019 (COVID-19). We determined the neurological features and long-term sequelae in hospitalized COVID-19 patients. Methods We retrospectively studied 95 consecutive hospitalized patients with COVID-19 between March 1 and May 13, 2020. Acute neurological presentations (within two weeks of the symptom onset of COVID-19) were compared between 60 non-severe and 35 severely infected patients who required high-flow oxygen. In the 12 ventilated patients (the most severe group), we evaluated neurological complications during admission, subacute neurological presentations, and neurological sequelae (51 and 137 days from the onset [median], respectively). Results Of the 95 patients (mean age 53 years old; 40% women), 63% had acute neurological presentations, with an increased prevalence in cases of severe infections (83% vs. 52%, p

Clock proteins maintain constant enzymatic activity regardless of temperature, even though thermal fluctuation is accelerated as temperature increases. We investigated temperature influences on the dynamics of KaiC, a temperature-compensated ATPase in the cyanobacterial circadian clock system, using quasielastic neutron scattering. The frequency of picosecond to sub-nanosecond incoherent local motions in KaiC was accelerated very slightly in a temperature-dependent manner. Our mutation studies revealed that internal motions of KaiC include several contributions of opposing temperature sensitivities. To take advantage of this balancing effect, the motional frequency of local dynamics in KaiC needs to exceed ∼0.3 ps-1. Some of the mutation sites may be in a pathway through which the motional frequency in the C-terminal domain of KaiC is fed back to the active site of ATPase in its N-terminal domain. The temperature-compensating ability at the dynamics level is likely crucial for circadian clock systems, into which the clock proteins are incorporated, to achieve reaction- or even system-level temperature compensation of the oscillation frequency.

Characterization of the dynamics of disordered polypeptide chains is required to elucidate the behavior of intrinsically disordered proteins and proteins under non-native states related to the folding process. Here we develop a method using quasielastic neutron scattering, combined with small-angle X-ray scattering and dynamic light scattering, to evaluate segmental motions of proteins as well as diffusion of the entire molecules and local side chain motions. We apply this method to RNase A under the unfolded and molten-globule (MG) states. The diffusion coefficients arising from the segmental motions are evaluated, and found to be different between the unfolded and MG states. The values obtained here are consistent with those obtained using the fluorescence-based techniques. These results demonstrate not only feasibility of this method but also usefulness to characterize the behavior of proteins under various disordered states.

Alpha-synuclein (aSyn) is an intrinsically disordered protein (IDP) that can form amyloid fibrils. Fibrils of aSyn are implicated with the pathogenesis of Parkinson's disease and other synucleinopathies. Elucidating the mechanism of fibril formation of aSyn is therefore important for understanding the mechanism of the pathogenesis of these diseases. Fibril formation of aSyn is sensitive to solution conditions, suggesting that fibril formation of aSyn arises from the changes in its inherent physico-chemical properties, particularly its dynamic properties because IDPs such as aSyn utilize their inherent flexibility to function. Characterizing these properties under various conditions should provide insights into the mechanism of fibril formation. Here, using the quasielastic neutron scattering (QENS) and small-angle X-ray scattering (SAXS) techniques, we investigated the dynamic and structural properties of aSyn under the conditions, where mature fibrils are formed (pH 7.4 with a high salt concentration), where clumping of short fibrils occurs (pH 4.0), and where fibril formation is not completed (pH 7.4). The SAXS measurements showed that the extended structures at pH 7.4 with a high salt concentration become compact at pH 4.0 and 7.4. The QENS measurements showed that both intra-molecular segmental motions and local motions such as side-chain motions are enhanced at pH 7.4 with a high salt concentration, compared to those at pH 7.4 without salt, whereas only the local motions are enhanced at pH 4.0. These results imply that fibril formation of aSyn requires not only the enhanced local motions but also the segmental motions such that proper inter-molecular interactions are possible.

α-Synuclein (αSyn) is an intrinsically disordered protein that can form amyloid fibrils. Fibrils of αSyn are implicated with the pathogenesis of Parkinson's disease and other synucleinopathies. Elucidating the mechanism of fibril formation of αSyn is therefore important for understanding the mechanism of the pathogenesis of these diseases. Fibril formation of αSyn is sensitive to solution conditions, suggesting that fibril formation of αSyn arises from the changes in its inherent physico-chemical properties, particularly its dynamic properties because intrinsically disordered proteins such as αSyn utilize their inherent flexibility to function. Characterizing these properties under various conditions should provide insights into the mechanism of fibril formation. Here, using the quasielastic neutron scattering and small-angle x-ray scattering techniques, we investigated the dynamic and structural properties of αSyn under the conditions, where mature fibrils are formed (pH 7.4 with a high salt concentration), where clumping of short fibrils occurs (pH 4.0), and where fibril formation is not completed (pH 7.4). The small-angle x-ray scattering measurements showed that the extended structures at pH 7.4 with a high salt concentration become compact at pH 4.0 and 7.4. The quasielastic neutron scattering measurements showed that both intra-molecular segmental motions and local motions such as side-chain motions are enhanced at pH 7.4 with a high salt concentration, compared to those at pH 7.4 without salt, whereas only the local motions are enhanced at pH 4.0. These results imply that fibril formation of αSyn requires not only the enhanced local motions but also the segmental motions such that proper inter-molecular interactions are possible.

Small-angle X-ray scattering experiments were carried out to investigate the structural changes of cardiac thin filaments induced by the cardiomyopathy-causing E244D mutation in troponin T (TnT). We examined native thin filaments (NTF) from a bovine heart, reconstituted thin filaments containing human cardiac wild-type Tn (WTF), and filaments containing the E244D mutant of Tn (DTF), in the absence and presence of Ca2+. Analysis by model calculation showed that upon Ca2+-activation, tropomyosin (Tm) and Tn in the WTF and NTF moved together in a direction to expose myosin-binding sites on actin. On the other hand, Tm and Tn of the DTF moved in the opposite directions to each other upon Ca2+-activation. These movements caused Tm to expose more myosin-binding sites on actin than the WTF, suggesting that the affinity of myosin for actin is higher for the DTF. Thus, the mutation-induced structural changes in thin filaments would increase the number of myosin molecules bound to actin compared with the WTF, resulting in the force enhancement observed for the E244D mutation.

A 73-year-old woman with untreated diabetes mellitus visited our emergency department with a 4-day history of progressive headache, fever, and chills. She received trigger point injections (TPI) into the right sternocleidomastoid for exercise-induced ipsilateral shoulder pain, 13 days before admission and into the right trapezius, 6 days before admission. Cerebrospinal fluid (CSF) evaluation revealed pleocytosis with a predominance of neutrophils, as well as elevated protein and reduced glucose levels. Magnetic resonance imaging of the cervical spine revealed inflammatory changes of the right-sided posterior cervical muscles and the right vertebral arch of the C5-C6 vertebrae without contrast enhancement of the right posterior cervical veins. She was diagnosed with bacterial meningitis and suppurative thrombophlebitis, and empiric broad-spectrum antibiotic therapy was administered intravenously. The initial blood culture yielded Streptococcus intermedius; however, CSF culture showed no growth. She recovered completely after a 4-week course of intravenously administered ampicillin and was discharged with oral clindamycin to complete a total 6-week antibiotic course. TPI are widely used as a safe therapeutic strategy associated with few complications, and serious infections are rare. However, clinicians must remain mindful of the possibility of these complications in immunocompromised patients, such as those with diabetes mellitus who undergo TPI. (Received September 18, 2020; Accepted December 21, 2020; Published June 1, 2021).

We retrospectively examined the differences between paramedic triage and final diagnosis in the cases that were transported to our hospital between May 2016 and March 2019. About 30% of the patients with suspected stroke were diagnosed other than stroke. Some of the patients without suspected stroke were diagnosed with large vessel occlusion and were treated with mechanical thrombectomy. The time from arrival at the hospital to treatment was significantly longer in the patients without suspected stroke than with suspected stroke. To achieve a better prehospital care, we need to accept a wide range of stroke mimics, and to continuously feedback the paramedics about the importance of paralysis, cortical symptoms in stroke.

Leuconostoc lactis, often found in fermented dairy products, although considered to have a low pathogenic potential, can cause life-threatening infections in immunocompromised hosts. We herein report a 62-year-old man with a history of alcoholic liver cirrhosis, hepatocellular carcinoma, and diabetes mellitus who developed a very rare case of bacterial meningitis caused by this organism. After we administered antibiotics including ampicillin, he recovered completely within two weeks. This gram-positive coccus (GPC) is sensitive to ampicillin but naturally resistant to vancomycin, while its susceptibility to ceftriaxone has not yet been established. In acute GPC meningitis in immunocompromised hosts, Leuconostoc lactis should therefore be considered as a possible pathogen.

Background We experienced two cases of ischemic stroke resulting from carotid artery occlusion associated with acute type A aortic dissection (ATAAD), in which carotid artery stenting before the surgery for ATAAD resulted in good clinical outcomes. Case 1 description: A 63-year-old woman was hospitalized for conscious disturbance, right hemiparesis, and total aphasia. Computed tomography of the head showed no abnormal findings. Computed tomography angiography showed ATAAD and bilateral common carotid artery occlusion. Surgery was not indicated for ATAAD because of a poor prognosis of ischemic stroke. However, carotid artery stenting of the left common carotid artery occlusion was successfully performed, and her neurological findings improved. The patient underwent hemiarch replacement for ATAAD on the day after carotid artery stenting. Her final modified Rankin Scale was 1. Case 2 Description: A 57-year-old woman was hospitalized for mild left hemiparesis. Magnetic resonance imaging showed right watershed infarction and right common carotid artery occlusion. Computed tomography angiography showed ATAAD. After hospitalization, conscious disturbance appeared and left hemiparesis worsened. Ischemic stroke indicated a poor prognosis for revascularization by surgery for ATAAD. Thus, carotid artery stenting of the right common carotid artery occlusion was performed. The patient’s neurological findings improved and she underwent hemiarch replacement for ATAAD at 19 days after carotid artery stenting. Her final modified Rankin Scale was 1. Conclusions In the present cases, although ischemic stroke was serious and precluded surgical indication for ATAAD, carotid artery stenting before surgery for ATAAD resulted in good clinical outcomes. Performing carotid artery stenting before surgery for ATAAD is challenging but achievable, and is a valid treatment option depending on the individual cases.

Background and Purpose: Efficacy of mechanical thrombectomy for acute cerebral large vessel occlusion depends on time from symptom onset to reperfusion. While time to treatment in hospital has been optimized in these days, it is not well-known about improving time in pre-hospital when suspected stroke. We sought to analyze time from emergency medical services (EMS) dispatch to arterial puncture in stroke patients eligible for mechanical thrombectomy. Methods: We analyzed time components from EMS dispatch to puncture in patients with acute large vessel occlusion within 6 hours from onset treated with mechanical thrombectomy between April 2015 and December 2018. We assessed the associated factors with each time component and patient outcomes. Results: Consecutive 195 patients were included in this analysis. The median EMS dispatch-to-scene, on-scene, transport, door-to-puncture (DTP), and scene-to-puncture (STP) times were 4, 16, 12, 40, and 70 minutes, respectively. Percentage of favorable outcomes were significantly higher in patients with STP within 60 minutes (57.5% vs 35.8%, p Conclusions: Reducing time in pre-hospital and in-hospital interact with each other. Education program and use of direct call from EMS contributed to reducing these times.

The IBARAKI Biological Crystal Diffractometer (iBIX) has been available for use at MLF (Material and Life Science Facility) in J-PARC (Japan Proton Accelerator Research Complex) since 2008. The development in state-of-the-art detector systems could enable iBIX to become one of the highest-performance neutron single-crystal diffractometers in the world. Here, together with other various developments, such as data reduction software, crystal growth, and new techniques in measurement coupled analysis, we provided new hydrogen and water structural data of several proteins and macromolecules. Although the proton power at MLF has not yet reached its planned maximum (1MW), a more powerful neutron source will be soon needed for neutron protein crystallography. A future idea is also proposed and discussed in this article.

ObjectiveTo describe our initial experience with the Versi Retriever for mechanical thrombectomy in patients with acute ischemic stroke.MethodsThis study is a single-center, single-arm, first-in-man registry under institutional review board control to evaluate the efficacy and safety of the new stent retriever, the Versi Retriever. Patients with acute ischemic stroke were consecutively enrolled between September and November 2017. The clinical and procedural data were retrospectively analyzed. The angiographic result after the procedure was self-graded based on the Thrombolysis in Cerebral Infarction (TICI) scale by each operator.ResultsEleven patients with a mean age of 69.4 years were treated with the Versi Retriever. Median National Institutes of Health Stroke Scale score on admission was 16 (IQR 10–34). The occluded vessel was located in the anterior circulation in 81.8%. Revascularization rates of TICI 2b–3 and TICI 3 at final angiogram were achieved in 100% and 63.6%, respectively. A favorable functional outcome (modified Rankin Scale 0–2) at 90 days was obtained in 72.7%. No symptomatic intracranial hemorrhage occurred and no procedure-related complication was observed.ConclusionsOur initial experience suggests that the Versi Retriever is a safe and effective stent retriever for mechanical thrombectomy in patients with acute ischemic stroke.Clinical trial registrationNCT03366818

A 37-year-old woman with systemic lupus erythematosus presented with gait disturbance and cognitive dysfunction. Brain magnetic resonance imaging (MRI) revealed small, punctate, T2-/fluid-attenuated inversion recovery-hyperintense and T1-hypointense lesions without gadolinium enhancement, which is atypical for progressive multifocal leukoencephalopathy (PML). On a pathological examination of biopsied brain tissues, JC virus-infected cells were hardly detected via immunohistochemistry but were certainly detected via in situ hybridization, conclusively verifying the PML diagnosis. After tapering off the immunosuppressant and mefloquine administration, the MRI findings revealed gradual improvement, and she has been stable for over 18 months. A punctate MRI pattern is not specific to natalizumab-associated PML but may be a ubiquitous early sign useful for the early diagnosis of PML.