Ayako Kuriki

Occurrence and Clinicotopographical Correlates of Brainstem Infarction in Patients with Diabetes Mellitus

BACKGROUND The goal of the study was to clarify the association between diabetes mellitus (DM) and brainstem infarctions (BSIs) and to investigate the clinicotopographic characteristics of BSIs in patients with diabetes. METHODS Data were retrospectively reviewed for 1026 consecutive patients admitted to our hospital because of acute cerebral infarctions from January 2004 to August 2010. Acute symptomatic BSIs were explored on radiologic images and classified into multiple infarctions with BSIs, multifocal BSIs, and monofocal BSIs. Isolated BSIs were further classified based on the vertical distribution into midbrain, pontine, and medullary infarctions, and on the horizontal distribution into anterior-dominant, posterior-dominant, and anterior/posterior BSIs. Neurologic symptoms of BSIs and clinical background were compared between DM and non-DM patients. RESULTS The prevalence of BSIs was 2.6-fold higher (P < .0001) in DM patients. Logistic regression analysis including age, sex, smoking, previous stroke, atrial fibrillation, other cardiac diseases, hypertension, hyperlipidemia, and DM showed that DM was independently associated with BSIs (odds ratio [OR] 2.814; 95% confidence interval [CI] 1.936-4.090; P < .0001). Compared with non-DM patients, DM patients showed more frequent monofocal BSIs (P < .0001) and multifocal BSIs (P = .0296). Monofocal BSIs (n = 114) more frequently involved the pons (P < .0001) and medulla (P = .0212). Anterior-dominant BSIs (P < .0001) were more common in DM patients than in non-DM patients. Symptoms of BSIs included more frequent motor paresis (P = .0180) and less frequent diplopia (P = .0298) in DM patients than in non-DM patients. CONCLUSIONS DM is important in the development of BSIs, and the associated clinical characteristics include more frequent motor paresis and less frequent diplopia.

Dilative arterial remodeling of the brain with different effects on the anterior and posterior circulation: An MRI study

OBJECTIVE The goal of the study was to investigate factors associated with dilation of the internal carotid artery (ICA) and basilar artery (BA), which reflect the anterior and posterior circulation respectively, and to examine if these arteries are affected differently by specific factors. METHODS The diameters of ICA and BA were measured using T2-weighted magnetic resonance (MR) images at the level of the brainstem in 304 outpatients, with the maximal width of the flow void taken as the diameter for each artery. The association between the diameters and clinical data including hemoglobin A1c (HbA1c) and estimated glomerular filtration rate (eGFR) was investigated. The same analysis was performed for the BA/ICA ratio. RESULTS Multiple regression analysis adjusted for confounding factors including gender and age showed that a lower eGFR was independently associated with dilation of both the ICA (beta coefficient -0.148, P=0.0135) and the BA (beta -0.219, P=0.0007). HbA1C was independently associated with a greater BA/ICA ratio (beta -0.183, P=0.0015) but eGFR did not show this association. Diabetes mellitus was significantly more frequent (P=0.0353) in patients with a BA/ICA ratio higher than the mean, compared to those with a lower BA/ICA ratio. CONCLUSION Kidney dysfunction was shown to be a dilative factor for the anterior and posterior circulation as reflected by the ICA and BA diameters, respectively. The association of the BA/ICA ratio with HbA1c suggests that diabetes mellitus may affect each circulation differently.

The brainstem is at high risk for recurrent noncardioembolic cerebral infarction in association with diabetes mellitus: a hospital-based study.

The goals of the study were to investigate the importance of brainstem infarction (BSI) in recurrent noncardioembolic ischemic stroke and to examine the relevant clinical background. Data were retrospectively reviewed for 655 consecutive patients with acute noncardioembolic infarction who were admitted to our hospital from January 2004 to August 2010. The patients were divided into first-stroke (n = 592) and recurrent-stroke (n = 63) groups. Acute infarcted lesions were explored on MRI, and clinical background factors including age, sex, smoking, atrial fibrillation, coronary heart disease, hypertension, hyperlipidemia and diabetes mellitus (DM) were assessed. The frequency of BSI in the recurrent-stroke group was significantly higher than that in first-stroke patients (30.2 vs. 14.9%, p = 0.0033). No other clinical background factors differed between the two groups. Only the frequency of DM differed significantly among four subgroups formed based on stroke recurrence and BSI (p < 0.0001): DM was present in 63.2% of recurrent-stroke patients with BSI, 54.5% of first-stroke patients with BSI, 27.4% of first-stroke patients without BSI, and 20.5% of recurrent-stroke patients without BSI. We conclude that the brainstem is at high risk for recurrent cerebral infarction in patients with DM.

Headache associated with focal brain edema in non-convulsive status epilepticus

We report a 27-year-old man who presented with a continuous headache, nausea, and lack of awareness after convulsive attacks. Electroencephalography showed rhythmic theta activity or generalized sharp-and-slow wave complexes that met EEG criteria for NCSE. A Magnetic resonance imaging study showed focal cortical edema in the mesial temporal lobes, anterior cingulate gyri, and frontal bases on both sides. Single photon emission tomography showed focal hyperperfusion of the left frontal and temporal lobes. Continuous electrical activity in those areas may underlie the patients symptoms including headache and neuroimaging abnormalities.

Multiple strokes in a young patient associated with an unruptured sinus of Valsalva aneurysm

An unruptured sinus of Valsalva aneurysm (SVA) is a rare anomaly caused by weakness at the junction of the aortic media and the annulus fibrosus [1]. Cases of unruptured SVA presenting with embolic strokes have been described previously [2–5]. However, there has been no report of an unruptured SVA as the source of multiple strokes. We describe a young patient with multiple strokes in whom an unruptured SVA originating from the right coronary sinus (rSVA; see Fig. 1 for schematic representation) was thought to be the source of multiple strokes. A 38-year-old man experienced sudden onset of left hemispatial visual loss. His own and his family’s histories were unremarkable. Physical examination showed a left superior quadrantanopia but otherwise normal findings. Magnetic resonance imaging (MRI) showed two separable hyperintense areas involving the right posterior cerebral artery (rPCA) and right posterior inferior cerebellar artery (rPICA) territories on the T2-weighted image (Fig. 2a). A lesion in the rPCA territory showed hyperintensity on the diffusion-weighted image (DWI) but hypointensity on the apparent diffusion coefficient (ADC) map. Compared to this lesion, the lesion in the rPICA territory showed hyperintensity on both the DWI and the ADC, indicating that the symptomatic infarction in the rPCA territory occurred a few weeks after the onset of the asymptomatic infarction in the rPICA territory. Transthoracic and transesophageal echocardiography (TTE and TEE) with the microbubble test detected an unruptured rSVA without other possible embolic sources, including a patent foramen ovale. In addition, a spontaneous echo contrast in the unruptured rSVA was detected by TEE (Fig. 2b). Biochemical and hematological variables were within normal limits. Three-dimensional computed tomography (CT) angiography and ultrasonography showed no abnormalities in the vertebral or basilar arteries. Contrast-enhanced chest CT, as well as electrocardiography including Holter monitoring, also showed no abnormalities. We thus inferred that the unruptured rSVA was the source of the multiple strokes. He underwent surgery for the unruptured rSVA.