Kenichi Sakuta

Olfactory function combined with morphology distinguishes Parkinson's disease

OBJECTIVE This study aimed to examine whether the volume of the olfactory bulbs and tracts (OB & T) on magnetic resonance imaging (MRI) is useful for differentiating Parkinsons disease (PD) from PD-related disorders. METHODS The study group comprised 13 patients with PD, 11 with multiple system atrophy (MSA), five with progressive supranuclear palsy, and five with corticobasal degeneration (PSP/CBD). All patients were evaluated using the odor stick identification test for Japanese (OSIT-J), (123)I-meta-iodobenzylguanidine (MIBG) scintigraphy, and brain MRI. OB & T areas on 1-mm-thick coronal images were measured and summed for volumes. We examined relationships between olfactory function and volume, and cardiovascular dysautonomia. We defined the cut-off values for OSIT-J score or MIBG uptake and OB & T volume to discriminate PD from PD-related disorders and calculated the proportional rate of PD in four categorized groups. RESULTS OB & T volume was smaller in PD than in MSA or PSP/CBD (p < 0.05 each). The cut-off for detecting PD patients was OSIT-J score <8, heart/mediastinum ratio <1.6, and OB & T volume <270 mm(3). In the group with OSIT-J score <8 and OB & T volume <270 mm(3), the proportion of PD patients among all patients with PD-related disorders was 91%. The rate of probable PD gradually increased as OSIT-J score and OB & T volume decreased (p < 0.001). CONCLUSIONS Although preliminary, these data obtained from a combined morphological and functional evaluation of OB or cardiovascular dysautonomia could be useful for further differential of PD and other PD-related disorders.

Stiffness Parameter β of Cardioembolism Measured by Carotid Ultrasound Was Lower Than Other Stroke Subtypes

BACKGROUND We estimated the stiffness parameter β (β value), which is useful in the assessment of premature atherosclerosis, among patients with different subtypes of cerebral infarction (CI; eg, small-vessel occlusion, large-artery atherosclerosis, cardioembolism, and other determined and undetermined etiologies) to determine the clinical utility of the β value in classification of stroke patients into CI subtypes. METHODS Carotid ultrasonography (ALOKA ProSound SSD-alpha10) was performed in 31 CI patients and 38 control subjects, and the β value of the bilateral common carotid artery at 2.0 cm proximal to the bifurcation was measured using the echo-tracking method. The relationship between β value and age was examined, and the β value was compared among the different CI subtypes. RESULTS Positive β value correlated with age in control subjects (R=.69, P<.001) but not in CI patients (R=-.01, P=.996). There was no significant difference in the β value when comparing control patients and patients with cardioembolic stroke (P=.106), but the β value were lower in patients with cardioembolic stroke than in patients with noncardioembolic stroke (eg, small-vessel occlusion, large-artery atherosclerosis, and others, P=.009). CONCLUSIONS The β value was lower in patients with cardioembolic stroke than in patients with noncardioembolic stroke. The β value may be useful for estimating the risk of different stroke subtypes.

Clinical characteristics associated with corticospinal tract hyperintensity on magnetic resonance imaging in patients with amyotrophic lateral sclerosis

OBJECTIVE The usefulness of conventional magnetic resonance imaging (C-MRI) for diagnosing amyotrophic lateral sclerosis (ALS) remains controversial. The aim of this study was to investigate the utility of C-MRI in identifying ALS, specifically the association between corticospinal tract (CST) hyperintensity on C-MRI and clinical characteristics in patients with ALS. METHODS Between June 2008 and April 2012, we retrospectively enrolled consecutive patients diagnosed with sporadic ALS who underwent C-MRI. Patients with ALS were classified as definite-phase ALS (D-ALS) and indefinite-phase ALS (ID-ALS). We focused on the hyperintensity of T2-weighted images in the CST in patients with ALS. Based on the MRI results, we divided patients into two groups: a positive CST group showing CST hyperintensity; and a negative CST group with no such findings. Clinical characteristics of the two groups were compared. RESULTS Seventeen patients (median age, 62 years; 8 women, 9 men) were enrolled in this study, with D-ALS in eight (47%) and ID-ALS in nine (53%). Eight patients (47%) showed CST positivity. The rate of CST positivity was higher in patients with D-ALS (75%) than in patients with ID-ALS (22%, p=0.03). CONCLUSIONS CST positivity appears significantly increased in D-ALS patients. C-MRI can play an important role in diagnosing ALS.

Decrease of Hyperintense Vessels on Fluid-Attenuated Inversion Recovery Predicts Good Outcome in t-PA Patients.

Background and Purpose: Hyperintense vessels (HV) detected on fluid-attenuated inversion recovery (FLAIR) in patients with acute ischemic stroke (AIS) indicate cerebral hypoperfusion. However, the clinical meaning of changes in HV is yet to be clarified. Here, we investigated serial changes to HV in patients with AIS who received tissue plasminogen activator (t-PA) therapy. Methods: We studied t-PA patients presenting with HV on FLAIR in the middle cerebral artery territory. Patients underwent brain MRI 1 h before and after t-PA infusion. HV scores (range 1-7) were evaluated according to Alberta Stroke Program Early Computed Tomography Score territories, and then by subtracting HV scores at 1 h after t-PA infusion from those on admission, with a result of >1 defined as decrease in HV score (DHV). Patients were divided into 2 groups based on the presence or absence of DHV. Multivariate logistic regression analysis was conducted to identify variables independently associated with good outcome (modified Rankin Scale score at 90 days after stroke onset of 0-1). Results: A total of 118 consecutive patients were enrolled (73 men; mean age 76 ± 9.7; median initial National Institutes of Health Stroke Scale (NIHSS) 13; median initial HV score 5), of whom 52 (44%) had DHV. Patients with DHV showed a significantly lower NIHSS time course (p < 0.001) and significantly smaller infarct volume time course (p < 0.001) compared to those without DHV. Multivariate analysis showed that DHV was independently associated with good outcome (OR 3.89; 95% CI 1.55-9.77; p < 0.01). The sensitivity and specificity of DHV for good outcome were 70 and 68%, respectively. Conclusion: A DHV on FLAIR predicts good outcome in patients receiving t-PA.

A novel probe attached to the neck can accurately detect a large patent foramen ovale

PURPOSE We developed a novel probe (pastable soft ultrasound probe; PSUP) attached to the neck for right-to-left shunt (RLS) detection. The purpose of this study was to evaluate the diagnostic ability of the PSUP for RLS detection by comparison with transesophageal echocardiography (TEE). METHODS The subjects were patients with ischemic strokes and transient ischemic attacks who underwent TEE. Based on TEE, patients with patent foramen ovale (PFO) were divided into two groups by the number of microbubbles (MBs): small PFO (1-29 MBs) and large PFO (≥30 MBs). Then, PSUP examination of one common carotid artery (CCA) was started using a procedure similar to TEE. RLS was diagnosed by PSUP when one or more microembolic signals were found in the CCA. The detection rate by size of PFO was compared between TEE and PSUP, and the diagnostic accuracy of PSUP was calculated. RESULTS From May 2014 to July 2016, 84 patients (63 males, median age 63 years) were included; 41 (49%) were diagnosed with PFO by TEE, while PSUP detected PFO in 31 (37%). Using TEE findings as the reference, PSUP for PFO showed sensitivity of 68%, specificity of 93%, and accuracy of 81%. On TEE, 22 patients had large PFOs, and 19 patients had small PFOs. The PSUP could identify large PFOs in grade I and II of International Consensus Criteria more accurately than small ones (58 and 86% vs. 29 and 14%, P = 0.003). CONCLUSIONS The PSUP has considerable accuracy for diagnosing large PFOs. PSUP should play an important role in detecting large PFOs.

The NAG scale: Noble Predictive Scale for Hematoma Expansion in Intracerebral Hemorrhage

BACKGROUND AND PURPOSE Early hematoma expansion (HE) is not rare in intracerebral hemorrhage (ICH) patients, but detecting those patients with high risk of HE is challenging. The aim of this retrospective study was to investigate the factors associated with HE in acute ICH patients, and to develop a simple predictive scale for HE. METHODS We retrospectively reviewed consecutive patients with primary ICH, who received an initial non-contrast computed tomography (CT) scan within 24 hours from symptom onset. Patients underwent follow-up CT scans at 6 hours, 24 hours, and 7 days after admission. We compared the clinical characteristics of patients with and without HE (defined as an increase in intracerebral hemorrhage volume >33% or an absolute increase >6 mL on follow-up CT scans), and performed a logistic regression analysis to determine the predictors of HE. RESULTS A total of 118 patients (78 men; median age 63 years; interquartile range 54-73) were included in our study. HE was observed in 30 patients (25%). HE patients showed higher rates of anticoagulant use (20% vs. 2%, respectively; P=0.003), high National Institutes of Health Stroke Scale on admission (13 vs. 7, respectively; P=0.001), and high plasma glucose (141 mg/dl vs. 113 mg/dl, respectively; P=0.001) compared with patients without HE. After multivariate logistic regression analysis, we selected three factors for defining the NAG scale (1 point as baseline National Institutes of Health Stroke Scale ≥10, 1 point as anticoagulant use, and 1 point as plasma glucose ≥133 mg/dL). The frequencies of HE associated with the NAG scale scores were as follows: score 0, 4%; score 1, 25%; score 2, 60%; score 3, 100%. CONCLUSION Stroke severity, hyperglycemia, and anticoagulation use were factors independently associated with HE. The NAG scale consists of readily available factors and can predict HE.

Transcranial color-coded sonography of vertebral artery for diagnosis of right-to-left shunts

BACKGROUND It is unknown whether contrast transcranial color-coded sonography of vertebral artery monitoring via the foramen magnum window (cTCCS-VA) is useful to detect right-to-left shunt (RLS). We investigated whether cTCCS-VA can be proposed as an alternative to middle cerebral artery monitoring via the temporal bone window (cTCCS-MCA) for RLS detection, as compared with contrast transesophageal echocardiography (cTEE). METHODS We evaluated 112 patients with ischemic stroke or transient ischemic attack. We compared the sufficiency of both acoustic windows in each age tertile. Then, we analyzed the accuracy of cTCCS in diagnosing an RLS for a patent foramen ovale (PFO) detected by cTEE. RESULTS In the higher-age tertile, the foramen magnum window was significantly more sufficient than the temporal bone window (100% vs. 71%, p<0.001). In 94 patients having both windows, diagnosis of an RLS using cTCCS-MCA revealed a specificity of 42%, and a sensitivity of 84%. Diagnosis of an RLS using cTCCS-VA revealed a specificity of 40%, and a sensitivity of 91%. Analysis of the subgroup with large PFOs revealed a specificity of 71% using both cTCCS-MCA and cTCCS-VA. CONCLUSIONS cTCCS-VA should play an important role in detecting an RLS, especially in elderly stroke patients having large PFOs.

Chronic kidney disease is independently associated with acute recurrent cerebral infarct in patients with atrial fibrillation

BACKGROUND AND PURPOSE The present study aimed to determine the frequency and time of recurrent cerebral infarct (RCI) in patients with acute ischemic stroke (AIS) and atrial fibrillation (AF), and to clarify associated factors. METHODS We retrospectively assessed and compared the clinical features of 79 consecutive patients (male, n=56; median age, 75y; median baseline NIHSS, 4) who were hospitalized due to AIS accompanied by AF, and who did or did not develop RCI between January 2012 and March 2015. RESULTS Direct oral anticoagulants were administered to 59% of the patients after a median of two days from the onset of the index stroke. Stroke recurred in 10 (13%) of the 79 patients about 5days after admission. The proportion of men was lower (30% vs. 77%, P=0.005) and the patients were older (82vs. 75y, P=0.049) in the group with RCI. Chronic kidney disease was significantly more prevalent in the group with RCI (50% vs. 16%, P=0.025) and independently associated with RCI (OR, 6.59; 95%CI, 1.19-36.63; P=0.031). CONCLUSIONS We found that RCI frequently develops about 5days after admission in patients with AIS and AF and that chronic kidney disease is independently associated with RCI.

Venous Stasis and Cerebrovascular Complications in Cerebral Venous Sinus Thrombosis

Background/Aims: The factors related to cerebrovascular complications in cerebral venous sinus thrombosis (CVST) are controversial. We focused on venous stasis and investigated its relationship with cerebrovascular complications in CVST. Methods: CVST patients between June 2013 and October 2016 were enrolled. Relationships between cerebrovascular complications, defined as cerebral venous infarction, intracerebral hemorrhage, or subarachnoid hemorrhage, and cerebrum venous stasis and other clinical information were retrospectively analyzed. Venous stasis was evaluated by the prominence of the veins on susceptibility-weighted imaging (SWI). The cerebrum was divided into 10 regions according to the venous drainage territories, and venous stasis was quantified by adding one point for venous prominence on SWI for each region (CVST SWI score). Results: All 5 cases in the noncomplicated group had a CVST SWI score of 0. The 3 patients with CVST SWI scores higher than 0 had cerebrovascular complications. The CVST SWI scores were higher in the complicated group than in the noncomplicated group (3.0 vs. 0, p = 0.010). Seizures were seen in all patients with complications and in none of the patients without complications (3 vs. 0, p = 0.018). Conclusion: Venous stasis evaluated by SWI can help predict cerebrovascular complications in CVST. A seizure is an important initial symptom that suggests cerebrovascular complications in CVST.

Cerebral venous sinus thrombosis and dural arteriovenous fistula in a 75-year-old man primarily presenting with repeated transient visual obscurations.

A 75-year-old man was admitted to our hospital because of repeated transient visual obscurations of greying vision. The transient visual obscurations were caused by rotating his neck or the Valsalva manoeuver, and they recovered in about 30 seconds. A few weeks later, pulsatile tinnitus of the right ear and a dull headache developed. Both ocular fundi showed papilledema, and there was significant intracranial hypertension on cerebrospinal fluid examination. He was diagnosed as having right sigmoid sinus thrombosis and a dural arteriovenous fistula with a rapid arteriovenous shunt from the right ascending pharyngeal artery and the right occipital artery to the right transverse sinus. Anticoagulant therapy was started, and coil embolization was performed. The transient visual obscurations, headache, and tinnitus improved dramatically after the procedure. We hypothesized that the transient visual obscurations were triggered by rotating the neck or performing the Valsalva manoeuver as they both increase the pressure of cerebrospinal fluid, inducing transient optic nerve ischemia and visual obscurations under mild intracranial hypertension. Transient visual obscurations are an important initial symptom of intracranial hypertension.