Manabu Izumi

Blood Pressure and Total Cholesterol Level Are Critical Risks Especially for Hemorrhagic Stroke in Akita, Japan

Background and Purpose: Stroke risk factors differ depending on the subtype of stroke; moreover, the distribution of risks is different among countries and races. Methods: Mass health screening data were collected from the Akita Prefectural Federation of Agricultural Cooperative for Health and Welfare from 1991 to 1998. Cerebrovascular events were determined from the Akita stroke registry from 1991 to 2001. Then, clinical risk factors for stroke, such as hypertension, hyperlipidemia and diabetes mellitus, were assessed in the different subtypes of stroke. Results: A total of 156,892 persons were included in this study (76,330 men and 80,562 women), and 1,323 subjects had a stroke during the 3 years of the screening period. The distribution of subtypes such as cerebral hemorrhage (CH), cerebral infarction (CI) and subarachnoid hemorrhage (SAH) was 27.3, 55.9 and 16.8%, respectively. Mean age and systolic and diastolic blood pressures (BPs) were significantly higher in stroke cases. CH and CI occurred more frequently in men, whereas SAH occurred more frequently in women. Serum total cholesterol (TC) <160 mg/dl was a risk factor for hemorrhagic stroke (CH and SAH), whereas TC >280 mg/dl increased the risk of CI. A multivariable analysis revealed that the lower TC level (<160 mg/dl) and the higher BP increased the relative risk of hemorrhagic stroke. Conclusions: BP was the strongest risk factor for any subtype of stroke. High BP and low TC (<160 mg/dl) were critical risks of hemorrhagic stroke.

Takotsubo Cardiomyopathy as a Delayed Complication with a Herbicide Containing Glufosinate Ammonium in a Suicide Attempt: A Case Report

Background. Glufosinate ammonium has a famous delayed complication as respiratory failure, however, delayed cardiogenic complication is not well known. Objectives. The aim of this study is to report a takotsubo cardiomyopathy as a delayed complication of glufosinate ammonium for suicide attempt. Case Report. A 75-year-old woman ingested about 90 mL of Basta, herbicide for suicide attempt at arousal during sleep. She came to our hospital at twelve hours after ingesting. She was admitted to our hospital for fear of delayed respiratory failure. Actually, she felt down to respiratory failure, needing a ventilator with intubation at 20 hours after ingesting. Procedure around respiratory management had smoothly done with no delay. Her vital status had been stable, however, she felt down to circulatory failure and diagnosed as Takotsubo cardiomyopathy at about 41 hours after ingestion. There was no trigger activities or events to evoke mental and physical stresses. Conclusion. We could successfully manage takotsubo cardiomyopathy resulted in circulatory failure in a patient with glufosinate poisoning for suicide attempt. Takotsubo cardiomyopathy should be taken into consideration if circulatory failure is observed for unexplained reasons.

Alcohol is a Risk Factor not for Thalamic but for Putaminal Hemorrhage: The Akita Stroke Registry

BACKGROUND Although the risk factors of cerebral hemorrhage were established long ago, there is little agreement as to the risk factors for the site of cerebral hemorrhage. METHODS We obtained mass health screening data collected between 1990 and 2000 regarding 151,796 subjects from the Akita Prefectural Federation of Agricultural Cooperative for Health and Welfare. A first-ever cerebral hemorrhage occurring <3 years after the screening examination was defined as an event. Stroke events were determined from the Akita stroke registry between 1990 and 2003. Clinical risk factors for stroke, such as age, blood pressure, severe obesity (body mass index >30 kg/m(2)), low serum total cholesterol, hepatic disorder, renal disorder, and drinking habits were then assessed. RESULTS Cerebral hemorrhage developed in 344 cases in the study population. The distribution of subtypes (putaminal hemorrhage [PH], thalamic hemorrhage [TH], and subcortical hemorrhage [SH]) were 122 cases (35.5%), 110 cases (32.0%), and 44 cases (12.8%), respectively. We evaluated the risk factors by multiple logistic regression analysis among these 3 groups. Age was a significant risk factor among these 3 groups, but blood pressure was not a risk factor in SH. Low serum cholesterol and drinking habits were significant risk factors only in PH. Hepatic disorder was a strong risk factor in PH and a weak risk factor in TH. Interestingly, a drinking habit was a significant risk factor only in PH. CONCLUSIONS Drinking habits had been a risk factor for cerebral hemorrhage, but it was a risk factor not for PH and not for TH or SH.

Convulsive syncope on electroencephalogram

A 55yearold woman visited our hospital with repeated episodes of syncope. She had no memories around syncope, but she had incontinent of urine. Her family reported the process of syncope; she screamed suddenly and went into systemic clonic convulsions soon. She slowly returned to normal status over several minutes with lack of memories during attack without any neurological deficit. On arrival at our hospital, she could present her history fluently. We performed a physical examination, chest Xray pictures, blood chemistry, and electrocardiogram; however, no abnormal findings were revealed. We took a computed tomography (CT) of her brain; however, it also reveals no abnormal findings. She was suspected of having epilepsy. Thus, we decided to take emergency electroencephalogram (EEG). In the middle of EEG, she presented systemic clonic convulsion. After few minutes, she recovered her consciousness clearly. Fortunately, we could record attack through EEG (Figure 1). Her EEG pattern was suddenly changed into generalized high voltage with electromyogram artifacts, just after 13 seconds absence of electrocardiographic R wave. Systemic clonic convulsion was brought by wholebrain ischemia from temporary cardiac arrest. After transient R wave pausing, her systemic convulsion was terminated. She recovered her consciousness gradually. EEG also recovered at the same time (Figure 2). Echocardiography revealed no abnormal findings, such as cardiac valve diseases, cardiac myopathy, and focal asynergy. Of course,

Necrotizing enterocolitis associated with Clostridium butyricum in a Japanese man

Necrotizing enterocolitis (NEC) caused by Clostridium butyricum is common in neonates; however, a case of NEC in adults has not been previously reported. An 84‐year‐old Japanese man developed C. butyricum‐related NEC during hospitalization for treatment of stab wounds to the left side of the neck and lower abdomen, without organ damage, and concomitant pneumonia.

Left ventricular apical and atrial appendage thrombus with hypertrophic cardiomyopathy in sinus rhythm : a case report

A 47-year-old female with a history of untreated hypertension and diabetes mellitus was referred because of a left ventricular echocardiographic mass with congestive heart failure. At the time of admission, she had already had a cardio-embolic stroke with loss of recent memory and slight paralysis of the right upper arm. It was difficult to distinguish between thrombus and tumor. However, her clinical condition required surgical resection as soon as possible. We performed cardiac CT to evaluate the coronary arteries and to scan the mass at the left ventricular apex. This CT evaluation revealed another mass at the left atrial appendage. Thus, these two masses were highly suggestive of thrombi. Subemergency surgical resection of the two masses and a part of the myocardium at the left ventricular apex was successfully performed. The pathological results showed that both the mass in the left ventricular apex and the mass in the left atrial appendage were thrombi, and the myocardial disarray confirmed the echocardiographic diagnosis as hypertrophic cardiomyopathy.

Reply to “The electroencephalogram in syncope”

Thank you for your interest in our paper. As you mentioned, we did not reference Gastaut’s research in this report. We researched various reports in PubMed, many of which discussed EEG and wholebrain ischemia. However, a large portion of them discussed the relationship between relative brain ischemia, which was brought on by the headup tilt test and the Valsalva maneuver, and severe hypotension. As far as we could ascertain, few reports discuss EEG, convulsion, wholebrain ischemia, and cardiac arrest. We apologize for lacking information on Gastaut’s works. By searching “Author; Gastaut H” in PubMed, we found 418 reports. Eighteen reports examined the occurrence of syncope among patients with hypotension when the vasovagal reflex occurs or they perform the Valsalva maneuver.1 Additionally, Lempert et al2 reported on convulsive syncope with hypotension through videometric analysis. Apart from us, DiazCastro et al3 also reported a case in which cardiac arrest caused systemic epilepsy. It is still a curious phenomenon for many physicians. However, there are ethical issues in conducting experimental trials to reveal the mechanism of this phenomenon in humans. Therefore, it is very important to add new knowledge through case reports. I have confidence that this case report has enough value to be published, even if my description of the background of this case did not refer to Gastaut’s works, because the cause of brain ischemia in our case is quite different from Gastaut’s. CONFLIC T OF INTERE S T

Fatal necrotizing myositis from fulminant Streptococcus dysgalactiae subspecies equisimilis (SDSE) infection: A case report of autopsy images

Over the past few decades, Streptococcus dysgalactiae subspecies equisimilis (SDSE) have been considered as weak pathogenicity compared with S. pyogenes (GAS). Some recent reports argue that SDSE may bring severe soft tissue infection as same as GAS. No reports have been tried to reveal the clinical characteristics and autopsy images of fulminant SDSE infection. In this case report, we aimed to present a case of fatal necrotizing myositis from fulminant SDSE infection at iliopsoas, including autopsy appearance.

Brain Images in Fatal Methanol Intoxication

A 64-year-old man with no significant medical history was admitted to the intensive care unit with a progressive visual abnormality and he was also in a coma. Because of a rapid exacerbation of his symptoms and the onset of severe metabolic acidosis, we treated him with fomepizole due to suspected methanol intoxication, however, he never recovered from the coma. An extremely high concentration of methanol was found in his urine led to a definitive diagnosis of methanol intoxication associated with severe brain damage (1, 2). At five days after admission, diffusion-weighted magnetic resonance imaging (MRI), T2-weighted imaging and apparent diffusion coefficient (ADC) map revealed the symmetric and extensive range of deep white matter damage but sparing the cortex. Furthermore, T2* images suggested a

Successful management of aortic thrombi resulting in spinal cord infarction in a patient with antiphospholipid antibody syndrome and acute cholecystitis

A 74-year-old man with coronary artery disease was suffering from acute nonobstructive cholecystitis and was admitted to a nearby hospital. Dual antiplatelet (aspirin and ticlopidine) therapy was discontinued before preparation for surgical resection of the gall bladder. During his time in hospital he was aware of lumbar pain and weakness in both legs. He was transferred to our hospital for further evaluation and therapy. Diffuse intra-aortic thrombi were revealed by computed tomography with contrast media, and magnetic resonance imaging showed spinal cord infarction. However, computed tomography scans of the descending aorta obtained 4 months before admission exhibited no signs of atherosclerotic plaques or intra-aortic thrombi. Laboratory data suggest that antiphospholipid antibody syndrome might have caused these acute multiple intra-arterial thrombi. By restarting dual antiplatelet therapy and increasing the dose of heparin (from 10,000 IU/day to 15,000 IU/day) we successfully managed the patient’s clinical condition and symptoms. It is important to understand that stopping antiplatelet therapy may rapidly grow thrombi in patients with a hypercoagulative state.