Right-to-left shunts may be not uncommon cause of TIA in Japan.

BACKGROUND AND PURPOSE: Although 30% to 60% of transient ischemic attacks (TIAs) have embolic sources, the etiology of the remaining TIAs is unknown. Right-to-left shunt (RLS) is one of the most important etiologies of cryptogenic stroke. The aim of this study was to determine whether RLS is related to transient ischemic attack (TIA) of unknown etiology. METHODS: We performed transesophageal echocardiography (TEE) and/or transcranial Doppler (TCD) studies for consecutive TIA patients in order to detect RLS from April 2004 to December 2006. TIA patients were divided into three groups, as follows: 1) Cardioembolic TIA, with a patent cardioembolic source, 2) thrombotic TIA, with an atherothrombotic and/or lacunar mechanism, and 3) undetermined TIA, without identified cause of TIA. We compared the characteristics and presence of RLS among these three groups. RESULTS: We enrolled 124 TIA patients (age: 67+/-13 years old, 80 men). There were 13 patients with Cardioembolic TIA, 25 with Thrombotic TIA, and 86 with Undetermined TIA. TEE and/or TCD were able to detect RLS in 61 of the 124 (49%) patients. RLS was frequent in patients with Undetermined TIA compared with those in the other TIA groups (60% in the Undetermined TIA group, 28% in the Thrombotic TIA group, and 15% in the Cardioembolic TIA group; p<0.001). Smoking and previous history of TIA were frequent in the Thrombotic TIA group (p=0.030 and p=0.016, respectively). CONCLUSION: RLS may play an important role in the etiology of TIA of undetermined cause

Two cases of multiple infarctions due to vertebral arterial occlusion associated with atlantoaxial subluxation caused by rheumatoid arthritis

Case 1: A 58-year-old woman with rheumatoid arthritis (RA) suffered from pontine and cerebellar infarctions and underwent three-dimensional computed tomography angiography (3D-CTA) of the vertebral artery (VA) with left-sided rotation of the head. This revealed a destroyed right atlantoaxial (AA) joint and right VA occlusion, which had caused the infarction. No recurrent infarctions have been observed after transarticular screw fixation (Magerl technique) was performed. Case 2: A 68-yearold woman with RA also suffered from pontine and cerebellar infarctions and underwent 3D-CTA of the VA with right-sided rotation of the head. This revealed a destroyed left AA joint and left VA occlusion, which had caused the infarction. No recurrentinfarctions have been observed after posterior fusion between the occiput and 3rd cervical vertebra was performed. In both cases of RA, who had multiple infarctions due to VA occlusion and a temporary thrombus formation, 3D-CTA in a rotated position helped to diagnose arterial occlusion. In addition, posterior fusion of the AA joint was a useful surgical technique

Development of D-to-D-to-P telemedicine at a remote island hospital using smart glasses

Background: Medical resources on remote islands are limited, which makes it difficult for patients to receive specialized medical care.Purpose: This study aimed to develop and evaluate a method to perform doctor-to-doctor-to-patient (D-to-D-to-P) telemedicine.Methods: The-D-to-D-to-P telemedicine was implemented to provide specialized medical support from a neurologist at Nagasaki University Hospital to a rural physician wearing camera-equipped smart glasses at Goto Chuoh Hospital on a remote island, which was called a virtual neurological outpatient (VNO). For the first six months, the rural physician independently saw patients with Parkinson’s disease (PD), and then for the next six months, VNO was implemented. Comparisons were made before and after the implementation of the VNO. Next, by adding a 4 K overhead camera, in-person examinations of a single outpatient were compared between the rural physician with VNO and another neurologist unrelated to the VNO.Results: The clinical efficacy of VNO was not superior to no VNO, but had a learning effect on rural physicians and was satisfactory for patients. By adding a 4 K overhead camera to the VNO, the accuracy of the in-person examination by the rural physician was shown to be equivalent to that of an in-person neurologist.Conclusion: VNO using smart glasses could be applied for D-to-D-to-P telemedicine in neurology. However, to promote telemedicine on remote islands, it will be necessary to improve the system to make it more accessible to rural physicians

Perfusion abnormality in neuronal intranuclear inclusion disease with stroke-like episode: A case report

Neuronal intranuclear inclusion disease (NIID) is a slowly progressive neurodegenerative disease. Some patients with NIID occasionally present with acute symptoms. However, its mechanism remains unclear. We report a patient with NIID who presented with a stroke-like episode. Arterial spin labeling magnetic resonance imaging revealed hypoperfusion in the focal cerebral region at the onset while no apparent arterial occlusion was observed. The abnormal perfusion area was normalized 6 days after admission. Therefore, the perfusion abnormality was likely the main cause of acute neurologic deficits in NIID. NIID should be considered in the differential diagnosis of stroke mimics

A phase 2 basket trial of combination therapy with trastuzumab and pertuzumab in patients with solid cancers harboring human epidermal growth factor receptor 2 amplification (JUPITER trial)

Introduction: Human epidermal growth factor receptor 2 (HER2) gene amplification and mutations have emerged as oncogenic drivers and therapeutic targets not limited to breast and gastric cancers, but also in a variety of cancers. However, even if an actionable gene alteration is found, the incidence of HER2 amplification in these cancers is less than 5%. It is too difficult to conduct a conventional randomized, controlled trial in a rare fraction. Therefore, we have designed a organ-agnostic basket study, which covers a variety of solid cancers harboring HER2 amplification, in 1 study protocol. Methods/Design: This trial is a multicenter, single-arm, basket phase 2 study in Japan. Patients with solid cancers harboring HER2 amplification that have progressed with standard treatment, or rare cancers for which there is no standard treatment, will be eligible. Target cancers include bile duct, urothelial, uterine, ovarian, and other solid cancers where HER2 amplification is detected by comprehensive genomic profiling using next-generation sequencing technology. A total of 38 patients will be treated with combination therapy with trastuzumab and pertuzumab every 3 weeks until disease progression, unmanageable toxicity, death, or patient refusal. The primary endpoint is the objective response rate, and secondary endpoints are progression-free survival, overall survival, and duration of response. Discussion: The aim of this trial is to evaluate the safety and efficacy of combination therapy with trastuzumab and pertuzumab in patients with locally advanced or metastatic, solid cancers harboring HER2 amplification. Instead of focusing on 1 organ type, our trial design uses a basket study focusing on HER2 amplification, regardless of the site or origin of the cancer. The results of our study will advance clinical and scientific knowledge concerning the treatment of locally advanced, rare solid cancers harboring HER2 amplification, using the combination of trastuzumab and pertuzumab. Trial registration: This trial was registered in Japan Registry of Clinical Trials (jCRT) on February 25, 2019, as jRCT2031180150

A score using left ventricular diastolic dysfunction to predict 90-day mortality in acute ischemic stroke: The DONE score

Purpose: The aim of this study was to identify whether diastolic dysfunction predicts death at 90 days after acute ischemic stroke.Methods: We retrospectively analyzed patients with ischemic stroke. All patients underwent transthoracic echocardiography to evaluate systolic function and diastolic function by means of assessing ejection fraction and septal E/e’.We evaluated the initial National Institute of Health Stroke Scale (NIHSS) score,arterial occlusion, and laboratory data. We used multivariate regression models to identify independent predictors of 90-day mortality. Results: Among 1208 patients, the overall 90-day mortality rate was 8%. In multivariate logistic regression analysis, a higher initial NIHSS score,plasma D-dimer level and E/e’ and occlusion of internal carotid artery or basilar artery were independent predictors of 90-day mortality.The DONE score derived from these valuables showed good discrimination with area under the curve (AUC) value of 0.82 (95% confidence interval [CI],0.78?0.87) to predict 90-day mortality. The DONE score also predicted poor outcome (modified Rankin scale score, 4?6) at 90 days (AUC, 0.82;95% CI 0.80?0.85). Conclusions: Higher E/e’ indicating diastolic dysfunction,may be associated with 90-day mortality in patients with acute ischemic stroke. The DONE score could readily predict poor outcome after acute ischemic stroke

Quantitative assessment of the stent/scaffold strut embedment analysis by optical coherence tomography

The degree of stent/scaffold embedment could be a surrogate parameter of the vessel wall-stent/scaffold interaction and could have biological implications in the vascular response. We have developed a new specific software for the quantitative evaluation of embedment of struts by optical coherence tomography (OCT). In the present study, we described the algorithm of the embedment analysis and its reproducibility. The degree of embedment was evaluated as the ratio of the embedded part versus the whole strut height and subdivided into quartiles. The agreement and the inter- and intra-observer reproducibility were evaluated using the kappa and the interclass correlation coefficient (ICC). A total of 4 pullbacks of OCT images in 4 randomly selected coronary lesions with 3.0 × 18 mm devices [2 lesions with Absorb BVS and 2 lesions with XIENCE (both from Abbott Vascular, Santa Clara, CA, USA)] from Absorb Japan trial were evaluated by two investigators with QCU-CMS software version 4.69 (Leiden University Medical Center, Leiden, The Netherlands). Finally, 1481 polymeric struts in 174 cross-sections and 1415 metallic struts in 161 cross-sections were analyzed. Inter- and intra-observer reproducibility of quantitative measurements of embedment ratio and categorical asses

Association between serum calcium levels and prognosis, hematoma volume, and onset of cerebral hemorrhage in patients undergoing hemodialysis

Background: High serum calcium levels should be avoided in patients on hemodialysis (HD) because they can induce cardiovascular diseases and worsen the patient\u27s prognosis. In contrast, low serum calcium levels worsen the prognosis of patients with cerebral hemorrhage in the general population. So far, whether serum calcium levels in patients on HD are associated with cerebral hemorrhage remains unknown. This study aimed to reveal the association between serum calcium and cerebral hemorrhage in patients on HD, including in-hospital death, volume of hematoma, and onset of cerebral hemorrhage. Methods: This cross-sectional case-control study included 99 patients on HD with cerebral hemorrhage at a single center between July 1, 2007 and December 31, 2017. Controls included 339 patients on HD at a single HD center between July 1, 2011 and June 30, 2012. Data on serum calcium level, patient demographics, and comorbid conditions were collected, and associations between cerebral hemorrhage and subsequent death were evaluated by multivariate logistic regression analysis. Further, the association of these backgrounds and hematoma volume was evaluated by multiple regression analysis. Results: Of the 99 patients, 32 (32%) died from cerebral hemorrhage. The corrected serum calcium level (odds ratio [OR], 2.49; 95% confidence interval [CI], 1.43-4.35; P < 0.001) and antiplatelet drug use (OR, 3.95; 95% CI, 1.50-10.4; P = 0.005)had significant effects on the prognosis. Moreover, the corrected serum calcium (P = 0.003) and antiplatelet drug use (P = 0.01) were significantly correlated with hematoma volume. In the patients, the corrected serum calcium level (OR, 1.54; 95% CI, 1.07-2.22; P = 0.02) was associated with the onset of cerebral hemorrhage, as was pre-hemodialysis systolic blood pressure (per 10 mmHg) (OR, 1.40; 95% CI, 1.23-1.59; P < 0.001). Conclusions: Although the precise mechanisms remain unknown, a high serum calcium level is associated with cerebral hemorrhage in patients on HD. Thus, we should pay attentions to a patient\u27s calcium level

Cardiac diastolic dysfunction predicts in-hospital mortality in acute ischemic stroke with atrial fibrillation

Background: The aim of this study was to identify whether diastolic dysfunction predicts in-hospital death in ischemic stroke patients with atrial fibrillation. Method: We retrospectively analyzed data fromenrolled patients with ischemic stroke patients with atrial fibrillation who presented within 24 h of onset. All patients underwent transthoracic echocardiography to evaluate diastolic filling pressure estimated as the ratio of early transmitral flow velocity (E) to mitral annular velocity (e\u27)within 24 h of admission.Weevaluated initial ischemic lesion volume andNational Institute of Health Stroke Scale (NIHSS) score. Results: Two hundred and sixty-six patients were enrolled.During hospitalization, 30 patients (11%) died. The deceased group had a higher NIHSS score, a higher D-dimer level, a higher creatinine level, a larger initial ischemic lesion volumeand a higher E/e\u27 ratio than those in the survival group. In amultivariate analysis, a higher E/e\u27 ratio was an independent predictor of in-hospital death. The cutoff value for the E/e\u27 ratio for prediction in-hospital death was 20 with the sensitivity of 75% and specificity of 86%. Conclusion: Diastolic dysfunction may be associatedwith in-hospital death in ischemic stroke patientswith atrial fibrillation

Current status of a helicopter transportation system on remote islands for patients undergoing mechanical thrombectomy

Background: Mechanical thrombectomy (MT) is standard treatment for acute ischemic stroke (AIS) with large-vessel occlusion within 6 h of symptom onset to treatment initiation (OTP). Recent trials have extended the therapeutic time window for MT to within 24 h. However, MT treatment remains low in remote areas. Nagasaki Prefecture, Japan has many inhabited islands with no neurointerventionalists. Our hospital on the mainland is a regional hub for eight island hospitals. We evaluated clinical outcomes of MT for patients with AIS on these islands versus on the mainland. Methods: During 2014–2019, we reviewed consecutive patients with AIS who received MT at our hospital. Patients comprised the Islands group and Mainland group. Patient characteristics and clinical outcomes were compared between groups. Results: We included 91 patients (Islands group: 15 patients, Mainland group: 76 patients). Seven patients (46.7%) in the Islands group versus 43 (56.6%) in the Mainland group achieved favorable outcomes. Successful recanalization was obtained in 11 patients (73.3%) on the islands and 67 (88.2%) on the mainland. The median OTP time in the Islands was 365 min. In both the Islands and Mainland groups, the OTP time and successful recanalization were associated with functional outcome. The modified Rankin Scale (mRS) score at 90 days ≤2 was obtained in two patients and mRS = 3 in four patients among eight patients with OTP time >6 h. Conclusions: Few patients with AIS on remote islands have received MT. Although patients who underwent MT on the islands had longer OTP, the clinical outcomes were acceptable. OTP time on remote islands must be shortened, as this is related to functional outcome. In some cases with successful recanalization, a favorable outcome can still be obtained even after 6 h. Even if OTP exceeds 6 h, it is desirable to appropriately select patients and actively perform MT