Rinshō shinkeigaku = Clinical neurology
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Recent epidemiological studies have suggested that 15 to 30% of all ischemic stroke is comprised of cardioembolic stroke. The presence of intracardiac thrombi might prove to be the most reliable tool when making a diagnosis of cardioembolic stroke, although not always easy to determine even with recent advanced technique. In this study, sensitivities to detect intracardiac thrombi of transthoracic echocardiography (TTE), transesophageal echocardiography (TEE), cardiac-enhanced CT (CCT) and scintigraphy with indium-111-tropolone-labelled platelets (PSG) were compared, in order to provide a relevant guideline for the diagnosis of intracardiac thrombi in 83 patients suspected of cardioembolic stroke. ⋯ Among the patients having intracardiac thrombi, frequently observed was the increase of beta-thromboglobulin, platelet factor 4, platelet lysis, thrombin-antithrombin III complex, D-dimer in 67%, 75%, 71%, 80% and 80%, respectively, as well as the shortening of platelet survival in 100%, while anrithrombin III was reduced in only 38%. In addition, when hemostatic abnormalities were compared between positive and negative groups of intracardiac thrombi, the shortening of platelet survival (p < 0.0001), the increase of platelet lysis, and the increase of D-dimer (p < 0.04) were more frequent in the positive group than in the negative group. These results indicate that the findings of activation of platelets and coagulation-fibrinolysis, except for the reduction of antithrombin III, especially the findings of platelet consumption and lysis as well as fibrinolysis activation are useful as sensitive parameters of in situ thrombosis or prothrombotic state, which may lead to the formation of intracardiac thrombi.
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Respiratory failure occurring during late adolescence is a major cause of death in Duchenne muscular dystrophy (DMD). A number of respiratory assistance techniques including tracheostomy and positive pressure mechanical ventilation have been utilized not only to prolong DMD patients' life but also to improve quality of their life. It is surprising that most of the tracheostomized DMD patients can speak under positive pressure ventilatory assistance. ⋯ In order to understand the mechanism of this phenomenon, we visualized the topographical relationship between trachea and the tube cuff using computed tomography by filling the cuff with aqueous contrast medium. We obtained following findings: 1) Trachea is flat and deviated from normal midline position, and 2) the tube cuff is located eccentrically in trachea resulting in compression of one side of the inner wall and leaving open space on the other side. We conclude that the tracheal malposition and deformity underlie this strange phenomenon and tight inflation of the cuff to prevent air leak may result in unfavorable complications in DMD patients.
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Eighteen autopsy cases of syringomyelia were studied neuropathologically. In 5 cases associated with Chiari type I malformation, the syrinx was irregular in shape and communicated with the subarachnoid space at the entry zone of the posterior nerve roots. The central canal above the level of the syrinx was patent in 2 but closed in 3 out of 5 cases. ⋯ In 6 cases associated with Chiari type II malformation, the syrinx central canal, and the central canal was patent from the 4th ventricle to the syrinx in all cases. In these cases, direct continuity between the 4th ventricle and the syrinx was essential for the development of the syrinx. In cases associated with posterior fossa or spinal canal tumors, the local circulatory disturbance and/or edema due to the tumors were thought to cause the syrinx.
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Previous studies have shown that migraine with aura is associated with the reduction of regional cerebral blood flow (rCBF). However, the question of whether the reduction of rCBF during migraine aura is caused by cerebral vasospasm or is secondary to the neural depression (spreading depression) is still disputed. We measured rCBF by high resolution SPECT method during the attack of migraine and examined whether the reduction in flow corresponds to the cerebral vascular territory. ⋯ Cerebral spinal fluid lactate level during the headache measured in one patient was higher (38 mg/dl) than the interictal period (12 mg/dl). Our data indicated that the reduction of rCBF during the aura is caused by ischemia probably due to the cerebral vasospasm and is not secondary to the neuronal depression. It was also suggested that the primary site of rCBF reduction during the visual aura is the occipital association cortex which is reported to be responsible for the visual hallucination.
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A 74-year-old man presented sudden onset hoarseness and dysphagia. Two months before this event, he had developed arthralgia of the shoulders, elbows, hands and foot and pleuritis which had been alleviated by a treatment with prednisolone. On admission, the patient could not phonate nor swallow at all. ⋯ The syndrome of aphonia and dysphagia due to paralysis of the unilateral soft palate and vocal cord is called Avellis syndrome. This syndrome has been reported mainly in relation with the infarction of lateral medulla. The present case shows that Avellis syndrome can be produced by mononeuritis of the vagus nerve.