Obstructive sleep apnea (OSA), a common comorbidity in patients with stroke, has shown increasing prevalence over the past few decades. OSA is an important risk factor for stroke in addition to other well-known contributors, including hypertension, hyperlipidemia, atrial fibrillation, and diabetes mellitus. Moreover, OSA is an independent predictor of neurological outcomes and mortality. The pathological mechanisms underlying the association between OSA and stroke include autonomic dysfunction, hypertension, cardiac arrhythmia, dyslipidemia, impaired glucose tolerance, hypoxia, and inflammation. Continuous positive airway pressure (CPAP) therapy has proven clinical utility in improvement of neurological symptoms in patients with stroke. Findings from a CPAP withdrawal model have shown increased sympathetic activity in OSA with a consequent significant elevation in blood pressure, relevant cerebral hypoxia, and disturbed cardiac repolarization. In this review, we present an overview of the literature that describes an association between OSA and stroke in addition to the vascular risk factors, including hypertension, hyperlipidemia, atrial fibrillation, and diabetes mellitus. This study highlights the importance of early and accurate diagnosis and management of OSA for stroke prevention and care and will benefit physicians in clinical practice.

PURPOSE: To report a rare case of Aspergillus endophthalmitis as a preceding symptom of central nervous system (CNS) lymphoma. CASE SUMMARY: A 66-year-old female was admitted to our clinic with mental change for 3 days. Seven months earlier, she had been diagnosed with retinal vasculitis in an ophthalmology clinic because of blurred vision in both eyes and was administered steroid therapy. Three months earlier, because of progressive symptoms, vitreous fluid culture had been performed and showed Aspergillus endophthalmitis. She was treated with intravitreous voriconazole injection and oral voriconazole. Initial brain magnetic resonance imaging (MRI) and cerebrospinal fluid study was normal. Two months later, a second MRI showed multiple enhancing lesions, which were aggravated on the third MRI at admission to our clinic. Although brain biopsy was not performed due to the poor condition of the patient, CNS lymphoma was suspected based on the neuroimaging. After steroid pulse therapy and whole brain radiation, follow-up neurologic examination showed improved mental state, and follow-up MRI showed remarkable shrinkage of multiple lesions. CONCLUSIONS: As Aspergillus endophthalmitis is an opportunistic infection in those with an immune-compromised state and the orbit is near the central nervous system, the clinician should be alert to concomitant disorders in CNS. For a prompt and accurate diagnosis of CNS disorder, early evaluation of neurologic symptoms beyond symptoms of endophthalmitis and neuroimaging is essential.
Aged ; Aspergillus* ; Biopsy ; Brain ; Central Nervous System* ; Cerebrospinal Fluid ; Diagnosis ; Endophthalmitis* ; Female ; Follow-Up Studies ; Humans ; Lymphoma* ; Magnetic Resonance Imaging ; Neuroimaging ; Neurologic Examination ; Neurologic Manifestations ; Ophthalmology ; Opportunistic Infections ; Orbit ; Retinal Vasculitis

Endoscopic intraluminal implantation of a self expandable stent has been increasing in patients with recurrent urethral strictures because of its simple and relative safe technique. There has been a few reports concerning luminal obstruction after implantation of Wallstent. We have experienced 4 cases of urethral obstruction after variable period of Wallstent implantation in the treatment of traumatic urethral stricture. Herein the methods for treatment of urethral obstruction are discussed. The patients were managed with two different types of treatment. The first one was transurethral resection of granulation tissue inside Wallstent. The other is reinsertion of Wallstent inside the first one after transluminal resection of granulation tissue in patients with urethral obstruction occurring within 5 months after Wallstent implantation. Retrograde urethrography and urethroscopy after 3 months have demonstrated patency of urethra and epithelial covering of the implant. Our experience shows that in all 4 patients with traumatic urethral stricture have developed variable degrees of urethral obstruction after a variable period of wallstent implantation. Therefore, we consider that our method is one of the alternatives to treat urethral obstruction after wallstent implantation in patients with traumatic urethral stricture.
Granulation Tissue ; Humans ; Phenobarbital ; Stents ; Urethra ; Urethral Obstruction* ; Urethral Stricture*

BACKGROUND: When attempting to identify lower lumbar spaces by palpating the spinous processes and iliac crests, the actual level often turns out to be higher than presumed. The rib cage line that joins the lowest points of the rib cage on the flank can be physically constructed in the same way as Tuffier's line. The purpose of this study was to assess the possibility that the rib cage line could be used as a marker for the lumbar spine level. METHODS: After IRB approval, 100 patients aged 20 to 69 were enrolled. The patients were stratified into 10 groups according to age and gender. Simple X-rays previously taken in the lateral neutral and lateral flexed positions were reviewed. In the lateral films, the rib cage line was drawn to connect the two lowest points of the tenth rib and Tuffier's line was drawn to the two uppermost points of the iliac crest such that the lines were perpendicular to the tangential line on the skin at the intersection points. Then, the vertebral body or intervertebral space, at which each line crossed, was identified and recorded respectively in the neutral and flexed positions. RESULTS: With maximum flexion of the lumbar spines, the vertebral level (25% to 75% range), at which the rib cage line crosses, appeared to be between the upper third of L1 and the upper third of L3. For Tuffier's line, the vertebral level was between the L3-4 intervertebral space and the lower third of L5. When the lumbar position was changed from neutral to flexed position, the rib cage line shifted cephalad (P < 0.05) and Tuffier's line shifted caudad (P < 0.05). CONCLUSIONS: We conclude that the rib cage line may be used as another marker of vertebral level and that it can act as a safeguard in that the spinal block should be performed one level lower than the rib cage line to prevent the spinal puncture from being performed at an undesirably high level.
Anesthesia ; Ethics Committees, Research ; Humans ; Lumbar Vertebrae ; Ribs* ; Skin ; Spinal Puncture ; Spine

There are various causes to a low level of consciousness in patients in the intensive care unit. Neurological injury, infection, and metabolic disarray are considered as some of the causes. A 39 year-old female patient was transferred to our hospital with septic shock due to ascending colon perforation. The patient had previously received ovarian cancer surgery and a cycle of chemotherapy at another hospital. Emergent operation for colon perforation was successful. After the operation, she was treated in the intensive care unit for infectious and pulmonary complications. She suddenly showed deterioration in her level of consciousness and had a generalized seizure. At the time of her seizure, she had severe hyperammonemia. Brain CT showed severe cerebral edema that was absent in the CT scan taken 2 days before. Continuous renal replacement therapy was conducted but was ineffective in lowering the level of serum ammonia and the patient subsequently died.
Ammonia ; Brain ; Brain Edema ; Colon ; Colon, Ascending ; Consciousness ; Female ; Humans ; Hyperammonemia ; Intensive Care Units ; Ovarian Neoplasms ; Renal Replacement Therapy ; Seizures ; Shock, Septic ; Status Epilepticus

BACKGROUND: Although clinicopathologic characteristics of acral lentiginous melanoma (ALM) is well established, immunohistochemical study on ALM has rarely been reported. OBJECTIVE: Our purpose is to evaluate the usefulness of several immune markers in the diagnosis of ALM. METHODS: An immunohistochemical study was performed on paraffin sections of 20 ALMs using S-100 protein, HMB-45, vimentin, epithelial membrane antigen (EMA), and CAM 5.2. RESULTS: 1. Nineteen (95%) and 16 (80%) out of 20 ALM showed reactivity with S-100 protein and HMB-45, respectively. 2. Melanin bleaching was useful for diagnosing heavily pigmented ALM using both S-100 protein and HMB-45. 3. The immunoreactivity of S-100 protein and HMB-45 did not correlate with tumor thickness or level of invasion of ALM. The intensity of HMB-45 correlated well with the melanin content. 4. One and 2 out of 20 cases stained focally with EMA and CAM5.2 respectively, but these cases stained also with HMB-45 and/or S-100 protein. CONCLUSION: S-100 protein and HMB-45 were relatively sensitive markers for diagnosing ALM. Despite the occasional positivity for the epithelial markers in ALM, all epithelial marker-positive cases stained also with HMB-45 and/or S-100 protein. Therefore, S-100 protein and HMB-45 are very useful markers for diagnosing ALM.
Biomarkers ; Diagnosis ; Melanins ; Melanoma* ; Mucin-1 ; Paraffin ; S100 Proteins ; Vimentin

A 59-year old man was admitted for drowsiness and stiff neck. CSF examination showed lymphocytic pleocytosis and PCR for herpes simplex virus (HSV)-1 was positive in CSF. Brain MRI revealed enhanced lesions in left temporal lobe. His symptom improved with acyclovir. Follow-up studies showed red blood cells in CSF and a hematoma in the left temporal lobe. There was no additional symptom related to the hematoma. He was discharged after conservative care. Although rare, hematoma can develop in HSV-1 meningoencephalitis.
Acyclovir ; Brain ; Encephalitis, Herpes Simplex* ; Erythrocytes ; Follow-Up Studies ; Hematoma* ; Herpes Simplex* ; Herpesvirus 1, Human ; Leukocytosis ; Magnetic Resonance Imaging ; Meningoencephalitis ; Neck ; Polymerase Chain Reaction ; Simplexvirus ; Sleep Stages ; Temporal Lobe