The spontaneous regression (SR) of cancer is defined as either partial or complete, and temporary or permanent, disappearance without appropriate treatment for the disease, and this phenomenon is rare in the case of small cell lung carcinoma (SCLC). We herein report an 83-year-old woman who presented with left-sided hemichorea associated with anti-SOX1 (SOX1-Ab) and -CV2/CRMP5 (CV2/CRMP5-Ab) antibodies with SR following a 7-year interval free of disease progression of SCLC. Hemichorea can present with the coexistence of anti-SOX1 and CV2/CRMP5-Ab with SR after a long interval free of SCLC. The immune response associated with these onco-neural antibodies may become independent of the original tumor trigger and remain active for many years.

© 2020 Japanese Society of Neurology and John Wiley & Sons Australia, Ltd F I G U R E 1 EEG and brain MRI findings. A, ASL perfusion MRI revealed bilateral hyperperfusion of the frontal lobes. B, Pretreatment DWI revealed no abnormalities. C, The EEG data showed intermittent frontal-dominant generalized multiple spikes and slow waves. D and F, Improvements in ASL and EEG findings after intravenous fosphenytoin treatment. E, Posttreatment DWI revealed no abnormalities. ASL acquisition parameters included 6 arms with 512 points in each spiral arm, phase encoding in the z direction = 32, section thickness = 3 mm, TR = 4906 s (AUTO), postlabeling delay = 1.523 s, and NEX = 3. ASL, arterial spin labeling; DWI, diffusion-weighted imaging; EEG, electroencephalography; MRI, magnetic resonance imaging; TR, repetition time; NEX, number of excitations (a)

Objectives: Small vessel disease (SVD) has been associated with motor and cognitive impairments in neurodegenerative diseases. We investigated SVD markers using brain magnetic resonance imaging (MRI) and the global SVD score in Parkinson's disease (PD). Patients and methods: Seventy-one patients with PD were assessed for vascular risk factors, motor severity, and motor phenotype. Global cognition was evaluated using the Mini -Mental State Examination (MMSE) and Montreal Cognitive Assessment (MoCA). Based on the MoCA score, we categorized cases into normal (> 23) or cognitively impaired (23). We calculated the total SVD score (range, 0-4) based on white matter hyper intensities (WMHs), lacunae, cerebral microbleeds (MBs), and enlarged perivascular spaces (PVSs). In addition, we evaluated global brain atrophy. Results: There were no significant associations with total SVD score and vascular risk factors, PD severity, and motor phenotype. Increasing age and reduced MMSE and MoCA scores were associated with increased SVD burden. Logistic regression analyses demonstrated that periventricular WMH (PVH), PVS in the basal ganglia (BG-PVS), and atrophy were predictors of cognitive impairment in PD. Conclusion: The contribution of SVD may be important in elderly patients with PD. Impaired cognition due to SVD-related brain changes was associated with BG-PVS and PVH. These measures suggest that PD with PVS can provide novel insights into SVD.

A 64-year-old woman with no previous mental illness took a single 500 mg tablet of levofloxacin for cystitis. Two hours later, she developed psychosis with involuntary movement and severe hyperventilation with respiratory alkalosis. Cranial magnetic resonance imaging findings were unremarkable, and an electroencephalogram revealed no epileptiform discharge. Her symptoms improved on the third day after levofloxacin was discontinued. Levofloxacin-associated encephalopathy with psychotic features is a rare adverse event. Disturbance of gamma-aminobutyric acid-ergic (GABAergic) interneurons by levofloxacin may lead to hyperventilation via dysfunction of the brainstem respiratory network. Physicians should be aware of hyperventilation as an additional serious symptom of levofloxacin-associated encephalopathy in acute settings.

A 41-year-old woman experienced back pain upon waking up. Immediately afterward, she experienced a continual orthostatic headache. Thereafter, right ear fullness and dizziness also occurred. One month later, she became aware of repeated numbness that started in the right hand and spread to the right half of the body and lower limbs and continued for repeated periods of approximately 20-30 min. Neurological examination revealed no abnormal findings except for orthostatic headache. Electroencephalography showed no epileptic discharge. Head MRI revealed left convexal subarachnoid hemorrhage (cSAH) restricted to the prefrontal sulcus, left frontal cerebral venous thrombosis, diffuse dural thickening with gadolinium enhancement, and subdural hematoma in the posterior cranial fossa. Spinal MRI revealed epidural fluid accumulation around the thoracic spine. CT myelography revealed cerebrospinal fluid leakages at the cervical, thoracic, and lumbar vertebrae levels. The patient was diagnosed with spontaneous intracranial hypotension (SIH), which was treated effectively with a blood patch. In this case, cSAH may have resulted from rupturing of the vessel wall as a result of cortical venous thrombosis induced by SIH. The repeated transient neurologic symptoms suggesting migraine aura may have originated from cSAH, which in turn led to cortical spreading depression. The diagnosis and management of SIH can be often difficult; therefore, repeated migraine-aura-like symptoms are a critical sign of complication with cSAH and cortical venous thrombosis.

internal carotid artery that had resolved prior to CT angiography.Emergency care clinicians should be aware that PMIFP may follow SSD.

A 59-year-old man with no history of seizure, who was undergoing treatment for chronic alcoholic cirrhosis, was admitted for a fever due to cellulitis and alcohol withdrawal.A generalized seizure with left facial twitching developed after the patient lost consciousness during status epilepticus (SE).Electroencephalogram showed periodic lateralized epileptiform discharges (PLEDs) over the right hemisphere (Picture A).The seizure stopped after intravenous administration of midazolam.Three days after SE onset, arterial spinlabeling perfusion magnetic resonance imaging, a noninva-

Aim: We investigated the characteristics of elderly medical patients with white matter hyperintensities on magnetic resonance imaging. Methods: A total of 213 patients (123 men and 90 women; mean age 74.8 years) reported their history of hypertension, diabetes, dyslipidemia, previous stroke, coronary heart disease and chronic kidney disease (CKD). All patients completed the Mini-Mental State Examination and Geriatric Depression Scale. White matter hyperintensities were evaluated for the periventricular region, basal ganglia (BGH), deep white matter and infratentorial region, and brain atrophy was calculated as bicaudate ratios. Results: Patients with cognitive impairment (Mini-Mental State Examination score < 24) were significantly older (P=0.001), had periventricular region hyperintensities (P=0.029) and BGH (P=0.0015), and showed atrophy (P < 0.0001). Logistic regression showed that cognitive impairment was predicted by stroke (OR 2.5, 95% CI 0.033-0.894, P=0.036) and atrophy (OK 8.43, 95% CI 5.71-37.0, P=0.0109). Multiple regressions showed that BGH was associated with CKD 03=0.213; P=0.003), and infratentorial region was associated with stroke (beta=0.157; P=0.035) and CKD (beta=0.172; P=0.016). Periventricular region was associated with age (beta=0.2; P=0.011) and Geriatric. Depression. Scale (beta=0.151; P=0.037), and deep white matter hyperintensities with age (beta=0.189; P=0.016). Conclusions: Although cognitive impairment in elderly medical patients is associated with stroke and brain atrophy, white matter hyperintensities, especially BGI and infratentorial region, are associated with cognitive decline in relation. to CKD.

We describe a patient with mitochondrial myopathy, encephalopathy, lactic acidosis, and stroke-like episodes (MELAS), with multiple cerebral vasodilatations in a stroke-like episode visualised by using magnetic resonance angiography (MRA) and CT angiography (CTA). In the acute stroke-like episode stage, T2-weighted and fluid-attenuated inversion recovery MRI showed high-intensity areas in the left occipital area. In addition, MRA and CTA revealed prominent dilatation of the left posterior cerebral artery and temporal branches of the middle cerebral artery with focal hyperperfusions using CT perfusion (CTP) that corresponded to the MRI. After 10 days, with the development of aphasia, MRI indicated the lesions had spread to the temporal and parietal regions, and this distribution was not confined to major vascular territories. The patient's symptoms gradually improved, accompanied by the attenuation of MRI, CTA, and CTP findings. These characteristic features along with the MRI changes that spread beyond vascular boundaries and the multiple cerebral vasodilatations prior to the development of clinical symptoms are not fully explained by the mitochondrial angiopathy or cytopathy theories. These findings provide further evidence supporting neuronal hyperexcitability in stroke-like episodes of MELAS.

A 26-year-old male was admitted because of a fever, headache and disturbance of consciousness with lymph node swelling of the neck two days after developing a rash. A neurological examination revealed restlessness with irritability in response to sensory stimuli, such as an injection. Diffusion-weighted brain magnetic resonance imaging (MRI) revealed a hyperintense ovoid lesion in the splenium of the corpus callosum, which showed a low coefficient in the ADC map: the lesion disappeared after 22 days. An enzyme immunoassay (EIA) of the serum and cerebrospinal IgM were positive for rubella virus. The patient was therefore diagnosed with rubella encephalitis. He recovered gradually and was discharged on day 19 after the onset of symptoms without any sequelae. To our knowledge, this is the first case of rubella encephalitis presenting as clinically mild encephalitis/encephalopathy with a reversible splenial lesion (MERS). Although the exact mechanism underlying the development of rubella encephalitis is not well established, this case indicated that our patient had an immune-mediated secondary encephalitis. According to the survey of the pandemic of rubella from 2012 to April 2013 in Japan, the incidence of rubella encephalitis is thought to be relatively higher than was previously noted. This emphasizes the importance of vaccination for preventing encephalitis.

A 60-year-old male was admitted because he had developed tremulous movement in both upper and lower limbs and gait disturbance over the course of 3 months. He had been on continuous ambulatory peritoneal dialysis almost 1 year earlier due to end-stage diabetic nephropathy. A neurological examination revealed a mild disturbance of his consciousness, asterixis in the upper limbs, bilateral extensor plantar responses and parkinsonism, which were characterized by bradykinesia, akinesia, rigidity, and bilaterally tremors at rest. Cranial magnetic resonance imaging (MRI) revealed swollen bilateral basal ganglia legions, which appeared hyperintense on T2-weighted images. The patient was treated for metabolic acidosis and continued hemodialysis three times a week; however, the parkinsonism remained 1 year later. Follow-up MRI revealed decreased swelling of the basal ganglia, and the pattern of diffusion-weighted images and the apparent diffusion coefficient (ADC) map indicated vasogenic and cytotoxic edema in bilateral globus pallidus. The case was diagnosed as encephalopathy due to diabetic uremic syndrome, initially characterized by Wang et al. (2003). Only 17 cases with parkinsonism have been reported. Diabetic uremic syndrome is characterized by acute or subacute onset consciousness disturbance and movement disorders such as parkinsonism, chorea and the other extrapyramidal signs to various degrees related to bilateral lesions of the basal ganglia.

Although sudden unilateral hearing loss is relatively common, espite clinical and radiological investigations, most cases remain diopathic. The central disorders causing sudden hearing loss are escribed in cases with vertebrobasilar insufficiency; multiple scleosis; sarcoidosis; meningitis; forms of vasculitis, such as Behc et isease; human immunodeficiency virus or cytomegalovirus infecion; and Susac syndrome [1]. Sudden hearing loss is usually nilateral; bilateral hearing loss is rare. Among various etioloies affecting auditory pathways, the incidence of bilateral hearing oss is estimated to be 0.5–1.2% in patients with vertebrobasilar schemia or occlusive disorders [1,2], and hearing loss resulting rom vertebral artery dissection is extremely rare. We report a case f bilateral intracranial vertebral artery dissection presenting as udden bilateral hearing loss with no abnormality in brainstem and erebellar structures on magnetic resonance imaging (MRI).

A lack of habituation in visual-evoked potentials (VEPs) is the main abnormality observed in migraineurs. However, no study of steady-state VEPs has yet evaluated pattern-reversal stimuli with respect to habituation behavior or spatial frequency. The aim of this study was to clarify habituation behavior in migraineurs between attacks and to establish characteristics of VEPs in these patients. Steady-state VEPs were sequentially recorded as checkerboard patterns in four consecutive blocks from 12 patients with migraine without aura (MO), 12 patients with migraine with aura (MA), and 12 healthy controls (HC) at four spatial frequencies of 0.5, 1.0, 2.0, and 4.0 cycles per degree (cpd) with a stimulus rate of 7.5 Hz (15 reversal/s). VEP amplitudes were consistently higher in migraineurs. However, habituation was not demonstrated in HCs, and migraineurs did not reveal a clear lack of habituation. MAs exhibited high-amplitude VEPs, depending on spatial frequency. In the MA patients, amplitude differences reached statistical significance at 2.0 cpd. The sequential amplitude changes at 0.5 cpd were significantly different in MAs compared with HCs. Migraine patients exhibited high-amplitude VEPs, which were dependent on spatial frequency, and may be related to altered excitability in pre-cortical and cortical visual processing.

An 86-year-old, right-handed, hypertensive man suddenly experienced blurring of vision predominating in the left visual field. Neurological examinations were normal, except for left homonymous hemianopsia. Goldmann visual field testing revealed a left congruent incomplete homonymous hemianopsia with macular splitting. Brain MRI, with a T2-weighted image, demonstrated a lesion of high intensity in the right lateral geniculate body (LGB), as well as the posterior part of the caudate nucleus, posterolateral thalamus, and dorsolateral thalamus. MRA revealed severe stenosis at the second segment of right posterior cerebral artery (PCA). SPECT revealed significantly decreased blood perfusion in the striate cortex. To the best of our knowledge, this is the first case of an isolated, congruent, incomplete, homonymous hemianopsia due to lateral posterior choroidal artery (LPChA) region infarction. The LPChA possibly supplied the LGB through the PCA system. A horizontal, homonymous sectoranopia is typically the hallmark of an LPChA region infarction. However, a homonymous hemianopsia may also occur when the entire LGB has been affected. In the case of homonymous hemianopsia, LGB damage due to LPChA region infarction should be considered, in addition to lesions of the visual pathway, such as the optic tract, optic radiations, and occipital cortex.

Herbal tea made from Verbena officinalis (V. officinalis) has traditionally been used for the treatment of insomnia and other nervous conditions. In this study, we examined the sleep-promoting activity of hastatoside, verbenalin, and verbascoside, which are the major iridoids (hastatoside and verbenalin) and polyphenol (verbascoside) components responsible for the pharmacological activity of V. officinalis, by electroencephalographic analysis of rats after oral administration of the compounds. Hastatoside (0.64 mmol/kg of body weight) and verbenalin (1.28 mmol/kg of body weight) increased the total time of non-rapid eye movement sleep during a 9-h period from 23.00 to 08.00 hours by 81% and 42%, respectively, with a lag time of about 3–5 h after the administration at 20.00 hours (lights-off time). Both compounds also increased the delta activity during non-rapid eye movement sleep. However, verbascoside had no effect on the amount of sleep. Therefore, hastatoside and verbenalin are major sleep-promoting components of V. officinalis.

The neuro-cardio-pulmonary function, including the Kohs block design test, the Up & Go, the Functional Reach and the Button tests, was examined in 40 elderly subjects (19 men and 21 women, mean age: 74.7±3.3 years) in Leh, Ladakh (altitude: 3524 m), for comparison with 324 elderly citizens (97 men and 227 women, mean age: 80.7±4.7 years) of Tosa, Japan (altitude: 250 m). Pulse wave velocity (PWV) was measured in these subjects using a VaSera CAVI instrument (Fukuda Denshi, Tokyo). SpO2 decreased while Hb and diastolic BP increased with increasing altitude.