Background and Purpose: To assess the status of intravenous recombinant tissue plasminogen activator (IV t-PA) administration in Japan, we investigated various components in relation to early admission management for acute stroke patients employing a questionnaire sent to hospitals. Methods: From August to October 2007, we sent out questionnaires concerning the infrastructure of acute stroke care to 8569 hospitals. The responses were categorized as follows: 1) stroke service prepared by stroke physicians (SPs) for 24 hr/day, 7 days/week (24/7) ; 2) IV t-PA available 24/7 (t-PA hospital) ; and 3) total number of SPs. The components related to t-PA hospitals were analyzed and the contributions of the number of SPs to the t-PA hospitals were evaluated. Results: Responses were received from 4690 (54.7%) of the 8569 hospitals. Of these, 1466 hospitals (31.3%) were admitting acute stroke patients, and 519 (35.4%) of these 1466 hospitals were t-PA available hospitals. The number of hospitals with fewer than 5 SPs was 326 (63.6%) of the 519 t-PA available hospitals and 861 (93.6%) of the 933 of no t-PA hospitals (p<0.001). Among the t-PA hospitals, 20% had 2 SPs, 50% had 5 SPs, and 90% had more than 10 SPs.
Conclusion: A decreased number of SPs shows an association with IV t-PA availability.

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Dysphagia is common after stroke, and its detection is an important part of acute stroke management. In this study, to investigate the clinical factors for aspiration in acute stroke, we compared bedside clinical assessments of swallowing with the findings of videofluoroscopy (VF). The subjects comprised 132 patients with stroke aged between 35 and 97 years, including 78 males and 54 females, in whom VF was performed for swallowing difficulty or suspected swallowing difficulty. They consisted of 94 patients with cerebral infarction, 23 patients with cerebral hemorrhage, and 15 patients with subarachnoid hemorrhage. Before VF, the pharyngeal reflex, physical status, and cognitive function were investigated as bedside clinical assessments. For swallowing evaluation at bedside, the repetitive saliva swallowing test (RSST) and modified water swallowing test (MWST) were performed. As a result, 43 (32.6%) of the 132 patients revealed some difference between the bedside clinical assessments of swallowing and findings obtained by VF. In patients with not only disability of the pharyngeal reflex but also cervical and trunk stability, cognitive dysfunction and aphasia, aspiration should always be supposed and observations for eating behavior against aspiration should be undertaken. In addition, in cases with such physical and cognitive disability at the acute stroke stage, we recommend the use of both tests (bedside clinical tests and VF) to establish the correct findings for swallowing, and it is worth conducting VF when aspiration is suspected based on neurological assessments.

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Background and Purpose: Acute occlusion of the vertebrobasilar artery is often diagnosed more than 6 hours after onset in clinical practice. The indications for thrombolysis in such cases are not well understood. Patients and Methods: A total of 19 cases with vertebrobasilar occlusion were treated. Intraarterial thrombolysis with urokinase was performed in 13 cases, urokinase with percutaneous transluminal angioplasty (PTA) in 4, and intravenous TPA in 2. Twelve cases were treated within 6 hours of onset, whereas 7 cases were treated 6 hours or more after onset. The treatment results in these two groups were compared using the modified Rankin scale (MRS) at 3 months. Results: Thrombolytic therapy within 6 hours yielded excellent outcomes, with 6 out of the 12 patients showing an mRS of below 2. However, in patients treated aftre 6 hours or more, only 2 out of the 7 patiens demonstrated an excellent result with mRS below 2. Conclusion: The findings obtained indicated that the treatment results were favorable in patients treated within 6 hours of onset, but in patients treated 6 hours or more after the onset of occlusion, a favorable outcome could only be expected when the initial INHSS was not severe.

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The trends in the incidence, subtype, severity, and short-term outcome of stroke at our hospital during 1997 to 2006 are reviewed. A total of 2,699 acute cases of stroke were admitted during this period, with 1,238 in the former and 1,461 in the latter 5 years. They included approximately 60% of ischemic stroke (CI), 25% of intracerebral hematoma (ICH), and 15% of subarachnoid hemorrhage (SAH). CI was slightly increased in the latter 5 years (59% to 62%). There were two new trends of treatment available: intravascular surgery for cerebral aneurysms and intravenous administration of tPA for ultra-acute cases of cerebral infarction. However, no significant improvement of short-term outcome was evident. The CI group showed the most favorable outcome. Mortality was the highest in the SAH group. The ICH patients most often exhibited severe functional disability. It was found that there was no obvious improvement in the prognosis of our patients over the past 10 years. However, the hospitalization period was markedly shortened between the former and latter 5-year periods, from 27.2 to 23.5 days, respectively. The average age of the patients in the latter group was 2.4 years higher than that in the former one. Of the 2,699 stroke patients, 528 (19.6%) required surgical treatments.

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We report here the case of a 57-year-old man with subclavian steal syndrome who demonstrated transient ischemic attack of the right middle cerebral artery. The patient had a history of transient dysarthria and right hemiplegia. The blood pressure in his left arm was 126/72 mmHg, whereas that in his right arm was very low (70/52 mmHg) and pulsation of the right radial artery was undetectable. Angiography revealed 90% stenosis of the brachiocephalic artery and reversed flow of the right vertebral artery. Also, 70% stenosis of the left internal carotid artery was observed, and collateral circulation to the posterior part of the left middle cerebral artery was noted from the left posterior cerebral artery. After undergoing angioplasty using a balloon-expanded stent, the patient showed no ischemic attack. In this case, the transient ischemic attack of the left middle cerebral artery territory was probably the result of concurrence of subclavian steal phenomenon from the severe stenosis of the brachiocephalic artery and left carotid artery stenosis.

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We report a rare case of ruptured superior cerebellar artery (SCA) aneurysm causing subarachnoid hemorrhage (SAH) with supratentorial intracerebral hematoma (ICH). A 48-year-old male suffered from sudden unconsciousness and right hemiplegia. Computed tomography scans revealed diffuse SAH with ICH extending from the left side of the upper pons and the left cerebral peduncle to the left basal ganglia. An angiogram demonstrated a left SCA aneurysm located in the anterior pontine segment, which was projecting up in a supratentorial direction. To avoid uncontrollable premature bleeding and excessive retraction of the brain, a coil embolization followed by hematoma evacuation was performed. The patient's consciousness level became clear, although he was suffering from aphasia and right hemiplegia (modified Rankin scale 4). Coil embolization followed by hematoma evacuation proved to be a very useful and safe technique in the present case.

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We report the case of 62-year-old woman who arrived at our hospital within 40 min from onset, after she had suddenly become aware of paresis and paresthesia in her right leg. Although she denied any chest, back, or abdominal pain, she reported knotted neck pain only before the onset of her leg symptoms. Due to her clear consciousness and atypical pain, we suspected not only stroke but also acute aortic dissection. We immediately conducted helical contrast CT scanning from the neck to the pelvis following conventional CT scanning of the head. On the contrast CT scan, we diagnosed a type A acute aortic dissection and consequent occlusion of the right femoral artery. After the diagnosis, the right femoral pulse was confirmed unpalpable. Emergent replacement of the ascending aorta and aortic arch using a prosthetic graft was carried out. In addition, bypass grafting from the left to right femoral artery was successfully performed. Contrast CT scanning of the chest and abdomen following CT scanning of the head is regarded as most available for the detection of aortic dissection, especially in the case of considering rt-PA therapy for acute ischemic stroke.

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A 47-year-old man was admitted to our hospital due to dysarthria and right hemiparesis without headache. A brain CT scan and MRI revealed cerebral infarction in the left frontal lobe. Cervical echo and cervical MRA did not demonstrate arteriosclerosis of the carotid arteries and intracranial cerebral arteries. A holter electrocardiogram and echocardiography yielded normal findings. Collagen diseases, anti-phospholipid antibody syndrome, sarcoidosis, protein C deficiency and protein S deficiency were not detected. We were unable to diagnose the cause of the cerebral infarction, but suspected a dissecting aneurysm. We therefore performed cerebral angiography, and a dissecting aneurysm with pearl and string signs at the A2 segment of the anterior cerebral artery was found. In the classification of the causes of cerebral infarction in patients with juvenile-onset, atherothrombotic infarction, cerebral embolism and "other causes of cerebral infarction" are recognized. Cerebral angiography was useful for making the diagnosis with anterior cerebral artery dissection in our case. It is important that we actively diagnose cerebral artery dissection as a cause of juvenile-onset stroke.

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In this prospective study, the authors assessed whether or not platelet aggregation underwent significant changes when an antiplatelet agent was shifted from 200 mg/day of ticlopidine to 75 mg/day of clopidogrel in 44 patients with transient ischemic attack or ischemic stroke. Platelet aggregation was monitored before and at 1 to 3 months after the drug shift. The results, obtained indicated that collagen- and ADP-dependent platelet aggregation did not exhibit any significant changes when the antiplatelet agent was shifted from ticlopidine to clopidogrel. The present findings strongly suggest that platelet aggregation is well inhibited and constant when ticlopidine is replaced by clopidogrel.

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We examined a recurrence cases of stroke during the "KAIFUKUKI" rehabilitation period. In total 1,538 cases, (cerebral infarction: 917 caces, cerebral hemorrhage: 621 cases) 20 cases had a recurrence. A total relapse rate was 1.3%. In cardioembolism, it was 3.4%. In atherothrombosis, it was 1.5%. In lacunar infarction, It was 0.5%. In cerebral hemorrhage, it was 0.5%. In total 20 cases of recurrence,11 cases were cardioembolism, 5 cases were atherothrombosis, 1 case was lacunar infarction, 3 cases were cerebral hemorrhage. In cardioembolism, 9 cases had a recurrence by cardioembolism and 2 cases had a recurrence by cerebral hemorrhage. In atherothrombosis, 4 cases had recurrence by atherothrombosis and 1 case had recurrence by cerebral hemorrhage. In cerebral hemorrhage, all 3 cases had a recurrence by cerebral hemorrhage. The reason why recurred about cardioembolism was the poor control of PT-INR (PT-INR<1.6: 4 cases, warfarin was unused: 4 cases, PT-INR 1.77: 1 case). The reason why recurred about athereothrombosis was not undergoing cerebral artery bypass surgery though patients had the indication of operation. The reason why recurred about cerebral hemorrhage was the poor control of boold pressure. We should control it below 130/80 mmHg severely because the patients who had a recurrence had over 140 mmHg once a week.

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