Purpose: To clarify the usefulness of carotid ultrasonography for evaluation of cross-filling through the anterior communicating artery (ACoA) of the circle of Willis, which is regarded as the primary collateral pathway in patients with trial occlusion of the internal carotid artery (ICA). Methods: Cross-filling on the angiogram was determined by contrast filling of the ACoA following an injection of contrast medium into the carotid artery with temporary manual occlusion of the contralateral common carotid artery (Matas test). The appearance of cross-filling was graded on the following 3-point scale: grade 1, there was no apparent cross-filling on the angiogram; grade 2, slight but definite collateral distribution, often with dilution, e.g. to the anterior cerebral artery alone or to both the anterior cerebral and middle cerebral arteries; grade 3, complete cross-filling, i.e. to the middle cerebral artery. On carotid ultrasonography, we measured the blood velocity in the ICA (V_ICA) before and during the Matas test. Correlation between the grade of cross-filling and the V_ICA in carotid ultrasonography was investigated in each case. Results: In grade 3 patients, the V_ICA increased immediately during Matas test, while that of other patients remained unaffected by occlusion test. Consequently, increased V_ICA (≥20%) on carotid ultrasonography during the Matas test suggested that cross-filling via the ACoA is a more effective pathway compared with unchanged V_ICA (‹20%) during the Matas test. Conclusion: A combination of carotid ultrasonography and the Matas test seemed to be useful and minimally invasive in predicting cross-filling via the circle of Willis.

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The purpose of this study was to investigate whether severity and outcome of acute cerebral infarction with non-valvular atrial fibrillation (NVAF) are related to CHADS₂ score or not. We reviewed medical records of 236 consecutive patients with acute brain infarction with NVAF. We investigated the relationship between CHADS₂ score and NIH stroke scale (NIHSS) at admission, and modified Rankin Scale (mRS) at discharge. The NIHSS was less than 5 in 41.1%, 5–22 in 54.7%, and more than 22 in 4.2%, and the mRS was 0 or 1 in 33.5%, 2–3 in 25.0%, 4–6 in 41.5%. There was no relationship between CHADS₂ score and NIHSS or between CHADS₂ score and mRS. The score of CHADS₂ is not related to neurological severity or outcome of brain infarction with NVAF. Even if CHADS₂ score is low, warfarin treatment may be recommended to avoid stroke.

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Background and Purpose: On occasion, the diagnosis of cerebellar infarction is initially missed. We analyzed the clinical features of cerebellar infarction to clarify factors contributing to the misdiagnosis of cerebellar infarction.
Methods: Twenty two (4.3%) of 514 stroke patients were diagnosed with cerebellar infarction at Asahikawa Medical College between 2006 and 2008. We examined the clinical features of these patients retrospectively.
Results: Eight patients (36.4%) presented with no more than one typical cerebellar symptom. Although three patients came to the emergency room of our hospital within three hours of onset, they were not initially diagnosed with stroke but were admitted to a non-neurology ward. All three patients complained mainly of vertigo and did not present with either dysarthria or gait disturbance. Five patients were not initially diagnosed with cerebellar infarction due to the absence of any cerebellar sign.
Conclusion: We emphasize that clinicians should consider the possibility of cerebellar infarction whenever patients complain of vertigo or vomiting only. We recommend that the stroke team be involved in the diagnosis of patients with vertigo or vomiting.

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Background and Purpose: This study compared the usefulness of different durations and intensities of rehabilitation training based on changes in activities of daily living (ADL) observed 18 months after discharge of stroke patients who had participated in the FIT (full-time integrated treatment) program.
Methods: 1) Subjects in the traditional rehabilitation system (Pre-FIT group) included 49 patients (mean age: 63.3±10.9 years old) who received standard training 5 days a week, 2). Subjects in the FIT program (FIT group) included 81 patients (mean age: 61.1±12.8 years old) who received short-term intensive training 7 days a week. The ADL of these patients was assessed by Functional Independence Measure (FIM). We used mainly the motor subscore of FIM (FIM-M) to analyze the course of changes in the ADL level.
Results: The average hospital stay in the FIT group was significantly shorter than that in the Pre-FIT group (Pre-FIT group: 91.8±27.9 days, FIT group: 78.2±41.8 days). Average score of FIM-M in the Pre-FIT group 18 months after discharge (64.0±23.4) was significantly smaller than that in the FIT group (71.8±19.3). The FIM-M score decreased significantly after discharge in both groups (Pre-FIT group: -4.7, FIT group: -3.8).
Conclusions: The advantage of the FIT group over Pre-FIT group in ADL gain was maintained even 18 month after discharge. A further study will be required to determine the optimal duration and intensity of training in the FIT program.

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Background and Purpose: The effectiveness of eicosapentaenoic acid (EPA) for prevention of cerebral vasospasm following subarachnoid hemorrhage (SAH) has been reported; however, the optimal dose is still unknown. We report here the outcome of high dose EPA administration compared with the outcomes of the control group and those treated with a conventional dose.
Methods: Between January 2005 and December 2008, we treated 87 consecutive SAH patients treated with clipping or endovascular coil embolization within 48 hours after onset. Among these 87 patients, 29 patients treated without EPA between January 2005 and August 2006 were classified as the control group. Thirty-one patients treated with 1,800mg of EPA orally or via nasogastric tube between September 2006 and September 2007 were classified as the conventional dose group. Twenty-seven patients treated with 4,400–5,700mg of EPA orally or via nasogastric tube between October 2007 and December 2008 were classified as the high dose group. We compared the rate of angiographic vasospasm and modified Rankin Scale (mRS) at discharge among these groups.
Results: Patients’ characteristics including age, sex, WFNS grade, aneurysmal location and Fisher grade did not show any significant difference between each group. The rate of angiographic vasospasm in the high dose group was significantly lower than that of the conventional dose group (p=0.031). On comparison among the three groups, the proportion of patients showing mRS 0 at discharge was significantly higher in the high dose group (p=0.014).
Conclusions: Although our sampling size was small, this study suggests that the effect of EPA for prevention of vasospasm after SAH is dose dependent.

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We report a patient with top of the basilar syndrome associated with persistent primitive hypoglossal artery (PPHA). A 94-year-old female was transported by ambulance because of disturbance of consciousness. She was in a deep coma. Her eyes were fixed in the middle position without pupillary light reaction. NIHSS score was 40. Head MRI demonstrated fresh infarction in the bilateral midbrain, cerebral peduncle, and thalamus. MRA demonstrated that the PPHA arose from the right internal carotid artery and formed the basilar artery (BA). BA was occluded in the end. Three-dimensional CT angiography after 4 days showed hypoplasia of the left vertebral artery and aplasia of the bilateral posterior communicating artery and the right vertebral artery. BA was recanalized, but the patient showed no improvement in symptoms. Because the development of collateral blood circulation was defective, top of the basilar syndrome may become severe in a patient with PPHA.

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The role of intravenous tissue plasminogen activator (tPA) in acute ischemic stroke in patients with left atrial myxoma is still unknown. A 72-year-old man was admitted to our hospital because of consciousness disturbance and left hemiparesis. Neurological examination on admission revealed disturbance of consciousness (Japan Coma Scale I-1), dysarthria, conjugate deviation to right, left hemiparesis (manual muscle testing [MMT]: 0–1/5) and sensory impairment. Cranial CT scan showed early CT sign of brain ischemia. Diffusion weighted magnetic resonance imaging showed high intensity in the right middle cerebral artery territory. Magnetic resonance angiography demonstrated incomplete right internal carotid artery occlusion. Since he was diagnosed as having a cardioembolic infarction, treatment with intravenous 0.6mg/kg tPA was started 100 minutes after the onset. Thirty minutes after infusion, MMT of his left lower limb was improved from 1/5 to 1–2/5. Cardiac ultrasonography suggested a left atrial myxoma, which was resected later and confirmed histologically. The present case was the third case of acute cerebral infarction associated with left atrial myxoma treated by intravenous tPA. Further clinical investigations are needed to estimate the safety and efficacy of tPA in acute ischemic stroke in patients with left atrial myxoma.

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The authors report a rare case of fenestration of the oculomotor nerve by an unruptured internal carotid–posterior communicating (IC–PC) aneurysm. A 71-year-old woman who presented with vertigo was noted to have an unruptured IC–PC artery aneurysm on MRI and CT scans. At aneurysm clipping surgery, it was observed that the aneurysm split the oculomotor nerve. Neurological examination revealed no deficit of oculomotor nerve function before and after aneurysm surgery. Careful dissection of the nerve and the aneurysm is required to preserve oculomotor function.

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We describe a patient who developed blunt traumatic extracranial internal carotid artery dissection with delayed symptoms.
A 54-year-old man was admitted to our hospital with right leg paralysis two months after a traffic injury. Cerebral angiography revealed severe stenosis of the left petrous internal carotid artery (ICA). Aphasia and left hemiparesis developed after admission. A cerebral angiogram showed progressive arterial stenosis and thrombus on day 4. Acute embolic infarctions were evident on diffusion-weighted MRI and cerebral blood flow in the left ICA area was decreased on SPECT. We diagnosed ischemic stroke with ICA dissection caused by the traffic injury 2 months previously. Artery-to-artery embolism with hemodynamic compromise was suggested by MRI and SPECT findings. Although the left ICA finally became occluded, hypervolemic and antithrombotic therapy improved the neurological symptoms.
Cerebral infarction due to cervical artery dissection can develop even several months after traffic accidents that apparently cause symptoms of only slight neck sprain.

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We report a 30-year-old man with right midbrain infarction due to right vertebral artery fenestration. He had no anamnesis and no abnormal family history. One day, he drank an excessive amount of alcohol. The next day, he had a headache, numbness in the left half of his body, and weakness of the left leg. Neurological examination revealed left hemiparesis and dysesthesia in the left half of his body. Diffusion-weighted magnetic resonance imaging (MRI) revealed right ventral midbrain infarction. There was no abnormality in MR angiography (MRA). We excluded angiitis, coagulation abnormality, cardiogenic embolism and paradoxical embolism. On cerebral angiograms, fenestration of the right vertebral artery was shown. Therefore, we diagnosed him with right midbrain infarction due to right vertebral artery fenestration.
The connection between fenestration and aneurysm has been demonstrated; however, there are limited case reports of cerebral infarction due to fenestration. It is important to perform cerebral angiography in the case of cryptogenic cerebral infarction.

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We report a case of cerebral venous sinus thrombosis in a 40-year-old Japanese male who had undergone sexual assignment surgery 13 years previously. One month before admission he began taking oral contraceptives to aid in his feminization. Then two days before he came to our hospital, he suffered a headache that progressively worsened. On admission, he showed a mild disturbance of consciousness and a slight increase in his blood coagulation. A head MR venogram showed that the left transverse sinus was occluded and the right highly stenotic, indicating venous sinus thrombosis. Local thrombolysis using a total dose of 480,000IU of urokinase was not successful. Anticoagulant therapy with heparin was continued despite hemorrhagic infarction, and resulted in the recanalization of the venous sinuses.
Risk of venous thrombosis from oral contraceptive use is well known. Combinatory use of oral contraceptives and anti-androgen drugs has been shown to be a higher risk factor than that from oral contraceptive use alone. This is the first report of cerebral venous sinus thrombosis in a patient after a male-to-female transsexual surgery. It should be pointed out that testicle removal, one of the anti-androgen therapies, is also a risk factor.

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We report a rare case of multiple true posterior communicating artery aneurysms that were difficult to diagnosis preoperatively. An 83-year-old female presented with sudden onset of headache and was diagnosed as having subarachnoid hemorrhage. Angiography and three-dimensional computed tomography angiography (3DCTA) demonstrated both an anterior communicating artery (Acom) aneurysm and a posterior communicating artery (Pcom) aneurysm. Surgery was performed by the right pterional approach. Intraoperative findings showed a ruptured Acom aneurysm and two unruptured true Pcom aneurysms. One true Pcom aneurysm originated from the bifurcation of the premammillary artery and had already been diagnosed preoperatively. The other small true Pcom aneurysm was located at the non-branching site. Both aneurysms were successfully clipped. Careful preoperative diagnosis and intraoperative investigation are important to detect small aneurysms, as in this case.

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Two cases were admitted to our hospital with hypertensive intracerebral hemorrhage. They had a past history of opposite temporal lobe lesions. The ABR was normal in both cases, and initially we thought they were in a sensory aphasic state. Later we reached a diagnosis of cortical deafness. Cortical deafness or auditory agnosia are caused by disturbance of the bilateral temporal lobes such as internal geniculate bodies, auditory radiations and Heschl’s transverse gyri. They may behave as deaf, or aphasic. This condition generally develops by opposite cerebral damage after other temporal lesions. “Auditory agnosia” is well known in textbooks. But we hardly experience such cases in daily clinical practice. We should pay attention to this clinical entity.

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Two men aged 27 and 39 years old, respectively, presented with sudden onset of vertigo, nausea and vomiting. CT and MRI demonstrated cerebellar hemorrhage. Cavernous angioma was suspected in each case. Conservative management was selected, because their symptoms disappeared quickly. However, rebleeding was observed two months later in Case 1 and eight days later in Case 2, respectively. Total removal of angioma was performed following suboccipital craniotomy and cavernous angioma was diagnosed from pathological findings in each case. Both patients recovered without neurological deficits. Surgical treatment is considered to be a safe and effective option for cerebellar cavernous angioma compared to those located in the brainstem or cranial nerves.

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We report a 59-year-old man with a brainstem infarction. He had previously suffered from cerebral infarction of the left frontal lobe, and it was pointed out at that time that his right anterior inferior cerebellar artery arose from the right vertebral artery. He was admitted to our hospital with dysarthria and left hemisensory disturbance. On arrival, he showed conjugate deviation of the eyes to the left, and after treatment he demonstrated internuclear ophthalmoplegia. His symptom suggested that the focus of brain infarction involved the right paramedian pontine reticular formation. Magnetic resonance angiography showed that the right vertebral artery occluded, and magnetic resonance imaging demonstrated a brain infarction in the posterior right middle upper medulla and inferior pons. It was suggested that the right pontine perforator arteries arose from the right vertebral artery, as his right anterior inferior cerebellar artery did. His eye movements after treatment were similar to those in left medial longitudinal fasciculus syndrome, although the focus of the infarction was demonstrated on the right pons. This was because the internuclear neuron, which connects the left oculomotor nucleus to the right abducens nucleus was injured between the right abducens nucleus and the left medial longitudinal fasciculus. Since the vertebrobasilar arteries showed a normal variant in which the right anterior inferior cerebellar artery arose from the vertebral artery, right vertebral artery occlusion led to pontine infarction and symptoms suggesting that the right pons was affected.

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