Antithrombotic therapy for ischemic stroke should be selected based on the stroke subtype ; however, the classification criteria are complex. In particular, it is difficult to diagnose the subtype in patients with multiple or only low-risk causes. However, it is important to accurately diagnose atrial fibrillation and deep vein thrombosis, which are indications for direct oral anticoagulants ; other cardiac diseases and cancer-related thrombosis, which are indications for anticoagulation therapy ; patent foramen ovale, which is an indication for device therapy ; and malignant and systemic diseases, which are indications for specific treatments.

  The effectiveness of mechanical thrombectomy (MT) for acute stroke with large-vessel occlusion has been established in several randomized clinical trials (RCTs), and MT is strongly recommended in both the Japanese and U. S. guidelines (Japanese : Recommendation A, U. S. : CLASS I). However, RCTs have reported cases of extensive ischemic lesions and basilar artery occlusion in patients with recommendations other than Recommendation A. Some of these cases showed the effectiveness of MT, whereas others did not. In addition, RCTs are currently underway for patients with acute stroke with mild symptoms and patients with acute stroke with distal or medium vessel occlusion.

  Therefore, the question remains of how we can apply the results of RCTs in clinical practice when their results differ from study to study. We believe that, in the future, this decision will be based on the discretion of physicians on a case-by-case basis, with reference to guidelines and recommendations.

  The diagnostic criteria and severity grade of moyamoya disease, a designated intractable disease in Japan, were recently updated. The long-term surgical outcomes of ischemic moyamoya disease are generally favorable ; however, the prevention of de novo hemorrhage after adolescence and support for patients with neurocognitive decline remain pressing issues. According to the results of the Japan Adult Moyamoya (JAM) trial, direct bypass is also considered for hemorrhagic moyamoya disease. Periventricular anastomosis has received attention as an important mechanism underlying hemorrhage. In addition, the Asymptomatic Moyamoya Registry (AMORE) revealed the incidence rate and predictors of stroke in asymptomatic moyamoya disease.

  Asymptomatic patients with severe carotid stenosis who did not undergo surgical intervention, the estimated rate of ipsilateral carotid-related acute ischemic stroke has being low. For example, atherosclerosis vulnerability regression has been evidenced mostly in randomized clinical trials with intensive lipid-lowering therapy.

  Carotid endarterectomy (CEA) still plays an important role in the treatment of stroke high risk patients like intraplaque hemorrhage or lipid rich plaque. CEA and carotid artery stenting (CAS) had a similar procedural risk of stroke or death within 30 days because of device improvement. CEA plus best medical treatment (BMT) seemed to have the best stroke preventive effect compared with CAS plus BMT or BMT alone. Transcarotid artery revascularization (TCAR) with reversal of flow emerged as a new treatment option for high-grade carotid stenosis.

  For future study, it is important to identify those patients with asymptomatic carotid artery stenosis who are at increased risk of stroke. In recent decades, plaque characterization, particularly the presence of significant lipid rich/necrotic core and intraplaque hemorrhage or thinned fibrous cap, has emerged as an indicator of plaque propensity to ulceration/erosion, triggering thrombosis and ischemia. However, to date, cutoffs of the plaque components that determine vulnerability are not available.

  The recurrence rate of stroke due to intracranial atherosclerotic stenosis (ICAS), which is more common in Asian populations than in European and American populations, is relatively high regardless of intensive medical therapy. Although the safety and effectiveness of surgical treatment against symptomatic ICAS in the subacute-chronic phase has not been established, some clinical trials have shown preferred results with endovascular therapy for medically refractory patients. However, the treatment of ICAS in the acute phase has raised new issues, due to the increasing chance of mechanical thrombectomy against acute ischemic stroke in recent years. Underlying severe ICAS may be a hidden cause of occlusions refractory to modern mechanical thrombectomy procedures. The optimal strategy for patients with ICAS-related emergent large vessel occlusions is still unclear. In this manuscript, endovascular therapies for acute and subacute-chronic ICAS are reviewed.

  Malignant brain tumors have an extremely poor prognosis and have a significant impact on the lives of not only patients, but also their families and caregivers. Thus, caregivers face the particularly challenging situation of providing care to patients with both cancer and brain dysfunction. In this study, we examined the burdens and needs of caregivers of patients with malignant brain tumors with the aim of developing better support systems for such patients and their caregivers.

  We examined the results of a national survey of supportive care for patients with brain tumors conducted by the Brain Tumor Patients and Caregiver Needs and Support Research Group in 2023. Free-text descriptions were categorized under the supervision of a nurse researcher experienced in qualitative research. This study was approved by the Research Ethics Review Committee of the National Cancer Center (approval No. : 2022-430).

  A total of 118 caregivers (37 males, 81 females) participated in the study. Most of the respondents were in their 50s (n=37), followed by their 60s (n=28). The most common relationship with the patient was spouse/partner (n=69), followed by parent (n=26) and child (n=17). Regarding the patients, 73 were male and 45 were female, and most were in their 60s. In addition, 85% of the patients lived with their patients, 67.5% of the caregivers reported having problems related to care, 43.4% of the caregivers were identified as having depressive symptoms. The caregivers' difficulties were grouped into six categories : ‘treatment and prognosis’, ‘morbidity’, ‘how to deal with patients’, ‘assistance and care’, and ‘relationships with other people’. The support from health-care providers considered necessary by the caregivers was categorized into four groups : ‘explanation and information’, ‘family care’, ‘psycho-psychological follow-up of the patient’, and ‘related to hospital visits and consultations’. Public support services that caregivers considered necessary were grouped into four categories : ‘financial support’, ‘family care’, ‘institutional accreditation’, and ‘adolescent and young adult generation-related’. The difficulties that carers reported facing when caring for the patient were grouped into three categories : ‘relationship with the patient’, ‘caregiver burden’, and ‘future prospects and prognosis’.

  Caregivers experience a range of psychological, physical, and socioeconomic burdens. Thus, there is an urgent need to reduce the burden on carers and to work with patients to help them and their carers have a better recuperation.

  The use of clazosentan in subarachnoid hemorrhage (SAH) complicated by takotsubo cardiomyopathy (TCM) has been avoided because of the side effects of pleural effusion and pulmonary edema. Based on our experience in treating six patients with SAH and TCM, we assessed the usefulness of perioperative management with clazosentan.

  Of the 55 patients who underwent perioperative management with single-agent clazosentan at our hospital from June 2022 to March 2024, six who had complicated TCM at admission were included. Fluid delivery, chest radiography, electrocardiography, ejection fraction, and cardiac markers (NT-proBNP, creatinine kinase [CK] , CK-MB, and troponin T) from Days 0 to 14 were examined retrospectively.

  Of the 55 patients who were administered clazosentan, six patients (10.9%) were diagnosed with TCM, as indicated by echocardiography upon admission, and three of these patients (5.5%) had congestive heart failure. Fluid management was maintained below＋500ml on Days 0-9. In those patients who presented with congestive heart failure, we frequently evaluated chest X-rays. Clazosentan was administered after the treatment for heart failure and hypotension. No adverse events were associated with clazosentan.

  With strict control of TCM and appropriate fluid management, clazosentan may be safely administered to patients with SAH and TCM.

  On average, traumatic cerebral aneurysms form about 21 days after head injury. They are often discovered only after an intracranial hemorrhage has occurred. Here, we describe a case of a traumatic cerebral aneurysm that rapidly formed and ruptured after head trauma.

  A 71-year-old woman with a history of a ruptured cerebral aneurysm and extensive dural calcification was brought to our hospital for head contusion due to transient loss of consciousness. Her level of consciousness at the time of arrival was JCS Ⅰ-1, and head CT showed a right temporal bone fracture, subarachnoid hemorrhage, and diffuse dural calcification. One hour after arrival, her level of consciousness decreased to JCS Ⅱ-10, head CT showed an intracerebral hemorrhage, head CTA showed a spot sign, and cerebral angiography showed an aneurysm in the peripheral branch of the right middle cerebral artery.

  The patient was judged to have intracerebral hemorrhage due to a ruptured aneurysm and underwent a craniotomy for removal of hematoma and aneurysm. Intraoperative findings revealed a pseudoaneurysm and the pathological examination revealed an acute lesion. Based on these results, we diagnosed a traumatic cerebral aneurysm that rapidly formed and ruptured, resulting in an intracerebral hemorrhage.

  This case demonstrates that traumatic cerebral aneurysms can rapidly form and rupture even after minor head trauma in patients with calcification of the dura mater. A CTA of the head was useful for this diagnosis. In addition, volume rendering using the data from the head CTA was useful to quickly identify the location of the aneurysm and perform the surgery.