Japan will become a full–fledged aged society. The elderly population aged 65 years or over will account for more than 26 percent of the population. One of four people was 65 years old or over. In Japan, the appropriate clinical management is thus important in elderly patients with neuro–infections including meningitides and encephalitides. Bacterial meningitis and encephalitides are lifethreatening neurological emergencies, and early recognition, efficient decision–making, and rapid commencement of therapy can be lifesaving. Empirical therapy should be initiated promptly whenever bacterial meningitis or encephalitides are a probable diagnosis. In this article, elderly patients with bacterial meningitis, Herpes simplex virus encephalitis, Japanese encephalitis, and autoimmune encephalitis are reviewed. Neurologist should be able to recognize the clinical signs and symptoms of these infections and familiarize themselves with a rational diagnostic approach and therapeutic modalities, as early recognition and treatment are key to improving outcomes.
Hypertension is the major risk factor for stroke. In the Hisayama study, the risks of cardiovascular disease increased significantly from the lower range (120–129/80–84 mmHg) of prehypertension in a general Japanese population. Since the clinical trial SPRINT demonstrated that targeting a systolic blood pressure of less than 120mmHg reduced fatal and nonfatal major cardiovascular events, blood pressure goals in patients with hypertension currently tend to be more intensive. However, we should conduct more careful antihypertensive treatment when setting blood pressure target in the elderly or patients with cerebral artery stenosis. The meta–analysis including the majority studies for primary stroke prevention has shown that reducing LDL cholesterol with statins reduces the risk of stroke, therefore statin therapy is recommended for patients with dyslipidemia, especially having diabetes mellitus. Early detection and treatment of atrial fibrillation are valuable prevention for stroke risk reduction in the elderly. Anticoagulation should be considered even for the patients with atrial fibrillation (CHADS2 0 or 1) and other vascular risk factors. Regarding primary prevention of stroke for patients with asymptomatic cerebral atherosclerosis and silent lacunar infarction, intensive management of vascular risk factors such as hypertension and diabetes mellitus is the most important treatment for stroke prevention, and antiplatelet therapy should be taken into considered only in patients with high risk of ischemic stroke.
It is also essential to educate and enlighten the knowledge of stroke risk factors and warning signs to the general public.
Stroke is the fourth most common cause of death in Japan and a significant cause of chronic disability. Delayed hospital arrival has been considered as the most significant prehospital barrier to acute stroke management. In order to reduce the time from stroke onset to arrival at the hospital, patients need to recognize stroke symptoms immediately, activate medical services, and emergency medical services (EMS) play critical roles in reducing prehospital delays and ensuring timely stroke treatment. Prehospital delay between stroke onset and hospital arrival is an ongoing problem. A widely held assumption that public stroke education by mass media, school education, helps potentially to increase public awareness of stroke warning signs will lead to earlier recognition, activation of EMS, and reduced prehospital delay. A variety of prehospital stroke scale and protocol have been developed to assist EMS to improve prehospital care and the accuracy of diagnosis of stroke. Public stroke campaigns should not only inform the public about stroke symptoms in order to ensure people act appropriately, but should also focus on increasing public awareness about the fact that an effective treatment exists. EMS education program, community outreach, and standardized protocols for acute stroke is warranted.
The effectiveness of mechanical thrombectomy in acute ischemic stroke due to large vessel occlusion was established by several randomized controlled trials published in 2015. Further, the effectiveness of reperfusion therapy in stroke patients with unknown time of onset has been reported since 2018. The evolution of reperfusion therapies for acute ischemic stroke has resulted from not only new technologies but also the rapid patient selection with imaging diagnosis. The neurologist should acquire latest knowledges of diagnosis and reperfusion therapy for acute stroke to relieve a lot of patients from disability.
Most of the stroke patients are transferred to the rehabilitation hospital after the acute treatment to get more concentrated and effective rehabilitation in the recovery period (convalescence). It is quite important to select and decide the second facility to experience qualified but fulfilling rehabilitation as well as to make utmost recovery after stroke. When the patients move to the convalescent ward from the acute one within 2 months after the ictus, maximum period of 6 months eligible for the rehabilitation will be approved to them. In this article, typical profile of stroke rehabilitation is disclosed in each stage of acute, convalescent and maintenance phase after stroke.
For the secondary prevention of stroke, the strict control of risk factors and the appropriate prescription of antithrombotic agents are necessary. The blood pressure level target for secondary stroke prevention is <140/90mmHg, but more strict control, i.e., <130/80mmHg as the target, is recommended for hemorrhagic stroke patients and for ischemic stroke patients with antithrombotic agents. In the control of dyslipidemia, PCSK9 inhibitors are expected to prevent the recurrence of stroke in ischemic stroke patients. Probucol has a strong anti–oxidative effect for LDL cholesterol. The recent PICASSO trial revealed significant efficacy of probucol in ischemic stroke patients who are at high risk of hemorrhage. The combination of antiplatelet therapy with cilostazol (CSPS.com) is effective in the secondary prevention of stroke among noncardiogenic ischemic stroke patients. Clinical trials have shown that in patients with atrial fibrillation, the Watchman left atrial appendage closure device is more effective than medical treatment using warfarin. A patent foramen ovale (PFO) closure device showed efficiency in cryptogenic ischemic stroke patients with a PFO.