Nosotchu Vol. 39(2017) No. 5

Background and purpose: The aim of the present study was to clarify the clinical characteristics of in-hospital stroke, under the introducing thrombolysis and thrombectomy. Patients and Methods: From January 2013 to May 2016, 24 consecutive patients with in-hospital stroke from the 39,877 patients who were hospitalized in our hospital were included in this study. Results: The clinical types of stroke were 1) cerebral infarction was the higher in 18 patients, 2) intracerebral hemorrhage in four patients, and 3) subarachnoid hemorrhage in two patients. The major subtypes of cerebral infarction were cardioembolic stroke in eight patients, iatrogenic stroke in five patients, and atherothrombotic infarction in two patients. Although the median modified Rankin Scale (mRS) on admission was 1.5, that of at discharge was worsen to 4. Conclusions: In-hospital stroke onset was not uncommon. The neurological deficits in patients with in-hospital stroke were severe and the outcome was worse. In-hospital stroke was more common in patients with an emergency hospitalization than planned hospitalization. Iatrogenic cerebral infarction is a feature of in-hospital stroke in this study. The patients with in-hospital cerebral infarction quite often have some contraindications to the acute intravenous thrombolysis treatment. In such cases, the thrombectomy should be considered.

This study examined the timing of the resumption of anticoagulants and its relationship to clinical outcomes in patients with intracerebral hemorrhage. The subjects comprised of 380 patients with non-traumatic intracerebral hemorrhage treated at our hospital between January 2013 and December 2014. Of the 380 patients, 37 (9.7%) had been receiving anticoagulant treatment: warfarin in 32 and direct oral anticoagulant (DOAC) in 5. The median age was 72 years, the median bleeding volume was 9 ml, and median international normalized ratio on admission was 1.81. A total of 20 patients resumed anticoagulant treatment during hospitalization, of which over half of them (11 patients) were given a DOAC. The CHA₂DS₂-VASc score was used as the criterion for the resumption of anticoagulants, and the median value was 3.5. The median time to the resumption of anticoagulant treatment was 4 days. At the time of resumption, the median HAS-BLED score was 3 and median systolic blood pressure was 139 mmHg. Two patients had cerebrovascular events: one had a cerebral infarction 6 days after the withdrawal of anticoagulants and another had an intracerebral hemorrhage 18 months after the resumption of warfarin. No recurrent intracerebral hemorrhage was observed in patients who resumed DOAC. These results showed that patients who resumed anticoagulants after 4 days of withdrawal had a low risk of recurrent intracerebral hemorrhage. The low incidence of recurrent intracerebral hemorrhage was considered to be related to the risk management at the time of resumption and selection of DOAC for the majority of patients.

Objective: Spontaneous cerebellar hemorrhage (SCH) is associated with high mortality rates. However, in some cases, the prognosis is good after a quick and appropriate treatment. Although prognostic factors of SCH have been discussed in detail in the previous reports, these studies differed in population, design, and outcomes. Our institution is the only tertiary level institution in the district, with a population of 430,000 residents; thus, all the cases of severe intracerebral hemorrhage are treated at our institution. This study aimed to investigate the prognostic factors of SCH at our institution and to assess the treatment status for SCH in the district. Methods: We retrospectively evaluated SCH cases treated at our institution between January 2005 and June 2016. The patients with a modified Rankin Scale (mRS) of ≤2 before the SCH occurrence (171 cases) were investigated. Result: The average age of patients was relatively high (72.2±10.6 years). While mRS ≤3 was achieved in 54.4% of patients, mRS ≤2 was achieved in only 18.7% of patients. Among patients with fourth ventricle occlusion or disappearance of basal cisterns, surgery significantly improved their outcome. Older patients tended to have a higher risk of complications, which significantly influenced their outcomes. Conclusion: For SCH management, the initial treatment, including surgery, is important. Furthermore, because elderly people are at a high risk of complications, the management of complications is also very important, particularly, in an aging society such as that in our district.

Here, we report a case of a patient with vertebrobasilar dolichoectasia (VBD) complicated by hydrocephalus after almost 4 years of observation. In the 61-year-old male patient, the basilar artery directly elevated the floor of the third-ventricle obstructing the foramen of Monro and causing hydrocephalus. The patient had a decreased consciousness level; therefore, we performed bilateral ventriculoperitoneal shunting. Although hydrocephalus was improved by the shunt surgery, and the patient temporarily recovered, he did not have a good outcome because of sustained impaired consciousness and brain stem infarction. To summarize, in the 4 years of observation, the patient was clinically stable for 3 years, followed by sudden-onset and rapid elongation of the basilar artery, causing hydrocephalus and impaired consciousness due to the decreased blood flow velocity in the basilar artery. Further, elongation caused distortion of the perforating artery of the brain stem, resulting in brain stem infarction. From our point of view, these events such as hydrocephalus, impaired consciousness, and brain stem infarction are serial changes caused by the rapid elongation of the basilar artery. While following patients with VBD, measuring the length of the basilar artery is useful as any drastic changes in it are crucial for predicting the events that complicate VBD.

A 65-year-old man developed sudden-onset consciousness disturbance and was diagnosed as having subarachnoid hemorrhage. Cerebral angiography and three-dimensional computed tomography demonstrated an aneurysm arising from the distal portion of the posterior communicating artery. Neck clipping of the aneurysm was performed with accidental proximal ligation via ipsilateral pterional craniotomy. It is well known that patients who have experienced long-term hemodynamic stress have a risk of developing an aneurysm. However, an aneurysm arising from the posterior communicating artery itself is rare, especially in the distal portion. Here, we discuss a variety of pitfalls of direct surgery. We report a rare case and review the related literature.

We report a case of a 49-year-old woman admitted for headache, confusion, and right hemiparesis. Computed tomography showed a small subcortical hemorrhage in the left frontal lobe. Cerebral angiography revealed a superior sagittal sinus thrombosis. She was treated with unfractionated heparin. Follow-up imaging revealed bilateral cerebellar infarcts and a small cerebellar hemorrhage. On day 12 in hospital, she was switched from heparin to rivaroxaban. Her symptoms significantly improved, and after 3 weeks of the therapy, magnetic resonance venography showed complete recanalization of the superior sagittal sinus. Rivaroxaban might be a better option for the treatment of cerebral venous thrombosis.

Stereotactic radiosurgery, including gamma knife surgery, has been widely performed as minimally invasive treatment for arteriovenous malformation (AVM). While its safety and efficacy have been well reported, some problems also have been reported. Patients who undergo radiosurgery must wait for a few years from the time of treatment and remain exposed to the risk of bleeding until obliteration of the AVM is confirmed, and technical limitations may lead to incomplete administration of the intended treatment. In addition, severe complications are occasionally reported. Here, we present a case of obstructive hydrocephalus caused by aqueductal stenosis in a 63-year-old man who underwent gamma knife surgery for AVM around the pineal body 8 years previously. On visiting our department, he presented with mild disturbance of gait and consciousness. Other physical and neurological examinations were unremarkable. CT demonstrated dilatation of the lateral ventricles and the third ventricle. Because the aqueduct of the midbrain and fourth ventricle were not dilated, obstructive hydrocephalus due to localized aqueductal stenosis was suspected. Endoscopic neurosurgery was performed and stenosis in the aqueduct of the midbrain caused by a membrane-like structure was confirmed. Aqueductal stenosis occurred as a result of inflammation following gamma knife surgery, which extended to the cicatricial tissue and eventually caused a stenosed aqueduct of the midbrain. After the endoscopic third ventriculostomy, the hydrocephalus improved and no recurrence has appeared since. To the best of our knowledge, there have been no previous reports of obstructive hydrocephalus attributable to aqueductal stenosis caused by inflammation following gamma knife surgery.

We report a case of a 16-year-old boy with chronic headache, who was diagnosed as arteriovenous malformation (AVM) on occipital lobe (Spetzler-Martin grade 5). He continued to suffer from the attack of migraine-like headache with visual aura of homonymous hemianopia even after proton therapy. Due to initiating preventive drug for migraine, the headache attack was relieved rapidly. However, relapse of the attack was noted in the subsequent year, and then specific treatment with triptans was started in the acute stage. Because migraine-like headache lasted progressively despite the use of triptans, matching definite increase in occipital blood flow, such situations seemed to be some possibilities of adverse effects by triptans affecting blood flow. By finishing the triptans, chronic headache disappeared quickly. An etiologic relationship was suggested between the headache attack and the increase of regional cerebral blood flow, since the obvious decrease in blood flow was apparent during non-headache phases. It seemed probable that regional blood flow in normal brain may shift to the region in nidus because of little difficulty in induction of vascular contractile effect in AVM with an abnormal structure of blood vessels as to the using triptans against migraine-like headache. It may be suggested to lead to worsening headache symptoms based on hyperperfusion with further increase of nidual blood flow in cases of migraine attacks with AVM.

We report a rare case of traumatic carotid artery dissection that movable dissecting flap intermittently obstructed the internal carotid artery and caused the repeated transient ischemic attack. A 66-year-old female with transient motor weakness of her right hand continues from 30 seconds to 1 minute attend to our hospital. Cervical MR angiography revealed left internal carotid artery stenosis. MRI denied new ischemic lesion in the cerebrum. Her symptom was considered as transient ischemic attack related to her cervical artery stenosis. Catheter angiography revealed left internal carotid artery dissection, and medical interview disclosed her the history of manual strike 1 month before admission. CT and MRI revealed no evidence of obvious thrombus in the false lumen of the dissection. Cerebral blood flow images with SPECT showed no hypoperfusion and cerebrovascular reserve in her cerebral hemisphere. The mechanism of her cerebral ischemic attack was unclear. But a decision was made to treat the dissection flap by stent placement. Vascular endoscope during the treatment procedure found out the movable dissection flap and it was suggested blood inflow to the false lumen made intermittently close the flow to true vascular lumen resulted in ischemic attack. Her ischemic attack was completely dissolved after stenting. The pathophysiological mechanisms of repeated ischemic attack and optimal treatment for traumatic carotid artery dissection are discussed.

A 56-year-old female without any medical history was admitted to our hospital for impaired consciousness and right-sided hemiplegia. A head CT showed left putaminal hemorrhage. Conservative medical therapy was performed. However, hematoma was expanded. Endoscopic hematoma removal was done under general anesthesia for symptom improvement. Clinical condition about the speech was improved. However, severe right-sided hemiplegia remained. The patient used compression stocking and intermittent pneumatic compression for the prevention of thrombosis after the operation. She scheduled changing the hospital for continuing rehabilitation. Sudden hypotension and oxygen desaturation occurred 7–8 days after the operation. Plasma d-dimer level elevated sharply. Deep venous thrombosis in the right-sided popliteal vein was identified by ultrasonography. We reached a diagnosis as a severe pulmonary embolism. A huge blood clot in right atrium was identified and attached to tricuspid valve by transthoracic echocardiography. Emergency thrombectomy was performed in a thoracotomy and her life was saved. Pulmonary embolism is a remarkable complication in stroke. We have to pay attention not only preventing the onset but also early diagnosis and starting rapid therapy for patient’s survival.

A 37-year-old woman was admitted to our hospital with retro-orbital pain, chemosis, and vascular bruit. Magnetic resonance imaging revealed a varix in the right middle cranial fossa and dilated superior ophthalmic vein with orbital cavernous malformation (CM). Cerebral angiography demonstrated dural arteriovenous fistula (DAVF) of middle cranial fossa fed by branches from external carotid artery. We performed transvenous endovascular embolization of DAVF. Postoperative angiography and MRI showed disappearance of the fistula, reduction of CM and her symptoms were improved. Nine months later, chemosis and exopthalmos developed suddenly and MRI showed relapse of DAVF and orbital CM which was more dilated than before. We treated with endovascular treatment again, DVAF was disappeared and CM was reduced immediately. The coexistence of DAVF of middle cranial fossa and orbital CM is extremely rare, but may indicate the underlying mechanism of the formation and regrowth of CM.

Apathy can be seen in patients with stroke, resulting in adversely affecting the feasibility of rehabilitation. Here, we report a case of post-stroke apathy in which transcranial direct current stimulation improved their spontaneity. A 50-year-old male suffered from multiple cerebral infarction following acute aortic dissection (Stanford type A). He showed severe aspontaneity, leading to inability to intentionally speak and move by themselves, even though intensive rehabilitation and amantadine were given. After obtaining the written informed consent from his family, the transcranial direct current stimulation (tDCS) treatment was started at 100 days post-ictus. Anodal tDCS was applied to the right prefrontal area with an intensity of 2 mA lasting for 20 minutes once a day, during which intensive physical therapy was given concomitantly. Before and after the intervention, neuropsychological testing and resting state fMRI were conducted. Prefrontal tDCS of 11 sessions recovered his spontaneity, resulting in the improvement of the Apathy scale (from impossible to examine to 23), clinical assessment for spontaneity (from 59 to 40) and Hamilton Rating Scale for depression (from 16 to 10). In addition, the resting state fMRI demonstrated the normalization of functional connectivity in the default mode network after tDCS therapy on the right hemisphere. tDCS of the prefrontal area could be one of the treatment options in patients with post-stroke apathy.

Rehabilitation is one of the essential treatments for the patients with stroke to achieve good functional recovery and subsequent social participation of the patients. In this mini review, we show two basic researches of our laboratory. One is neuroprotective effects of rehabilitation for Parkinson’s disease model of rats and the other is decreased neurogenesis by the lack of exercise through hindlimb suspension of rats. Finally, the significance of rehabilitation with future direction of regenerative medicine for the patients with stroke in this field is stressed.

Dyslipidemia is a well-known cardio- and cerebro-vascular risk factor. Older antiepileptic drugs (AEDs), including carbamazepine (CBZ), phenytoin (PHT) and phenobarbital, induce the hepatic cytochrome P450 (CYP) system that is extensively involved in the synthesis and metabolism of cholesterols. Those AEDs can increase the potential of dyslipidemia development. The present study sought to examine the changes of serum lipid levels after the single administration of valproate (VA), CBZ, PHT, zonisamide (ZNS), levetiracetam (LEV) or lamotrigine (LTG) for 3 months in epileptic patients after cerebral infarction. CBZ or PHT monotherapy increased the serum TC and LDL-C levels significantly. The serum levels of TC and LDL-C did not differ significantly after the administration of VA, ZNS, LEV, or LTG. Serum HDL-C and TG levels did not differ after treatment with any AEDs significantly. Thus, we should pay more attention to serum lipid levels in post-stroke epileptic patients treated with CYP-induced AEDs. For the secondary prevention of brain infarction, switching to non-CYP-induced AEDs might be considered in patients who CYP-induced AEDs increased serum LDL-C levels.