Background and purpose: Single photon emission computed tomography (SPECT) is recommended for assessing cerebral ischemia in patients with symptomatic stenosis or occlusion of the middle cerebral artery (MCA) and internal carotid artery (ICA). The purpose of this study was to investigate the relationship between MCA signal density on magnetic resonance angiography (MRA) and cerebral blood flow findings on SPECT. Methods: We retrospectively studied the relationship between unilateral MCA density on MRA and regional cerebral blood flow (rCBF) and cerebrovascular reactivity (CVR) by SPECT examination in 243 patients who were suspected to have anterior circulation disease. Results: There was no difference in rCBF at the MCA area between patients with poor density of the unilateral MCA signal (poor MCA images group) and those without (good MCA images group). However, CVR was significantly lower in the poor MCA images group than in the good MCA images group. Hemodynamic cerebral ischemia met the criteria of the Powers classification stage II (CBF at rest in the MCA area <80% of the contralateral side, and CVR <10%) in 8 of 243 patients (3.3%). All the eight cases belonged to the poor MCA images group, not to the good MCA images group. Conclusion: The observation that all patients with hemodynamic cerebral ischemia belonged to the poor MCA images group suggests that SPECT examination for rCBF and CVR is not required in patients with good MCA images.
Background and purpose: External ventricular drainage (EVD) is ordinarily performed for intraventricular hemorrhage (IVH) caused by intracerebral hemorrhage. The purpose of this study was to assess the efficacy and safety of endoscopic evacuation of IVH compared with EVD. Methods: Between 2010 and 2014, nine patients treated with EVD and nine with endoscopic evacuation of IVH were studied. The following clinical data were evaluated: age, Glasgow Coma Scale (GCS) score, IVH volume, duration of EVD placement, time in rehabilitation for ambulation, duration of hospital stay, shunt dependency, complications, and modified Rankin Scale (mRS) at discharge. Results: The clinical data of the nine patients in each group showed no significant differences in age or Graeb score. Significant differences in preoperative GCS (9.7 ± 2.8 vs. 6.6 ± 1.5, p=0.017) and bicaudate cerebroventricular index (20.9 ± 9.2 vs. 24.2 ± 2.1, p=0.031) were observed. The duration of EVD placement (9.9 ± 2.8 days vs. 3.6 ± 4.3 days, p=0.019) and time in rehabilitation (10.8 ± 3.4 days vs. 6.4 ± 2.3 days, p=0.021) were significantly shorter in the endoscopic evacuation group than the EVD group. However, there was no significant difference in shunt dependency rate, complications, hospital stay, and mRS at discharge. Although endoscopic surgery was used for severe IVH, the neurological outcome at discharge was the same in both groups. Conclusions: Endoscopic intraventricular hematoma evacuation reduces the duration of EVD placement and leads to early ambulation, enabling early transfer to a rehabilitation hospital with a more favorable outcome.
We compared clinical features of 4 patients with severe pseudobulbar palsy due to stroke. Case 1: A 65-year-old man with an ischemic stroke in the left middle cerebral artery (MCA) territory 10 years before admission was diagnosed as right MCA occlusion. Case 2: A 70-year-old woman with a lacunar infarction in the left corona radiata 2 years before admission was diagnosed as an acute lacunar infarction in the right corona radiata. Case 3: A 63-year-old man with a left putaminal hemorrhage 2 years back was admitted for a right putaminal hemorrhage. Case 4: An 83-year-old man was admitted for an ischemic stroke in the left anterior lobe. He was diagnosed as cardiogenic embolism, and another ischemic stroke was observed in the right frontal and occipital lobes 20 days after admission. Results: All 4 patients showed almost complete aphonia. Cases 1, 2, and 3 had total tongue paralysis, whereas case 4 was partially paralyzed. Pharyngeal reflex was absent and jaw-jerk reflex was inconsistent among them. Cases 1, 2, and 3 showed trismus, whereas case 4 did not. Videofluorography indicated severe oral and moderate pharyngeal disorder in cases 1, 2, and 3. Case 4 showed moderate oral and mild pharyngeal disorder. Cases 1, 2, and 3 did not improve in swallowing function. Case 4 resumed oral food intake after 5 months. No pneumonia occurred in these 4 patients. Conclusion: Trismus may be a predictor of poor outcome in swallowing function in patients with severe pseudobulbar palsy.
We report a case of cerebral infarction due to middle cerebral artery (MCA) occlusion in a pregnant woman successfully treated by endovascular thrombectomy. A 33-year-old woman (gravida 1, para 1) at 37th gestational week presented a sudden onset of right hemiparesis. She was transferred to a nearby hospital and her National Institutes of Health Stroke Scale (NIHSS) was 13 with no significant ischemic change in head computed tomography (CT) scan. Magnetic resonance imaging (MRI) demonstrated occlusion of the first segment of right MCA, and Alberta Stroke Program Early CT Score-Diffusion Weight Imaging (DWI-ASPECTS) score was eight. Drip of recombinant tissue plasminogen activator (rt-PA) was initiated and she was transferred to our hospital for endovascular thrombectomy. On arrival, she showed no neurological improvement. Subsequent thrombectomy achieved thrombolysis in cerebral infarction (TICI) score 2b. She gave birth to a baby boy 2 days after the treatment by a caesarean section, and showed significant improvement of hemiparesis with NIHSS score 0 at discharge. This is the case of drip, ship, retrieve, and childbirth that was successfully performed.
An 80-year-old woman with hypertension and dyslipidemia was admitted because of consciousness disturbance. She also had right upper limb paresis, right facial palsy, and dysarthria. Normocytic normochromic anemia was observed in the initial blood examination. Bilateral multiple high intense lesions in the cortex and subcortex including watershed area were also observed in the initial magnetic resonance imaging (MRI) diffusion-weighted image, but there was no significant stenosis or occlusion in the extracranial or intracranial cerebral arteries. She had a black stool before admission, and a gastric ulcer of A1 stage without active bleeding was shown in the gastroendoscopy. At first, she underwent erythrocyte transfusion for anemia, and neurological symptom rapidly improved. An anticoagulant treatment with heparin was started after confirmation of no bleeding in the gastroendoscopy examination. Global cerebral hypoperfusion and anemic hypoxia were possible etiologies of her brain infarction despite the lack of significant stenosis or occlusion of the cerebral arteries. Transesophageal echocardiography revealed a severe aortic arch atheroma and aortogenic brain embolism was also a possible etiology. Neither neurological deterioration nor recurrence of stroke was observed during the hospital days and she was discharged home on foot.
A 58-year-old male was transferred to our hospital after a sudden disturbance of consciousness. The patient exhibited
decerebrate-like posturing, indicating a state of deep coma. The brain computed tomography scan showed bilateral
putaminal hemorrhage, with approximately 36 mL of blood on the right side and 40 mL on the left. Because of
the severe disturbance of consciousness due to the large hematoma, emergency neuroendoscopic hematoma removal
surgery was performed with an operation time of 1 hour and 44 minutes. During hematoma removal surgery via craniotomy,
which is the conventional method used to remove the hematoma on both sides, a change of position is necessary,
and a prolonged surgery is expected. Neuroendoscopic hematoma removal surgery is thought to be an effective
and minimally invasive technique that allows treatment of both sides of the brain during the same procedure in a
shorter time than a conventional approach.
When repetitive transcranial magnetic stimulation (rTMS) is introduced as a therapeutic tool for post-stroke patients, rTMS should be applied so that compensating areas for impaired neurological function could be activated. However, simply applying rTMS does not seem to be enough for bringing about sufficient recovery after stroke. Therefore, we considered that not only rTMS but also rehabilitative training is needed to maximize functional recovery and proposed combined protocol of rTMS and intensive occupational therapy (OT) for post-stroke patients with upper limb hemiparesis. As of March 31, 2015, more than 1,700 post-stroke patients with upper limb hemiparesis received our proposed 15-day combined protocol. During hospitalization for the protocol, two treatment sessions of low-frequency rTMS over the non-lesional hemisphere and intensive OT were provided daily. So far, clinical result of the protocol has been generally favorable. No adverse event was found in any patients. The protocol significantly improved motor function of the paretic upper limb. Recently, we have tried to modify the protocol for enhancing its beneficial effect. For example, instead of conventional rTMS, theta burst stimulation was introduced in the protocol. Levodopa and atomoxetine were prescribed concomitantly with rTMS application. For patients with spastic upper limb hemiparesis, botulinum toxin type A was injected prior to NEURO protocol. In conclusion, therapeutic rTMS for post-stroke patients should be applied combined with rehabilitative training, since rTMS is just an enhancer of neural plasticity. Neural plasticity enhancement with rTMS can be a basis for stroke rehabilitation in the future.
Cerebral microbleeds (CMBs) are small perivascular hemosiderin deposits from leakage through cerebral small vessels. At least two pathological mechanisms, which are hypertensive microangiopathy and cerebral amyloid angiopathy, may lead to CMBs. CMBs are classified into deep CMBs and lobar CMBs according to their locations. Deep MBs and lobar MBs are presumed to be mainly caused by hypertensive microangiopathy and amyloid angiopathy, respectively, although these two pathologies may interact/coexist in clinical practice. CMBs are observed approximately in 5%, 30%, and 60% of the healthy adults, patients with ischemic stroke, and patients with intracerebral hemorrhage, respectively. Growing evidence suggests a link between CMBs and increased risk of stroke, especially of intracerebral hemorrhage. A systematic review and metaanalysis revealed that the risk for recurrent stroke after ischemic stroke/transient ischemic attack increases in patients with CMBs, and that the risk for intracerebral hemorrhage appears to be greater than the risk for ischemic stroke especially in Asian cohorts. An association between CMBs and intracerebral hemorrhage that occurred in antithrombotic users, especially in warfarin use, has been reported, whereas it remains to be cleared whether administering antithrombotic drugs increases subsequent intracerebral hemorrhage in patients with CMBs.
In a rapidly aging society, the number of stroke patients with chronic kidney disease (CKD) is increasing. We previously reported that patients with ischemic stroke complicated by CKD exhibit several specific features, including older age and higher frequencies of hypertension, atrial fibrillation, and cardioembolic stroke when compared with ischemic stroke patients without CKD. Laboratory data also indicated the presence of anemia, hypercoagulability, and inflammation in ischemic stroke patients with CKD. Consequently, CKD patients showed poor functional outcome and prognosis after ischemic stroke. Thus, CKD is a predictor for poor clinical outcomes after ischemic stroke. However, it remains unclear whether CKD is independently associated with clinical outcomes after ischemic stroke. We recently investigated the association between estimated glomerular filtration rate (eGFR) or proteinuria and clinical outcomes after acute ischemic stroke using the database of a large hospital-based stroke registry. In that study, proteinuria, but not eGFR, was independently associated with poor functional outcome after ischemic stroke, suggesting that proteinuria may be a key indicator for unfavorable outcomes. The possible mechanism for the association between proteinuria and ischemic stroke are discussed herein.
Chronic kidney disease (CKD) has been accepted as an emerging cardiovascular risk factor, and it is being increasingly investigated with respect to its relevance to cerebral small vessel disease (SVD) related magnetic resonance imaging (MRI) abnormalities (including lacunae, white matter lesions, cerebral microbleeds, and brain atrophy), as well as to cognitive impairment. Although the mechanisms underlying the pathological association between kidney dysfunction and SVD or cognition remain unclear, several hypotheses might explain such associations (i.e., the similarity of the vascular bed function of the kidney and brain, endothelial dysfunction, and the renin-angiotensin-aldosterone system). Previous studies demonstrated clinical relevance of CKD to SVD and cognition might indicate that treatment of CKD might control age-related degenerative processes of the brain.
Botulinum toxin type A (BTXA) injections are effective for treating upper and lower limb spasticity after stroke. Treatment has been shown to reduce the spasticity in both the upper and lower limbs, assisting the patients with such activities of daily living as hand hygiene and dressing. However, the evidence for this therapy providing functional improvement is unclear. We performed BTXA injections, combined with an intensive rehabilitation program, to realize functional improvements in post-stroke patients with hemiparesis. First, we set a realistic goal with each patient. Second, we diagnosed the high-tone muscles and gave injections to achieve the goal. Third, we provided an intensive patient rehabilitation program, including stretching, task-oriented training, robotic therapy, and self-exercise. We treated some patients, having upper and lower limb spasticity, and observed improved motor functions. BTXA is a useful tool for treating upper and lower limbs spasticity. Combining BTXA and rehabilitation might improve both spasticity and motor functions in post-stroke patients.