A patient with familial antithrombin III (ATIII) deficiency was reported, who showed myocardial infarction at 30 years old and multiple cerebral infarctions after 43 years old. Cerebral angiogram showed severe atherosclerotic changes in internal carotid artery and anterior cerebral artery. Serum ATIII concentration and activity was markedly decreased to 7 mg/dl and 40%, respectively. One of his brothers also showed decreased concentration and activity of ATIII to 18 mg/dl and 46%, respectively. After the administration of anti-platelet drug, its concentration increased gradually.
It is extremely rare that multiple thrombosis develop in arterial system in a case of familial ATIII deficiency, although venous thrombosis are popular. This case suggests that decrease of ATIII may play a role in atherogenesis and anti-platelet therapy could be effective in such a patient.

View full abstract

We have studied seven patients with infarction in the territory of the anterior choroidal artery.
In all patients examination on admission revealed hemiplegia, hemianesthesia and homonymous hemianopsia, which were called the triad of infarction in the perfused area of the anterior choroidal artery. In addition to these signs, patients showed absence of spontaneous activity, disturbance of memory, and higher cortical signs, such as hemispatial agnosia and anosognosis. These signs were, however, transient and resolved within the acute stage. CT scan demonstrated an area of reduced denisty in the posterior limb of the internal capsule and the lateral geniculate body, sparing the thalamus, which corresponded exactly with the area of supply of the anterior choroidal artery. In some patients a cerebral angiogram revealed a stenosis at the origin of the anterior choroidal artery and irregularity on the wall.
It may be possible to make a correct diagnosis on infarctio in the territory of the anterior choroidal artery with clinical signs and characteristic CT findings.

View full abstract

Recovery of walking ability in the stroke patients is known to be one of the most important factors in the rehabilitation. It means not only a mere improvement of the disability level but an enhancement in the ADL which is associated with the QOL of the patients as well as their surroundings. We attempted in this study to find an optimal method to predict recovery rate of the outdoor walking ability in the stroke patients based on the factors prior to the rehabilitation.
1016 cases of the stroke patients (676 male, average age 58.9 yrs) admitted to Nanasawa Rehabilitation Center, 1981-1983, were statistically analyzed for the study. They were classified into recovery group and non-recovery group according to the 12 staged criteria of the disability level. The overall recovery rate was 63.2% (642/1016) : 66% in male, 57% in female. The age of the patients was found to be related to the recovery rate : 81% of the cases younger than 50 years of age regained the walking ability, 69% in the 50 years, 57% in the 60 years and 44% in the older than 70 years. Higher recovery rate was noted in the group of the patients who could sit up or stand up earlier, who did not have deep sensory disturbances. They had to be rated at more than Brunnstrom recovery stage III to be expected to show any recovery in the outdoor walking ability.
Aphasia was not directly related to the recovery of walking ability, whereas the hemi-spatial agnosia in the group of the moderate paralysis and lesion in the pyramidal tract as examined by CT scan proved to have an effect on the outdoor walking ability.
As the result of factor analysis and subsequently performed multiple regression analysis, the following three items were found to be significant predictors of the recovery of the outdoor walking ability : Brunnstrom recovery stage in the motility disturbances of the lower extremities, age which is related to the overall factors of improvement such as plasticity of nerves, the muscle force of the inaffected side as an indicator of the remaining ability. The multiple correlation coefficient was 0.60, and the rate of discrimination in the discriminant analysis was 0.80.

View full abstract

Whole blood viscosity (WBV) and its major determinants (hematocrit (Ht), plasma viscosity (PV) and indirect deformability of red blood cells (RD-Index)) were measured successively in 40 normal subjects and 18 patients with acute cerebral thrombosis (6 cases with cortical artery thrombosis, 12 with perforator thrombosis). WBV and PV were measured with a cone-plate viscometer (Tokyo Keiki Co.) at the shear rates of 75.5 and 377.5/sec. These rheologic factors were analysed in relation to subtypes of cerebral thrombosis and to the time elapsed from onset (Day 1-3; acute, Day 8-14; subacute, Day 28 over; chronic stage).
In the group of cortical artery thrombosis, WBV in acute stage were significantly higher than other stages, and all rheologic factors, such as Ht, PV and RD-Index, appeared to have contributed to increased WBV. In the group of perforator thrombosis, however, WBV was not higher than that in normal subjects throughout the course, and only RD-Index were significantly increased in acute stage, indicating poor RBC deformability (<0.05 vs chronic stage). PV were the highest in subacute stage in both group.
From the above results, it is suggested that pathophysiologic effects of these rheologic factors on cerebral circulation appears to be differently subtypes (cortical thrombosis, perforator thrombosis). Then, the principle for treatment should be aimed at hemodilution to decrease blood viscosity in patients with cortical artery thrombosis, and at improving RBC deformability to maintain cerebral microcirculation in perforator thrombosis.

View full abstract

The effects of a calcium antagonist, nifedipine, on the response of cerebral circulation to arterial Pco₂ and arterial Pco₂ changes were tested in 12 adult cats. Regional cerebral blood flow (rCBF) was measured using both hydrogen clearance method and heat clearance method in the thalamus, the frontal cotex and the deep white matter. Cerebrovascular reactivity to hypercapnia and hypoxemia was compared before and after intrarectal administration of nifedipine (1 mg/kg). Although resting rCBF values were significantly increased after nifedipine administration both in the gray matter and white matter, increment of rCBF during the inhalation of 5% CO₂ in air or 10% O₂ with 90% N₂ was markedly reduced after nifedipine. These findings suggest that calcium antagonist may modulate the chemical control of cerebral circulation and that calcium ions may be involved in the chemical control as a final common path to the contraction of vascular smooth muscles. Furthermore, these findings may have significant implications for the therapeutic use of calcium antagonists in acute cerebrovascular accidents.

View full abstract

A 48-year-old-female was admitted because of sudden severe neck pain, nausea, vomiting and vertigo. After admission, she revealed the feature of lateral medullary syndrome. Left vertebral angiography showed aneurysmal dilatation and narrowing of the vertebral artery. In the late arterial phase, retention of contrast medium in the part of aneurysmal dilatation of vertebral artery was observed. These neuroradiological findings strongly suggested the presence of a dissecting aneurysm of the vetebral artery. Suboccipital craniectomy was performed. After the left vertebral artery was clipped proximal to the aneurysm, the aneurysm revealed more expansion by retrograde blood flow. Therefore, we determined only proximal ligation was an incomplete method in this case and performed trapping of the vertebral artery. Review of literature, revealed there are 47 cases of dissecting aneurysms of the vertebral artery. In these cases, proximal ligations were performed in 19 cases, and 16 cases of them were excellent. But, we must give attention to the following rebleeding after proximal ligation which was observed in one case; Angiographical thrombosis of dissecting aneurysm was observed in only 8 cases, and in some these cases, the period of follow-up was not long enough. Therefore, when the choice of surgical treatment is only proximal ligation without satisfactory conditions to trap the vertebral artery, we must consider that there is a possibility of rebleeding and long-term follow-up is necessary.

View full abstract

We investigated the influences of acute cerebral perfusion disorder and the occurrence and extent of symptomatic vasospasm. In 63 SAH patients, excluding ventricular puncture and complicated intracerebral hematoma, the measurement of cerebral blood flow (CBF) by ¹³³Xe bolus injection was effected within the first 72 hours after the crisis. CBF was denoted as mean hemispheric gray matter blood flow (MFG) (ml/100g/min). According to MFG, the 63 patients were divided into the following three groups : Group A-17 patients with normal or increased values (MFG>70), Group B-30 patients with slightly decreased values (50<MFG≤70), and Group C-16 patients with very decreased values (MFG≤50). The symptomatic vasospasm (SVS) was defined as follows :
cases with findings of re-ruptured aneurysm on CT, decreased level of consciousness without an exacerbated hydrocephalia or localized cerebral symptom were designated as SVS-positive and divided into slight SVS, transient neurological deterioration; moderate SVS, permanent slight neurological deficit; and severe SVS, permanent severe neurological deficit or death.
The frequencies of SVS were as follows : Group A 17.7%, Group B 76.7%, and Group C 100%. In Groups A and B, no cases of severe SVS were observed, however in Group C 84.5% of the cases showed severe SVS.
In the 63 cases, in cases showing Fisher's Type 3 CT findings and those showing Hunt and Kosnik Grade III and IV upon hospitalization, severe SVS appeared in only 41.4% and 38.2%, respectively.
Furthermore, dividing the cases that belonged to Fisher's Type 3 CT and Hunt and Kosnik Grade III and IV upon hospitalization into a group under acute MFG 50 and a group over MFG 50, 90% in the former group had an unfavorable prognosis and showed a final picture of an uncomfortable death.
It is well known that acute changes in the cerebral circulation and metabolism appear simultaneously with SAH crisis. From our results, it was assumed that such a cerebral disorder of circulation and metabolism at the early stage of SAH may exert a great influence on the occurrence of symptomatic vasospasm and the degree of this severity.

View full abstract

In order to determine the distribution and frequency of infarction due to occlusion or stenosis of middle cerebral artery (MCA) trunk, 223 patients with occlusion or stenosis at levels from M1 to M2 were studied according to angiographic (AG) findings and computed tomography (CT) with emphasis on the mechanisms of obstruction, such as embolism. Patients were divided into 4 groups based on AG findings as follows; 84 cases of M1 occlusion (G-I), 88 cases of M2 occlusion (G-II), 31 cases of M1 stenosis (GIII) and 20 cases of M2 stenosis (G-IV). CT findings, which revealed LDA in 199 patients, were classified into 8 types on the basis of the branch artery territory as follows; S + D type (60 cases), D + WB type (47 cases), S type (45 cases), B type (18 cases), WB type (15 cases), D type (10 cases), H type (3 cases) and WM type (1 case). Though the S + D type and D + WB type were seen frequently in G-I, when patients with embolism are included in the groups, 85% and 77% were thought to be due to M1 occlusion, respectively. While a half of the S + D types were caused by embolism, almost none of the D + WB types were due to embolism. This suggested that infareted area in nonembolic obstruciton at the level of M1 creates smaller lesion with a sufficient collateral circulation through leptomeningeal anastomoses. Eighty percent of S type lesions were seen in M2 lesion (G-II, IV). All the B types, in which the LDA was localized to the subcortical white matter, were seen in nonembolic obstruction of G-II-IV. WB type, seen in G-I-III, and D type, were seen in 9% of M1 lesions and were infrequently caused by embolism. WM type and H type were considered to be associated with the other arterial lesions. These findings suggested that the mechanisms of obstruction influenced the size of infarcted area, not only the D type, like D + WB types, but also in WB types which could account for nonembolic occlusion of M1 or M2. Furthermore, it should be emphasized that B type were seen frequently in nonembolic M2-stenosis.

View full abstract

A 72-year-old man showed the right frontal artery sign and contralateral external carotid artery sign after a hemiplegic insult. The pulsation of his left angular artery was more prominent than the right. In addition to a complete occlusion of the right common carotid artery, cerebral angiography revealed crossed anastomosis between the left superficial temporal artery and the right frontal artery with a retrograde filling of the right internal carotid artery via the right ophthalmic artery. CT scan of the brain showed widespread hypodense areas in the right hemisphere. After recenalization of the right external carotid artery, the external carotid artery sign was now positive on the right, and the right frontal artery was found anastomosed with bilateral superficial temporal arteries. The right angular artery pulsation was more prominent than the left.
Both of the frontal artery sign and the external carotid artery sign were reported as a bedside indicator of internal carotid occlusion, usually positive on the side of occlusion. In the case of frontal artery sign with contralateral external carotid artery sign, this syndrome, suggesting one of the crossed external carotid-internal carotid collaterals, will be a diagnostic indicator of common carotid artery occlusion.

View full abstract

The locations and the types of arterial diseases in the patients with cerebrovascular disease depicted by IVDSA (intravenous digital angiography) were evaluated. Correlated risk factors, platelet aggregability, treatments and prevention of the cerebrovascular disese as well as the usefulness and complications of IVDSA were discussed.
1031 IVDSA were performed at our fascilities in the past four years. 243 cases, male 183, female 51, 9-83 years old (average 61.4) were included in this study with detailed histories, serial blood pressure mesurements, complete blood counts, blood chemistries and platelet agreggabilities before and after treatments with antiplatelet agents were amply documented. Of 234 cases, 225 had episodic cerebrovascular accidents and in the rest sclerotic arterial changes were accidentally found by IVDSA.
All patients were divided into 6 groups by the IVDSA findings. Those include internal carotid artery (ICA) occlusion 38, ICA stenosis 21, middle cerebral artery (MCA) occlusion 27, MCA stenosis 51, marked arteral elongation 52, near-normal 21 cases. 19 normal control cases were studied by IVDSA to clarify the etiology of headache or lassitude and found to have no neurologic diseases, normal angiography and normal CT findings. Cases with pure ACA or PCA lesions were too few to be included in the statistical processing. As satisfactory images were unobtainable due to the misregistration artifacts in cases with vertebrobasilar insufficiency, those cases were not included in this study.
IVDSA and the conventional angiography were performed almost at the same time in 43 cases to evaluate the diagnostic potentiality and clinical usefulness of IVDSA.
Complications concerned with IVDSA were also documented.
IVDSA was found to be less of burden to patients, had as much diagnostic potentiality as conventional angiography as to the main trunks and the large cortical vessels (lesions capable of diagnosed by IVDSA/those by conventional angiography; 67-96%), but gave fewer informations about the small vessels (25-40%).
There were no fatal or life-threatening complications. Most common complication of IVDSA was coughing (55%), followed by dermal reactions (20%), nausea and vomiting (16%), elevation of blood pressure (8%), chest discomfortness (1%), and intraatrial subintimal injection (1%).
The large portion of the internal artery occlusion group was of sudden onset and had fewer percentage of hypertention. Etiological interest in this group was that embolism, intra-atheromatic hemorrhage and dissecting aneurysm were more involved as well as ordinary atherosclerosis.
The major risk factors in the arterial diseases of the main trunks and large cortical vessels were hypertention, smoking, diabetes mellitus, ischemic heart diseases. severer hypertention, high hematocrit and elevated platelet aggregability were more related with lesions of the small cortical arteries and arterioles. In “ELONGATION” group, in which the main finding of IVDSA is arterial elongation without clear-cut stenoses, platelet aggregabilities elicited by ADP were resistive to be suppressed by antiplatelet agents like ticlopidine and aspirin. A wise treatment of patients with marked arterial elongation is subtle use of the antiplatelet agents so as to lower ADP-elicited platelet agreggability as much as possible from the preventive point of view.

View full abstract

MRI findings of acute (11 cases), subaute (2 case), and chronic (1 case) stages of aneurysmal SAH were summarized and compared with those of CT. In all 11 cases of acute SAH, fluid-fluid levels indicating the presence of the blood, were found in the lateral ventricles on ρ-weighted and T2-weighted images. In 13 of 14 cases, T2-weighted images showed high intensity signals not only in the large cisterns and cerebral fissures but also in the fine sulci. Periventricular high intensity, probably corresponding to edema, was found much earlier than the appearance of periventricular lucency on CT. MRI disclosed small infarcts, but no findings indicating the presence of cerebral ischemia due to early vasospasm were found. The focus of signal void not unlike an aneurysm was seen in the absence of aneurysm.

View full abstract

The purpose of this study is to determine the effect of blood glucose control on the subsequent development of cerebrovascular disease (CVD) in the diabetics.
A total of 432 diabetics with less than one year duration of diabetes and at least five years of follow-up were entered to this study. During median follow-up of 13.2 years 36 cases developed CVD (32 cerebral infarctions and 4 cerebral hemorrhages).
In the group with CVD mean fasting blood glucose (FBS) during the first five years of observation was 132.5 mg/dl, significantly higher than 117.1 mg/dl of the group without CVD (p<0.05).
When all subjects were divided into the good group (FBS<110 mg/dl), fair group (FBS : 110-130) and poor group (FBS>130) by mean blood glucose level during the first five years, the relative risk to develop CVD in the fair group was 2.0 and in the poor group 3.1, compaired with the good group. Aging and higher systolic blood pressure also seems to be associated with the increased incidence of CVD, but there seems to be no apparent relationships with sex, diastolic blood pressure, serum cholesterol, serum triglyceride and obesity.
A multivariate analysis using the proportional hazards model of COX was employed to demonstrate the relative importance of blood glucose control. It also showed that FBS had the strongest effects on developing CVD.
It appears that the blood glucose control seems to be an important factor in the development of CVD in the diabetics.

View full abstract