We performed B-mode carotid ultrasonography in 200 cases of lacunar infarction to calculate the plaque scors (PS : mm), and then used the data obtained to evaluate the frequency of occurrence of carotid atherosclerosis and clinical significance. There were 47 cases (23.5%) having a high PS in excess of 7.4 mm, which was more than the mean + 2 SD of the PS of healthy age-matched controls. Among the patients with a high PS, 1) no difference was confirmed regarding the infarction site, 2) 20 cases (42.6%) were complicated by stenosis of an intracranial large vessel on MR angiography, 3) patients with a high PS alone were likely to be older than those with intracranial large vessel stenosis alone, and 4) the levels of serum thrombin-ATIII complex and lipoprotein (a) were higher than those in patients without large vessel disease in the cervical orintracranial regions. Advanced cervical plaque in patients with lacunar infarction may thus be accompanied by intracranial large vessel disease, be more strongly affected by aging than intracranial large vessel disease, and activate coagulation. We conclude that ultrasographic examinations are useful in determining the treatment for lacunar infarction.

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We evaluated the outcome, discharge rate to other hospitals, and length of hospital stay in 281 cases of acute brain infarction admitted within the first week after onset among 368 cases of ischemic stroke from April 1995 to March 1997. The introduction rate of acute brain infarction from clinics and other hospitals to our hospital was 65%. The inhospital mortality was 4%. The discharge rate to other hospitals was 38%, and the discharge rate to the patient's own home was 58%. The discharge rate to other hospitals and length of hospital stay were, respectively, 21% and26 days in lacunar brain infarction, 42% and 30 days in atherothrombotic brain infarction, and 56% and 39 days in cardioembolic brain infarction. The proportion of patients with a length of hospital stay in excess of 60 days was 8%. The main cause of a long hospital stay was complications. The length of hospital stay was longer and the discharge rate to other hospitals was higher in cardioembolic brain infarction than in other kinds of brain infarction.

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Single photon emission CT (SPECT) using I-iomazenil (IMZ), which selectively binds to central benzodiazepine receptor, has been applied to imaging neuronal damage of the brain. Recent studies have focused on the late image of IMZ-SPECT as a newly developed form of brain function imaging. On the other hand, the early image of IMZ-SPECT, under the direct influence of the regional blood flow, has been regarded as equivalent to conservative flow imaging. To evaluate the clinical value of the early image of IMZ-SPECT, we investigated the early regional radioactivity and dynamics of IMZ in the brain by means of semiquantative analysis in comparison with data for I-iodoamphetamine (IMP) using dynamic SPECT and static SPECT in cases with cerebrovascular disease. Ten patients having old cerebrovascular lesions in the territory of the supratentorial perforating arteries were studied (mean age, 50.8 years). On SPECT images, four regions of interest (ROIs) were selected on the fronto-temporal cortex and cerebellar hemisphere bilaterally, which included both normal sites and diaschisis sites. In the dynamic SPECT studies, we analyzed the serial changes in local radioactivities of each ROI every 1 min and obtained time activity curves (TAC) during the first 30 min of injection. The early static SPECT images were obtained by reconstruction of the dynamic SPECT data, and the late static SPECT images were acquired at 3 hours after the injection. Comparison of the IMZ-dynamic SPECT with the IMP-dynamic SPECT in the ROT of normal sites revealed a dissociation between the shapes of TAC at the super-early phase immediately after the injection. Analysis of the IMZ-dynamic SPECT demonstrated that the difference in radioactivity between the ROI of normal sites and diaschisis sites reached a maximum almost at the time of acquisition of the early SPECT image. Comparison tests involving static SPECT with IMP indicated that the early image of IMZ and the late image of IMZ showed a significant (p<0.01) difference in the reduction of the radioactivity in the RO1 of diaschisis sites. The reduction of radioactivity in the ROI of diaschisis sites seen in early IMZ-SPECT was less than that in IMP-SPECT, but the difference was not significant (p=0.07). These characteristics of the early regional uptake and dynamics of IMZ suggest a clinical specificity for the early image of IMZ-SPECT. We conclude that early IMZ-SPECT images may help to elucidate the detailed relationships among regional hypoperfusion, neuronal damage and benzodiazepine receptor distribution.

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We measured the plasma basic fibroblast growth factor (bFGF) antigen levels of patients at the acute and chronic phases of cerebral infarction. Cerebral infarction was classified into 3 groups : the atherothrombotic brain infarction (AI) group, lacunar infarction (LI) group, and cardiogenic embolism (CE) group. The clinical significance of the plasma bFGF levels was compared among these subjects. The plasma bFGF levels in each of the three groups were elevated as compared to those of the control group at the 1 st and 7 th days of hospitalization. The plasma bFGF levels in the AI and LI groups revealed a tendency to decrease between the 1 st and 7 th hospital days, while that of the CE group tended to increase during the same period. The plasma bFGF levels were still elevated in each of the three groups as compared to the control group at the chronic phase. Postulating that the elevation of the plasma bFGF at the acute phase might reflect its release from the ischemic brain tissue, we examined the relation between the 1 st and 7 th day plasma bFGF levels and the size of the area of infarction. However, no correlation was found between them. Elevation of the plasma bFGF levels at the acute phase might represent a reaction of a more general systemic nature.

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We describe the changes in incidence, consciousness on arrival, and mortality of cases of subarachnoid hemorrhage based on an analysis of stroke patient registration in Iwate Prefecture, Japan, in both 1980 and 1992. The crude incidence was 19.9 per hundred thousand population in 1980, and 19.7 in 1992. We further analyzed the incidences by sex and age, demonstrating an increase in elderly women, but decreases in all generations of men and younger women. Subarachnoid hemorrhage from ruptured cerebral aneurysms accounted for 66.5% of all onsets in 1980, and 69.9% in 1992. Excluding subarachnoid hemorrhage of unknown origin, it accounted for over 95% of onsets in both years. The consciousness on arrival did not change. The fatality rate was increased from 29.5% to 41.5%, especially in elderly persons.

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Brain infarction may occur in patients with severe stenosis or occlusion of the proximal cerebral arteries and an inadequate collateral blood supply, when cerebral perfusion is critically decreased. Our previous stud-ies failed to demonstrate any relationships between cerebral vasodilatory capacity and stroke recurrence, although the clinical significance of the cerebral vasodilatory capacity remains unclear. We performed a prospective study on ischemic stroke patients with occlusive large-artery diseases to determine whether or not white matter abnormalities and silent brain infarction were associated with a reduced cerebral vasodilatory capacity. During the period from 1987 to 1995, we examined the cerebral vasodilatory capacity by single-photon emission CT and acetazolamide challenge in 105 consecutive stroke patients with severe stenosis (>75% in diameter) or occlusion of the internal carotid artery or the trunk of the middle cerebral artery. Ninety patients (age, 64±8y.o.; M/F, 76/14) who underwent MRI studies within 3 months after the onset of the index stroke were enrolled in the present study. Based on the criteria reported earlier, the patients were divided into 2 groups : a normal (negative ACZ, n=41) and a reduced ACZ reactivity (positive ACZ, n=49). The severity of the white matter abnormalities on MRI at entry was evaluated according to the grading scale reported by Fazekas et al. The observations were terminated when stroke recurred, a surgical treatment such an extracranial-intracranial bypass and carotid endarterectomy was performed, or the patient died. There were no significant differences in severity of white matter abnormalities or number of silent brain in-farcts at entry between the ACZ-positive and negative groups. During the observation period, 13 patients suf-fered stroke recurrence, 13 were treated surgically, 8 died, and 28 dropped out of the follow-up study. Finally, 37 patients who were followed for a median of 2.8 years underwent MRI studies without recurrence. New silent brain infarctions were documented with a follow-up MRI in 1 patient, who had been assigned to the ACZ-positive group at entry. The severity of white matter abnormalities did not change during the follow-up period in all patients. In conclusion, we found no evidence that a reduced vasodilatory capacity plays a role in the development of white matter abnormalities or silent brain infarction in patients with occlusive large-artery diseases.

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Several studies have suggested that patients with significant carotid occlusive diseases are at high risk of perioperative cerebrovascular accidents in cardiovascular surgery. We investigated the determinants of severe carotid occlusive diseases in candidates for elective cardiovascular surgery. A prospective analysis was performed on 388 consecutive candidates (276 men and 112 women with a mean age of 63 years) for elective cardiovascular surgery, including coronary artery bypass grafting (CABG), cardiac valve replacement, aortic or peripheral vascular surgery, between June 1996 and May 1997. The subjects were divided into 2 groups: a CABG group (n=143) and a non-CABG group (n=245). Preoperative clinical evaluations and carotid duplex ultrasonographic studies were performed on all patients. The diagnostic criterion for severe carotid occlusive diseases in the duplex ultrasonography was an follows : stenosis of over 75% in area or a side-to-side ratio of the end-diastolic blood flow velocity of over 1.4. Twenty-seven patients had severe carotid occlusive diseases, including 17 in the CABG group and 10 in the non-CABG group. Severe carotid occlusive diseases were thus found more frequently in the CABG group than in the non-CABG group (12% vs. 4%, p<0.05). Multivariate analysis demonstrated that diabetes mellitus and atherosclerotic vascular diseases in the CABG group and a history of stroke in the non-CABG group were significantly associated with severe carotid occlusive diseases. To prevent ischemic cerebrovascular accidents during and immediately after cardiovascular surgery, preoperative carotid screening is necessary, particularly in patients with diabetes mellitus and atherosclerotic vascular diseases in CABG and those with a history of stroke in non-CABG surgery.

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Retrospective analysis of the operative indications for brain stem cavernous angiomas was undertaken. Six angiomas, 5 in the pons and 1 in the medulla, were totally removed when three conditions such as repeated symptomatic hemorrhage, abutment to the fourth ventricle floor or brain surface, and progressive neurological deficits were fulfilled. The outcomes for the pontine angiomas were 4 cases of moderate disability and 1 of severe disability, while the 1 medullary angioma showed good recovery. The preoperative size of the angiomas and the serial changes in neurological deficits, from onset, the preoperative stage, just after surgery, at 1 week after surgery, and at 1 month to 1 year after surgery, were observed. It was found that the severity of preoperative neurological deficits paralleled the size of the angiohias and was closely related to the outcome. In pontine angiomas, abducens nerve palsy, facial nerve palsy and cerebellar ataxia remained for 1 year after the surgery and tended to cause a poor outcome. The data indicated that the less the size and preoperative deficits, the better was the outcome that occurred. It is concluded that even if one symptomatic hemorrhage occurs, surgical removal is recommended.

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The purpose of the present study was to evaluate the clinical usefulness of diffusion-weighted magnetic resonance imaging (DWI) in the diagnosis of cerebral hemorrhage. Twenty-six parenchymal hematomas between 2 hours and 150 days old in 26 patients were studied. DWI was performed by 1.5 Tesla magnetic resonance imaging (Magnetom Vision, Siemens, Germany) with an echo-planar imaging sequence. The ratios of the apparent diffusion coefficient (ADC) in the hematoma to that in the contralateral areas were calculated. Hyperacute (<6 hours old) hematomas were characterized by hyperintensity on DWI. Acute (>6 hours and <7 days old) hematomas revealed a heterogeneous intensity (mixed hypo- and hyperintensity) on DWI. Subacute and early chronic (>7 days and <30 days old) hematomas had hyperintensity. Late chronic (>30 days old) hematomas displayed peripheral hypointensity on DWI. This hypointensity proceeded to replace hyperin-tensity. The ratios of the ADC ranged widely between 0.70 and 1.31 within 24 hours after onset. The values declined to 0.45-0.77 at 4-5 weeks after onset, and then increased gradually to more than 1.0 at 3 months after onset. DWI hyperintensity in cerebral hemorrhage within 6 hours after onset is not distinguishable from that in ischemic lesions. Furthermore. the ratio of the ADC in cerebral hemorrhage was variable within 24 hours after ontet. CT should therefore be used to diagnose cerebral hemorrhage during the first 6 hours after ictus.

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The expressions of tissue plasminogen activator (tPA) and plasminogen activator inhibitor-1 (PAI-1) were examined in cerebral vessels in order to evaluete the differences in vessel size and location in human autopsy brains, employing immunohistochemistry. In the extraparenchymal pial and major cerebral arteries, tPA was expressed in the adventitia, and PAI-1 was expressed in the endothelium, media and adventitia. In the carotid bifurcation, the expression of tPA was increased in the endothelium. In the carotid bifurcation and regions with fibrous hyperplasia, the expression of PAI-1 was increased in the endothelium and media. In the brain, the microvascular expressions of tPA and PAI-1 were more intense in the white matter than in the cortex and putamen. In the perforating arteries (25 to 200 μm) of the putamen and white matter, the expressions of tPA and PAT-1 were faint. The increased expressions of tPA and PAI-1 in the white matter could in part be related to frequent development of small infarcts in the white matter and diffuse white matter lesions as observed in Binswanger's leukoencephalopathy, although the mechanisms remain to be determined.

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A 52-year-old man had suffered from schizophrenia for about 30 years, and had been treated with neu-roleptics such as haloperidol and levomepromazine. On admission, he was in semicoma and showed right hemiplegia MRA revealed a complete obstruction of the left middle cerebral artery. Thrombolytic therapy with argatroban was performed for 7 days. His consciousness level was improved, and haloperidol at 2.25 mg/ day (before admission : 21 mg/day) was readministered. One day later, he developed muscle rigidity, tremor and sweating. Laboratory examinations disclosed an increase in serum CK (273 IU/l), which indicated that the patient was suffering from neuroleptic malignant syndrome (NMS). He was therefore treated with dan-trolene and bromocriptine. After 2 weeks, his symptoms subsided and his CK level returned to normal. We should treat patients with cerebro vascular disease carefully, because they may suffer from NMS when pre-scribed antipsychotics or L-dopa.

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