Adhesion molecules of circulating leukocytes (LFA-1) and endothelial cells (ICAM-1) may play an important role in the pathogenesis of cerebral infarction. Twelve patients with lacunar infarction and 12 agematched controls were investigated, employing immunofluorescence flow cytometry and ELISA to measure the leukocyte membrane expression of LFA-1 a (CD 11 a) and LFA-1 β (CD 18), and the plasma levels of soluble (s) ICAM-1 within 24 h after the onset of symptoms. Sequential measurements were performed at 1.2 days, 5-7 days, and 3-5 weeks after stroke onset. There were two distinct fractions with bright and dull expressions of CD 11 a and CD 18 of leukocytes (monocytes, lymphocytes, and granulocytes). The percent expression of the CD 11 a and CD 18 bright population was determined. The expression of monocyte LFA-1 was significantly increased within 24 h after the onset of symptoms as compared with the control (p<0.01). Follow-up measurements of the monocyte LFA-1 revealed a significant decrease from the acute to the chronic stage (p<0.01). The expression of lymphocyte LFA-1 was significantly increased from 24 h after the onset of the disease to 3-5 weeks (p<0.01). No difference in granulocyte LFA-1 expression was detected during the course of the disease. The plasma sICAM-1 levels at 5-7 days after onset were significantly higher than those of the controls (p<0.01). After vascular injury, the expression of LFA-1 in the circulating leukocytes seemed to appear in a particular order : first in the granulocytes, next in the monocytes, and then in the lymphocytes. The above findings suggest that changes in the leukocyte adhesion dynamics occur during the course of cerebral infarction.

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Although hyperthermia is a common clinical feature of various diseases, and if excessive, can lead to cerebral dysfunction and/or neuronal damage, its effect on cerebrovascular autoregulation has not yet been well established. The purpose of the present study was to examine the effects of high temperature on cerebral blood flow (CBF) in the rat cortex and on pial vessel diameter, in order to elucidate the effect of hyperthermia on cerebrovascular autoregulation in various diseases.
Twenty-four male Wistar rats (300-400 g) were anesthetized with a-chloralose under mechanical ventilation. The animals were divided into 4 groups, i. e., a normothermic group (cranial and rectal temperatures : 37.0±0.5°C, n=6), andthree hyperthermic groups (I:39.0±0.5°C, n=6;II:40.0±0.5°C, n=6;III: 41.0±0.5°C, n=6). The cranial and rectal temperatures were controlled at the same level in each group by using a thermocontrolled chamber with hot air. MABP was lowered by exsanguination at a rate of 10 mmHg/min, and kept at the desired level for at least 2 min. The pial vasculature was visualized through a closed cranial window (dura removed) which was implanted in the right parietal bone. The cortical regional CBF was monitored continuously using a laser-Doppler flowmeter. Pial vessel diameter was estimated with a CCD camera and a video dimension analyzer. The arterial blood gases, blood glucose, and hematocrit were also measured as physiological variables. Although the CBF declined with reduction of MABP at 401C, the fall was not signifi-cant in the range from 100 to 70 mmHg. In the hyperthermic group, the CBF fell significantly with decreasing MABP, indicating that cerebrovascular autoregulation was disrupted at 41t. In contrast, the alteration in pial vessel diameter (mainly 30-60 μm in diameter) with decreasing MABP in the normothermic group was abolished even in the mild hyperthermic group (39°C). These results suggest that autoregulation was abolished or at least impaired, nuder hyperthermic conditions, and there are some discrepancies between blood flow responses and arterial responses. Our findings are thought to be very important for the management of patients with high fever.

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By the advent and advance of microsurgery, neuroimaging, ganmma knife and endovascular surgery, any kind of cerebrovascular diseases can be now treatable in Japan. However, to questionnaires on current problems in the treatment of cerbral stroke, executive members of Japan Stroke Society answered and pointed out the following issues, namely, lack of a stroke care unit (SCU) ; beds can not be used freely ; Limitation of hospital stay ; few referable hospitals for severely disabled patients ; lack of staffs ; t-PA is not available and so on.
In conclusion, diagnosis and treatment for stroke patients are now muck advanced, and however, it is now an urgent problem in Japan to constract a seamless network for treatment of stroke patients including S (C) U, acute rehabilitation facilities and nursing homes for severely disabled patients.

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Purpose : To evaluate superselective local intraarterial fibrinolysis (LIF) using tPA for acute embolic middle cerebral artery (MCA) occlusion, 77 patients receiving LIF were investigated. Methods : The indication of this treatment includes : 1) within 6 hours after onset of symptoms, 2) no responsible lesions in CT findings, 3) less than 75-year-old. HMPAO SPECT was carried out, if possible. The supplementary indication in SPECT findings is : 4) residual flow in affected side is between 35 and 70% comparing contralateral side. Diagnostic angiography was followed by LIF. Microcatheter was introduced in or beyond the embolus and tisokinase was infused with a maximum amount of 4.8 million LU..
Results : Recanalization was achieved in 73 cases (95%). The intervals from onset to admission, and recanalization are 2.4 hrs, and 5.5 hrs in average, respectively. NIHSS improved 4 points or more in 26 comparing the scores on admission and in the next day. 57% of the patients showed Modified Rankin Scale 3 or better. The cause of the mortality was diffuse hemorrhagic transformation in all 3 cases.
Conclusions : Superselective LIF for acute embolic MCA occlusion is excellent treatment because it carries high recanalization ratio and good clinical outcome.

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Since 1994, we have treated hyperacute cerebral embolism within six hours onset with local intra-arterial thrombolysis (LIT). Seventy-six cases were treated. Occlusive sites were: IC top in 16 cases, MCA in 39 cases, Basilar a. in 8 cases, and others in 13 cases. Mean initial NIHSS score was 18.4 points. We used urokinase with maximal dose of 1 MIU and achieved recanalization in 51 cases (67.1%). Twelve cases (15.8%) were complicated with intracranial hemorrhage within 24 hours. Mortality was 28.9%. As to MCA (M 1 and M 2) occlusion, we obtained the similar results to PROACT II. We discussed on indication and contraindication of LIT, comparing the results with other already-published, randomized studies.

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Disruption of an atherosclerotic plaque with resultant intraluminal thrombosis is an important mechanism of plaque development and progression, and also plays a fundamental part in the development of the acute coronary syndromes. The same mechanism contributes a development of ischemic cerebral symptom in the territory of carotid artery. We retrospectively analyzed 62 cases with symptomatic high grade carotid artery stenosis. In these 62 cases, contributing mechanism of ischemic symptoms were considered as hemodynamic ischemia due to acute progression of atheromatous plaque in 5 cases, artery to artery embolism originating from carotid stenosis in 37 cases, unclassified in 20 cases. In 5 cases, 4 cases with hemodynamic ischemia and 1 case with a floating thrombus just distal to the carotid stenosis, emergency treatments including 4 percutaneous transluminal angioplasty with/without stenting and a EC-IC bypass were performed. All cases made a rapid recovery from the ischemic symptoms. Emergent treatments of acute carotid syndrome due to rapid progression of atheromatous plaque produced dramatic effect, although candidates for emergency treatment were less than 10% of all symptomatic high grade carotid artery stenosis.

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Purpose: We reviewed our clinical results of local fibrinolysis for Middle cerebral artery embolism (MCAE) and Basilar artery embolism (BAE) to discuss the propriety of our criteria for the indication of this treatment by comparing the results with conservative medical therapy.
Materials and Methods: Since 1990.10 to 1999.11 we have had 75 cases of local fibrinolysis (MCAE 52 cases, BAE 19 cases and others 4 cases). Our criteria for the indication are 1) Cerebral embolism without any ischemic change at the initial CT, MRI and MRI-DWI. 2) Cerebral embolism within 6 hours from the onset (MCAE). 3) Preserving the residual CBF of ischemic territories over than 15 ml /100 g/min in 133 Xe-SPECT (MCAE). 4) No time limitation in BAE. Endovascular technique using microcatheter was applied for local fibrinolysis and rtPA (5-15 M units) or Urokinase (0.24-0.96 M units) were injected at the position of embolus or beyond the embolus.
Results: Angiographical results were (MCAE/BAE) full reopening 17/12, partial reopening 23/4, embolus migration 4/1 and no change 7/2. Three months follow-up outcome evaluated by Glasgow Outcome Scale were (MCAE/BAE) good recovery 34/11, moderate disability 10/0, severe disability 4/1, persistent vegetative state 0/2 and death 4/5. In comparison with the conservative medical therapy group, local fibrinolysis is superior in GR and SD rate, and large infarction rate in MCAE and in GR rate in BAE.
Conclusions: Local fibrinolysis with evaluation of residual CBF in MCAE could achieve angiographical and clinical improvements. And it is superior to the conservative medical therapy group in some points.

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Backgrounds: Thrombolytic therapy for acute ischemic stroke remains unapproved in Japan, although thrombolysis with intravenous recombinant tissue plasminogen activator (rt-PA) within 3 hours of stroke onset has been officially available in the USA since 1996.
Methods: We report our experince of angiography-based thrombolysis trials and acute stroke care at our medical center.
Results: During 1983-95, 95 acute ischemic stroke patients were given either intraarterial urokinase (n = 44), intravenous rt-PA (n = 19) or placebo (n = 12), or intraarterial rt-PA (n = 19) within 6 hours of onset. Reperfusion rates after thrombolysis were 36% with La. urokinase and 47% with i.v or La. rt-PA, being higher than 17% with placebo. The frequency of intracranial hemorrhage was comparable among urokinase-, rt-PA-and placebo-given groups. The rtPA-treated patients showed significantly favorable neurological outcome. Of 254 acute ischemic cerebrovascular events within 7 days of onset during the recent 18 months, 32% presented within 3 hours of onset and cumulatively 40% did within 6 hours. Antithrombotic therapies were given in 93%. Although 7% of all patients fulfilled the guidelines of NINDS i.v. rt-PA, 0.8% of all patients finally received thrombolysis.
Comments: Thrombolytic therapy appears to be feasible in selected patients with hyperacute ischemic stroke. The official approval for rt-PA is expected in Japan. Emergency stroke care systems should be also organized.

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We analyzed our stroke care unit (SCU), which was established 20 years ago, from the clinical and financial points of view. Our SCU has 15 beds, 22 nurses, and 30 doctors, who also work in general wards, and can afford to permit thrombolytic and hypothermic therapies. During the last 20 years, the number of patients increased gradually exceeding 500 patients/year in 1999. The increase has been accelerated since 1997 when a hot-line system with ambulance was established. The main diagnosis was acute stroke in 75% of patients, and other neurologic emergencirs was the remainders. Mean ages of patients increased by 5 years during the 20 years. The increase of elderly patients resulted in the increase of poor outcome cases and the prolongation of admission period. Since the critical-path was partially introduced in 1999, the period of hospital stay has re-duced. The financial state of our institute was analyzed 1999. The income expenditure balance in SCU was the worst among general wards and intensive care unit. The main reason for poor balance is that the costs for acute stroke diagnosis and management are rated disproportionally low in spite of a large amont of manpowers. While SCU appears to be effective to bring about better clinical outcome of stroke, its financial problems have to be solved urgently.
(Jpn J Stroke 22: 546-548, 2000)

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The efficacy of Stroke care unit (SCU) was reported by the Copenhagen Stroke Study in 1995 and the concept of the SCU influenced the world around. The real concept of SCU is total care for stroke patients cooperated by every kind of medical staff members however. it is often confused with stroke intensive care unit for only acute phase stroke therapy.
We started to work at functional SCU by well-organized staff members of neurosurgical and rehabilitation departments without special ward since 1996. We compared control group (488 cases: 1993-1995) with SCU group (483 cases: 1996-1998) concerning the time of standing by for rehabilitation after admission, the length of stay in hospital and patient's outcome at their discharge. The SCU made the length of stay in hospital shorten about 19 days with better outcome compared with control group. The occurrence rate of lung complication, which is main mortal factor after stroke, was decreased by early rehabilitation.
For the good management of SCU, the social work is one of the most important part in the SCU. However there are not enough social workers at present, moreover the relationship between hospitals and social welfare is poor in Japan.

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Critical care neurology has become recognized as one of the subspecialty in neurology in the United States (U. S.). There is progressive increase of neuro-intensive care unit (neuro-ICU) after 1990s especially in the U. S. and Germany. To evaluate the merits and problems of neuro-ICU, we conducted comparative simulation study between stroke care unit (SCU) and neuro-ICU in terms of clinical presentation and manage-ment.
Among the 442 inpatients who admitted to our department during 1998, we extracted patients qualified of admitting to either SCU or neuro-ICU using the criteria of Mayo Medical Center (EFM Wijdicks, 1997).
Patients qualified of admission was 50 patients (11%) in SCU, and 69 patients (16%) in neuro-ICU. Clinical diagnosis of SCU patients were as follows: cerebral infarction 84% (mainly, cardioembolic), cerebral hemorrhage 14%, cerebral venous thrombosis 2%. In neuro-ICU: cerebral infarction 61%, CNS infection 15% (mainly, viral encephalitis), cerebral hemorrhage 10%, Guillain-Barre 6%, status epilepticus 4%, myasthenia gravis, head trauma, and cerebral venous thrombosis 1%, respectively. Multiple departments attended the service in 22% of SCU patients and in 63% of non-stroke patients. Patients with difficult diagnosis at admission, i.e. possible stroke which turned out to be non-stroke, were observed in 4% of SCU patients. Mortality was 24% in SCU. 23% in neuro-ICU. and 4% in patients not cualified of admission to both.
Patients qualified of admission to neuro-ICU are in equally critical state as in case of SCU, and needs multidisciplinary and integrated approach. Considering together the patients with difficult diagnosis at admission, integrated approach, and cost-efficacy, neuro-ICU may be more rational than SCU. We needs positive evidence for neurn-TCIJ and also to develop neurointensivist.

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The recent development of therapy shows a possibility to improve neurological deficits in the acute stroke patients. According to the development of the therapy, it has been desirable that an appropriate system managed by the expert medical staff should be applied for the treatment of stroke patients, especially for treatment of acute patients. Stroke care unit (SCU) has been applied as the intensive care unit for acute stroke patients. In the past, the efficacy of SCU was not confirmed statistically to decrease the mortality rate of acute stroke. Recently, SCU is required to treat acute stroke patients, especially for carrying out effective therapies in the restricted acute stage. SCU is the special unit for stroke patients, and expert medical staff must be needed. In our hospital, we have had neurological intensive care unit (NCU) from 1969, but we had not doctor team managing the unit nor any definite guidline for the treatment of acute stroke patients. In 1997, we established the department of strokology, which was constituted by both of neurologists and neurosurgeons. Doctors of department of strokology treat stroke patients in SCU under the definite guidline of stroke management. Our guidline is to be revised based on the evaluation of outcome of our patients. We consider that SCU managed by expert medical staff under a definite guidline is necessary to improve the clinical outcome of stroke patients.

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We studied the effects of stroke unit for prevention of respiratory infection in patients with ischemic stroke.
We performed a retrospective study of consecutive acute ischemic stroke patients. They were divided into two groups which were both cared by stroke units. Group W included 181 patients in a hospital which introduced proper stroke wards system. Group T included 77 patients in another hospital which introduced mobile stroke team system. The two groups were compared about prevalence and outcome of respiratory infection.
The prevalence of respiratory infection was 15.5% in group W and 22.1% in group T (p=0.08). Of the patients with respiratory infection, mean modified Rankin Scale at discharge was 5.2±1.5 in group W and 4.4±1.5 in group T (p=0.14). Mean length of hospital stay is 31.5±14.3 days and 27.1±15.3, mortality is 25% and 11.8% (p=0.45).
Introduction of proper stroke wards system of stroke unit may decrease prevalence of respiratory infection in acute ischemic stroke, although it may worsen severity of respiratory infection.
(Jpn J Stroke 22: 560-563, 2000)

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In SNUH, Department of Neurology takes primary responsibility for care of ischemic and non-surgical hemorrhagic stroke patients. Dept. of Neurosurgery puts up with most of surgical hemorrhagic strokes, arteriovenous malformations, carotid artery stenosis, etc. SNUH has 28 beds in surgical ICU and medical ICU, and Depts. Of Neurosurgery and Neurology have 8 beds in base. In surgical ICU, we have 1053 patients in Neurosurgical field for the last three years. Of them, 414 patients (39.3%) had cerebrovascular diseases, and the mean stay in ICU was 6.7 days. For the management of ischemic stroke patients, ICU care is not generally required in SNUH. In hyperacute phase, when thrombolytic therapy with urokinase or r-TPA is used, and interventional injection of antithrombotic agent aided, closed observation is performed in intensive care unit. Basically, neurological, neurosurgical and interventional radiosurgical parts are involved for the effective care and protocols for acute management are developed. In hemorrhagic stroke patients, joint management is done by neurosurgical and neurological units, and the need for ICU care is determined by the patients' status. Neurosurgical part leads the care in surgically indicated patients, and neurological part supports general care or postoperative care of the patients. Basically, ICU is required in peri-operative periods. In SNUH, intensive care for stroke patients are not well organized and systemized yet, but efforts are being made for improved proto-cols and better care units. We hope for Cerebrovascular Disease Center be developed in recent period, and more systemic approach for stroke patients are anticipated.

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This analysis indicates the results of a prospective study of 102 patients with 124 asymptomatic unruptured aneurysms without operation from 1993. The patients (M: 33, F: 69) were followed from 2 to 83 months (mean 38.2). The ages at diagnosis ranged from 21 to 78 years (mean 64.1) The locations were ICA: 48, MCA: 37, AcomA: 23, the vertebrobasilar artery: 9, ACA: 6 and PCA: 1. The average aneurysmal diameter was 4.3 mm, a range of 2 to 12 mm. They were followed up radiologically using MRA, MRI and 3D-CT angiography. Among the 102 patients, five had suffered subarachnoid hemorrhage (SAH) due to rupture of the aneurysms (MCA: 3, BA-SCA: 1, IC-PC: 1) The maximal diameter of the aneurysms at diagnosis ranged from 4.5 to 8 mm. The period from discovery to SAH was from 4 to 69 months and the cumulative rate of rupture of the aneurysms was 1.5 percent per year. The present study demonstrates that five asymptomatic unruptured aneurysms less than 10 mm in diameter subsequently ruptured. We ought to consider the data that unrup-tured aneurysms less than 10 mm in diameter have a very low probability of subsequent rupture published the New England Journal of Medicine (1998) very seriously.

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Purpose and Method : In order to prevent stroke in perioperative period of cardiovascular surgery, we analyzed silent cerebrovascular factors. Seventy-seven patients with Coronary Artery Bypass Graft Surgery (CABG) and forty-three patients with other cardiac operations (non-CABG) were recruited and evaluated by MRI, MRA and cervical duplex ultra-sonography.
Result : The frequency of the silent brain infarction in CABG group (49.4%) was not statistically significant from that in non-CABG group (41.9%). In both groups, almost all of lesions were lacunar infarctions locating in deep carebral white matter.
Severe stenosis or occlusive lesions in intra and/or extracranial major arteries were more frequently found in CABG group than in non-CABG group (29.9% vs 11.6%, p=0.026). The intracranial vascular lesions rather than extracranial ones were more predominantly revealed in our series.
Conclusion : To reduce the peri-and postoperative complications of patients underwent cardiovascular surgery, preoperative evaluation of stenotic vascular lesions in cervical and intracranial areas is very important.

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We performed brain MRI, transthoracic echocardiography and transesophageal echocardiography to 86 patients with atrial fibrillation, who had no history of stroke. Silent cerebral infarctions were detected in 44 of all patients. Cortical, perforating and subcortical infarctions were found in 7, 8 and 43 patients, respectively. Patients with cortical infarctions showed significantly lower peak flow velocity in the left atrial appendage, rather higher grade of spontaneous echo contrast (SEC) and higher incidence of thrombus formation in the left atrium, as compared with patients without cortical infarctions. The grade of aortic atherosclerosis (AO-G) as well as the intima-media thickness of aorta (IMT) was significantly greater in patients with perforating infarctions rather than in those without perforating infarctions. In patients with subcortical infarctions, AO-G and IMT were significantly greater than in those without subcortical infarctions, and also rather higher grade of SEC was detected.
Above data suggested that silent cortical infarctions in patients with atrial fibrillation were supposed to be cardiogenic, but that silent perforating infarctions might be lacunar or atherothrombotic. On the other hand, silent subcortical infarctions were considered to have a variety of etiologies.

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It has been said that the rupture rate of asymptomatic aneurysms is 1-2% per year. However, according to the recent International Study of Unruptured Intracranial Aneurysms, the rupture rate of small unruptured aneurysms was only 0.05% per year, and 0.5% per year for large (> 10 mm diameter) and all unruptured aneurysms inpatients who had subarachnoid hemorrhage (SAH) previously.
During 1987-92 in Izumo City, Japan, Inagawa et al reported the age-and sex-adjusted annual incidence rate of aneurysmal SAH was 23-29 per 100, 000 population. Based on these data and those for published autopsy studies, the annual rupture rate of unruptured cerebral aneurysms was estimated. Rupture risk ratio (ruptured cerebral aneurysms/ruptured and unruptured cerebral aneurysms) stratified by age and location were calculated. Rupture risk ratio of anterior communication artery aneurysms was significantly higher than the other site of aneurysms. The annual rupture rate of unruptured cerebral aneurysms seems to be over 0.8 %per year. Whereas therewas no significant relationship between rupture risk ratio and age, both the incidence rate of aneurysmal SAH and the possible annual rupture rate increased with age. When we encounter patients with unruptured cerebral aneurysms, we should take into account that these lesions have relatively high risk for rupture.

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We studied the relationship between silent cerebral infarction (SBI), periventricular hyperintensity (PVH) and blood pressure. Subjects were 1522 neurologically normal adults without history of stroke (mean age, 57.8±8.4 years) who received the brain chech-up from 1988 through 1998. We divided into 8 groups according to JNC-IV in blood pressure at brain check-up.
The abnormality of ECG and family history of stroke increased with severity with hypertension. Incidence of SBI was 15.4% and it increased with age. SBI and PVH were related with the severity of blood pres-sure grading, especially with stage 2 or more. SBI was more related with uncontrolled blood pressure at brain check-up than history of hypertension, whereas PVH was motre related with history of hypertension than blood pressure at brain check-up.
These results suggent that there is some different underlying mechanism related with blood pressure between SBI and PVH.

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The results of a prospective cooperative multi center study on hypertensive intracerebral hemorrhage in Japan are reported. Nine neurosurgical centers participated in this study during from January to December 1999. Total of 717 cases were registered and followed up for one month. Among then, 603 cases were admitted on day 0. Neurological grade at admission were as follows ; grade-1, 354 cases ; grade-2, 78 cases ; grade-3, 49 cases ; grade-4a, 43 cases ; grade-4b, 79 cases ; grade 5, 39 cases. 510 cases (73.2%) were treated conservatively and 185 cases (26.8%) were treated surgically. Incidences of surgical treatment and method of surgical evacuation of the hematoma such as craniotomy or trepanation were variable in each center. Brain stem hemorrhage showed the worst prognosis and subcortical and cerebellar hemorrhage were the better results. Incidence of mortality was less and morbidity was higher in the cases of surgical treatment.

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In order to elucidate the usufulness and safety of CT-guided stereotactic surgery for the treatment of Pa-tients with high-grade putaminal hemorrhage, we retrospectively compared the outcome of patients treated by stereotaxic surgery or craniotomy under general anesthesia. For the past eight years, 33 patients with high-grade putaminal hemorrhage were treated by craniotomy and 27 patients were treated by stereotaxic surgery. For stereotaxic surgery we used Komai CT stereotactic apparatus and inserted two drainage tubes to different target points through one burr hole under strict control of blood pressure. The tube placed in the center of the hematoma cavity was used to inject a solution of 6, 000 IU urokinase in 2 ml saline and the other tube placed in the posterior site of the cavity was for persistent drainage of the hematoma clot expecting syphone effect.
Overall satisfactory outcome was obtained in 18 of 33 patients (54%) in craniotomy group and in 17 of 27 patients (63%) in stereotaxic group. In craniotomy group, 8 of 15 patients (53%) with poor outcome deterio-rated due to pulmonaly complication. In stereotaxic group, postoperative CT scan demonstrated sufficient re-duction of hematoma volume without rebleeding in all patients except for three patients with chronic renal failure.
As a conclusion, stereotaxic surgery under the close control of bood pressure was safe and usuful method for the treatment of patients with high-grade putaminal hemorrhage as far as the patients do not have chronic renal failure.

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The indication of operation for hypertensive intracerebral hemorrhage (HICH) is mainly determined by the extention and volume of the hematoma on initial CT findings1)2). Howevere, CT findings are not always indicate the exact involvement of the internal capsule and prediction of the outcome of patients.
The Authors then studied motor evoked potential (MEP) in patients with HICH and analyzed the degree and prognosis of motor dysfunction. When MEP of the patients with HICH is recorded on admission, the degrees of motor paresis improved, even if initial CT showed involvement of the posterior limb of the internal capsule. The motor dysfunction also inproved by surgical treatment, and the motor paresis successfully improved for these patients. MEP recording is therefore valuable to predict the motor dysfunction and to determine the indication of operation for the patients with these patients.

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OBJECTIVE : To evaluate the efficacy of the endoscopic hematoma aspiration treatment method, we compared the outcome at three postoperative months of our patients with those reported in 1989 for conventional aspiration and craniotomy. METHODS : In this study, we surgically treated 92 patients admitted to our hospital and affiliated hospitals with putaminal hemorrhage using a rigid neuroendoscope. RESULTS : The average hematoma aspiration rate was 85% (range, 55-100%), and was 82% even in the acute phase. The results of a cooperative study in Japan in 1989 were compared with those for 62 of our patients who participated in a follow-up survey of Activites of Daily Living three months postoperatively. For NG IVa patients, prognosis following endoscopic surgery was significantly better than that after conventional stereotactic aspiration, and for NG II and III patients, it was significantly better than hematoma removal by craniotomy. CONCLUSION : Endoscopic surgery for intracerebral hemorrhages enables the surgeon to observe the hematoma clearly on the monitor, and also to manage cases of intraoperative bleeding by promoting hemostasis. In addition, it is applicable to the surgical treatment of large hematomas in the acute phase, because it can be used conveniently and quickly. This endoscopic method combines the beneficial features of safety and reliability of craniotomy with those of minimal invasiveness and convenience of conventional stereotactic aspiration to treat intracerebral hemorrhage effectively.

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From September 1997, we organized the department of strokology which was constituted by neurologists and neurosurgeons, and started to treat stroke patients cooperatively. In July 1998, we made a clinical guidline which indicated the method of treatment for stroke patients based on retrospective studies, and started to apply clinically. According to the guidline of hypertensive intracerebral hemorrhage (HIH), the systolic blood pressure was controlled betweeen 160 and 140 mmHg in the acute stage to prevent further bleeding. The surgical indication was restricted by both of the level of consciousness and the hematoma volume. Stuporous or semicomatose patients with intracerebral hematoma above 21 ml or intracerebellar hematoma above 2.1 cm in diameter were indicated for the surgical therapy. Comatose patients with normal brain-stem evoked potentials were indicated for surgical therapy. Some comatose patients were registered to the clinical study of hypothermia therapy under the informed conscent. We evaluated the clinical outcome of patients who were applied for our clinical guidline (July 1998-December 1999), and compared to the outcome of patients who were admitted prior to the application of our guidline (January 1994-June 1998). After the introduction of our guidline, the incidence of surgical therapy was decreased from 17.9% to 12.1%, and the incidence of patients who showed independent daily life on discharge was increased from 37.1% to 44.7%. These differences were not significant statistically, however, the efficacy of our system for the treatment of HIH by applying the guidline in the department of strokology was suspected.

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During a recent 10-year period, the incidence and risk factors of aneurysmal subarachnoid hemorrhage (SAH) in Shimokita area of Aomori prefecture was investigated. A total of 195 patients were registere, and the age-adjusted annual incidence was 20.7 per 100, 000 population. The age-specific annual incidences ranged from 32 to 40 per 100, 000 population at the age of 40-79 years in men. In Women, they became higher with increasing age, and revealed a peak, which was around from 60 to 70 per 100, 000 population after the sixth decade of life. This results suggested that Japan has much high incidence of SAH compared with other countries.
Case-control study was performed to evaluate the risk factors of SAH. Hypertension, cigarette smoking were a risk factor for both men and women. Alcohol consumption over 500 g/week was a risk factor for men, and familial history of SAH was a risk factor for women. The same factors can be risk factors in Japan as in other countries.

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We describe the incidence, consciousness on arrival, circadian change of onset, prognosis, operative rate of subarachnoid hemorrhage based on an analysis of stroke registration in Iwate Prefecture, Japan, from 1991 to 1996. The crude incidence was 14.2 per hundred thousand population for men, and 23.7 for women. We further analyzed the incidence by sex and age, demonstrating higher incidence in elderly women than in elderly men. A circadian change of onset was observed obviously with higher in middle morning and in the evening, otherwise nadir at midnight and noon. The consciousness on arrival in elderly person was more severe and their prognosis was worse than younger. The case fatality rate decreased from 41.8% to 28.3%. A stroke registration is important for an analysis of onset stroke and it will be useful for stroke prevention.

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To investigate present status of ischemic stroke patients in Japan, a nation-wide, hospital-based survey was performed during a period from April 1997 to March 1998. Questionnaires were sent by mail to 4, 957 institutes selected on the basis of hospital lists published by the Ministry of Health and Welfare and of active members of Japan Stroke Society, Japanese Society of Neurology, Japanese Society of Emergency Medicine, and members of rank-A Neurosurgical training hospital.
2, 048 valid responses were obtained from 1, 787 institutes (Responses were sent from 2 or more departents of the same institute).
Results are summarized as follows :
1) Ischemic brain infarction was found to be over 70% of all strokes. 2) Less than 30% of patients visited hospital within 6 hours of onset. 3) 43.6% of the institutes replied that they used thrombolytic agents at least in one patient (Thrombolytic agents were used, by calculation, in 8.3% of all patients), but true thrombolytic therapy (sufficient dose for thrombolysis) were performed in less than 17% of the institutes. 4) Intraarterial thrombolysis was carried out in 26% of the institutes, which made 2.7% of the all patients, by rough calculation. 5) The drug most frequently used for acute ischemic stroke in Japan was ozagrel sodium. 6) Only 3% of the institutes were equipped with stroke (care) unit (SCU). In 73% of the institutes, stroke patients were treated in general wards. 7) A mean hospital stay exceeded 28 days in 75% of the institutes (41 days in average). 8) An estimated mortality during admission was about 9%.

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We investigated seasonal and temporal variation in the incidence of cerebral infarction for 577 serial patients admitted between January 1993 and December 1997. Based on the clinical findings, the cerebral infarction was classified into lacunar infarction (n=333), atherothrombotic infarction (n=145), cardioembolic infarction (n=99). We interviewed the time and season of stroke onset, and classified the stroke onset time into 4 groups ; at midnight and early morning (0-6h), in the morning (6-12 h), in the daytime (12-18 h), at night (18-24 h). For cerebral infarction, summer and winter were the two peak seasons ; and in the daytime was the peak time. For lacunar infarction, summer and winter were peak seasons, and in the daytime was the peak time. There were no significant seasonal and temporal variations in atherothrombotic infarction. For cardioembolic infarction, winter was the peak season and in the daytime was the peak time. Then we studied relation with cerebral infarction and age, sex, hematocrit, hypertension. There were several relations with seasonal and temporal variations of the cerebral infarction, such as older patients (over 65 years), male, high hematocrit (over 45%), hypertensive patients.

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From January, 1997 to December 1999, the first-stroke-in-life of the approximately 14, 000 residents were evaluated in Oguni and Minamioguni towns in Kumamoto prefecture. The subjects were the patients treated at Oguni Municipal Hospital.
The annual incidence rate was 228 per 100, 000. The sex ratio was 50: 50. The group aged more than 65 had the higher rate of 758, and constituted 81% of the subjects. The rates of cerebral infarction (CI), intracerebral hemorrhage (ICH), and subarachnoid hemorrhage (SAH) were 140, 62, and 28, respectively. The percentages were 61%, 27% and 12%. The average age was 72 years old. The average ages of the men and women of CI were 71 and 77; of ICH, 64 and 73; and of SAH, 70 and 73. The average hospital stay was 27 days. The outcome was evaluated at the discharge. 64% of CI were good. 55% of SAH and 50% of ICH died. Altogether, 51% were good, 25% were dependent, and 24% were dead. The age group of 80's and older had poor prognosis.
The aging caused more incidence and poor prognosis of the stroke.

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The cerebrovascular disease (CVD) and coronary artery disease (CAD) are focused as the primary cause for sudden death in Japan. The common risk factor for CVD and CAD is concerned atherosclerosis. We investigated the back ground of both CVD and CAD. The research was conducted on 240 patients of CVD treated by hospitalization and on 274 patients of CAD treated by PTA, stenting, and CABG in our institute. As the risk factor of atherosclerosis, the "life style diseases" (hypertension (HT), diabetes mellitus (DM), hypercho-lesterolemia (HC) ) and the patient's habit (smoking and alcohol) were investigated. 1) The CVD group had the "life style disease" in 73%. HT was seen in 65% DM in 28%, and HC in 19%. The combination rate of CAD was 22%. Obesity was seen in 48%. Forty-two percent of the patients had smoking experience and 46% had drinking alcohol history. Family history of the CVD was seen in 20%.2) The CAD group had the "life style disease" in 76% of 274 patients. HT was seen in 50%, DM in 32%, and HC 23%. And 19% of the patients had also the CVD. Obesity was revealed in 58%. Forty-seven percent of the patients had smoking experience and 22% of them had drinking alcohol history. Family history of the CAD was seen in 14%. 3) The incidence of the "life style disease" on CVD and CAD group is significantly higher than that of the health check-up group in our institute (21%).
The incidence of the "life style disease" on the CVD and the CAD was significantly high. And approximately 20% of CVD and CAD were contained each other. Therefore, it is significantly important to check and treat the "life style disease" as the common risk factor of atherosclerosis for preventing the CVD and CAD.

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A long term follow-up study was coducted with lacunar infarct patients to assess whether or not demographics, conventional risk factors, MRI findings, to include lacunar infarcts and diffuse white matter lesions (DWML), and ambulatory blood pressure monitoring (ABPM) values can predict subsequent development of dementia, stroke recurrence, and/or death.
One hundred fifty patients were tracked (mean follow-up period : 9.2 years) and divided into 5 groups as follows : Group 0, 70 patients with no subsequent event: Group 1, 25 patients who subsequently developed dementia ; Group 2, 15 patients who suffered from a recurrent stroke attack ; Group 3, 18 patients who succumbed to vascular death ; Group 4, 15 patients who died non-vascular death. The risk of each group relative to Group 0 was evaluated for prognostic factors.
Logistic regression analysis demonstrated that age (OR: 1.08; 95% CI : 1.0-1.16), male sex (OR: 8.17; 95% CI : 1.97-33.7), confluent DWML (moderate, OR; 7.7, 95% CI ; 1.9-31.7, severe, OR: 112.8; 95% CI : 15.5-818.2), and non-dippers (OR: 8.57; 95% CI : 1.56-47.0) were independent predictors for dementia, while diabetes mellitus (OR :17.1; 95% CI : 2.95-99.3) and multiple lacunae (moderate, OR; 14, 95% CI ; 2.9-67.6, severe, OR : 44.6 ; 95% CI : 5.3-369.8) were independent prodictors for recurrent stroke. Finally, age (OR :1.09 ; 95% CI : 1.01-1.19), diabetes mellitus (OR: 6.9; 95% CI : 1.1-40.9) and multiple lacunae (moderate, OR; 5.6, 95% CI : 1.3-23.6, severe, OR: 44.6; 95% CI : 5.3-369.8) were independent predictors for vascular death.
Confluent DWML and non-dipper state were independent predictors for subsequent developement of de-mentia, while diabetes mellitus and multiple lacunae were independent predictors for stroke recurrence and cardiovascular death

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The present study was aimed to clarify if cerebrovascular reactivity to acetazolamide can be a reliable predictor for fuether ischemic stroke in medically treated patients with internal carotid artery (ICA) or middle cerebral artery (MCA) occlusion. Ninety-one patients met inclusion criteria of cerebral angiography, no or localized cerebral infarction on MRI or CT, and no or minimal neurological deficit. Regional cerebral blood flow and reactivity to acetazolamide were determined by single photon emission computed tomography (SPECT). All patients were medically treated. Follow-up study during mean 42.9 months revealed that annual risks of ipsilateral and total stroke were significantly higher in the patients with reduced blood flow and reactivity risk than others (Kaplan-Meier method and Mantel-Cox log-rank statistics). Annual risk of ipsilateral stroke was 21.8% in these patients, whereas it ranged from 0.5 to 2.4% in others. Annual risk of total stroke was 32.7% in these patients, whereas it ranged from 2.4 to 4.8% in others. The present results strongly suggest that reduced blood flow and reactivity to acetazolamide is predictive for subsequent ischemic stroke in patients with ICA or MCA occlusion.

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