We studied the 3-month outcome in acute ischemic stroke patients without thrombolysis. In total, 312 ischemic stroke patients (mean age, 73.5 years) who were admitted within 3 hours and received conventional therapies were registered on the stroke database of the Japanese standard stroke registry study (JSSRS). We followed up their outcomes based on the modified Rankin scale (mRS) at 3 months after the onset. A good recovery (mRS 0-1) accounted for only 21% of all patients ; there were 24% in the mRS 2-3 group, 44% in the mRS 4-5 group and 11% in the mRS 6 group. According to the severity at admission as evaluated by the NIHSS, the NIHSS 5-9 group showed 40% of good recovery at 3 months, but the rate was significantly decreased to 13.6% in the NIHSS 10-14 group, 3.3% in the NIHSS 15-20 group and 3.6% in the NIHSS 20 or more group. In conclusion, ischemic stroke patients of moderate severity admitted within 3 hours and treated by conventional therapy exhibited a good recovery in only one fifth of all cases.

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Purpose and background
Stroke in young adults differs from that in older persons. However, the detailed characteristics of stroke in young adults remain unknown in Japan. We therefore performed a multicenter survey to establish a stroke data bank for young adults in Japan.
Methods
We collected clinical data for 7, 245 acute stroke patients admitted to 18 hospitals in Japan. Among them, 5, 661 were 51 years old or more (the non-young group) from 1998 to 1999 and 1, 584 were 50 years old or less (the young group) from 1995 to 1999.
Results
Among the patients admitted within the first 7 days of stroke from 1998 to 1999, those aged=<50, = <45, and=<40 accounted for 8.9%, 4.2%, and 2.2%, respectively.
Hypertension (62.7% vs. 48.5%, p<0.01), diabetes mellitus (21.7% vs. 13.6%, p<0.01), hypercholesterolemia (16.5% vs. 13.1%, p<0.01), and non-valvular atrial fibrillation (21.2% vs. 4.7%, p<0.01) were significantly more frequent in the non-young group than in the young group. On the other hand, a smoking habit (19.3% vs. 27.3%, p<0.01) and patent foramen ovale (0.7% vs. 1.2%, p=0.07) were more frequent in the young group than in the non-young group.
Brain infarction was the most predominant stroke subtype in the non-young group, but not in the young group (62.6% vs. 36.7%, p<0.01). Brain hemorrhage (20.8% vs. 32.1%, p<0.01) and subarachnoid hemorrhage (7.3% vs. 26.1%, p<0.01) were more frequent in the young group. Transient ischemic stroke was comparable in frequency between the two groups (5.7% vs. 5.0%).
The causes of brain infarction and hemorrhage were often atypical in the young group (2.8% vs. 25.1%, p<0.001, and 4.6% vs. 20.2%, p<0.0001, respectively). Among patients with brain infarction, they were often atypical:cerebral arterial dissection in 41 patients, Moyamoya disease in 33, antiphospholipid syndrome in 14, fibromuscular dysplasia in 3, sinus thrombosis in 3, polyhemia in 3, and dolicoectasia in 3. The sites of brain infarction were more predominantly in the vertebrobasilar than in the carotid territory (24.9% vs. 32.2%, p<0.001). Among patients with parenchymal hemorrhage without hypertension, arteriovenous malformation was demonstrated in 83 and Moyamoya disease in 13. Among patients with subarachnoid hemorrhage without saccular aneurysm, arterial dissection was noted in 16 and arterial venous malformation in 11.
Conclusion
Since the causes and underlying risk factors of stroke in young adults tend to be quite different from those in older patients, we need to establish a detailed data bank and to explore the optimal measures for the diagnosis and management of young stroke patients.

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We examined the effects of thrombolytic therapy in acute ischemic stroke patients registered on the Japanese Standard Stroke Registry database. The subjects consisted of 437 patients (mean age, 74 years) who were admitted within 3 hours from the onset and whose NIH stroke scale (NIHSS) was 6-29 at admission. Among these subjects, 88 patients were treated by intravenous or intra-arterial thrombolytic therapy. We performed a case control study using sex, age and NIHSS at admission, and undertook multivariate logistic analysis using the same items for functional outcome and dementia at discharge. The thrombolytic therapy group showed a significantly less functional severity (OR 0.554, 95%CI 0.314-0.976 against mRS 2-6) and less dementia (OR 0.369, 95%CI 0.169-0.864) than the non-thrombolytic therapy group on multivariate logistic analysis. The case control study revealed a significantly lower incidence of dementia in the thrombolytic group than in those without therapy. In the thrombolytic group, those patients who were admitted within 3 hours from the onset (86 patients;mean age, 69.6 years) demonstrated a significantly better outcome than those admitted at more than 3 hours (28 patients;mean age, 66.8 years). Although the present study was retrospective, the results obtained suggest that thrombolytic therapy may be effective in Japanese ultra-acute ischemic stroke patients.

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A total of 296 patients with TIA or cerebral infarction were followed up for an average of 780.8 days. Forty-two patients suffered from cerebral infarction, and 6 patients had cerebral hemorrhage during the follow-up period. The cumulative recurrence rate was 8.5% by 1 year, 14.1% by 2 years, 20.0% by 3 years, and 26.1% by 4 years. Hypertension, a history of cerebrovascular disaese, a diastolic blood pressure of<75 mmHg or>86 mmHg, HbAlc>6.2%, anticoagulant intake, and a lack of antiplatelets were associated with an increased risk of cerebrovascular recurrence. Most recurrent strokes were of the same subtype of index cerebral infarction. Of the 6 patients with cerebral hemorrhage, 5 had lacunar infarction as an index cerebral in-farction, 6 had hypertension, 2 had a history of cerebral hemorrhage before admission, and 5 took an antithrombotic agent during the follow-up period (2 took an antiplatelet agent, and 3 took an anticoagulant agent).

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The gradient-echo T₂^*-weighted sequence in magnetic resonance imaging is known to be useful for detecting microbleeds (MBs) in patients with intracranial hemorrhage or lacunar stroke. We investigated the characteristics of apparently healthy adults with MBs but without stroke, employing echo-planar gradient-echo T₂^*-weighted MRI. The subjects were recruited from among 3, 537 participants who underwent brain check-ups at the HIMEDIC Imaging Center. Of the 3, 537 participants, 3, 296 (mean age, 55±11 years) without any history of cerebrovascular disease or apparent focal neurological manifestations were selected for the present study. MBs on echo-planar gradient-echo T₂-weighted MRI were observed in 74 (2.2%) of the 3, 296 subjects. Of a total of 133 lesions found in these 74 persons, 31 were located in the basal ganglia or corticosubcortical regions. Thirty were in the deep white matter, 19 in the thalamus, 16 in the cerebellum, and 6 in the brain stem. The subjects with MBs were significantly older than the subjects without MBs, and the mean values for their systolic and diastolic blood pressures were higher than those in the subjects without MBs. Asymptomatic cerebral infarction, periventricular hyperintensity, and deep and subcortical white matter hpyerintensity on T₁-and T₂-weighted MRI were more frequent in the subjects with MBs, as compared with those without MBs. Asymptomatic cerebral infarction, periventricular hyperintensity, and deep and subcortical white matter hpyerintensity on T₁-and T₂-weighted MRI were more frequent in the subjects with MBs of the basal ganglia or thalamus than in those with MBs in other regions. MBs on echo-planar gradient-echo T₂^*-weighted MRI were thus relatively rare in apparently healthy adults. However, MBs in the basal ganglia or thalamus are suggested to be closely related to intracerebral microangiopathy. Persons with MBs in such regions should therefore be carefully checked for cerebrovascular risk factors, especially hypertension.

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Quantitative analysis of platelet aggregation is difficult, and the conditions of platelet aggregation in patients with acute cerebral infarction have not previously been examined in sufficient detail. We quantitated the spontaneous platelet aggregation (SPA) in patients with acute cerebral infarction using laser-scattered light aggregometry. The subjects comprised 98 patients with acute cerebral infarction. The subtype diagnoses included atherothrombotic infarction (ATI ; n = 45), lacunar infarction (LI ; n = 21) and cardioembolic in. farction (CE; n=32).The SPA was evaluated on days 1, 3, 7, 14 and 28 after the onset of cerebral infarction.The serum lipid, plasma glucose and diastolic blood pressure levels were relevant to the SPA after the onset of cerebral infarction. The maximum SPA was significantly increased in the patients with ATI and CE as compared to those with LI. No significant changes in SPA were recognized during the acute stage of cerebral infarction in cases of ATI or LI. The SPA on day 3 was significantly increased as compared to that on day 14 in CE. These findings suggest that activation of SPA differs among patients with different subtypes of cerebral infarction, and the SPA represents a useful marker of platelet activation.

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A 49-year-old woman experienced brainstem infarction at one week after presenting with symptoms of herpes zoster in the distribution of the thoracic root (Th 5). She was treated with acyclovir by a family physician, but her condition deteriorated along with development of headache and nausea. On the 7th day of the herpes zoster, her condition became further aggravated through loss of sensation in her left cheek and acquirement of Horner's sign and lateral medullary syndrome. Based on the results of brain angiography and head MRI, we judged this case to be brainstem infarction following herpes zoster. Generally, strokes associated with herpes zoster are caused in the territory of the anterior circulation, rather than of the posterior circulation. This case is thus rare, since the region affected by herpes zoster was located away from the lesion of the brainstem.

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Diabetes-associated striatal hemorrhage-like lesions represent a currently emerging entity, which develops an acute onset of involuntary movement. We report the case of a diabetes-associated hemorrhagic lesion in the striatum causing a stroke-like onset of hemiparesis. A 75-year-old woman suffering from diabetes experienced a stroke-like onset of left hemiparesis. Brain CT on admission demonstrated a slight high-density area in the right striatum, which disappeared 19 days later without a low-density area in situ. MRI on admission revealed high intensity on the T1-weighted image and slight low intensity on the T2-weighted image in the right striatum. The patient's hemiparesis underwent gradual improvement over a period of 2 weeks. These CT and MRI findings are unusual as a result of hypertensive intracerebral hemorrhage. The hemorrhage was considered to represent a lesion associated with diabetes. This is the first report of a diabetes-associated striatal hemorrhage-like lesion developing stroke-like onset of hemiparesis.

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A 41-year-old man was admitted to our hospital because of fever and general fatigue. Before admission, he had been under treatment for multiple hepatocellular carcinoma for 1 year and for liver cirthosis (type C) for 6 years. On the 4th day after admission, he presented with disturbance of consciousness. No history of head injury was discovered. Head computed tomography demonstrated a crescent-shaped high density area on the left side. Under a diagnosis of acute subdural hematoma of the left side, emergency removal through a small burr hole was performed. Postoperatively, on the 7th day after admission, the patient suddenly became unconscious and CT scans showed recurrence of the subdural hematoma. Temporo-parietal craniotomy was immediately carried out. The exploration performed after removal of the hematoma revealed a mass extruding into the subdural space froni the dura. Both the dura and the abnormal tissue were biopsied for hiistological examination. The pathological diagnosis of the specimens was metastasis of hepatocellular carcinoma. Although the patient became alert postoperatively, his general condition deteriorated slowly. After 31 days of hospitalization, he died of liver failure and renal failure. At autopsy, metastatic hepatocellular carcinoma was identified at the dura, the spinal cord, lymph nodes of the liver hilus and the lung. Nontraumatic subdural hematoma secondary to dural metastasis is rare, but should be considered in the differential diagnosis of patients with internal malignancies.

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A questionnaire was sent to 80 Japanese medical schools to investigate the status of undergraduate education for cerebral stroke. Data from 70 medical schools showed that approximately 10 hours of lecture were assigned for clinical stroke, and 60% of the lecture were given by the neurosurgical department. The chance to see acute stroke patients in the university hospital was provided in 45% of all medical schools, and in 25% the chance to see at outside hospitals was provided.
The following substantial amendments were indicated necessary, 1) to increase lecture hours for stroke, 2) to systematize stroke education by cooperation of different specialties, 3) to provide a chance to see acute stroke patients in all university hospitals, and 4) to raise doctors who devote themselves to stroke care.

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