“Purpose” To evaluate the prognostic value of admission blood pressure in patients with acute ischemic stroke by determining whether or not it contributes to clinical outcome. “Methods” We studied 300 consecutive patients admitted within the first 48 hours after the onset of ischemic strokes, employing systolic and diastolic blood pressure measurements recorded within 36 hours after admission. High blood pressure was defined when the mean of at least 2 blood pressure measurements was ≥200mmHg systolic and/or ≥110mmHg diastolic at 6 to 24 hours after admission or ≥180mmHg systolic and/or ≥105mmHg diastolic at 24 to 36 hours after admission. “Results” The high blood pressure group was found to include 18% of the patients. Age, sex, diabetes mellitus, hyperlipidemia, atrial fibrillation, ischemic heart disease, stroke anamnesis, leukoaraiosis, and mortality were not significantly correlated with either the high blood pressure or non-high blood pressure group. High blood pressure on admission was significantly associated with a past history of hypertension, kidney diseases, carotid artery stenosis, and the modified Rankin Scale. On logistic regression analysis, with no previous history of hypertension, diabetes mellitus was an independent risk factor associated with the presence of high blood pressure (odds ratio, 2.29; 95% confidence interval, 1.13-4.64; p=0.02). “Conclusion” Patients with high blood pressure had a poor functional outcome after acute ischemic stroke.

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The modified Rankin Scale (mRS) is commonly employed in the world as a measure of global outcome after stroke. The purpose of the present study was to investigate the reliability of the mRS for the first time in the current clinical setting in Japan. We developed a guidance scheme for the mRS and a questionnaire corresponding to it. Nine neurologists interviewed 46 patients with cerebral infarction on the basis of the questionnaire. This interview was recorded on videotape. In order to examine the reliability of the rating scale, 20 raters (10 neurologists, 6 nurses and 4 physiotherapists) watched the videotapes and assessed the mRS twice at an interval of approximately 8 weeks. The agreement between the raters, as evaluated from the intraclass correlation coefficient, was found to be satisfactory with values of 0.947 for neurologists and 0.963 for health care professionals. The reproducibility at an interval of ca. 8 weeks was also satisfactory with values of 0.865 and 0.871, respectively. The above results suggest that our guidance scheme and questionnaire are useful for ensuring the quality of assessments of the mRS, and are applicable to clinical studies made in the current clinical setting in Japan. Our findings have already been published in the English language (Cerebrovasc Dis 21: 271, 2006). However, in order to disseminate assessment by the mRS using our guidance scheme and questionnaire in the clinical setting in Japan, the Japanese versions of these tools are also required. This is why we now publish this study in Japanese.

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The purpose of this study was to evaluate the long-term angiographic and clinical efficacy of stent assisted intracranial angioplasty (SAIA) for the treatment of symptomatic atherosclerotic occlusive disease. Since November 2000, 15 elective cases (13 men and 2 women; mean age, 70.4 years) have been followed up for at least 12 months after SAIA (mean follow-up, 27.2 months; range, 12-64 months). In all cases, medical therapy had failed and all lesions showed >70% luminal, long and tortuous stenosis or total occlusion (Mori type B 11 and type C 4) which was unsuitable for treatment by balloon angioplasty alone. The lesions were located at the intracranial ICA in 6, M1 in 1, intracranial VA in 5 and BA in 3 patients. The average stenosis rate was reduced from 81.7% to 17.0%. No periprocedural complications occurred in any of the cases. The periprocedural neurological morbidity and mortality was 0%. Angiographic follow-up was available in all cases, and significant restenosis was observed in 2 cases (13.3%) during the follow-up period. One case of restenosis was detected at 3 months after SAIA and was treated by percutaneous transluminal balloon angioplasty. The other was detected after 12 months. There was no recurrent clinical ischemia following successful SAIA, including the 2 cases which exhibited restenosis. With safe procedures and strict indications, SAIA is considered effective for long-term stroke prevention.

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Medico-economic evaluation for cerebrovascular disease therapies has not been fully explored in Japan. In this study, the cost-effectiveness of a treatment using fasudil, a Rho-kinase inhibitor, for ischemic stroke was assessed. The estimated efficacy range was taken from a prospective placebo-controlled double-blind trial of fasudil in patients with acute ischemic stroke. The costs of acute stroke care, rehabilitation and quality adjusted life years (QALYs) were analyzed based on 70-year-old male employing the distribution of the modified Rankin Scale at 1 month after stroke onset. The cost of acute care was calculated on the basis of the Diagnosis Procedure Combination payment system in Japan. The costs of long-term care and QALYs were estimated using the Markov model. The treatment with fasudil resulted in cost-savings of 60,000 yen per month in acute stroke care and 1,410,000 yen in long-term care. The QALYs increased by 0.79. Sensitivity analysis proved that none of the costs or QALYs resided in the negative range. In conclusion, fasudil is considered to be a cost effective option for treating ischemic stroke as shown by a medico-economic evaluation. This also demonstrates the importance of medico-economic evaluation as a valuable method for use in accessing cerebrovascular disease therapies.

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(Background and Purpose) In cervical carotid disease, the risk of stroke from lesions causing low-grade stenosis is poorly understood and the benefit of endarterectomy (CEA) for low-grade stenosis remains unclear. However, some cases can have a thick plaque volume. The purpose of this study was to determine whether evaluation of plaque volume by high-resolution MRI prior to CEA could be of benefit or not. (Methods) We studied 22 consecutive patients (22 vessels) who underwent CEA between April 2003 and October 2005. Plaque volume was calculated quantitatively by proton density weighted imaging (PDWI), and the findings were related to the clinical data. (Results) The mean plaque volume on asymptomatic lesions (1,154.0±666.2mm³) was significantly elevated as compared to that on symptomatic lesions (983.9±349.4mm³) (p=0.02). In the asymptomatic lesions, numerous intraplaque hemorrhages were observed. (Conclusions) We suggest that neovascularization and intraplaque hemorrhage may play a role in the progression of atherosclerotic carotid plaques. For the management of cervical carotid disease, we should not take the degree of luminal narrowing but rather the plaque component and volume into consideration.

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(Purpose) Although it is strongly recommended in treatment guidelines for acute stroke that the initial therapy be conducted in the Stroke Unit, well-defined criteria have not yet been established in Japan for the management systems of the Stroke Unit. A study was therefore made on the management of the Stroke Unit from the standpoint of rehabilitation. (Methods) Among the cases of complete stroke excluding subarachnoid hemorrhage admitted to our hospitals within 3 days after onset during a period of one year from December 2004, a study was made of 3,765 cases with independent ADL (mRS 0-2) prior to admission by comparing 2,655 cases with rehabilitation commencing within 7 days (the rehabilitation group) and 1,100 cases without rehabilitation (the non-rehabilitation group). (Results) The two groups did not show any differences with regard to age, gender, underlying disease, disease type, and examination-therapy following admission. The number of days of rehabilitation during hospitalization was 13.7 days in the rehabilitation group and 3.0 days in the non-rebabilitation group; and for the rehabilitation group, swallowing evaluations, clinical path analysis, and joint multidisciplinary conferences were conducted at a high rate. As regards outcome, no difference was observed in the discharge rate to the patient's home, the rate being 51.9% in the rehabilitation group and 58.4% in the non-rehabilitation group. However, a remarkable difference in mortality rate was obeserved, the rate being 2.6% for the rehabilitation group and 16.6% for the non-rehabilitation group. (Conclusion) In the management of the Stroke Unit, multidisciplinary team therapy including rehabilitation is essential.

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A 79-year-old woman experienced cardioembolic cerebral infarction in the left cerebral hemisphere. She was treated with the free-radical scavenging agent, Edaravone, without anticoagulant agent because of hemorrhagic changes in the area of infarction. On the 6th day after admission, the serum lactate dehydrogenase (LDH), transaminases and C-reactive protein were markedly elevated. Although the patient she did not complain of low back pain, cast formation of urinary sediment and elevation of LDH isozyme 1 and 2, each suspicious for renal infarction, were detected. Contrast-enhanced abdominal computed tomography and renal scintigraphy demonstrated renal infarction on the left side. Edaravone has been inferred to be a causal agent of acute renal failure. However, some case reports have shown renal infarction to be a cause of acute renal failure during Edaravone treatment. Renal infarction was found not to be unusual among cases with atrial fibrillation and cerebral embolism. It is necessary therefore that cases with an obvious nephrotoxic factor other than Edaravone, such as renal infarction, during Edaravone treatment should be eliminated in order to assess closely the mechanism of acute renal failure caused by Edaravone.

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A 55-year-old woman visited our hospital within one hour of sudden onset of severe pulsatile pain in the front of the head accompanied by limb dominant left hemiplegia. She had previously suffered migraines but had no history of hypertension or cardiac disease. Since brain CT revealed no cerebral hemorrhage, a diagnosis of cerebral infarction was made, and administration of tissue plasminogen activator (tPA) was considered. However, because cerebral arterial dissection could not be excluded, conservative treatment was selected and produced improvement. Consequently, cerebral infarction was detected in the region of the right anterior cerebral artery by brain MRI with no other intracranial vessel abnormalities. After 15 days, stenosis and sacciform dilation on the A2 segment of the right anterior cerebral artery were found and a diagnosis of cerebral infarction caused by cerebral artery dissection was made. Images of cerebral artery dissection are frequently demonstrated by examinations undertaken within 3 months, especially within 2 weeks, and hence complication by subarachnoid hemorrhage due to cerebral artery aneurysm formation occasionally leads to critical results. Thus, in patients with cerebral artery dissection, the time course of imaging examinations is important and the application of t-PA must be carefully considered.

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A 43-year-old woman was admitted to our hospital at 12 hours after onset because of left hemiparesis. On admission, she was alert, but displayed severe left hemiparesis. CT revealed a small low density area in the right internal capsule. Administration of sodium ozagrel and edaravone was initiated. After admission, her hemiparesis gradually became aggravated. CT at 2 days after onset showed a small infarction in the region of the frontal lobe. Right carotid angiography demonstrated string-like narrowing of C1-C2, so that anticoagulation therapy was started. On the 11^th day, the patient became confused. On the 12^th day, CT showed infarction in the region of the middle cerebral artery. A 3D CT angiogram revealed that the distal portion of the internal carotid artery (ICA) was occluded. On the 24^th day, she became drowsy, and CT showed massive cerebral infarction in the right hemisphere. External decompression was therefore performed, and her consciousness improved after the operation.
Repeat angiography after 3 months showed recanalization of the right ICA.
Intracranial ICA dissection is rare. We therefore present our case together with a literature review of 13 cases.

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The significance of the stroke unit (SU) in Japan, where the medical system differs from those in Europe and the USA, remains unclear. We conducted a prospective multicenter study to clarify this issue. The study subjects consisted of 7614 consecutive patients with completed stroke, excluding subarachnoid hemorrhage, who were admitted to 117 hospitals in Japan within 72 hours of stroke onset from December 2004 to December 2005. We divided the hospitals into those with and those without an SU, and investigated whether or not the treatment in the SU could improve the patients' clinical outcome. In our preliminary analysis using data for the initial 4268 patients, logistic regression analysis demonstrated that the only significant and independent predictor of case fatality at 28 days and 3 months after onset was the NIHSS score on admission. Treatment in the SU, however, was significantly associated with a favorable outcome (mRS, 0-2) at 3 months after stroke onset as well as age, male gender, the pre-stroke mRS score, and the NIHSS score on admission. Assessments of swallowing functions and the application of an early rehabilitation program within the initial week were more frequently given in acute stroke patients at hospitals with an SU than at those without an SU. The present results indicate that the treatment in an SU may also improve the clinical outcome of patients at 3 months after stroke onset in Japan.

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