Background and Purpose: To promote improvement of the quality of stroke care, the stroke team at Sunagawa City Medical Center (SCMC) provides various services. Methods: The stroke team consists of neurosurgeons, a neurologist, experienced nurses, physiotherapists, a speech therapist and case workers. The team organizes educational seminars at primary care facilities without neurological specialists. To increase the number of attendees, the team visits hospitals and educates whole institutes. To standardize the care, the stroke team has developed a common critical path for the treatment of acute and subacute stroke that can be easily and safely utilized at every institute and allows collaboration among hospitals. Our field of activity ranges within 30 km from SCMC. The subjects of our activities comprise all staff members working at each hospital located in this field from which possible candidates for rt-PA treatment will be referred to the stroke unit at SCMC. Our educational program follows Japanese guidelines for the management of stroke (2004). In this program, we educate on how to use anti-platelet and anti-coagulation drugs, the care of dementia, and clinical indicators that contribute to a better outcome and decreased mortality at the stroke unit, including the prevention and care of disturbed swallowing, the importance of early planning and initiation of rehabilitation programs. Results: The common critical path was found to contribute to the early transfer of acute stroke patients to the non-specialized institutes and the prevention of recurrence. Conclusion: On site educational seminars by the stroke team facilitated collaboration among regional institutes and improved the quality of stroke care.

View full abstract

To clarify the relationship between clinical manifestations and MRI findings in the early diagnosis of medullary infarction (MI), the present study was undertaken on 114 consecutive patients with MI who were admitted at the acute stage between 1991 and 2006. The MRI findings were classified into medial (MMI, n=53) and lateral (LMI, n=59) groups. According to the horizontal localization, LMI was then subclassified into 5 categories: dorsal (DS), postero-ventral (PV), antero-ventral (AV), extensive ventral (EV), and antero-lateral (AL) lesions, and MMI was subdivided into large and small lesions. The mean age was significantly older in MMI than in LMI (68.3 vs. 63.1 years, P<0.05). Alternative hemihypesthesia was observed more frequently in the MMI group. The patterns of sensory disturbance differed within the LMI group: a combination of ipsilateral face and contralateral body was most frequent in PV lesions (55.6%), whereas isolated ipsilateral face disturbance was mainly noted in DS lesions (41.2%). The lesions were predominantly located in the rostral portion in MMI (66.0%) and in the middle portion in LMI (66.1%). Sensory disturbance (54.1%), Horner's sign (58.1%) and hiccups (66.7%) were more frequently observed in patients with middle lesions. The responsible lesions were not visualized on the diffusion-weighted image (DWI) in 18 patients within 48 hours of onset, and these false negative findings were predominantly located in the rostral portion (83.3%, P<0.01). Since a combination of facial palsy and hiccups in addition to hemihypesthesia may imply MI, MRI should be performed repeatedly at the acute stage, even though the initial DWI is negative for MI.

View full abstract

Pure dysarthria from brain infarction is a rare condition, and its pathophysiology remains unclear. To clarify the underlying mechanism of pure dysarthria, we investigated the lesion sites and regional cerebral blood flow in patients with pure dysarthria. We examined 18 consecutive patients with pure dysarthria (9 men and 9 women; mean age, 71 years) who underwent MRI and cerebral blood flow studies. To visualize the regional cerebral blood flow, we generated Z score images using the three-dimensional stereotactic surface projection (3D-SSP) method with single-photon emission computed tomography (SPECT) and N-isopropyl-p[¹²³I]iodoamphetamine. Data on the brain surface perfusion extracted by the 3D-SSP analysis were compared between the PD patients and 9 control subjects. MRI revealed multiple lacunar infarctions involving the internal capsule and/or corona radiata in 11 patients, left internal capsule-corona radiata infarction in 4 patients, and pontine infarction in 3 patients. SPECT with 3D-SSP demonstrated bilateral frontal cortical hypoperfusion in all patients, particularly in the anterior opercular region. Based on intergroup comparisons, the PD group exhibited pronounced cortical hypoperfusion in the opercular and medial frontal regions, left more than right. In conclusion, pure dysarthria is considered to originate from frontal cortical hypoperfusion, mainly in the anterior opercular and medial frontal regions, which is probably due to interruption of the corticosubcortical neural networks relevant to speech expression and articulation. In addition, it is suggested that left hemispheric lesions may make a greater contribution to the development of pure dysarthria than do right ones.

View full abstract

Background and Purpose: Several recent studies have demonstrated that the presence of severe white matter lesions (WML) is a risk factor for stroke. We examined the characteristics of acute infarct in patients with severe WML. Methods: We retrospectively analyzed 22 infarct patients with severe WML. They were admitted to our hospital due to non-cardioembolic stroke in the anterior circulation. Diffusion-weighted MRI (DWI) was used to detect the presence of any acute infarcts. Results: Twenty of the patients (90.9%) showed lacunar syndrome at onset. DWI revealed multiple small infarcts, so suggesting an infarct mechanism of artery-to-artery embolism, in 12 patients, branch atheromatous disease in 6 patients, lacunar infarction in 2 patients, and other types of atherothrombotic infarction in 2 patients. Patients with severe WML had a higher incidence of multiple small infarcts, as compared to the patients without severe WML (54.5% vs. 24.7%; P<0.05). Conclusion: In patients with severe WML, the occurrence of acute infarct is considered to be closely associated with large-artery atherosclerosis, even though such patients may demonstrate lacunar syndrome.

View full abstract

Case 1: A 63-year-old male patient suffered sudden right hemiplegia and total aphasia. A computed tomography (CT) scan did not reveal any early CT signs of cerebral infarction. An angiogram showed left cervical internal carotid artery occlusion by giant thromboemboli. A catheter was introduced through the cervical emboli, and thrombolysis was performed which resulted in a remarkable improvement of the symptoms. Severe right hemiparesis appeared two days later because partially recanalized cervical thrombi occluded the distal cerebral artery. Case 2: A 79-year-old male patient suffered sudden right hemiparesis and aphasia. An angiogram showed giant thrombi in the left cervical carotid artery, and collateral flow filled the left middle cerebral artery. Since retrograde collateral flow filled the petrous portion of the left internal cerebral artery, thrombectomy was urgently performed. The neurological deficits improved remarkably after the operation. Acute embolic stroke by giant thromboemboli occluding the cervical internal carotid artery is a rare incident. Intravenous tissue plasminogen activator injection is considered to be a standard treatment for acute ischemic conditions. However, in some cases, the neurological symptoms may be aggravated because of distal embolic showers following recanalization of the primary lesion. We propose a flowchart of a strategy for this clinical category.

View full abstract

A 42-year-old man exhibiting left-sided hemiparesis and drowsiness was transferred to our hospital. A computed tomography (CT) scan of the head showed no ischemic parenchymal changes. A thorough examination revealed that he had suffered a coronary spastic myocardial infarction about 10 days before admission. Cerebral angiography confirmed right internal carotid artery (ICA) occlusion. Intraarterial (IA) suction thrombectomy followed by local IA fibrinolysis was performed. Subsequently, there was successful recanalization of the cerebral arteries and a favorable recovery. The incidence of coronary spasm is relatively high among Japanese as compared to Caucasians. The mean age is lower in patients with coronary spasm than in those with organic angina. Coronary spastic myocardial infarction is one of the potential risk factors of ischemic stroke among young adults.

View full abstract

Although it is very important to establish an overall, objective evaluation system for assessing the quality of community-based stroke care, there has never been such a system in Japan. To overcome this problem, a research group for “the choice of indicators and the development of audit's system on the community-based stroke care” was organized with the support of a Grant-in-Aid from the Ministry of Health, Labor, and Welfare of Japan. In the United States (US) and Europe, an appropriate evaluation system using clinical indicators has been devised. In the US, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) conducts a certification of primary stroke centers (PSC) based on recommendations made by the Brain Attack Coalition (BAC). The JCAHO at Oak Brook, Illinois, is an independent, not-for-profit healthcare accrediting organization. We had an opportunity to visit the JCAHO and a primary stroke center of Northwestern Memorial Hospital, Chicago, in December 2006. Northwestern Memorial Hospital is a representative primary stroke center chaired by Professor Mark J. Alberts, a chairman of the BAC. We obtained useful information on evaluation systems for assessing the quality of acute stroke care during this visit. However, the system devised by the JCAHO does not evaluate the quality of the overall community-based stroke care. We should seek to establish a certification and audit system that is unique to our country while referring to that in the US and Europe.

View full abstract