A helicopter emergency medical service (HEMS) system was initiated in Chiba Prefecture and the southern area of Ibaraki Prefecture from October 2001. Helicopter transport for patients with acute stroke appears beneficial, although the data are limited. We retrospectively investigated the use of helicopter transport from October 27, 2001 to December 31, 2004. The time from emergency call to arrival at our hospital via helicopter transport was 28.4±6.8 min (15-57 min) for the emergency transport of 338 patients who were admitted to the Neurological Institute, Nippon Medical School Chiba Hokusoh Hospital. There were 77 patients (34.8%) with intracerebral hemorrhage, 53 (24.0%) with subarachnoidal hemorrhage, 46 (20.8%) with cardiogenic embolism, 30 (13.6%) with atherothrombotic infarction, 7 (3.2%) with lacunar infarction, 6 (2.7%) with other types of cerebral infarction and 2 (0.9%) with transient ischemic attack. Thrombolysis was performed in 3 patients with severe cerebral infarction, although reperfusion was not observed. The HEMS system appears to be effective for the acute treatment of stroke without regional differences. Helicopter transport for patients with milder cerebral infarction may be needed for effective thrombolysis.

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Border-zone infarcts usually represent cerebral hypoperfusion caused by either hemodynamic or microembolic mechanisms. Although cortical and internal border-zone infarcts have been well recognized, border-zone infarcts formed between small insular cortical penetrating branches of the middle cerebral artery (MCA) and the lenticulostriate arteries have not been described in Japan. Such border-zone infarcts have been reported as deep cerebral infarcts extending to the subinsular region (DCIs) by Wong et al. We now describe 2 patients with DCIs. Patient 1: a 75-year-old man. He was found lying on the floor in a state of unconsciousness. After being transferred to our hospital, his consciousness recovered. He was recognized as having right hemiparesis, dysarthria, and hypophonia. MRI revealed DCIs and MRA showed a left MCA occlusion. Angiography demonstrated that the MCA trunk had been partially recanalized. Patient 2: a101-year-old woman. She noticed left hemiparesis as she was talking with her family. When she was transferred to our hospital, she was found to be somnolent and to have right hemiparesis and dysarthria. MRI revealed DCIs and MRA showed a right MCA occlusion. She then became worse and finally died. Although we could not detect the potential source of embolism, embolic occlusion and recanalization of the MCA trunk were the presumed stroke mechanism. Wong et al. observed 3 patients with DCIs out of 8 caused by cardioembolism. DCIs have been considered to represent a subtype of internal border-zone infarction. Identifying DCIs as border-zone infarcts helps us to understand the pathophysiology of ischemic stroke more precisely.

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Only a few reports have discussed the detailed clinical symptoms and pathogenesis of bilateral thalamic infarction. The thalamus is composed of different functional nuclei and supplied by vessels containing several variations from the main arteries, leading to difficulty in the precise evaluation of bilateral thalamic infarction. In the present study, we assessed the prognosis of bilateral thalamic infarction based on the distribution of stroke lesions. From among the consecutive ischemic stroke patients admitted to hospital between April 2001 and March 2005, cases of acute bilateral thalamic infarction were selected for this study (n=9; 65.1±13.6 y.o.). The stroke lesions and vascular abnormalities were investigated by magnetic resonance imaging and magnetic resonance angiography on admission. Outcome was evaluated from the modified Rankin scale (mRS) at discharge. Good outcome patients (mRS 0-2; n=5) showed memory disturbance, cognitive impairment and hypersomnia. On the other hand, quadriplegia, oculomotor disturbance and bulbar palsy were observed in the poor outcome patients (mRS ≥4; n=4). The critical features of a poor outcome were the age at onset (72.0±15.3 vs. 58.2±11.9 y.o.), inclusion of brainstem lesions and total occlusion of the basilar artery. In conclusion, older age at onset and/or basilar artery occlusion may be critical factors for predicting a poor outcome in bilateral thalamic infarction cases.

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Background and Purpose: Concise and non-invasive methods to detect the risk of cerebrovascular disease in high risk patients are considered useful. The purpose of this pilot study was to evaluate the contribution to ischemic cerebrovascular risk of the Revised Atherosclerotic Index (RAI) which is calculated from the Atherogenic Index (AI), patient's age and number of risk factors of atherosclerotic disease. Methods: I studied retrospectively the serum lipid levels, carotid stenosis measured by ultrasonography and cerebral infarction diagnosed from the symptoms and CT in 56 hypercholesterolemic outpatients. I assessed the relation between the RAI and carotid stenoic findings, history of cerebral infarction, and type of cerebral infarction. I also assessed the relation between the RAI and changes in LDL-cholesterol level before and after atorvastatin administration. Results: The RAI was significantly increased in patients with carotid lesions and cerebral infarction, but the AI was not. While the odds ratio of the AI for carotid lesions was high but not significantly so, that of the RAI increased with statistical significance. The odds ratio for cerebral infarction was high for the RAI but not for the AI. Furthermore, the RAI was significantly high in patients with aortic thrombotic cerebral infarction as compared to that in patients without any infarction. The serum lipids were well controlled under administration of atorvastatin and the mean RAI was also significantly decreased; however, more comprehensive control of risk factors might be necessary. Conclusion: The AI adjusted for patient's age and number of risk factors might be useful for assessing the risk of carotid lesion atherosclerosis and aortic thrombotic cerebral infarction.

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Background and Purpose: In our institution, we attempt to recanalize the occluded vessels of acute ischemic stroke patients using intravenous rt-PA (IVtPA) firstly. However, for patients with an absolute contraindication to IVtPA or those with neurological severity, we perform emergency neuroendovascular revascularization (ENER). We investigated the potential role of ENER after approval of IVtPA. Methods: Among 301 consecutive acute ischemic stroke patients admitted to our institution, revascularization therapy was performed within 3 hours after stroke onset in 24 patients (8.0%). We classified these patients into two groups, those who were treated with ENER (the ENER group) and those with IVtPA (the IVtPA group), and compared the baseline NIHSS score, rate of recanalization, favorable neurologic outcome (improvement of the NIHSS score of 4 or more at 24 hours after treatment), symptomatic intracranial hemorrhage within 36 hours, and favorable clinical outcome (0-2 points on the 3-month modified Rankin Scale) between the two groups. Results: In the ENER group (n=11) and IVtPA group (n=13), the baseline NIHSS score was 20 and 16 (P<0.05); the rate of recanalization achieved was 9 and 5 patients (P<0.05); a favorable neurologic outcome was seen in 7 and 5 patients (not significant; NS); symptomatic intracranial hemorrhage occurred in 0 and 1 patients (NS); and a favorable clinical outcome was achieved in 4 and 6 patients (NS), respectively. Conclusion: Since the clinical outcome was similar in the ENER and IVtPA groups, for patients with an absolute contraindication to IVtPA or those with a severe neurological status, ENER may be the first choice of revascularization therapy.

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A 68-year-old woman was admitted to our hospital because of convulsive seizures followed by dysarthria and motor aphasia. At 3 days before admission, she presented with acute onset of right arm weakness. Neurological examinations on admission revealed consciousness disturbance, global aphasia, and right hemiparesis. Cranial routine diffusion-weighted magnetic resonance imaging (MRI) on admission and at 3 days after admission demonstrated cortical-ribbon of the left frontal cerebral hemisphere, although T2 weighted MRI showed no abnormality on admission and serial MRI examination. The patient was diagnosed as having cerebral infarction with early seizures and was treated with anti-platelet therapy, since her clinical course had progressively deteriorated before admission. Moreover, anticonvulsant was added due to generalized tonic seizures that were recurrent after admission. Her aphasia and motor weakness had almost improved within 12 hours, and all symptoms disappeared within 3 days after treatment. At 4 days after admission, EEG revealed irregular alpha wave BGAs and occasional theta waves in the left frontal lobe. However, neither periodic lateralized epileptiform discharges nor spike waves were demonstrated. The abnormalities in the left frontal cerebral hemisphere detected on admission vanished completely 2 months later. We conclude that focal inhibitory seizures should be taken into consideration in the differential diagnosis of other conditions such as ischemic stroke.

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A 61-year-old man with a history of hypertension suffered dysarthria, and visited our hospital in July 2006. Diffusion-weighted magnetic resonance imaging (MRI) after arrival revealed cerebral infarction of the cerebral cortex in the territory of the left middle cerebral artery, and MR angiography (MRA) demonstrated mild irregularity of the left internal carotid artery. The patient was given a platelet inhibitor intravenously after admission. At 7 days after onset, he suddenly developed pain and cyanosis of the left leg. Three-dimensional computed tomographic angiography (3D-CTA) showed severe stenosis of the left iliac artery. The thrombus in the iliac artery was removed by cardiovascular surgeous. The following day, a mobile thrombus in the aortic arch was observed on cine-MRI. After treatment with both anti-platelet and anti-coagulant agents for 2 months, the thrombus in the aortic arch was no longer visible on cine-MRI.
This patient had developed cerebral and iliac arterial embolisms due to aortic atherosclerotic disease, with a mobile thrombus in the aortic arch. Cine-MRI may be useful for detecting mobile thrombi in the aortic arch.

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We report a case of a 67-year-old woman who demonstrated paradoxical embolic stroke with hereditary angioneurotic edema. She had been suffering from recurrent transient skin edema induced by bruising or sprain and transient whole face swelling after dental anesthesia since the age of 30. At the age of 47, this patient, her father, and her brother were diagnosed as hereditary angioneurotic edema due to familial deficiency of C1-inhibitor. At the age of 62, she was hospitalized with motor aphasia and weakness of the right upper extremity in June 2002. Brain magnetic resonance images revealed multiple infarctions in the left corona radiata and the subcortex of the parietal lobe, and transesophageal echocardiography showed patent foramen ovale. Further investigations demonstrated pulmonary embolism and deep venous thrombosis. She was finally diagnosed as paradoxical embolic stroke. In the case of C1-inhibitor deficiency, such as hereditary angioneurotic edema, a higher risk of embolism should be considered due to inhibition of fibrinogenolysis.

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Takayasu arteritis (TA) is a chronic inflammatory arteriopathy of unknown origin characterized by granulomatous vasculitis of medium and large arteries. Extracranial artery involvement causes stroke in 8 to 35% of patients with TA. Cerebral artery involvement in TA is extremely rare. A 3-year-old boy with juvenile idiopathic arthritis suffered from generalized convulsions. Computed tomography (CT) revealed cerebral hemorrhage and subarachnoid hemorrhage in the left temporal lobe. Cerebral angiography showed irregular dilatation and narrowing of the cerebral arteries in the left hemisphere and cerebellar arteries in the left cerebellar hemisphere. CT aortography demonstrated dilatation of the aortic arch and its main branches, thick vessel walls and renal artery stenosis which caused sustained high blood pressure and increased serum rennin. We diagnosed TA and hemorrhagic infarction of the left temporal lobe. No surgical evacuation of cerebral hemorrhage was required. Perifocal edema was treated with osmotic agents. We increased the dose of steroid and administered methotrexate for the TA. This treatment resulted in clinical remission of the inflammation, and the patient was discharged with minimum neurological deficit. Cerebral arteriopathy due to Takayasu's arteritis is rare. However, we should consider TA in the differential diagnosis of children presenting with stroke attack. Both early diagnosis and appropriate treatment may prevent deterioration of the chronic inflammation and improve the outcome.

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Chronic encapsulated intracerebral hematomas (CEIH) are rare. A 60-year-old woman presented with memory disturbance and right hemiparesis. CT and MRI disclosed a hematoma in the left putamen. After 18 days, the hematoma had grown larger, and the memory disturbance had worsened. After 21 days, endoscopic surgery was carried out. The surgery revealed an old hematoma with fibrous-like tissue. We removed the entire hematoma, and undertook a biopsy of the capsular tissue. The histological diagnosis was granulation tissue. Progressive memory disturbance caused by expansion of the encapsulated hematoma was completely resolved by the hematoma evacuation only. The cause of CEIH is unknown. The most common treatment for CEIH is hematoma removal with the capsule by craniotomy, because of the possibility of capsular tissue involvement in the formation process, and of cavernous angioma. However, burr hole surgery has also been reported to be effective. The present case was successfully treated by endoscopic surgery. We therefore consider endoscopic surgery to be suitable for the treatment of CEIH.

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Purpose: To investigate the influences of stroke recurrence and aspiration pneumonia during the acute phase of swallowing rehabilitation for lateral medullary syndrome (LMS). Subjects and Methods: Twenty consecutive LMS patients were selected retrospectively and divided into two groups: (1) the untreated group (10 cases) who had not undergone swallowing rehabilitation before the year 2004 when we had began swallowing rehabilitation, and (2)the treated group (10 cases) who had undergone swallowing rehabilitation after 2004. These two groups were compared for age, treatment response time, risk of stroke recurrence/aspiration pneumonia, length of hospitalization, and outcome. Results: The mean age of the untreated group was 64 years (M/F, 9/1; ischemia/hemorrhage, 8/2). The mean age of the treated group was 60 years (M/F, 8/2; ischemia/hemorrhage, 10/0). The term of fast in the treated group (2.3 days) was shorter than that in the untreated group (10.9 days; p=0.005). The gait ability was the same between the two groups at discharge. The treated group demonstrated better recovery of swallowing function (deglutition food evaluation of Fujishima) than the untreated group at discharge from our hospital. However, there were no differences of swallowing function between the two groups at the final function. The occurrence of aspiration pneumonia in the treated group (3 cases) was less than that in the untreated group (6 cases; p=0.04). Three cases in each group of recurrence did not correlate with swallowing rehabilitation for dysphagia during the acute stage, since many patients had recurrent stroke when they were removed from their total bed-rest. Conclusion: The approach of emproging swallowing rehabilitation in the acute phase of LMS did not influence the stroke recurrence. Instead, it appeared to promote a faster recovery of swallowing function, and to prevent aspiration pneumonia.

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