We attempted to establish a Fast-Track hospital teamwork system including emergency medical services to perform swift and efficient intravenous t-PA therapy for stroke patients at the hyperacute stage. We devised a new prehospital stroke scale, TOPSPIN (TOYOTA prehospital stroke scale for t-PA intravenous therapy), as an effective triage for hyperacute stage stroke patients, especially for ischemic stroke patients with an indication for intravenous t-PA therapy, and then introduced this prehospital stroke scale into our emergency system. The TOPSPIN consists of five evaluation points: 1, consciousness; 2, atrial fibrillation; 3, language disorder; 4, hemiparesis of the upper extrenities; and 5, hemiparesis of the lower extremities. In total, 155 patients had been transported using TOPSPIN by November 6, 2007 (since December 12, 2006). The stroke diagnosis rate was 72%, including 56 cerebral infarction cases (36%), 3 TIA cases (2%), and 46 cerebral hemorrhage cases (30%); and t-PA was administered in 14 patients (9%). We also analyzed 218 stroke patients transported by our emergency medical system, and found that almost half of the cases had been transported using TOPSPIN triage. However, about half of the cases had thus been transported without TOPSPIN triage. The reasons why TOPSPIN triage was not indicated were: 1, the cases were transferred from other hospitals or medical clinics after the diagnosis as stroke; 2, they were stroke cases after the acute stage; 3, the cases were transported by emergency corps other than that of Toyota City; and 4, the cases had symptoms of only vertigo/drift/vomiting and hemianopia. TOPSPIN was demonstrated to be an effective triage system for performing swift and authentic t-PA therapy.

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We attempted to establish a Fast-Track hospital teamwork system including emergency medical services to perform swift and efficient intravenous t-PA therapy for ischemic stroke patients at the hyperacute stage. We had devised a new prehospital stroke scale, TOPSPIN (TOYOTA prehospital stroke scale for t-PA intravenous therapy), as an effective triage for acute stage stroke patients, especially for ischemic stroke patients with an indication for intravenous t-PA therapy, and then introduced this prehospital stroke scale into our emergency system. We now constructed and managed an electronic medical path system (3 TOP system) consisting of three-step paths: 1, a TOPSPIN path to accomplish several examinations as a basis for making decisions about t-PA therapy in the emergency room (ER); 2, TOPSPEED (TOYOTA path for stroke with t-PA therapy after emergency evaluation and decision), a path for administering intravenous t-PA in the intensive care unit (ICU); and 3, TOPSTAR Jr. (TOYOTA path for stroke treatment, activity and rehabilitation judged by reexaminations), a path for performing next-step therapy after t-PA therapy in the ICU or stroke unit (SU). In total, 96 patients had been transported using TOPSPIN after 3 TOP system induction, by November 6, 2007 (since April 1, 2007); and t-PA treatment was performed in 11 patients.
The 3 TOP system and TOPSPIN in conjunction with the 3 TOP system were demonstrated to provide an effective total system for performing swift and authentic t-PA therapy.

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Background and Purpose: Mounting evidence from a variety of research fields has drawn attention to the participation of vascular factors in the underlying pathophysiology of Alzheimer's disease (AD). To clarify the influence of vascular and genetic risk factors, we investigated the relationships between cerebral blood flow images provided by single photon emission CT (SPECT) and blood pressure, brain natriuretic peptide (BNP), and ApoE4 phenotyping in AD patients. Methods: The present study was based on 197 patients with probable AD. All patients underwent biochemistry tests, neuropsychological evaluation, magnetic resonance imaging (MRI), and ^99mTc ECD SPECT. Results: The MMSE score was correlated with the diastolic blood pressure positively, and with BNP negatively. Statistical parametric mapping (SPM) revealed significant hypoperfusion in the posterior cingulate gyri, precuneus, and parieto-temporal region in those patients having ApoE4 as compared to those without ApoE4. When compared to those patients without white matter hyperintensity (WMH) on MRI, those with mild WHM demonstrated significant hypoperfusion in the anterior cingulate gyri, right superior, middle and inferior temporal gyri, and left inferior frontal gyrus, and those with marked WMH demonstrated more expansive hypoperfusion areas on SPM. Those with greater BNP levels showed significant hypoperfusion in the anterior cingulate gyri and superior frontal gyri as compared to those with smaller BNP levels. Conclusions: Posterior hypoperfusion as related to the presence of ApoE4 may imply a degenerative process in AD, whereas anterior hypoperfusion as related to increased BNP levels may indicate the participation of vascular factors in AD.

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In January 2006, a stroke team was organized at Asahikawa Medical College, consisting of members in the fields of neurology, neurosurgery, emergency medicine, cardiology and radiology, to promote the acceleration and standardization of stroke management. To assess the significance of the stroke team, we compared the data obtained among those before and after the stroke team had been established, and data from the Japanese stroke data bank 2005. We surveyed all 158 stroke patients under our stroke team in 2006. The clinical characteristics of these stroke patients were similar to those of the Japanese stroke data bank 2005. Access times to our hospital became remarkably shortened after the stroke team had been established because of notification to the ambulance office. It was found that stroke management in at Asahikawa Medical College Hospital had been accelerated and standardized by the stroke team setup. For further improvement in the quality of stroke management, a stroke care unit is essential.

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Background and Purpose: Massive hemispheric embolic infarction associated with acute brain swelling and rapid clinical deterioration is known as malignant infarction because of the significant rates of mortality and morbidity. Decompressive hemicraniectomy is effective; however, the timing and outcome still remain unclear. Methods: Ninety-four patients with massive embolic hemispheric infarctions (infarct volume>200 ml) were retrospectively divided into 3 groups: 29 patients, treated conservatively (conservative group); 33 patients, operated on after the appearance of signs of brain herniation (late surgery group); and 32 patients, operated on before the onset of signs of brain herniation signs (early surgery group). Results: The mortality at 1 and 6 months in the late surgery group (15.2% and 24.2%, respectively) was significantly improved as compared to the conservative group (62.1% and 69.0%, respectively) (p<0.01), and was further improved in the early surgery group (3.2% and 12.5%, respectively). In particular, both an infarction volume of more than 240 ml and a midline shift of more than 8 mm were severely associated with malignant infarction. Concerning functional recovery, in the early surgery group, the Glasgow Outcome Scale (GOS) and Barthel Index (BI) at 6 months after ictus were significantly improved as compared to the late surgery group (p<0.05), in which they were not significantly improved as compared to the conservative group. The BI score for patients under 70 years old treated by early surgery was significantly improved. Conclusions: Decompressive hemicraniectomy for massive embolic hemispheric infarctions (volume>200 ml) should be performed before the onset of brain herniation. Early surgery may achieve a satisfactory functional recovery.

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The relationship between migraine and cerebral infarction is complex and still remains a problem under debate. We report here 3 patients who demonstrated posterior cerebral artery infarction during migraine attack without aura, and examine the stroke mechanisms using digital subtraction angiograms. Case 1: a 21-year-old female presented with hemorrhagic infarction in the left posterior cerebral artery territory. Debris-like shadows and hyperperfusion were observed on her digital subtraction angiogram. Cryptogenic embolism and its recanalization were presumed to be the stroke mechanism. Case 2: an 18-year-old female presented with right posterior cerebral artery infarcts, and hyperperfusion was observed on her digital subtraction angiogram. We could not clarify the stroke mechanism. Case 3: a 29-year-old female presented with left posterior cerebral artery infarction. The left posterior cerebral artery demonstrated tapered stenosis, indicating arterial dissection. The stroke mechanisms of cerebral infarction occurring during migraine attacks appear to be varied, and further research is needed to clarify the nature of migraine-related strokes more precisely.

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Background and Purpose: The guidelines for the chronic stage after stroke have not focused on the recovery from chronic hemiparesis but mainly on second prevention of stroke. We investigated the effects of motor cortex stimulation with rehabilitation therapy on the recovery from upper extremity paresis in patients with chronic stroke. Methods: In 5 patients who had moderate arm and finger paresis at more than 4 months after stroke, an electrode was placed through a small craniotomy on the epidural space of the motor cortex which was identified using functional MRI. Motor cortex electrical stimulation during occupational therapy for one hour was performed 4 times a day for at least 4 weeks. Results: The mean scores for Fugl-Meyer assessments of the arm improved, from 37 preoperatively to 46 postoperatively. The mean grip strength improved from 1.6 to 7.6 kg. All patients appeared satisfactory in their results because they recognized an improvement of arm function, and the improvement never returned to the preoperative level after cession of the cortical stimulation. Conclusions: Although the effects of motor cortex stimulation on recovery after stroke might still be inchoate, our data support the initial favorable results obtained in studies in the U.S.A. Motor cortex stimulation could become a novel treatment modality for the chronic hemiparesis occurring after stroke.

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Background and Purpose: The Japanese government emphasizes the importance of long-term community care for stroke patients by acute hospitals (AH), convalescent rehabilitation units (CRU), general practices (GP), sanatorium type wards (STW), long-term care facilities (LTCF) and in-home and commuting care services (IHCCS). We conducted a nationwide questionnaire survey to assess the current role of IHCCS in stroke care. Subjects and Methods: Twelve representative prefectures were selected. Questionnaires concerning the facility status, community-based referral system, long-term care insurance system and their appropriate indicators were sent to 10% of the IHCCS. Results: 22% these of IHCCS answered. 80% offered post-stroke care services, and half of these did so regardless of the condition of the post-stroke person. Each IHCCS looked after 112±210 (mean±SD) persons including 26±41 post-stroke cases. Although 81% engaged in some form of post-stroke rehabilitation, only 10% answered that their post-stroke rehabilitation was adequate. CRU (38%) were expected to play a central role in the community-based referral system. Good or fair relationships with AH, CRU, GP, STW/LTCF, other IHCCS, the general community and the local authority were found in 37%, 37%, 51%, 48%, 58%, 38% and 20%, respectively. Medical/care information sharing was achieved in 9%/10% and not scheduled in 62%/59%. The proper assessment indicator for IHCCSS by a third party was the communication with care managers for long-term care services (44%). Conclusions: The cooperation between IHCCS and AH, CRU and the local authority was insufficient. At present, the information sharing for stroke patients in IHCCS remains unsatisfactory.

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Background and Purpose: The Japanese government emphasizes the importance of long-term community care for stroke patients by acute hospitals (AH), convalescent rehabilitation units (CRU), general practices (GP), sanatorium type wards (STW), long-term care facilities (LTCF) and in-home and commuting care services (IHCCS). We conducted a nationwide questionnaire survey to assess the current role of STW/LTCF in stroke care. Subjects and Methods: Twelve representative prefectures were selected. Questionnaires concerning the facility status, community-based referral system and their appropriate indicators were sent to 771 STW/LTCF. Results: 24% of these STW/LTCF answered. 82% were engaged in stroke long-term care. There were 106 (mean) beds (37 for stroke patients). The waiting period to enter was over 6 months in 22%. The main reasons for the observed difficulty in returning home were living alone (73%), only elderly people's households (76%) and other reasons for lack of care (77%); and only 10% of stroke patients returned home. Only 15% could maintain adequate function for rehabilitation. AH (42%) were expected to play a central role in the community-based referral system. Good or fair relationships with AH, CRU, GP, other STW/LTCF/IHCCS, the general community and the local authority were found in 63%, 42%, 52%, 54%, 49% and 24%, respectively. Medical/care information sharing was achieved in 8%/8% and not scheduled in 64%/61%. The proper assessment indicator for STW/LTCF by a third party was the measurement of rehabilitation function (47%). Conclusions: The main reasons for the difficulty in returning home for stroke patients in STW/LTCF are troublesome issues. At present, the information sharing for stroke patients in STW/LTCF remains unsatisfactory.

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Background and Purpose: The Japanese government emphasizes the importance of long-term community care for stroke patients by acute hospitals (AH), convalescent rehabilitation units (CRU), general practices (GP), sanatorium type wards (STW), long-term care facilities (LTCF) and in-home and commuting care services (IHCCS). We conducted a nationwide questionnaire survey to assess the current role of GP in stroke care. Subjects and Methods: Twelve representative prefectures were selected based on the population density. Questionnaires concerning the facility status, community-based referral system, long-term care insurance (LTCI) system and their appropriate indicators were sent to 3,709 GP. Results: 21% of these GP answered. 58% attended stroke patients. 11% had 17±5 (mean±SD) inpatient beds, and stroke patients used 7±6 of these beds. 81±96 post-stroke patients out of 622±521 attending patients were treated by each GP per month. 32±66 post-stroke patients were found to be dependent. 57% engaged in-home care for dependent individuals, and 37% undertook post-stroke rehabilitation. Only 5% answered that their post-stroke rehabilitation was adequate. A simple independence scale for LTCI was mainly used to assess ADL. AH (68%) were expected to play a central role in the community-based referral system. Good or fair relationships with AH, CRU, other GP, STW/LTCF/IHCCS, the general community and the local authority were found in 68%, 47%, 45%, 58%, 59% and 31%, respectively. Medical/care information sharing was achieved in 11%/10% and not scheduled in 57%/60%. Many problems in the cooperation system with medical insurance and LTCI were evident. The proper assessment indicator for GP by a third party was the measurement of the cooperation with AH (68%). Conclusions: GP recognized that the post-stroke rehabilitation was inadequate. At present, the information sharing for stroke patients remains unsatisfactory.

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Background and Purpose: The Japanese government emphasizes the importance of long-term community care for stroke patients by acute hospitals (AH), convalescent rehabilitation units (CRU), general practices (GP), long-term care facilities (LTCF) and in-home and commuting care services (IHCCS). We conducted a nationwide questionnaire survey to assess the current role of CRU in stroke care. Subjects and Methods: Twelve representative prefectures were selected based on the population density. Questionnaires concerning the facility status, community-based referral system, long-term care insurance system and their appropriate indicators were sent to all 347 CRU hospitals. Results: 50% of these hospitals answered. 95% were engaged in stroke rehabilitation. The main reasons for declining admission were a patient need for artificial respiration (55%) and hemodialysis (60%). 47% received patients within 7 days after referral. The main assessment scale for ADL was FIM (72%). The mean length of stay was 88 days, and 61% of the patients returned home. AH (42%) and CRU (38%) were expected to play a central role in the community-based referral system. Good or fair relationships with AH, other CRU, GP, STW/LTCF/IHCCS, the general community and the local authority were found in 93%, 42%, 71%, 87%, 78% and 43%, respectively. Medical/care information sharing was achieved in 13%/13%, and planned in 56%/55%. Many problems in the cooperation system with medical and long-term care insurances were evident. The proper assessment indicator for CRU by a third party was the measurement of rehabilitation function (86%). Conclusions: CRU and AH played a central role in the community-based referral system for stroke care. Although more than half of the CRU had already planned information sharing, it still remained inadequate.

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We report a case of cavernous hemangioma, in which it was difficult to make a differential diagnosis. A 70-year-old male came to us due to a continuous headache that had lasted for approximately 1 month. Computed tomography (CT) scan and magnetic resonance imaging (MRI) findings revealed a mass lesion of about 2 cm in diameter, together with hemorrhage and perifocal brain edema in the left temporal region. Cerebral angiography demonstrated a tumor stain corresponding to the hemorrhagic mass. A Tl-201 SPECT study revealed a high L/N ratio in the early phase (5.4), a high L/N ratio in the delayed phase (4.8), and a high L/E ratio (0.89) corresponding to the hemorrhagic mass, although FDG-PET showed less uptake than normal white matter. We made a preoperative diagnosis of malignant brain tumor and performed a total tumor resection, since the border between the tumor and normal brain tissue was clear. The tumor was elastic hard and its color was yellowish-brown. The pathological diagnosis was cavernous hemangioma with bleeding in the cerebrum. It is necessary to consider the possibility of a cavernous hemangioma when a hemorrhagic mass with perifocal edema is encountered in the brain parenchyma, even with brain tumor-like radiographic findings.

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A 59-year-old female was admitted to hospital due to sudden dizziness and vomiting. Brain MRI of the patient revealed an acute cerebellar infarction in the left superior cerebellar artery (SCA) territory. The symptom of cerebellar ataxia improved gradually. Although her consciousness was clear, marked impairment of cognitive functions, including memory/executive functions, was noted at 5 days after admission. On SPECT imaging, the cerebral blood flow (CBF) was found to be decreased over a wide area that included the bilateral basal ganglia, cerebellum, temporal lobe, parietal lobe, and frontal lobe. Cognitive functions became rapidly improved as the CBF improved after 1-2 months. This patient was considered to have cerebellar cognitive affective syndrome (CCAS) due to cerebellar infarction. It has been reported previously that behavioral disorders can appear with dysfunctions of the posterior cerebellum; that affective symptoms are associated with dysfunctions of the cerebellar vermis; and that cognitive dysfunctions are associated with the area supplied by the posterior inferior cerebellar artery (PICA) but not with that supplied by the SCA. However, the present patient, who had an infarct in the left SCA territory, displayed an executive dysfunction but no emotional disorder.

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Background and Purpose: MRI is useful for detecting early ischemic lesions prior to administration of tissue plasminogen activator (t-PA) in hyperacute ischemic stroke patients. However it is unclear whether early ischemic change seen on DWI can be used to predict patient outcomes.
Methods: Consecutive anterior-circulation ischemic stroke patients treated with t-PA within 3 h of stroke onset were prospectively studied. The NIHSS score was obtained before and 7 days after t-PA administration. MRI including DWI was done prior to t-PA thrombolysis. The relationship between the DWI ASPECTS and patients' outcomes was assessed.
Results: The subjects consisted of 49 consecutive stroke patients (27 males; mean age, 72.9±10.3 years). The median (range) of the baseline DWI ASPECTS value was 9 (3-10). Dramatic improvement was seen in 1 of 8 patients with an ASPECTS ≤5 compared to 21 of 41 patients with an DWI ASPECTS >5 (P=0.0592). On the other hand, worsening was noted more frequently in patients with a DWI ASPECTS ≤5 (3 of 8 patients) than in patients with an ASPECTS >5 (4 of 41 patients; P=0.0753). Bad outcome was seen more frequently in patients with an DWI ASPECTS ≤5 (6 of 8 patients) than in patients with an DWI ASPECTS >5 (2 of 41 patients; P<0.0001). Multivariate logistic regression analysis demonstrated that an DWI ASPECTS ≤5 was the only independent predictor of a bad outcome (OR 33.4 95%CI 2.7-410.8, P=0.0062).
Conclusion: DWI ASPECTS appears to be a reliable tool for predicting bad outcome. Patients with an DWI ASPECTS >5 should be considered eligible for t-PA therapy.

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