The goal of stroke care is to minimize brain injury and maximize patient recovery. The Guidelines 2000 for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care recommended the 7 "D's" of stroke management (Detection, Dispatch, Delivery, Door, Data, Decision, and Drug). In Japan, no algorithm has been established for acute stroke. Immediate Stroke Life Support (ISLS) provides a standard education as off-the-job training. It focuses on the initial out-of-hospital care, assessment at the emergency department and management of the patient with acute stroke. We directed 13 courses of ISLS and evaluated the results with a questionnaire. The subjects comprised 183 persons who attended the course. Based on the attendants' impression, the ISLS course was useful for understanding the "stroke chain of survival" and also for reaching a consensus among the emergency medical services, emergency experts and stroke experts. The ISLS course also proved useful for residents' education.

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We investigated the preventive effect of elastic stocking on deep venous thrombosis (DVT) in patients with intracerebral hemorrhage (ICH). We enrolled 45 patients with ICH (age,; 70.4±10.5 yr; males, 20; females, 25), who were not found to have DVT by ultrasonography on admission. Although the patients admitted before January 2006 did not wear elastic stockings, those admitted after February 2006 who suffered from severe paralysis of a lower extremity did wear elastic stockings. We examined the presence or absence of DVT by ultrasonography at 2 weeks after the occurrence of ICH, and statistically investigated the relationship between the wearing of elastic stockings and the presence of DVT. The number of patients with elastic stockings was 15, and that without was 30. In total, we detected DVT in 13 patients at 2 weeks after the occurrence of ICH (28.9%). The frequency of DVT in patients with elastic stockings was not significantly decreased as compared to that without. No preventive effect of elastic stockings on DVT was observed in patients with consciousness disturbance, paralysis in a lower extremity, severe neurological deficit, large hematoma or without operation. It appears therefore that the wearing of elastic stockings does not prevent patients with ICH from developing DVT.

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We retrospectively evaluated the clinical features of acute cerebral infarction in young adults at our hospital. We enrolled a series of 2,080 patients with acute cerebral infarction admitted to our hospital between Jan. 1, 2002 and Dec. 31, 2006. We divided them into two groups: a young group (50 years old and younger) comprising 93 patients (4.5%), and an aged group (51 years old and older) comprising 1,987 patients (95.5%). The mean age of the young group was 42.4±8.8 years old and the youngest age was 15 years old. The proportions of hypertension, diabetes mellitus and atrial fibrillation in the aged group were significantly higher than those in the young group, On the other hand, the proportions of smoking, headache at onset, other etiologies such as arterial dissection and angiitis, and unknown etiologies in the young group were significantly higher than those in the aged group. The Modified Rankin Scale at discharge was significantly lower in the young group. There were no statistically significant differences in proportions of patients visiting a hospital within 3 hours and patients with rt-PA administration between the two groups. The proportion of nonvalvular atrial fibrillation in cardioembolic stroke within the young group was low, but the proportion of patients with some congenital cardiac disorders was high. The rapid increase of strokes with arteriosclerosis at 40 years old suggests that stroke with arteriosclerosis is appearing at a younger age than ever before.

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Background and Purpose: Dysphagia is one of the most important dysfunctions occurring among stroke patients. The purpose of this study was to clarify the effectiveness of a nurse-led dysphagia rehabilitation program in the acute stroke unit. Methods: We prospectively studied 96 consecutive stroke patients at the acute phase admitted to our stroke unit (mean age, 69.9 years). Nurses examined all the patients for dysphagia on admission. A structured swallowing training program was provided for those patients with dysphagia. Medical doctors and rehabilitation staff belonging to the stroke ward participated in the program interdisciplinarily. Progress in functional levels of oral intake, length of stay (LOS), NIHSS, and occurrence of pneumonia were the main outcome measures. Results: 34.3% (33/96) of the patients had dysphagia (the dysphagia group). The mean NIHSS score in the dysphagia group was higher than that in the normal group (8.3 versus 5.0; p<0.05). The mean LOS in the dysphagia group was 27.1 days as compared to 18.3 days in the normal group (p<0.01). The levels of oral intake improved in 81.8% (27/33) of the patients. Only one patient developed pneumonia during the hospital stay. Conclusions: The present study demonstrated that nurse-led dysphagia rehabilitation in the stroke unit can reduce the risk of aspiration pneumonia and promote the oral intake of patients with dysphagia. Nursing care is indispensable for stroke unit care against dysphagia.

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We report here a case of acute ischemic stroke exhibiting rapid recovery after intravenous rt-PA therapy without recanalization of a culprit large vessel. An 83-year-old woman who displayed drowsiness, total aphasia, and right-sided hemiparesis was transferred to our institution at 40 min after the onset. Her NIHSS score was 22 points and cranial computed tomography (CT) revealed neither a high density area nor early CT findings. Her carotid ultrasonography demonstrated patency of the left internal carotid artery. Her clinical information satisfied an indication for intravenous rt-PA therapy, and she therefore received the therapy at 130 min after the stroke onset. Her symptoms improved remarkably at 170 min after the onset during the rt-PA infusion, but her magnetic resonance angiography (MRA) performed immediately after completion of the rt-PA therapy demonstrated no recanalization of the left middle cerebral artery (MCA) which was considered as her culprit large vessel. On the second day, her neurological symptoms improved completely, but occlusion of the left MCA was again confirmed by a second MRA. Finally, patency of the left MCA was confirmed by a fourth MRA performed on the 17th day. During the hospital stay, her neurological symptoms did not reworsen and she was discharged without any sequelae on the 24th day. This case experience suggests that the rapid effect of rt-PA therapy on clinical improvement occursing immediately after the infusion is due to recanalization of not only a culprit large vessel but also other small vessels such as the branches of the anterior/middle cerebral artery or the leptomeningeal anastomosis.

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We report here two cases of acute brain-stem infarction diagnosed using axial images plus sagittal images of diffusion weighted magnetic resonance imaging (DWI). Routine DWIs for the diagnosis of acute cerebral infarctions are usually visualized as axial sections. Brain-stem infarctions are, however, sometimes difficult to display only on axial DWI sections, due to the size of the lesions and pathophysiological delay of signal changes. The usefulness of a combination of multiple DWI sections in the diagnosis of acute phase brain-stem infarctions is demonstrated.

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Dural sinus thrombosis can still cause death or permanent disability, despite improvements in diagnosis and treatment. The initial diagnosis of mild cases may be mistaken, because the symptoms and clinical course are highly variable. We report here 4 mild cases of dural sinus thrombosis, in 2 males and 2 females aged between 20 and 72 years, manifesting as headache in 3 patients, including 2 with thunderclap headache, and transient lower limb weakness in one patient. CT and MR imaging revealed no abnormalities of the brain parenchyma. The final diagnosis was established by angiography, but T1-weighted MR imaging was useful for thrombus detection in the dural sinus at the early stage. The occlusions were located in the superior sagittal sinus, transverse sinus and sigmoid sinus. All patients were treated by anticoagulant therapy and demonstrated good clinical courses. Early diagnosis and treatment are essential for dural sinus thrombosis.

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In Japan, intravenous thrombolysis with recombinant tissue-type plasminogen activator (rt-PA) was approved in 2005. A drastic reconstruction of the medical service system for acute stroke is therefore urgently needed. We had an opportunity to visit Austin Hospital, Melbourne, which is a representative acute stroke hospital in Australia. We obtained useful information concerning the acute stroke care system, inter-hospital cooperation, and evaluation system for the quality of acute stroke care, during this visit. It appeared that the stroke care system in Australia, where the health-insurance system covers all of the citizens, is similar to that in Japan.

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We had an opportunity to visit the Kerckhoff Klinik, a representative cardiovascular hospital with high-quality health care, the Kopfklinik of Heidelberg University, a representative acute stroke hospital in Germany, and the Kliniken Schmieder, a rehabilitation hospital. As a result, we obtained useful information concerning the healthcare system, acute stroke care system, inter-hospital cooperation, and evaluation system for the quality of medical care in Germany.

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