The authors report a relatively rapid recovery of motor function in 3 patients with locked-in syndrome due to basilar artery occlusion, who underwent transcutaneous electrical nerve stimulation (TENS) as an adjunctive treatment of physiotherapy. A 64-year-old male (Patient 1) suffered from diffuse infarction of the cerebellum and pons after intraarterial thrombolytic therapy for basilar artery occlusion (BAO). One week's conventional physiotherapy proved ineffective, so TENS was started as an additional physiotherapy. On the day when the TENS was initiated, he began to move his upper extremities voluntarily. A 65-year-old male (Patient 2) suffered cerebellar and pontine infarction after intraarterial thrombolytic therapy for BAO. In this patient, TENS was started in addition to conventional physiotherapy. Three days later, he experienced improvement in his upper extremity motor function, and was capable of grasping his hands on command. A 77-year-old male (Patient 3) suffered pontine infarction after intravenous thrombolytic therapy for BAO. Three days' physiotherapy did not improve his motor function, so TENS was started, and his left arm then began to move voluntarily. It is postulated that TENS in association with physiotherapy can enhance recovery of motor function in patients with locked-in syndrome.

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Background and Purpose: Ischemic stroke is the most common type of stroke in young adults in Japan. However, its cause has not so far been sufficiently investigated. Here, we examined several aspects of ischemic stroke in young adults at our hospital. Subjects and Methods: Among 263 patients with brain infarction hospitalized at our hospital, we evaluated 26 patients (20 males and 6 females) who developed the disease aged 50 years or under in terms of their infarction type, length of stay, and disease outcome. Results: Patients aged 50 or younger accounted for 9.9% of all patients with cerebral infarction. The types of cerebral infarction were classified into lacunar (7 patients; 6 were >46 years old), atherothrombotic (5 patients), cardioembolic (3 patients), other (6 patients), and undetermined infarction (5 patients). The group designated as other type included cerebral artery dissection, patent foramen ovale, aortic dissection, and tumor-associated embolism. The mean length of stay was 15 days. As for the disease outcome, 14 patients (54%) were discharged with ADL self-support and 1 patient died. Conclusion: Cerebral infarction in patients aged 45 years or younger is frequently attributed to abnormality in the cerebral blood vessels, especially cerebral artery dissection. Close investigation of the cerebrovascular lesions is necessary in such patients. Adequate caution should therefore be exercised upon early thrombolytic therapy.

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We retrospectively evaluated cases of super-acute phase cerebral infarction who were excluded from thrombolytic therapy. Seventy potential candidates for intraarterial or intravenous thrombolytic therapy were included in the present study. Forty-eight cases were men and 22 were women. Their mean age was 70.3 years old. They consulted Chiba Cardiovascular Center within 2 hours after symptom onset between April 2002 and September 2007. All of them were excluded from thrombolytic therapy because their neurological symptoms were mild or rapidly improved. The proportion of a poor prognosis (modified Rankin Scale score at discharge ≥3) and the factors related to a poor prognosis were evaluated statistically using commercially available software. Three of the 45 cases with mild neurological symptoms and 8 of the 25 cases with rapid improvement had a poor prognosis. The proportion of a poor prognosis was significantly high in the cases with rapid improvement (Fisher's exact test, p=0.0128), and no other factor was related to the poor prognosis. Exclusion from thrombolytic therapy should be undertaken with caution, if no other exclusion criterion has been found except for rapid improvement of neurological symptoms.

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To evaluate the clinicoradiological findings of patients with small infarction at the level of the corona radiata, such patients were divided into three groups: Group A (facio-lingual weakness), Group B (arm-dominant weakness) and Group C (leg-dominant weakness). The anteroposterior position and maximum diameter of the radiata infarcts were assessed by axial T2-weighted imaging. In total, 59 consecutive patients (42 men and 17 women) were selected. The frequency of radiata infarct is 9.4% among cerebral infarct patients. The male/female ratio was 1.3. The mean age (SD) was 68.9 (9.5) years. The number of patients was 23 in Group A, 19 in Group B and 17 in Group C. Group B patients needed aid in their daily life, when compared to Group A and Group C. The cerebrovascular risk profiles demonstrated hypertension in 43 patients (72.9%), diabetes mellitus in 15 (25.4%), current smoking in 22 (37.3%), dyslipidemia in 16 (27.1%) and arterial fibrillation in 11 (18.6%). The clinical subtypes revealed 48 patients with lacunar infarct and 11 with cardiogenic emboli. The somatotopical distribution of motor fibers of Groups A to C was arranged in antero-posterior order. There were 24 patients with right lesions and 35 with left lesions. The size of the left infarcts was significantly smaller than that of the right infarcts. The clinical outcome of patients with arm-dominant weakness was relatively poor as compared to that of patients with dysarthria or leg-dominant weakness. The neuroradiological data suggest that left radiata infarct is smaller and more frequent than right infarct.

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An 80-year-old male was admitted to hospital in a coma, suffering from atrial fibrillation and oculomotor nerve palsy. MRI diffusion weighted imaging revealed a high intensity area in the left cerebellar hemisphere on the first day. The patient was diagnosed as having top of the basilar syndrome. Anticoagulant and antidysrhythmic therapy was administered to prevent recurrence of the embolism, and the patient's heart resumed a sinus rhythm on the 15th day. On the 31st day, he experienced sudden severe abdominal pain and nausea and died of shock with metabolic acidosis at 8 hours after the onset. An autopsy disclosed that the patient had an embolic occlusion of the superior mesenteric artery with intestinal necrosis. This acute mesenteric ischemia was inferred to have been the cause of death. Since ulceration and parietal thrombus were found in the aortic arch, but no thrombus was observed in the atrium of the heart, the aortic arch lesion was assumed to have been the origin of the embolic occlusion. It is concluded therefore that sudden onset of severe abdominal pain followed by shock could be a sign of acute mesenteric ischemia in patients with embolic stroke, and aortic arch plaque may represent one of the origins.

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We describe here a patient with cerebral infarction induced by nonbacterial thrombotic endocarditis (NBTE) with cervical cancer. The patient was a 42-year-old woman who suffered from cerebral infarction in the territories of the left middle cerebral artery and right posterior cerebral artery. She was diagnosed as having cryptogenic stroke and was discharged from our hospital on Day 11, taking clopidogrel to prevent a second stroke. However, she suffered from recurrent cerebral infarction on Day 12, and was readmitted to our hospital on Day 13. Diffusion-weighted imaging on readmission (Day 13) revealed multiple high intensity areas in the territories of the bilateral middle cerebral artery and left posterior cerebral artery. Transthoracic echocardiography on admission demonstrated no vegetation; however, that on Day 14 showed vegetation (11 mm×8 mm) of the posterior mitral leaflet, while that on Day 35 showed no vegetation of the mitral valve. The patient was diagnosed as having cardioembolic stroke induced by NBTE. Intravenous infusion of heparin sodium was then started, while she continued to take clopidogrel. On Day 42, she was transferred to the Department of Obstetrics and Gynecology at our hospital for radiation therapy of her cervical cancer. Although NBTE induced by cervical cancer is rare, extensive workup for embolic sources including vegetation by transthoracic or transesophageal echocardiography should be repeated in such patients with cryptogenic stroke.

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A 32-year-old man noticed weakness of his right hand and slight faintness while working. Initially, his consciousness was slightly disturbed and nuchal stiffness was also evident. Laboratory tests revealed that he was serologically positive for syphilis and HIV. An MRI examination demonstrated high signal intensities in the left basal ganglia. The cerebral arteries, especially the bilateral middle cerebral arteries and the basilar artery, exhibited marked narrowing and stenosis. A CSF examination disclosed pleocytosis and an elevated protein content. On the basis of these findings, the patient was diagnosed as having cerebral infarction associated with meningovascular neurosyphilis. Following 3 weeks administration of penicillin, MRA showed improvement of blood flow and he was discharged from our hospital without neurological deficits. At 1 month after discharge, he was re-admitted to our hospital complaining of gradual worsening of his left-sided weakness. His consciousness was disturbed and both eyes were deviated to the right side. A cranial diffusion weighted MRI image demonstrated scattered high signal intensities. The right MCA was not depicted at the beginning from the internal carotid artery. After 3 months of rehabilitation, the patient regained his ability to walk with assistance and return home. In the case of our patient, the initial penicillin was believed to have ameliorated the marked narrowing of the cerebral arteries, which was revealed by MRA. However, there are some cases of arteritis that do not respond well to penicillin. Additional therapy, such as antiplatelet medication, must be considered in order to suppress the arteritis and stenosis more efficiently, and to improve cerebral blood flow.

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Purpose: Temporomandibular joint dislocation (TJD) may be associated with neurological disorders. However, little is yet known about this clinical entity. We reviewed our consecutive cases for clarification of the clinical features of TJD in stroke patients, and patient management. Methods: Patients entered on our dental-clinic database were reviewed. Results: Of 10 stroke patients with TJD, 6 manifested hemiplegia and 3 quadriplegia; one exhibited no weakness. All TJDs were anterior; 2 were unilateral and 8 were bilateral. They occurred at 12 days to 9 months (mean, 94.1 days) after stroke onset. Nine patients underwent manual repositioning; one had repositioning surgery. Conclusions: The mouth-closing muscles (masseter, temporalis, and medial pterygoid) raise the mandible to fit the temporomandibular joint, and they are innervated by a motor branch of the trigeminal nerve which also bilaterally innervates the supranuclear region. In stroke patients, these muscles may be weakened by unilateral pyramidal tract damage, suggesting that maintenance of the bite force depends on bilateral complete innervation. While TJD associated with stroke is rare, it should be borne in mind in order to facilitate early detection and repositioning.

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