In the approval of rt-PA intravenous treatment for acute ischemic stroke in Japan, The Committee for Improvement of Stroke Therapy of The Japan Stroke Society played an important role since the first application for its approval. This therapy was approved in Japan under the premise that training in the correct use of this drug would be provided and the committee held training classes in each prefecture across Japan. 189 classes were held reaching more than 10,000 participants over a 3-year period. As a result, it is estimated that protocol violations occurred in only 6% of approximately 15,000 cases that underwent this treatment. In this article, the situation related to approval and training in the use of rt-PA intravenous treatment for ischemic stroke, and the present use of this drug in Japan are described.

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To promote rt-PA therapy, the medical staff in our hospital began to participate in Immediate Stroke Life Support (ISLS) in April 2007, and we have accepted acute stroke patients transported on Prehospital Stroke Life Support (PSLS) system since October 2007. The aim of this study was to evaluate the effects of introducing the PSLS and ISLS systems on intravenous rt-PA therapy. We determined the time elapsed before initiation of rt-PA therapy between an early period (May 2006–December 2007) and a later period (January 2008–December 2008). Additionally, the correlation between National Institutes of Health Stroke Scale (NIHSS) and Kurashiki Prehospital Stroke Scale (KPSS) neurological assessments by emergency medical service paramedics was investigated. The rate of therapeutic efficacy (defined as improvement from the baseline score on the NIHSS by 4 or more points 24 hours after the administration of rt-PA) was 61.5%, and the modified Rankin Scale (mRS) score of 0–1 was 36% at discharge. When compared to the early baseline period, the in-hospital time (latency to rt-PA administration) was significantly shortened (early period: 93 min., later period: 76 min., p‹0.005) and the total number of patients receiving rt-PA was increased in the later period (patients with rt-PA administration/all admissions of acute ischemic stroke: 27/208, 13.0%). A positive relationship was discovered between NIHSS and KPSS score (r=0.78, p‹0.001). Both a reduced time to rt-PA therapy and an increased number of patients receiving rt-PA revealed an additive effect of PSLS/ISLS systems.

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Background and Purpose: The purpose of this study was to obtain fundamental information of recurrence risk factor (RF) in patients with mild ischemic stroke (IS).
Methods: Consecutive patients with acute IS who met a criteria of modified Rankin Scale 0–2 were enrolled in this study. Exclusion criteria were as follows: over 80 yo, cardiogenic stroke, dementia, psychiatry disorder, extracorporenal dialysis. The following data were assessed during the hospitalized phase and after 6 months from onset: hypertension (HT), dyslipidemia (DL), diabetes mellitus (DM), obesity, smoking, alcohol, and physical activity (PA).
Results: A total of 106 patients were enrolled in the study. The percent of patients with RF in the hospitalized phase were HT 75.3%, DL 65.1%, DM 30.7%, obesity 29.2%, smoking 62.2%, alcohol 31.1%, PA 64.2%. The number of risk factors per patient was 0: 1.9%, 1: 8.5%, 2: 13.2%, 3 or more: 76.4%. Similarly, after 6 months from onset (68 subjects) the percents were HT 36.8%, HL 29.4%, DM 11.8%, obesity 20.6%, smoking 16.2%, alcohol 13.2%, PA 51.5%. In particularly, obesity and PA did not achieve guideline recommendations.
Conclusion: The possession rate of RF was high, and most patients did not achieve guideline recommendations in the recovery phase. Progressive preventive intervention is important for patients with mild IS.

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Background and Purpose: Most patients who have an internal carotid artery (ICA) stenosis with cerebral lesion have some cognitive dysfunction. To clarify the clinical efficiency of the Auditory Verbal Learning Test (AVLT) and to assess the relationship between AVLT and cerebral damage, we examined AVLT in patients with ICA stenosis.
Methods: 44 patients (35 males and 9 females) with ICA stenosis aged 56 to 83 (69.6±6.5) years old were evaluated. The educational periods were from 9 to 16 (12.3±2.8) years. Their activities of daily living (ADL) were independent. We assessed cognitive function with neurosychological tests including AVLT, Mini-mental State Examination (MMSE), Raven’s coloured progressive matrices (RCPM) and Frontal Assessment Battery (FAB), etc. We assessed cerebral damage (periventricular high intensity; PVH and white matter hyperintensity; WMH) with MRI. Then, we investigated the relationship between AVLT and other neuropsychological tests, and the relationship between AVLT and carotid/cerebral lesion.
Results: There was no association with lesion side of ICA stenosis and the scores of AVLT. In patients with ICA stenosis and cerebral damage (PVH and/or WMH), there was a significant relationship between the severity of cerebral damage and the scores in AVLT. AVLT had a significant relationship to other neuropsychological tests.
Conclusions: AVLT might be a good cognitive assessment for patients who have cerebral damage due to ICA stenosis.

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Objective: To investigate the differences in usefulness between head CT and MRI for selecting patients for intravenous injection of rt-PA during hyperacute brain infarction.
Subjects: Of a total of 1280 brain infarction patients who were admitted from October 2005 to March 2009, 45 patients (33 men and 12 women with an average age of 69.2±11.6 years) received intravenous rt-PA. Of these, 16 patients in whom only head CT was performed (593 inpatients from October 2005 to March 2007, CT standard group, 11 men and 5 women, average age 67.4±15.4 years) and 29 patients in whom head CT and MRI were performed (687 inpatients from April 2007 to March 2009, MRI standard group, 21 men and 7 women, average age 70.1±9.0 years) were studied.
Results: The median NIHSS scores immediately before intravenous rt-PA for the CT and MRI standard groups were 19 and 11, respectively; disease severity was lower for the MRI standard group. Three months later, the modified Rankin Scale (mRS) score for the MRI standard group (0–1: 31%, 2–3: 38%, 4–5: 24%, and 6: 12%) was better than for the CT standard group (0–1: 25%, 2–3: 25%, 4–5: 38%, and 6: 12%). The frequency of symptomatic intracranial hemorrhage was lower for the MRI standard group (6.9%) than for the CT standard group (18.8%). However, there was no statistical difference in the prognosis and incidence of intracranial hemorrhage between the 2 groups, due to the small number of cases.
Conclusion: When selecting patients for intravenous rt-PA, brain infarction improved more, prognosis was better three months later, and the frequency of symptomatic intracranial hemorrhage was lower among patients selected based on MRI standards than among those selected based on CT standards.

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We prospectively investigated oral intake ability in 57 dysphagic patients (41 cases were in recovery stage of acute stroke) managed with continuous nasal catheter feeding (CNG) or gastrostomy.
71.4% of the cases whose feeding methods were changed from CNG to intermittent oral catheter feeding (IOC) were able to eat orally three times a day, with a significantly higher incidence (p‹.05) than that in the CNG group, 21.4%, or gastrostomy group, 9.1%.
We also performed gastric motility study in 23 dysphagic patients managed with IOC or gastrostomy (16 cases were stroke patients). In that study, barium balls with colloidal fibers were infused into the stomach by catheter, and their retention time in the stomach was monitored. In the gastrostomy group, significantly more patients showed longer retention time (›35 min) compared with the IOC group (p‹.05).
These results indicate that gastrostomy disturbs physiological movement of the stomach and IOC should be considered before the application of gastrostomy in dysphagic patients in the recovery stage of stroke.

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It is well known that matrix metalloproteinase (MMP) families, especially MMP-2 and MMP-9, play an important role in progression of saccular cerebral aneurysms. However, the functions of MMP-2 and MMP-9 have not been reported for the early stage of progression of saccular cerebral aneurysms in detail. Clarification of the production mechanism for cerebral aneurysms is needed for further improvement of remedies against cerebral aneurysms. Thus, expression of MMP-2 and MMP-9 in the early stage of cerebral aneurysms was investigated by RT-PCR and immunostaining with anti-MMP-9 antibody to cereberovasculature of rats that had cerebral aneurysm induced by ligation of left common carotid artery.
MMP-2 gene was constitutively expressed at the anterior cerebral artery-olfactory artery junction regardless of whether ligation of the left common carotid artery was performed or not. MMP-9 gene was expressed at the anterior cerebral artery-olfactory artery junction on the non-ligated side 4 weeks after the operation. These results suggest that continuous expression of MMP-2 gene is independent of cerebral aneurysm inducing factors and that MMP-9 gene is expressed during the progression of cerebral aneurysms. Therefore, it is possible that MMP-9 participates in the formation of cerebral aneurysms while MMP-2 is expressed continuously.

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Epileptic seizures are one of the important clinical symptoms, and have the possibility to bring about various dysfunctions after cerebral stroke. Dysphagia is a common complication of stroke, but few investigators have discussed swallowing disorders in patients with poststroke epilepsy (PSE). We report the clinical features of swallowing function in PSE to clarify those relationships.
The study subjects were 15 patients (10 males and 5 females) with PSE, who were receiving rehabilitation on an inpatient basis. The age ranged from 59 to 95 years old and the underlying disease was cerebral infarction in all cases. The mean duration from stroke onset to seizures was 37.5±31.7 months. Patients were evaluated for swallowing function using bedside swallowing in the acute phase. Dysphagia based on the patient’s type of diet and outcomes were assessed on discharge.
As results, 6 of 15 patients consuming a regular diet (including porridge) could return home on discharge, but 3 patients were nutritionally managed with a dysphagia diet and 5 patients with enteral feeding were referred to another hospital. One patient died.
In conclusion, up to 50% of patients with PSE had swallowing problems and it influenced their outcome. We suggest that careful correspondence is necessary for patients with PSE with evaluation for swallowing disturbance.

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We report a 67-year-old man with right conjugate deviation. He had right digiti quinti sign, right hemi paresthesia and right conjugate deviation, and no abnormal findings were observed on the first brain MRI, including diffusion weighted images (DWI) at the emergency unit. After admission, the symptoms worsened to bilateral gaze palsy and finally into tetraparesis. The second MRI DWI (18 hours after the first MRI) showed the responsible lesion from the bilateral ventral to paramedian dorsal medulla and lower dorsal pons. The gaze palsy recovered through symptoms of bilateral gaze palsy on the third day and left medial longitudinal fasciculus syndrome on the fourteenth hospital day. In many cases of early brain-stem infarction, it is difficult to detect the lesion of infarction in the acute phase. In this case, we examined eye movement more carefully, so we could diagnose the lesion of infarction from hour to hour. Therefore, it is important to examine eye movement for evaluation of ischemic area in brain stem.

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We report a case who underwent external decompression for a hemorrhagic infarction after a thrombolysis with an intravenous injection of a recombinant tissue-type plasminogen activator (rt-PA, alteplase). A 71-year-old man was admitted to the emergency room of our hospital with hemiparesis, dysarthria and unconsciousness. A computed tomography scan showed no signs of ischemia. Intravenous rt-PA therapy (348,000IU/kg) was administered. He showed significant improvement just after administration, but a hemorrhagic transformation was recognized, with neurological deterioration 9 hours later, and external decompression was started 15 hours after administration. Hemostasis was normal during the surgery, from skin incision to closure. We concluded that craniotomy or craniectomy could be performed safely at least 15 hours after rt-PA administration.

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We report a transverse-sigmoid dural arteriovenous fistula (DAVF) successfully treated by trans-arterial sinus packing. A 63-year-old man complained of visual field disturbance and suffered from convulsion. Angiography showed isolated sinus DAVF fed by the middle meningeal and occipital arteries that drained into the straight sinus and Galenic vein. We attempted transvenous approaches to the affected sinus, but failed to access the site. Two days later, the patient complained of dysarthria, and CT showed diffuse edema in the cerebellum. The emergent angiograms showed increased shunt flow and venous retention. We introduced a microcatheter into the middle meningeal artery to reduce shunt flow. At the procedure, we could advance the guide wire and catheter into the affected sinus, and successfully embolized the isolated affected sinus. The patient felt symptom relief the day after the procedure. We propose that the expansion of the shunt channel due to the increased shunt flow might have induced the successful catheter advancement into the affected sinus.

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We report a case of an 80-year-old man who was admitted to our hospital due to right hemiparesis. He suffered from headache, walking difficulty and disorientation for three months. Brain CT scan and MRI revealed left lacunar infarction with hydrocephalus and paranasal sinusitis. After admission, he had repeated fever and consciousness disturbance. After a careful examination, we diagnosed hydrocephalus, cerebral infarction and syndrome of inappropriate secretion of ADH caused by meningoencephalitis and vasculitis. He then developed extensive cerebral infarction and finally died from subarachnoid hemorrhage. On autopsy, we diagnosed aspergillus meningoencephalitis with vasculitis. Aspergillus meningoencephalitis is rare, and its clinical diagnosis is difficult, and generally, final diagnosis is made by autopsy. This case is clinically rare because he had few underlying diseases and fulminate course after cerebral infarction.

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Churg-Strauss syndrome (CSS) is a systemic small-vessel vasculitis characterized by the presence of asthma, hypereosinophilia, and necrotizing vasculitis with extravascular eosinophil granulomas. Neurologic involvement in CSS is frequent, usually manifesting as peripheral neuropathy. Central nervous system involvement is much less frequently reported than peripheral neuropathy.
We report a rare case of CSS with unruptured cerebral aneurysm. The patient, 34-year-old man, had suffered from asthma, paranasal sinusitis, peripheral neuropathy, and eosinophilia. He was treated with prednisone and cyclophosphamide under the diagnosis of CSS. Four years later, he presented with syncope by vasovagal reflex during hospitalization. On brain MRI and MRA, a cerebral aneurysm was found incidentally. Angiography demonstrated fusiform aneurysm on the peripheral portion of the middle cerebral artery (MCA). Clipping was performed to obliterate the aneurysm and to clip-reconstruct the parent vessel, which was composed of a single inflow and outflow vessel. Extracranial-intracranial bypass was not performed, as flow to the distal MCA was restored. Microscopic examination of the excised aneurysmal wall revealed increased fibrous connective tissue without infiltration of eosinophils or inflammatory cells.
This case was considered very rare; the literature contains very few cases of cerebral vascular disease associated with CSS. We can’t exclude the possibility that the aneurysm was idiopathic and unrelated to his vasculitis. However, we think this is unlikely because of the location, shape and formation of the lesion. Standard treatment for cerebral aneurysm associated with vasculitis has not been identified because the natural history of each patient is unknown, so appropriate management is recommended.

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To assess the factors in stroke patients with severe disabilities affecting home return from a convalescent rehabilitation ward, we compared various factors in patients returning home (Home group) and those requiring long-term institutionalization (Institution group) as follows: age, severity of motor paresis and cognitive dysfunction, serial changes in their activities of daily living (ADL) level after admission, period of the admission, and number of family members. There was no difference in the ages, paresis and ADL score on admission between the two groups. The Mini-Mental State Examination (MMSE) scores in the Home group were significantly higher than those in the Institution group. The Home group had more family members and showed a significant increase in their ADL score 1 week after admission.

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In Japan, practice of cerebral vascular disorder could be grouped into three categories; acute, convalescence and maintenance phase. We introduce the method how we practice the acute phase in our institution. Our basic concept is comprehensive medical care, and to carry out efficient operation, Clinical Pathway (CP) has been introduced since 1999. CP is a multidisciplinary management tool based on evidence-based practice, in which the different tasks by the professionals involved in the patient care are defined. From the point of view of nurses, this enabled to intervene in patients’ early ambulation, preventing complications and preventing disuse syndrome. CP alone is not fully functional for patient care in daily practice since the aim is weighted mainly in treatment, and assistant tool is required to complete this. For example, we use assistant tool such as evaluation sheet of activity of daily life to set the goal of activity in each patient. Final evaluation of patients before discharge is discussed in a conference held once a week participated with doctor, nurse, therapist and medical society worker. In summary, for the treatment of acute phase, training of each professional is important, and team approach is required.

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Medical treatment of stroke becomes so complex that medical services are best provided effectively by interdisciplinary team care. Our stroke team is at the forming stage to organize a stroke unite near future. To clarify the present status of stroke care team, we conducted questionnaire survey on team work efficiency in three medical care teams, stroke rehabilitation, heart rehabilitation and breast surgery team. Compared with two other teams, our stroke team members need sharing the clear common vision, effective mutual communication and structure, which enriches each expertise. Team members, moreover, should understand the team process and always make an effort which improves the quality of stroke care by the feedback of outcome indicators.

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As an acute phase hospital, we do not have recovery phase medical wards. Therefore, it is important to have a team medical treatment within the hospital and enhance cooperation between hospitals. The functions of medical wards are segmentalized by symptoms or phases, so the cooperation between medical wards and the enhancement of team medical treatment are necessary. As cooperation between medical wards, nurses of each medical ward visit other wards for in-hospital apoplexy cooperation aiming for smooth ward transfer. In 2006, we established a stroke unit to conduct various team medical treatments in order to prevent disuse syndrome of egestion organs with “Rehabilitation from mouth and next to egestion.” as a keyword, and to prevent a pulmonary complication in “No Pnuemonia Week,” and also to aim for “No Inhibition.” As inter-hospital cooperation, the nurses and therapists periodically have visited our patients since eight years ago in order to prevent inconvenience in hospital transfer or time consumption in medical care. Furthermore, “Kochi Rehabilitation Nursing Study Group” focuses on improvement and cooperation of nursing technique for apoplexy within the prefecture.

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