Acute revascularization of carotid artery occlusion after carotid artery stenting (CAS) remains controversial. This report describes successful revascularization by the deployment of rescue stents in two patients with subacute in-stent thrombosis (SAT) of internal carotid arteries (ICA) that had become re-occluded. The postoperative courses of both patients were uneventful, and the patency of the ICA was confirmed at follow-up one year later. The development of SAT in these two patients might have been due to insufficient antiplatelet therapy. We used proximal and distal balloon catheters as protection devices during all procedures and subsequently aspirated clots. Rescue stent-in-stenting is an effective alternative treatment for SAT if all clots can be safely removed under absolute carotid protection without migration into the brain.

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Background and Purpose: A rural-urban disparity exists in the management and care of acute stroke. We investigated the effectiveness and problems of stroke mobile telemedicine (SMT) for acute stroke.
Methods: We conducted SMT using a mobile phone with a video system (real-time, 2-way audio/video). When patients were suspected of having an acute stroke on arrival at Kagamino Hospital, a rural hospital, we contacted stroke experts at Kawasaki Stroke Center. The patient’s symptoms, neurological findings, and neuroimaging were assessed using SMT. After clinical assessment, recommendations were made for the patient’s management and care.
Results: From September 2008 to January 2009, 6 patients were enrolled (male 4, mean age 76.5 years). Three had ischemic stroke (cardioembolism: 1, large artery atherosclerosis: 1, others: 1), 1 had TIA, 1 had intracranial hemorrhage and 1 had vertigo. SMT provided a clear image of patients’ neurological findings and neuroimages, including CT and MRI, to stroke experts. Stroke experts then recommended the medication and care for patients.
Conclusions: SMT is a useful telemedicine method for acute stroke care.

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Background and Purpose: We evaluated the usefulness of assessing by diffusion-perfusion mismatch (D/P mismatch) whether there is adaptation of neuroendovascular revascularization for acute ischemic stroke out of IV t-PA.
Methods: We retrospectively analyzed 24 patients who underwent D/P mismatch and endovascular treatment between October 2005 and September 2008. This investigation included stroke patients with a National Institutes of Health Stroke Scale (NIHSS) score less than 4.
Results: Sixteen acute ischemic stroke patients had an NIHSS score greater than 5. Eight patients (50%) had a favorable neurological outcome (modified Rankin Scale 0 to 2). Eight acute ischemic stroke patients had an NIHSS score equal to or less than 4. Four patients who underwent emergency endovascular treatment on admission had a favorable neurological outcome, but 3 patients treated for progressive stroke after admission all had a poor prognosis.
Conclusion: Evaluating D/P mismatch was useful for determining the adaptation of emergency neuroendovascular revascularization for acute ischemic stroke out of IV t-PA. Acute ischemic stroke patients with an NIHSS score equal to or less than 4 and diffusion/perfusion mismatch need careful observation to enable endovascular treatment immediately after progressive stroke.

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Background and Purpose: In our institution we attempt to recanalize embolic occlusion of the distal internal carotid artery in acute ischemic stroke patients with an emergency mechanical embolectomy (EME), mainly using suction with a balloon-guided catheter. In April 2009, the running aspiration technique with an inner-guided catheter (RAT) was introduced for EME. Here we clarify the safety and efficacy of EME with RAT.
Methods: Of 1105 consecutive acute ischemic stroke patients admitted to our institution from April 2006 to February 2010, patients receiving EME were assessed. We analyzed the background of subjects, the combined techniques used during EME, and the outcome after EME.
Results: EME was performed in 8 patients, all of whom were contraindicated for intravenous rt-PA and 5 of whom were treated with RAT. Both clot retrieval with a microsnare and angioplasty with a balloon catheter were combined with EME in the 5 patients. A large volume of retrieved clots, the appearance of back flow from the balloon-guided catheter, and complete recanalization were seen in 1, 0, and 0 of 3 patients receiving EME without RAT, whereas 5, 5, and 4 of 5 patients with RAT, respectively. Neither severe procedure-related complications nor symptomatic intracranial hemorrhage occurred in the 8 patients. A favorable clinical outcome (0-2 points on a 3-month modified Rankin Scale) was obtained in 4 patients, all of whom were treated by EME with RAT and recanalized completely.
Conclusions: Safe and effective EME with RAT was feasible for embolic occlusion of the distal internal carotid artery.

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The use of recombinant tissue plasminogen activator (rt-PA) was approved in Japan in October 2005, and has had a marked effect on the treatment of patients presenting with acute ischemic stroke. Since the administration of rt-PA might cause intracerebral hemorrhage (ICH) and a poor prognosis, it is necessary to identify predictors of ICH after treatment with rt-PA. In this article, we examined 58 consecutive patients with acute ischemic stroke treated with intravenous rt-PA within 3 hours of symptom onset for 45 months, March 2006 to November 2009. In principle, we evaluated patients before and one day after rt-PA with MRI. We made a retrospective comparison of 21 patients with hemorrhagic change on CT and MRI T2* within 36 hours and 37 patients without hemorrhagic change.
The rate of ICH with or without symptoms was increased with a higher NIHSS and infarction range, defined by DWI ASPECTS. Major artery occlusion and reperfusion, including partial recanalization in MRA, were taken as factors in the hemorrhage group.
In conclusion, DWI ASPECTS and NIHSS were useful predictors of ICH after rt-PA administration.

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A 34-year-old woman, who had gradually developed right lower-limb-dominant hemiparesis over two days, was admitted to the Department of Neurology at our hospital. Buccal erythema, hyperesthesia, and low-grade fever had occurred occasionally during the 3 years before presentation. On admission, the platelet count was 89000/mm³. Diffusion-weighted (DW) MRI showed multiple cerebral infarcts in the left frontal and parietal lobes. MRA showed occlusion of the left common carotid artery. Transesophageal echocardiography showed spontaneous echo contrast within the left atrium. Transvenous echo of the lower limbs showed deep vein thrombi (DVT). She was given aspirin, heparin, and edaravone. The next day, delirium developed. DW MRI showed a large infarction from the left lobe to the parietal lobe. Intravenous methylprednisolone (1000 mg/day) was given for 3 days. After 6 days, she became alert; however, right hemiparesis and transcortical motor aphasia remained. After 7 days, ANA, ds-DNA and lupus anticoagulant (LA) were positive. She was given a diagnosis of SLE on the basis of the buccal erythema, hyperesthesia, low platelet count, and positive tests for ANA and ds-DNA. Antiphopholipid syndrome (APS) accompanied by SLE was diagnosed on the basis of the brain infarction, DVT, and positive repeated tests for LA, and she received prednisolone, aspirin, and warfarin. After 2 months, the neurological symptoms improved, and she was discharged.
APS was suspected on the basis of the patient s age, sex, medical history, and results of neurologic examinations. Although antibodies for APS cannot be measured on emergency admission, early treatment of APS is essential.

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We have experienced two cases of mobile carotid plaque detected by carotid ultrasound sonography. A 55-year-old woman, in the terminal stage of stomach cancer, suffered a cerebral infarction in the region of the left MCA. Carotid artery stenosis was not detected by MRA, but carotid mobile plaque was detected by carotid ultrasound sonography. The mobile plaque disappeared with only antiplatelet therapy. The other patient, a 69-year-old woman, had a history of angina and had taken two antiplatelet drugs. She suffered a right cerebral infarction and carotid artery stenosis was not detected by MRA, but carotid mobile plaque was detected by carotid ultrasound sonography. We added another antiplatelet drug, but her symptoms progressed. We performed CAS, which stopped symptom progression. Generally, mobile plaque was not detected by MRA, and carotid ultrasound sonography was reliable to evaluate carotid mobile plaque. We suggest that carotid mobile plaque should be treated with conservative therapy initially, but when symptoms progress, CEA or CAS should be performed promptly.

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Acute phase basilar artery occlusive disease may readily become serious, and recanalization therapy is very important. We performed direct PTA for four consecutive patients with acute basilar artery occlusion for whom intravenous rt-PA therapy was not indicated. As a result, recanalization was achieved in all cases. A PTA balloon was used in the first case, but it was replaced with a silicone balloon because recanalization could not be achieved. A silicone balloon was used from the outset in the other three cases. A silicone balloon is softer than a PTA balloon, has almost no potential for dilating arteriosclerotic lesions, and can be used for bend lesions if carefully manipulated. Because our four patients had cardiac embolism, recanalization was probably achieved because there were few arteriosclerotic changes. This is a useful therapeutic modality in selected cases.

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A 61-old-year man was admitted to our hospital because of transient motor aphasia. On admission, he was free from neurological symptoms, and diffusion-weighted MRI was normal. He was diagnosed with TIA and received argatroban and edarabone. After 2 hours, motor aphasia recurred. After 50 hours, JCS was III-100, and right hemiplegia had developed. Although the clinical symptoms appeared to be caused by diffuse lesions in the middle cerebral artery region, diffusion-weighted MRI showed left frontotemporal infarction, indicating considerable clinical-diffusion mismatch. One month later, his symptoms improved. Argatroban therapy for 7 consecutive days may be effective to manage cases of clinical-diffusion mismatch.

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