Purpose: Our aim was to investigate whether stroke mobile telemedicine (SMT) should determine the outcome in acute ischemic stroke patients admitted to a regional hospital.
Methods: Our study was conducted in nine areas of Japan and included a total of 23 hospitals and-nine stroke centers in connection with 14 regional hospitals. In the first period, from June to August 2009, we continued the medical support system that had already been established in each area (non-SMT group). In the second period, from September 2009 to January 2010, we built a new medical support system using SMT (SMT group). We compared the frequency of favorable outcomes (modified Rankin scale 0–2), death one month after onset, and the usage ratio of intravenous thrombolysis using tPA (IV tPA) between the non-SMT and SMT groups.
Results: A total of 134 patients were admitted to the regional hospitals in this study. This group consisted of 66 patients (male: 35, median age: 81 years) in the non-SMT group and 68 patients (male: 32, median age: 78 years) in the SMT group. Ischemic stroke was found in 43 (65%) of the non-SMT group and 38 (56%) of the SMT group. Among the ischemic stroke patients who had a follow-up one month after admission, IV tPA was administered to 1 of 40 (3%) in the non-SMT group and 4 of 34 (12%) in the SMT group (p=0.173). Favorable outcomes were observed in 19 patients (48%) in the non-SMT group and 15 (44%) in the SMT group (p=0.818).
Conclusion: IV tPA was administered to 12% of the acute ischemic stroke patients, and the outcomes of the non-SMT and SMT groups were not significantly different. SMT may play an important role in reducing the disparity of stroke services in Japan.

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Our goal was to clarify the relationship between blood pressure (BP) and functional outcome at discharge in patients with intracerebral hemorrhage (ICH) by using the dataset of the Fukuoka Stroke Registry (FSR). We selected the patients with ICH who were admitted to the hospitals within 24 hours of onset between June 2007 and May 2008. A good functional outcome was defined as a modified Rankin Scale score of 2 or less at discharge. BPs were recorded at admission, 6 hours after admission, 24 hours after onset, and 7 days after onset, and multivariable analysis was performed to compare the BPs and baseline characteristics of the patients with and without good functional outcomes. Furthermore, the BPs of patients with ICH during antithrombotic therapy were compared of those with and without good outcomes. The multivariable analysis indicated that in all ICH patients, the systolic BP at 24 hours after onset was associated significantly with the outcome at discharge (p<0.05). Good functional outcomes were predicted for patients when their systolic BPs were less than 135 mmHg at 24 hours after onset. In the patients with ICH during antithrombotic therapy, the BP at admission was related to the patients functional outcomes (p<0.1). In conclusion, BPs during the acute phase were associated with the functional outcomes at discharge of ICH patients.

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Purpose: The aim of this study was to clarify the prognosis of dysphagia at discharge in a convalescent rehabilitation ward.
Subjects and Methods: The subjects were 47 patients, including 17 with intracerebral hemorrhage (ICH), 19 with cerebral infarction, and 11 with subarachnoid hemorrhage (SAH). All of the patients were fed with nasogastric tubes when they were transferred to our hospital. The mean age was 71.0 (SD 12.6). We divided them into two groups depending on the prognosis of feeding at discharge: oral intake and tube feeding. Then we compared the following factors between the groups: clinical features, physical function, cognitive function, swallowing function, and activities of daily living (ADL). In addition, we examined the differences among the etiologies.
Results: Those in the oral intake group were younger and had better physical function, cognitive function, swallowing function, and ADL. In addition, dysphagia in the patients with ICH improved more rapidly, and that improvement mostly started from about six weeks after onset. However, in the patients with SAH, the dysphagia started to improve about eight weeks after onset.
Conclusion: Our investigation showed that rehabilitation was necessary for not only swallowing function but also physical and cognitive function in patients with dysphagia in a convalescent rehabilitation ward. In addition, etiology might be important when considering the prognosis of dysphagia.

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We investigated transient ischemic attack (TIA) patients who were admitted to our hospital within 48 hours to clarify their risk of an acute stroke within 90 days using the ABCD² score. An acute ischemic stroke occurred in 8 patients (5%, stroke group) within 7 days of the onset of TIA (median, 2.5 days), and half of these were lacunar infarctions. The blood pressure (BP) on admission in the stroke group was significantly higher than that in the non-stroke group. Multivariate analysis revealed that the total but not the individual items (age, BP, clinical features, duration of symptoms, diabetes mellitus) of the ABCD² score tended to be a risk factor for ischemic stroke early after admission. The frequency of patients with both atrial fibrillation and arterial stenosis/occlusion was significantly higher in the stroke group than in the other group. It seems that a high BP, high ABCD² score, and a combination of atrial fibrillation and occlusive arterial disease are risk factors for acute strokes in TIA patients.

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Background and Purpose: Moyamoya disease, especially the hemorrhagic form, is rare, so many of its features are unknown. This study aims to clarify the current epidemiological features of hemorrhagic moyamoya disease.
Methods: The epidemiological features of the disease were analyzed, based on data from 416 patients who were diagnosed with moyamoya disease, registered with the Hokkaido Prefectural Government from 2002 to 2009. The features of hemorrhagic moyamoya disease were investigated and compared to those of ischemic moyamoya disease.
Results: Of the 416 patients, 85 were diagnosed with the hemorrhagic form of the disease. The average age of onset tended to be older with this form, peaking at ages 35–39 and 55–64. The detection rate of hemorrhagic moyamoya disease per year was 0.21 patients per 100 000 people. Upon onset, the activities of daily living (ADL) of patients with the hemorrhagic form were worse than those with the ischemic form, and there tended to be fewer cases of revascularization with the hemorrhagic than the ischemic form.
Conclusions: It is unclear whether revascularization is effective in treating hemorrhagic moyamoya disease or not, so the results of a more extensive clinical study, such as the JAM trial, must be examined.

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Background and Purpose: Neurological progression is often observed among patients with perforating artery territory stroke. The J-BAD Registry database was analyzed to determine the prevalence of neurological progression and clinical outcomes at discharge among patients with branch atheromatous disease (BAD).
Method: Eight Japanese hospitals registered acute stroke patients admitted within seven days of onset whose infarction areas were restricted to the lateral lenticulostriate artery (LSA) territory or paramedian pontine artery (PPA) territory; 413 patients were registered. BAD was defined as an infarction more than 20 mm long along the LSA or a characteristic pontine infarction shape extending to the ventral surface, with neither atrial fibrillation nor more than 50% stenosis of the large artery.
Results: Of the 305 patients with LSA infarctions and the 108 patients with PPA infarctions, 133 (43.6%) and 55 (50.9%), respectively, were classified as having BAD. Neurological progression (a worsening of more than one NIHSS score despite treatment during admission) was found in 30.1 and 15.7% of the LSA patients with and without BAD and 43.6 and 9.4% of the PPA patients with and without BAD. A good clinical outcome at discharge (modified Rankin Scale score of 0 or 1) was observed in 40.5 and 60.0% of the LSA patients with and without BAD and 36.5 and 67.6% of the PPA patients with and without BAD.
Conclusion: The prevalence of BAD was about half of all cases with localized LSA or PPA infarctions. BAD was characterized by neurological progression and a worse clinical outcome at discharge.

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Background and Purpose: Near occlusion (NO) is a description of the luminal diameter decrease or collapse of the distal internal carotid artery, owing to the severe stenosis of the carotid bulb. The goal of this study was to elucidate the pathogenesis of NO by histologically investigating carotid endarterectomy specimens.
Methods: We reviewed 38 continuous carotid endarterectomy specimens with severe stenosis (>85%; 95% with NO) using digital subtraction angiography. The uninterrupted plaques of the stenotic lesions were removed using carotid endarterectomy, sliced at 2-mm intervals, and histologically investigated using special staining.
Results: 11 out of 18 NO specimens (61%) histologically showed multiple remnant channels in occlusive thrombi or honey-comb patterns of neovascular channels, but only 1 out of 20 non-NO specimens showed such features.
Conclusions: The luminal narrowing or collapse of the distal internal carotid artery is caused by a significant decrease in perfusion pressure. Of the NO plaque specimens, 70% had histological findings of multiple and irregular luminal patterns in the acute or chronic occlusive thrombi caused by a rupture of the fibrous cap, which may be the cause of the extremely low perfusion pressure.

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Objective: Possible contributing factors for developing pneumonia in the acute phase of brain stroke were evaluated from the viewpoint of dysphagia rehabilitation.
Subjects and Methods: Patient characteristics, swallowing function, lesions, and the presence or absence of dysphagia rehabilitation of 504 patients with acute brain hemorrhage or infarction were assessed to determine the association of these with the onset of pneumonia.
Results: Ninety-one patients (18.1%) contracted pneumonia. Of these, 38 developed pneumonia within 3 days of hospital admission and 53 developed the disease, 4 days or later. Thirty-nine patients developed pneumonia while they were fasting, 5 patients, after resuming oral food intake but before dysphagia rehabilitation, and 9, after dysphagia rehabilitation.
Conclusion: Pneumonia, common in elderly patients, especially in those with severe neurological symptoms or cognitive disorders, or with bilateral multiple lesions, is associated with prolonged length of stay in the hospital and decline in the activity of daily living (ADL) after discharge from the hospital. Inappropriate interventions may also cause pneumonia, and it will affectively lower the functional prognosis of the patient and decline in the ADL. Therefore, adequate caution must be exercised when starting oral food intake for acute stroke patients.

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We clinically investigated 10 patients with spontaneous cervical internal carotid artery dissections (age range 36–70, mean 52±12 years; 8 male and 2 female) who were admitted to our university hospital between August 2002 and 2009. Cervical internal carotid artery dissection was diagnosed using findings from MRI, MRA, 3D-CTA, cerebral angiography, and carotid artery ultrasonography according to the diagnostic criteria of brain artery dissociation defined by the brain artery dissociation working group of the Strategies Against Stroke Study for Young Adults in Japan. The initial symptoms were stroke in eight patients, only neck pain in another, and no symptoms in the last. Four patients (40%) had neck pain or headache at onset. Five of the 10 patients had radiological improvements within three months after onset. The outcomes at three months were relatively good, with seven and three patients scoring 1 and 2, respectively, on the modified Rankin Scale. Disease did not recur in any patients during an average of 17.2 months of follow up. Spontaneous cervical internal carotid artery dissection is not rare in Japan. This condition should be considered when patients present with internal carotid artery occlusion or stenosis.

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Background and Purpose: Carotid stenosis is known to occur after neck radiotherapy. However, there are few reports of radiation-induced carotid artery lesions in patients with neck cancers in Japan. This study aimed to clarify the ultrasonographic characteristics of radiation-induced carotid artery lesions.
Methods: We evaluated 11 patients after neck radiotherapy for pharyngeal or laryngeal cancer. The mean time from radiotherapy to carotid ultrasound sonography was 55.6 months (range: 3–156 months). The carotid artery diameter, maximum intima medial thickness (max-IMT), peak systolic velocity (PSV), and distribution and properties of plaques were measured using carotid ultrasound sonography.
Results: All patients had increased IMT of the bilateral carotid artery. There was a linear correlation between the max-IMT and the duration of the post-radiation therapy interval. Four of the 11 patients (36%) developed carotid stenosis greater than 50% on the bilateral carotid artery, and their plaques were all unstable. Two patients developed cerebral infarctions at a mean of 12.3 years following radiotherapy.
Conclusion: Radiation-induced carotid artery lesions have a wide range of clinical courses in the bilateral carotid artery. Periodic carotid ultrasonography examinations are necessary to detect radiation-induced carotid artery lesions.

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Background and Purpose: The progression of neurological deficits in patients suffering from small deep infarcts (SDIs) of the brain is difficult to predict. Therefore, we classified these infarcts into two subtypes, branch atheromatous disease (BAD) and non-BAD, and investigated the clinical characteristics of the progression cases.
Methods: One hundred sixteen patients with acute SDI were classified into 60 BAD cases and 56 non-BAD cases. The cases were then divided into progress and non-progress groups, and the clinical characteristics were compared.
Result: Twenty-nine patients showed progression of symptoms, 22 in the BAD group and 7 in the non-BAD group. Significantly more progression cases were in the BAD group (p=0.003). Serial neuroimaging using MRI was obtained for 68 patients, and 41 of these had progressive symptoms. The rate of patients with enlarged lesions was 81.4% in the BAD group, 24.0% in the non-BAD group, 48.9% in the non-progress group, and 82.6% in the progress group. The lesion was enlarged significantly more often in the BAD group (p<0.001) and the progress group (p=0.006). A history of diabetes mellitus was associated with progressing stroke (p=0.024). In the BAD group, infarcts in the lateral lenticulostriate artery region were less progressive (p=0.029), whereas those in the paramedian pontine region were more progressive (p=0.043). None of patients with lesions in thalamoperforating arteries had neurological deterioration. The non-progress group (p<0.001) and non-BAD group (p=0.006) showed good outcomes.
Conclusion: The clinical characteristics, classification as BAD or non-BAD, and the serial neuroimaging of patients with SDI are useful as predictors of progressing stroke.

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Background and Purpose: To examine whether a telestroke system is an effective method of providing expert stroke care to patients in rural areas.
Methods: Videoconferencing and radiological imaging linked the stroke center of Asahikawa Medical University Hospital and the emergency room of Furano Hospital (a rural hospital without access to a stroke specialist). The stroke patients referred to Furano Hospital were diagnosed using the telestroke system and started on medication. The clinical courses and outcomes of the patients were reviewed.
Results: A stroke specialist at a university hospital obtained clinical information on stroke patients at Furano Hospital through the videoconferencing system and viewed brain MRI/MRA/CT images of the patients. As a result, the time from the onset to starting treatment for the stroke patients was shortened.
Conclusions: The telestroke system is a useful tool for rural stroke medicine.

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Purpose: To show problems in the rehabilitation system for stroke patients in the suburbs of a metropolitan area, the efficiency and outcomes of rehabilitation were investigated before and after a stroke unit (SU) was opened in our university hospital.
Methods: Seven hundred eighty-eight stroke patients who were admitted to our university hospital from 3/1/2006 to 3/31/2009 with residual disability from stroke were retrospectively analyzed on an annual basis with respect to patient age, hospital stay, FIM scores on admission and discharge, and to where they were discharged, namely, home, convalescent rehabilitation units, or nursing home-type units.
Results: In 2006, right after an SU was opened in our hospital, the hospital stay of stroke patients became markedly shorter than it had been previously. However, the length of stay returned to the prior length, especially for the patients who returned directly home. The rates of transfer within the residential district were 58.7% for convalescent rehabilitation units and 41.8% for nursing home-type units.
Conclusion: A relative lack of convalescent rehabilitation units and nursing home-type units in the metropolitan area increases hospitalization in acute-care hospitals and lowers the cost-effectiveness of SU care. The SU in this area is obliged to provide some post-acute-phase rehabilitation.

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Objective: To evaluate the clinical features of the acute phase of cerebellar hemorrhage and the factors that influence functional improvement and outcomes.
Materials and Methods: Subjective symptoms such as nausea and vertigo, cognitive function, swallowing function, hematoma volume, activities of daily living (ADL) after hospital discharge, and outcome as well as neurological symptoms at initial presentation were evaluated in 45 patients with cerebellar hemorrhage (28 men and 17 women). The mean length of the hospital stay was 24.6 days.
Results: Eleven patients had disturbances of consciousness, all of whom had an increase in hematoma volume and poor functional outcomes and could not be discharged. Among the 34 patients without disturbances of consciousness, 14 had nystagmus, 22 developed nausea and vertigo, 19 had extremity ataxia, 16 had truncal ataxia, 19 had dysphagia, 8 had dysarthria, and 24 had cognitive impairment. Twelve patients were discharged home, safely performed ADL, and had good cognitive and swallowing functions.
Conclusion: For patients in the acute phase of cerebellar hemorrhage, not only disturbance of consciousness and ADL but also cognitive and swallowing functions are important factors that determine when those patients can be discharged.

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Background: We used 3D ultrasonography, which gives the precise 3D morphology of carotid arterial plaques, to assess medical therapy for such plaques.
Cilostazol, an antiplatelet agent, is known to have a pleiotropic effect on the carotid arterial endothelium in addition to its antiplatelet effects. The purpose of the present study is to evaluate the effect of cilostazol on reducing carotid arterial plaques using 3D ultrasonography.
Method: The subjects were 21 patients with cerebral infarctions with carotid arterial plaques (M:F=16:5, mean age: 67±7) treated with cilostazol (200 mg daily). They had regular follow-ups at our out-patient clinic. Their medications were unchanged for over 3 months before the cilostazol administration. Measurement of plaque volumes and serological analyses of all subjects were performed 3 months after beginning administration and compared with those at the baseline.
The 3D plaque images were acquired using a Voluson 730 Expert (GE Health Care) with a 3D/4D probe.
Results: Among all subjects taking cilostazol, the carotid arterial plaque volume was reduced from 0.44±0.39 to 0.39±0.40 cm³ (p=0.005). Among the 19 subjects who did not show increased plaque volumes, serum high-density lipoprotein-cholesterol (HDL-C) was significantly increased from 59±22 to 65±23 mg/dl (p=0.017) in 3 months.
Conclusions: The present study using 3D ultrasonography showed that cilostazol reduces the volume of atherosclerotic carotid plaques within 3 months after administration. Among the subjects who did not show increased plaque volumes, serum HDL-C was significantly increased. The above data indicate that cilostazol reduces the volume of carotid arterial plaques and improves the lipid metabolism of the carotid arterial endothelium.

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We report a case of infarctions in the brain stem and cerebellum due to a vertebrobasilar artery dissection. A 47-year-old female suffered from sudden vertigo and headache without any focal neurological deficits. At first, computed tomography (CT) showed no significant findings, and her vertigo and headache became milder with rest. She failed to be diagnosed as having a brain infarction. The next day, dysarthria, dysphagia, left facial palsy, left hemiparesis, and left sensory disturbance developed, and she was admitted to our hospital. The initial diffusion-weighted image showed multiple high intensity lesions in the bilateral pons, midbrain, and right cerebellum. A severe narrowing of the bilateral intracranial vertebral arteries and the distal basilar artery were found using MRA and 3D-CT angiography. On the other hand, a basi-parallel anatomical scanning (BPAS) image showed an extension of the external diameter of those arteries. She was diagnosed as having multiple brain infarctions due to the vertebrobasilar artery dissection and was treated with anticoagulant agents and edaravone. The symptoms and the vascular narrowing gradually improved, and she moved to a rehabilitation hospital on the 55th hospital day. Brain artery dissection is relatively frequent in patients of 50 years or younger and sometimes occurs with only headache or vertigo. Emergency outpatient units can sometimes fail to distinguish a vertebrobasilar artery dissection from peripheral vertigo, as in the present case. Diagnostic guidelines should be established for vertebrobasilar artery dissection by using MRA, 3D-CT angiography, and BPAS images.

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An 80-year-old man had a 15-year history of diabetes mellitus and hypertension. The diabetes mellitus was poorly controlled for the previous five months. A pancreatic body tumor was diagnosed using contrast-enhanced computed tomography (CT) of the abdomen. Because the cancer was resectable, he was scheduled to undergo an operation in the Department of Surgery of our hospital. Right-sided motor weakness then developed gradually. Two days after onset, the patient was admitted to the Department of Neurology. Right-lower-limb-dominant hemiparesis and dysarthria were present. CT and diffusion-weighted magnetic resonance imaging of the brain showed a small infarct in the left pons. The D-dimer level was 6.2 µg/ml. The patient was diagnosed with Trousseau syndrome associated with the pancreatic body tumor. We started intravenous heparin therapy at a dose of 10,000 units per day from the day of admission to the day of surgery. The patient’s condition worsened gradually over the course of seven days. Enlargement of the infarct in the left pons was confirmed on a CT scan obtained five days after admission. However, the clinical symptoms gradually improved six days after admission. The D-dimer level was 0.8 µg/ml 15 days after admission. Because the patient’s general condition was good, distal pancreatectomy and celiac axis resection were performed 17 days after admission. Cerebral infarction did not recur during intravenous heparin therapy. Trousseau syndrome is generally associated with multiple acute infarcts; however, patients with malignancies can have only a single small infarct. If cerebral infarction develops in patients with malignancies, neurologists should administer heparin from admission to operation.

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We report a case of cerebral thrombosis associated with left middle cerebral artery stenosis and hyperhomocysteinemia. A 48-year-old man, without underlying previous illness, was admitted to our hospital presenting repeated episodes of a few minutes of right hemiparesis and dysesthesia. MRI FLAIR and diffusion-weighted imaging revealed a high intensity signal in the left posterior putamen. MRA and cerebral angiography showed left middle cerebral artery stenosis. He was diagnosed as having cerebral thrombosis and treated with Argatroban, edaravone, aspirin, and cilostazol, resulting in recovery from symptoms within five days after the initiation of treatment. Hyperhomocysteinemia and vitamin B6 and folic acid deficiencies were detected using a series of blood tests. His methylenetetrahydrofolate reductase 677 polymorphism was the TT genotype. Recently, two meta-analyses reported that lowering homocysteine using folic acid and vitamins B6 and B12 reduced the risk of stroke.
In cerebral infarct cases without known causes, we need to assess the blood homocysteine level and may consider prescribing folic acid and vitamins B6 and B12 in addition to antiplatelet treatment.

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We describe a case (66 year-old male) of delayed onset of a left vertebral artery (VA) occlusion after blunt cervical trauma caused by an operational error when using a cultivator. Left-side neck pain and occipital headache persisted after the accident, then disappeared. Ten weeks later, the man was admitted to our hospital because of consciousness disturbance and left hemiparesis. MR angiography revealed complete left VA occlusion, and a basi-parallel anatomical scanning MRI showed the appearance of the left VA. Diffusion-weighted images showed an infarction of the territory of the left posterior inferior cerebellar artery as well as the anterior spinal artery. Hyperdense artery signs were seen from the left VA to the basilar artery on the cranial CT. Based on these findings, a diagnosis was made of VA injury, which is considered to have caused the dissection, associated with the cervical hyperextension. This case illustrates a rare cause of blunt carotid trauma. VA injury should be considered in patients presenting with persistent neck pain and occipital headache after blunt carotid trauma, even if the period from the accident to the appearance of neurological symptoms is long.

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The authors report a case of three-month-old boy who suffered a subarachnoid hemorrhage and was admitted to our hospital. A neuroimaging study suggested a partially thrombosed cerebral aneurysm, and extirpation to prevent rebleeding was performed at the subacute stage. The postoperative pathological diagnosis was arteriovenous malformation (AVM), which yielded a discrepancy between pre- and intraoperative findings. Total removal of the lesion was confirmed on postoperative examination, and the patient was discharged without any complications. Subarachnoid hemorrhage is more commonly due to an AVM than to cerebral aneurysm in childhood hemorrhagic stroke, but its onset in infancy is very rare. The AVM was safely removed because of the lack of an arteriovenous shunt. AVM is a differential diagnosis for preoperative images showing cerebral aneurysms.

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Physostigmine is used to treat emission loss. We report on a 31-year-old male who used physostigmine for artificial ejaculation after a cervical spinal cord injury. He suffered an acute intracerebral hemorrhage after a subcutaneous physostigmine injection and artificial ejaculation. We examined him carefully using MRI, digital subtraction angiography, and so on, but there were no malignancies, aneurysms, or any other vascular abnormalities to induce the hemorrhage. Physostigmine is known as a safe drug to stimulate the parasympathetic system. Physostigmine injection and autonomic hyperreflexia due to artificial ejaculation may increase blood pressure and the risk of intracerebral hemorrhage in spinal men.

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We report our experience with patients for whom favorable outcomes were obtained following endovascular therapy during the acute stage for progressing stroke in which a relapse of symptoms could not be controlled despite medical treatment. Patient 1 had severe stenosis of the internal carotid artery, and a cerebral infarction was thought to have occurred due to either artery-to-artery embolism or hemodynamic factors. Patient 2 had severe stenosis of the basilar artery that was thought to have been caused by hemodynamic factors. Usually, acute treatment of a cerebral infarction resulting from stenotic lesions of intracranial or major neck or cerebral arteries generally involves medical treatment such as antithrombotic therapy, with surgical treatment considered on an elective basis. However, in cases of progressing stroke where symptoms cannot be controlled with medical treatment, surgical treatment may be considered during the acute stage. Unlike elective surgery, however, emergency surgery is associated with an increased risk of treatment-related complications. It is therefore important to accurately assess the pathology of each patient and to determine whether the patient is a candidate for surgery.

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The patient was a 69-year-old male prisoner. He had total aphasia and right hemiparesis. CT and MRI showed a left MCA area infarction. The family of the patient was not notified of the admission. Two prison guards always restrained the patient. The patient had no health insurance, so the prison paid for all medical expenses. The patient was moved to another hospital for the convenience of the prison. In this case, the patient could not exercise his autonomy because of the total aphasia. Beneficence, non-maleficence, and justice totally depended on our hospital. The transfer to another hospital was not ethically appropriate. The confirmation and documentation of the living wills of prisoners and ethical guidelines for medical practice for prisoners is necessary.

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A 72-year-old man was admitted to our hospital for the treatment of asymptomatic progressive stenosis of the left internal carotid artery resistant to medical therapy. Because he did not have any risk factors for cerebral hyperperfusion syndrome (CHS), we performed carotid artery stenting (CAS) under local anesthesia. Immediately after the placement of two stents with the use of a filter protection device, his systolic blood pressure dropped below 80 mmHg, and intravenous administration of a vasopressor was needed. Three hours after the CAS, the patient suddenly became restless and exhibited sensory aphasia and right hemiparesis and had progressive worsening of these symptoms, but CT did not show any signs of hemorrhage. Neither MRI nor angiography performed the following day could detect signs of either a large infarction or arterial occlusion. During the progression of symptoms, a drip infusion of large doses of a vasopressor was needed to maintain his systolic blood pressure over 100 mmHg. On the second day, he had two convulsive seizures, and we identified the development of CHS. We decreased the drip infusion of vasopressor and strictly maintained his blood pressure below 100 mmHg. The neurological deficit improved quickly and disappeared completely within two days. Four days after the CAS, SPECT showed hyperperfusion on the left side. He had not shown any risk factors for CHS, and CSH developed under low blood pressure. We speculate that the sharp fluctuation of blood pressure and microemboli produced dysfunction of the cerebral autoregulation, which caused CHS under these conditions.

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A 70-year-old man with a ruptured aneurysm located at the right middle cerebral artery underwent neck clipping three days after the onset of a subarachnoid hemorrhage. Four days later, the patient suddenly went into a shock state due to intra-abdominal bleeding. Angiography showed a ruptured hepatic artery aneurysm that was embolized using the coil-through endovascular technique. The subsequent postoperative course was uneventful. The present case suggests that an incidental visceral artery aneurysm may rupture during therapy for cerebral vasospasm following a subarachnoid hemorrhage.

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We retrospectively examined the waiting periods for 295 patients who were transferred from acute hospitals in Nagano prefecture to subacute hospitals in other prefectures over a two-year period. Stroke (51 patients) accounted for 54% of the endogenous disease cases. The number of patients with apoplexy reached a monthly maximum in August and a minimum in February. Cerebral hemorrhage accounted for 41% of the cases, which was higher than the prevalent reported ratio. The average waiting period for the stroke patients was 15 days. Among the patients with a waiting period of 14 days or longer, stroke accounted for the highest proportion (32%) of cases. Rehabilitation hospitals were identified by family members (55%), medical social workers (16%), or website information regarding the hospitals (12%). The reason for the long waiting period for stroke patients is thought to be that the doctors providing treatment during the acute phase may not have knowledge of the medical care system in the patients’ home villages or in other prefectures. We expect that community medical support hospitals or hospitals certified by the Japan Stroke Society in the area where the patients live generally serve as the contact facilities for hospital transfers.

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Background and Purpose: The purpose of this study was to identify the clinical features and outcome of dysphagia among hospitalized patients after having a pontine infarction.
Methods: Thirty patients suffering from acute pontine infarction referred to our hospital were studied. Patients were clinically evaluated by age, neurological symptoms, cognitive function, swallowing function and lesion. Twenty patients underwent videofluoroscopy to assess whether they were aspiring their food. We divided 30 patients into three groups, regular diet group, dysphagia diet group and enteral feeding group at discharge. Lesion localization and clinical features were compared.
Result: In terms of age, neurological symptoms and cognitive tests, there were significant differences among the three groups. Dysphagia was seen in 25 of 30 patients, and 11 of the 25 could not eat anything at hospital discharge. Aspiration on video fluoroscopy was found in 16 of 20 (80.0%) patients (9 patients had silent aspiration).
Conclusion: The outcome of dysphagia due to pontine infarction was favorable, but the incidence of silent aspiration was high. Therefore, we have to continue monitoring the swallowing ability of patients who had experienced a pontine infarction.

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The aims of this study were to develop a motor ability scale (MAS) for stroke patients and to verify the validity and the reliability of this scale. The subjects were 12 stroke patients in a convalescent rehabilitation ward. The MAS consists of 12 items, and each item is rated on a five-point scale. The MAS, Brunnstrom stage (BrS), and functional independence measure (FIM) were used to evaluate the patients. The results showed significant relationships between each item of the MAS (Cronbach’s alpha: 0.956). The total score of the MAS and the motor items of FIM had a strongly significant relationship (r=0.876, 95%, CI: 0.607–0.965, power at alpha 1%: 0.926).

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As is well known, apathy often occurs after cerebral infarction and is an important symptom preceding vascular dementia. It is important that we diagnose apathy in its early stage and prevent patients from developing vascular dementia using medical and social interventions to apathy. However, there are few studies on the pathophysiology of post-stroke apathy, and the evidence level is low for its treatment. In addition to anti-platelet and neuroprotective functions of cilostazol, animal studies showed an increased dopamine level in the brain after cilostazol administration, suggesting that this drug might reduce apathy after cerebral infarction. In this study, we compared the effects of cilostazol and aspirin on the apathy scale in patients with cerebral infarction at an acute stage. The drugs were administered for six months. The patient group given cilostazol showed lower apathy scores compared to the aspirin group. This result suggests that cilostazol is effective for preventing apathy after cerebral infarction.

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We report the present conditions of the rt-PA therapy in the small institution.
The rt-PA therapy was started from Oct. 2007 in our hospital. Since then until March 2010, 314 cases of acute cerebral infarction were transferred to our hospital. In 15 (4.8%) out of those 314 cases, rt-PA treatment was applied. Just after their admission to the hospital, CT, MRI and MRA were routinely carried out in those 15 cases. Re-canalization of the occluded artery was obtained in 12 cases, not in remaining 3. There was a discrepancy in post treatment symptomatic changes between the cases showed the re-canalization and the no re-canalization. Cases in which the re-canalization was obtained, did not always show the improvement of symptoms.
As a result, 12 cases showed the improvement of clinical symptoms, 2 cases showed no change and one died by digestive organ bleeding.
In the small institution, cooperation with not only physicians in different department, nurses, medical technicians but also almost all the members in the hospital is indispensable. We have a class or course about the rt-PA treatment 3 times in a year to provide the motivation to all the staffs in our hospital.

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We report two patients who received early carotid artery stenting within 24 hours after intravenous thrombolysis for acute ischemic stroke. Both patients showed early clinical deterioration after initial improvement from intravenous administration of tissue plasminogen activator. In case of cerebral ischemia due to main trunk artery stenosis, patients are at risk for recurrent stroke. In those patients, rapid diagnosis is required. Furthermore, a treatment strategy needs to be established after intravenous thrombolysis.

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