Purpose: Our goal was to investigate the utility of 24-hour ambulatory blood pressure monitoring (ABPM) for the risk stratification of cardiovascular events in hypertensive patients with asymptomatic or symptomatic lacunar infarcts.
Methods: A total of 175 hypertensive patients with MRI evidence of asymptomatic or symptomatic lacunar infarcts (92 men, mean age of 69±11 years old) were studied. Patients with symptomatic infarctions were included whose events occurred more than 6 months after the onset. ABPM was performed in all patients in the outpatient clinic. Parameters obtained from ABPM were related to the composite outcome which consisted of all death and fatal or non-fatal cardiovascular events by using the Cox proportional hazard model.
Results: Mean follow-up period was 4.8 years and the composite outcome was recorded in 38 patients. 34 of them (89%) had recurrence of lacunar infarcts. Significant association between sleep-time lowest systolic blood pressure and composite outcome was demonstrated by multivariate Cox hazard analyses (HR 1.025, 95%CI 1.011-1.039, p<0.001). The risk for composite outcome in patients with the highest tertile of sleep-time lowest systolic blood pressure (≥133 mmHg) was significantly elevated when compared to the lowest tertile (<132 mmHg, HR 3.93, 95%CI 1.57-9.86, p=0.004).
Conclusions: Sleep-time lowest systolic blood pressure in ABPM may be a useful parameter for the risk stratification of future cardiovascular events in hypertensive patients with asymptomatic or symptomatic lacunar infarcts, especially for the recurrence of these events.

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Backgrand and Purpose: Reversible cerebral vasoconstriction syndrome (RCVS) is characterized by a thunderclap headache and constriction of cerebral arteries with or without focal neurological deficit. To identify clinical variations of domestic cases of RCVS, we investigated the clinical features of eight RCVS patients.
Method: Six consecutive patients diagnosed as RCVS from 2004 to 2010 in our hospital were investigated.
Results: There were 4 females and 2 males with a mean age of 44 years (39-53). All patients experienced a thunderclap headache. Three patients had cerebrovascular complications; one case of intra parenchymal hemorrhage and two cases of both cerebral hemorrhage and cortical subarachnoid hemorrhage. Five were treated with verapamil. Clinical courses were fairly benign; however, one patient had hemiparesis as a sequela.
Conclusion: RCVS should be considered in patients with a thunderclap headache as an important differential diagnosis.

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A 75-yearold man presented with convulsions and a history of minor head trauma. Fourteen days after the onset of trauma, he was comatose with a GCS of 7 and left hemiparesis. The NIH stroke scale score was 20, and the brain CT revealed a high density area, mainly in the right putamen. Thirty two days after the onset of trauma, subcortical hemorrhage appeared in the left temporal lobe. Cerebral angiography demonstrated a dural arteriovenous fistula (dAVF) draining into the left transverse-sigmoid sinus (TS). The retrograde venous drainage into the internal cerebral vein was observed. Retrospective review of the MRI obtained before the putaminal hemorrhage demonstrated that dAVF should be suspected when there is slight hyperintensity in the FLAIR image in deep brain structures and when visualization of the transverse sinus can be observed in patients with a history of minor trauma.

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We report a case of acute middle cerebral artery (MCA) occlusion which was half-recanalized after using a Merci retriever. A 76 year-old woman was found unconscious and transported to our institution 3.5 hours later. NIHSS was 35 on admission. Diffusion MR imaging showed a high intensity lesion in the left middle cerebral artery, and following an angiogram displayes total occlusion of the left M1 and unruptured aneurysms in the right MCA and left C3. She was diagnosed with a cardiogenic embolism due to poorly controlled arterial fibrillation. Mechanical thrombectomy using a Merci retriever was then attempted. After the first procedure, the occluded MCA was recanalized to the distal portion. Although recanalization was accomplished in less than 50% at the occluded part, we did not perform a second procedure. Angiogram at the recovery stage displayed stenosis of the M1 within another leg of the fenestration. Her neurological symptoms improved gradually, and NIHSS was 15 on discharge. Fenestration of the MCA is an unusual anomaly. The angiographic incidence of MCA fenestration is 0.02-1.0%. Such an anomaly needs to be taken into consideration before opening the occluded MCA when using a Merci retriever to avoid catastrophic vessel injury.

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An 86 year-old man was admitted to our hospital with sudden left paralysis. He had received no medical treatment though the ureteral carcinoma was pointed out as in the past. CT scan demonstrated subcortical hemorrhage in the right frontal lobe. MRI demonstrated no vascular abnormality. He was treated conservatively and moved to rehabilitation ward. He complained of a sudden headache on the 31st day of hospitalization. Subarachnoid hemorrhage was found in the left convexity area by CT scan and a de novo fusiform aneurysm was discovered at the peripheral branch of middle cerebral artery by MRA and angiography. Vascular trapping and resection of aneurysm was performed immediately. Postoperative, the pathological diagnosis was a neoplastic aneurysm. Atypical cells had invaded the aneurismal wall. After the operation, any cerebral infarction according to the vascular trapping did not develop. In the treatment of the patient with carcinoma, it is necessary to note that the formation and the rupture of a cerebral aneurysm will be caused in a short term.

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A 45 year-old man presented with dizziness and left neck pain (onset). Eight days later, he presented with an overall rash, fever and throbbing headache. At the first visit (ten days after the onset), he was diagnosed to have chicken pox. On seventeenth day, the cerebrocervical T₁-weighted MRI showed a dilated left vertebral artery and a high intensity intramural hematoma even though he had no neurological symptoms. The clinical course and neuroimaging findings confirmed the diagnosis of vertebral dissecting aneurysm in a subacute stage. Based on these findings, we administered oral varacyclovir and antihypertensive treatment without antithrombotic therapy. This is a rare case of a dissecting aneurysm associated with VZV infection, and their close association in time suggests a causal association between them.

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Background: Recently, the number of patients with a lung tumor, having CT-guided lung needle marking (CTLNM) as assisted by video during thoracoscopic surgery (VATS) has increased. The authors reported a rare case of a cerebral air embolism presenting immediately after CTLNM, in order to note, that a cerebral air embolism is a critical complication of CTLNM, in spite of its low frequency.
Case presentation: A 66 year-old male was admitted to have VATS for a lung nodule in the right S8 area. Immediately after CTLNM for VATS, the patient had loss of consciousness, right hemiplegia, and generalized convulsion. Multiple air embolisms were demonstrated on the brain CT immediately after occurrence of neurological deficits. Hyperbaric oxygen therapy, intravenous injection of edaravone and argatroban hydrate, and other therapies were performed for the treatment of the cerebral air embolisms. The neurological deficits were improved by these treatments, and the patient had an open chest surgery one month after the air embolism.
Conclusion: Air embolisms are rare complications of CTLNM, but often can lead the patients into a critical condition. The authors note that sufficient preparations for the treatment of air embolism are necessary before CTLNM.

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Early recurrence of ischemic stroke (ERIS), as well as symptomatic intracranial hemorrhage (SICH) and progressive stroke (PS), causes early neurological deterioration (END) after thrombolysis. This study's goal was to investigate the incidence, characteristics, and mechanisms of END within 24 h after rt-PA infusion. Of 200 patients (65 women, 74±11 years) who were treated with intravenous rt-PA, 15.0% developed END: 1.5% with ERIS, 3.0% with SICH, and 10.5% with PS. As compared to patients without END, those with ERIS were older and had a higher D-dimer level on admission. Patients with SICH and those with PS more frequently took oral warfarin and antiplatelets, respectively, prior to stroke onset. mRS at 3 months were higher in patients with END than those without.

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Acute stroke patients whose events occurred in an unknown time frame were treated with intravenous thrombolysis when showing DWI/FLAIR mismatch. From June 2009 to October 2011, 13 patients [83 (67-90) years; NIHSS score, 16 (11-20)] were enrolled. Interval between last known normal time and thrombolysis was 5.6 (5.0-11.6) h. Recanalization within 24 h was seen in 10 patients (complete, n=5). None of the patients experienced symptomatic cerebral hemorrhage. At day 7, 7 patients showed dramatic recovery (≥10-point reduction in NIHSS score or of 0-1). At 3 months, 5 patients had mRS score of 0-2. Stroke patients with DWI/FLAIR mismatch may be able to safely receive intravenous thrombolysis.

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