Objectives: Levetiracetam (LEV) was administered as an adjunctive to cilostazol (CSZ) and eicosapentaenoic acid (EPA) for the treatment of vasospasm after a subarachnoid hemorrhage due to a ruptured cerebral aneurysm to examine LEV-add-on therapy.Methods: Event rates of vasospasm and vasospasm-induced cerebral infarction as well as prognosis were examined in patients who had acute surgical operations due to a subarachnoid hemorrhage caused by a ruptured cerebral aneurysm between April 2005 and September 2011. The patients were assigned to a group of CSZ and EPA, a group of LEV-add-on, or the control group.Results: Forty patients were assigned to the control group, 14 patients to the CSZ and EPA group, and 19 patients to the +LEV group. Symptomatic cerebral vasospasm was inhibited in both of the treated groups compared to the control. Incidence of vasospasm-induced cerebral infarction decreased in the +LEV group.Conclusions: The inhibitory effect of coadministration of CSZ and EPA on vasospasm was confirmed in this study as previously reported. The effect of LEV on vasospasm was suggested clinically for the first time. Further studies to examine the inhibitory effect of concomitant use of various medicines are expected.

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Epileptic seizure is one of the major complications of moyamoya disease (MMD). We experienced seven epileptic patients with MMD. All patients were female with mental retardation and five patients had hemi- or diplegia. Ages at onset of MMD and epilepsy were 1-9 years (mean: 3.1±2.7) and 1-37 years (5.1±4.8), respectively. Of five patients who had a MRI-visible ischemic lesion, four had a bilateral lesion and one had a unilateral lesion. Six patients had surgery before the first visit. All patients were diagnosed with symptomatic focal epilepsy. Two patients had simple partial seizures with uncomfortable chest feelings, and seven patients had complex partial seizures with frontal lobe and temporal lobe symptomatology. All patients had epileptiform discharge (ED) within the frontal, temporal, central, and parietal leads, and none had ED in occipital leads. Two patients with infantile hemiplegia had startle-induced seizures, which may be one of the characteristics of epilepsy in moyamoya disease.

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Background and purpose: Antithrombotic agents, such as aspirin and warfarin, are recognized as having preventive effects against cerebral and cardiovascular events in patients with atherothrombotic disease. However, antithrombotic agents are known to increase the risk of bleeding in patients undergoing invasive surgical procedures. Therefore, we conducted a questionnaire survey to examine the current state and issues regarding the discontinuation of antithrombotic agents for invasive surgical procedures in Japan.Methods: A questionnaire containing items on the management of antithrombotic therapy for the invasive surgical procedures including dental extraction, cataract surgery, and endoscopic procedures was conducted on stroke specialists in 12 institutions in Japan in January and February 2010.Results: Responses were obtained from 180 stroke specialists. Dental extraction and cataract surgery were performed under the continuation of aspirin or warfarin therapy by 75% and 90% of respondents, respectively. For endoscopic procedures, especially low-risk procedures, 35-45% of respondents indicated that they performed the procedures under the continuation of antithrombotic agents, which goes against the established guidelines. Stroke due to transient withdrawal of antithrombotic agents occurred significantly more frequently in patients with symptomatic carotid stenosis or chronic atrial fibrillation than with asymptomatic carotid stenosis or paroxysmal atrial fibrillation (p<0.01).Conclusions: The majority of respondents performed dental extraction and cataract surgery under antithrombotic therapy. However, as many respondents do not follow the guidelines for endoscopic procedures, there is no consensus on the correct procedures.

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We could use rt-PA in patients with hyperacute ischemic stroke in our hospital since April 2006. The working style of neurologists responsible for ischemic stroke therapy changed, from requiring them to be on the premises while being on duty to allowing them to be off the premises. The on-duty system (on-duty group) and previous group (historical control group) were compared. There was no significant difference in patient characteristics and the time from onset to arrival between both groups. However, the probability of the pretreatment MRI and ASPECTS score was higher in the on-duty group. The patients in mRS 0-1 after 3 months were higher in the on-duty group (16% versus 38%, p=0.01). This suggested that doctors responsible for patients with hyperacute ischemic stroke are required to be on the premises in order to improve the prognosis of them.

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We report here three cases of symptomatic intracranial stenosis improved successfully with the administration of cilostazol. Case 1: A 62 year-old man, presented with a TIA due to stenosis of the left middle cerebral artery, was treated immediately with the administration of cilostazol. After three months, 3D-CTA showed improvement of the stenosis. Case 2: A 67 year-old woman, presented with a TIA due to severe stenosis of the basilar artery, was treated immediately with the administration of cilostazol. Cerebral angiography after three weeks showed complete improvement of the stenosis. Case 3: A 69 year-old man, presented with left pontine and cerebellar infarction due to severe stenosis of the basilar artery, underwent percutaneous transluminal angioplasty (PTA) of the basilar artery after the preoperative administration of cilostazol. After six months, 3D-CTA showed no restenosis, and cerebral angiography after twelve weeks showed improvement of the residual stenosis. Cilostazol has not only an antiplatelet effect but also many pleiotropic effects such as a protective effect on endothelial functions, a vasodilating effect, and an inhibition of proliferation on smooth muscle cells. Therefore, cilostazol is effective on the improvement of symptomatic intracranial stenosis, the prevention of restenosis, and the reformation of residual stenosis after PTA.

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We report the case of a patient who developed atherothrombotic brain infarction after carotid artery stenting (CAS) with a restenotic atherosclerotic lesion with vulnerable plaques in the cervical internal carotid artery as the embolic source, and who was successfully treated with carotid endarterectomy (CEA). The patient was a 75 year-old woman who had undergone CAS for stenosis in the right carotid artery at another hospital one year and three months before. She suddenly developed disorientation and left hemiplegia, and she was rushed to our hospital. She reached our hospital 30 min after the onset of the symptoms. Initially, paralyses of the left upper limb and the face were observed, but these neurological symptoms gradually improved, and eventually, only mild paresis remained. Diffusion-weighted magnetic resonance imaging (MRI) revealed a right-sided watershed infarction, and cerebral angiography revealed carotid restenosis accompanied by a pocket ulcer. We performed CEA with stenting and obtained good results. Sclerotic lesions including calcification and soft atheromatous lesions often coexist on the carotid artery wall, especially in elderly patients. The present case underscored the necessity of thorough assessment of the lesions before deciding the treatment.

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Prader-Willi syndrome (PWS) is a congenital disorder characterized by hypotonia, hypogonadism, hypomentia, and obesity. We report on a case of PWS complicated with juvenile cerebral infarction. A 26 year-old man, with a history of diabetes mellitus and hypertension, was admitted to our hospital with a left dysesthesia and hemiparesis. Magnetic resonance (MR) imaging depicted an infarct in the right putamen and corona radiata, and confirmed cerebral atrophy. The MR angiogram demonstrated prolongation and tortuosity of the bilateral cervical internal carotid arteries, and mild stenosis of the right middle cerebral artery (M1). Only a few cases of PWS with strokes have been reported, and each of them were complicated with diabetes mellitus and severe arteriosclerosis for their age. It might be the juvenile cerebral infarction related to PWS since the cases also had diabetes mellitus and arteriosclerosis and showed premature aging.

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Rectus sheath hematoma (RSH) is a rare, but sometimes fatal, clinical condition that presents as an acute surgical abdomen in patients receiving anticoagulant therapy. We describe herein a 74 year-old woman who suffered total secondary aphasia to the left carotid occlusion and presented hemorrhagic shock a month later. Physical assessment and abdominal-computed tomography lead to a correct diagnosis of RSH. The patient was treated by blood transfusion and supportive therapy without surgical intervention. In the management of aphasic or unconscious stroke patients, RSH is an important complication of anticoagulant therapy that stroke physicians must be aware of.

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A 44 year-old man experienced a sudden episode of a severe headache and left motor weakness while having a quiet smoke. He had in the past a habit of taking cold medicines. On admission, a CT scan revealed subcortical hematoma at the right frontal lobe. Brain diffusion-weighted MR images revealed hemorrhagic infarction at the same region. Cerebral angiography showed multiple vascular irregularities. He was treated conservatively, but right frontal craniotomy and excision of the hematoma was performed eight days after the onset in order to increase the headache and the progression of left sensory disturbance. These symptoms disappeared soon after the surgery. Repeated cerebral angiography five weeks after the onset demonstrated that most of the areas of segmental irregularity had improved. We gave a diagnosis of reversible cerebral vasoconstriction syndrome (RCVS) presenting as hemorrhagic cerebral infarction by the pathological findings and clinical courses. RCVS should be considered as an important differential diagnosis for patients presenting with a sudden onset of a severe headache, if subarachnoid hemorrhage was denied.

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A 29 year-old woman was admitted to our hospital complaining of a sudden headache and disturbed consciousness. A computed tomography (CT) revealed intraventricular hemorrhage, and an angiogram showed a ruptured aneurysm of the distal portion of the branches of the right anterior choroidal artery associated with moyamoya disease. She underwent a superficial temporal artery (STA)-middle cerebral artery (MCA) anastomosis with encephalomyosynangiosis (EMS) one month after the onset. Three months following the surgery, disappearance of the aneurysm was shown on the angiogram. Intraventricular hemorrhage could be caused by a ruptured aneurysm in the distal portion of the choroidal artery and comprises approximately 70% of the intracranial hemorrhage in adult patients with moyamoya disease. Revascularization surgery in the early stage of bleeding could prevent rebleeding from such a distal aneurysm in the choroidal artery associated with moyamoya disease.

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We report a case of cortical cerebral infarction manifested cheiro-oral syndrome. A 46 year-old woman noted dysesthesia in the lower left mouth corner and in the ipsilateral thumb, index, and middle fingers. Neurological examination did not show any disturbance except for subjective dysesthesia. Brain MRI showed a small infarction located at the base of the right central sulcus. Fortunately, her dysesthesia substantially improved by antiplatelet therapy. Recent reports indicate COS arises from varied sites from the medulla to the primary somatosensory area and has the potential of neurological deterioration in some patients. We should recognize needs for aggressive investigation and elucidate the underlying pathological condition in COS.

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Background and Purpose: CHADS2 score is used for risk stratification and treatment recommendation in patients with nonvalvular atrial fibrillation (NVAF).Methods: We retrospectively studied the risk of 40 cardioembolic stroke patients due to NVAF in a convalescence rehabilitation ward using CHADS2 score.Result: The CHADS2 score before cardioembolic stroke was 0 in 12.5%, 1 in 17.5%, 2 in 20.0%, 3 in 25.0%, 4 in 10.0%, 5 in 7.5%, 6 in 2.5%, and the average score was 2.4. The CHADS2 score after cardioembolic stroke was 2 in 12.5%, 3 in 20.0%, 4 in 27.5%, 5 in 35.0%, 6 in 5.0%, and the average score was 4.0.Conclusion: We should take into consideration the antithrombotic therapy in cardioembolic stroke patients due to NVAF in a convalescence rehabilitation ward.

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