Stroke is a major leading cause of disability in Japan. In order to improve stroke outcome, national and international quality initiatives should be indispensable. We developed evidence-based clinical indicators including 13 items for acute stroke care. In this study, we investigated the actual conditions of acute stroke care by use of the clinical indicators. We enrolled 1686 stroke patients in 44 hospitals with diagnoses of brain infarction, intracerebral hemorrhage, subarachnoid hemorrhage, and transient ischemic attack admitted within 3 days after the onset from July 2010 to September 2010. All hospitals were divided into bipartite by the number of population density and tertile by the number of registered patients, hospital beds, and physicians in charge of stroke. We compared states of achievement of clinical indicators. The states of achievement of brain CT/MRI, evaluation of cerebral arteries by carotid ultrasonography, MR angiography or CT angiography, prescription of antithrombotic agents, and measurements of blood sugar and lipid profiles were over 90%. The state of achievement of physical therapy was highest in the group of hospitals which registered a large number of patients (p=0.026) and the percentage of patients prescribed antithrombotic agents was highest in the group of hospitals which registered a small number of patients (p=0.0046). There was no relationship between states of achievement of clinical indicators and number of population density, hospital beds and physicians in charge of stroke, respectively. We showed the present conditions of acute stroke care in Japan by use of the clinical indicators. The next step is to organize a nationwide monitoring using clinical indicators.

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Background and aims: It has been recognized that patients with cerebral infarction have a a higher prevalence of asymptomatic coronary artery disease (CAD). CAD is the leading cause of death among cerebral infarction survivors.The aim of this study was to determine the prevalence of asymptomatic CAD needed to be treated with percutaneous coronary intervention (PCI) in patients with lacunar infarction.Materials and Methods: We evaluated 30 patients without any history of CAD admitted with first-ever lacunar infarction in our hospital. All patients underwent coronary computed tomographic angiography (c-CTA) after the written informed consent. The results were compared in terms of age, sex, and vascular risk factors between patients with and without silent CAD.Results: Ten patients (33.3%) were diagnosed to have CAD with significant stenosis in the coronary arteries by c-CTA. Seven patients (23.3%) were needed to be treated with PCI. The PCI treated group had higher HbA1c, LDL cholesterol, triglycerides, and LDL/HDL ratio levels compared with the non-PCI group.Conclusions: The risk for CAD is related with vascular risk factors such as diabetes mellitus and hypercholesteremia. Therefore, these data are useful to identify the subgroup of patients with lacunar infarction, which has higher risk for future cardiovascular events.

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Objective: Distal middle cerebral artery (MCA) aneurysm is rare among intracranial aneurysms. In diagnosing and treating distal MCA aneurysms, it is important to note that it differs significantly from other aneurysms located around the circle of Willis. The purpose of this study is to identify the clinical characteristics of distal MCA aneurysms.Method: We encountered 12 patients with distal MCA aneurysms at our institution from January 2000 to March 2011. They correspond to 0.7% of all patients with cerebral aneurysms over the same period. We retrospectively reviewed the records of patients with distal MCA aneurysms which include important parameters such as onset type (ruptured/unruptured), presence or absence of intracerebral hematoma, size of the aneurysm, treatment, and outcome.Result: Nine patients had multiple aneurysms. Eight patients had aneurysmal subarachnoid hemorrhage (SAH). Among the eight, 4 patients had a ruptured distal MCA aneurysm whereas the other 4 patients had ruptured non-distal MCA aneurysm and unruptured distal MCA aneurysm. Two patients with aneurysmal SAH had intracerebral hematoma. Eleven patients underwent clipping of distal MCA aneurysms.Conclusion: Distal MCA aneurysms differ from typical saccular aneurysms on major branch points of the circle of Willis and they need unique considerations in diagnosis and treatment.

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Background and purpose: Anticoagulation therapy increases the risk of chronic subdural hematoma (CSDH). In patients with mechanical heart valve prostheses, life-long oral anticoagulation therapy is recommended to prevent valve thrombosis and subsequent systemic embolism. The purpose of this study is to find out an appropriate perioperative management of CSDH in patients who are undergoing anticoagulation therapy after heart valve replacement.Methods: We retrospectively investigated the perioperative clinical course of five patients who underwent CSDH operation during anticoagulation therapy after heart valve replacement. Three of the five patients underwent mitral valve replacement and the other two patients underwent double (aortic and mitral) valve replacement. In all patients, warfarin was administered, while in three of these five patients, an antiplatelet was used together with warfarin. We evaluated the frequency of measurement of clotting time and CT imaging, timing of stopping anticoagulation therapy and removing drainage tube, presence of thromboembolic complications, and recurrence of the hematoma.Results: During the postoperative course, measurement of the clotting time and CT evaluation of the hematoma was performed 5.2 and 4.0 times per week, respectively, on the average. The subdural drainage tube was removed on postoperative day 1.8. Anticoagulation therapy was restarted with heparin and warfarin on postoperative day 1.2. Prior to surgery, warfarin was stopped in all patients and the reversal of anticoagulation with intravenous administration of vitamin K or fresh frozen plasma was achieved in two patients. All patients recovered without recurrence of the hematoma in the perioperative period.Conclusions: In the perioperative management of CSDH in patients undergoing anticoagulation therapy after valve replacement, repetitive CT evaluation and measurement of clotting time are suggested to be helpful to prevent the recurrence of CSDH and the possible thromboembolic complications.

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Background and Purpose: This study investigated the clinical pathway (CP) for patients with acute ischemic stroke. This investigation was approved by our hospital’s working group.Methods: Patient outcomes of 136 patients with acute ischemic stroke were assessed within 7 days after stroke onset (100 during the pre-approval period and 36 during the post-approval period).Results: Among 19 (53%) patients using the CP, 13 (68%) achieved independent living, the final outcome of the CP. The frequency of discharge to home was higher (p<0.001) and the period of hospitalization was shorter (p<0.001) in patients achieving the final outcome versus those who did not. Thirty-six patients (26%) were excluded for various reasons. Analysis of 100 (74%) patients showed that the NIHSS score on admission, modified Rankin Scale at discharge, and period of hospitalization in patients discharged to home were all significantly less than those of patients not discharged to home. Using an NIHSS score of ≤2 as a cut-off value, the sensitivity and specificity of our CP for identifying patients suitable for discharge to home were 73.4% and 75.0%, respectively.Conclusions: A CP based on NIHSS score on admission might be useful to achieve the medical process for patients with acute ischemic stroke.

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We attempted to determine the risk factors for stroke using data from Japan’s recently implemented “specific health checkup,” and to evaluate and determine the effectiveness of this checkup for metabolic syndrome as a policy for stroke prevention. The 174 cases were all those patients who had undergone a metabolic syndrome checkup in the Akita Prefecture screening program from 2007 to 2010 and suffered from stroke afterwards within 1 year of screening. The controls were all 47,969 subjects who were screened in the year 2008 in the same program. The predictors examined were sex, age, blood pressure, BMI, total cholesterol value, smoking habit, history of diabetes mellitus, presence of metabolic syndrome, and atrial fibrillation. The outcome was incidence of stroke. The analysis was conducted by stroke subtype using logistic regression. The risk factors for cerebral infarction were male sex, high blood pressure, diabetes, atrial fibrillaton, and smoking history. For cerebral hemorrhage, the risk factors were age and high blood pressure only. For subarachnoid hemorrhage, the risk factors were female sex and smoking history. Metabolic syndrome was not a risk factor for any of the 3 subtypes of stroke. High blood pressure and smoking history showed the largest population-attributable fraction. In conclusion, control of blood pressure and smoking cessation are the most important issues for population-focused stroke prevention policy. Metabolic syndrome is not a risk factor for stroke, and therefore, the “intensified intervention” after specific health checkup should be targeted to smokers and to those with hypertension rather than to patients with visceral fat obesity.

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We report a case of left cerebellar embolism with migraine, truncal and left hemiataxia, and dizziness. A 66 year-old woman suffered from migraine for more than 25 years, and had histories of brain infarction 4 times. A patent foramen ovale (PFO) was found using transesophageal echocardiography. Accordingly, she was diagnosed with paradoxical embolism. After transcatheter closure with Amplatzer^TM PFO occluder, her migraine disappeared and she had no more ischemic stroke recurrence. The present case suggests PFO as an important factor for migraine and stroke, which can be prevented by transcatheter closure with Amplatzer^TM.

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A 65 year-old man was admitted to our hospital due to sudden onset of left hemiparesis and dysarthria. In addition, he presented with left supranuclear facial nerve palsy and deep sensory disturbance in the left trunk and extremities. He showed deviation of the tongue to the left side on protrusion. Because fasciculation and atrophy of the tongue was undetectable three weeks after the onset, his hypoglossal nerve palsy was presumed to be supranuclear in origin. MRI revealed an infarction involving the ventromedial portion of the right upper and middle medulla oblongata extending to the tegmentum. We considered that the contralesional supranuclear facial and hypoglossal nerve palsy in this patient was caused by the disruption of supranuclear fibers projecting onto the contralesional facial and hypoglossal nerve nuclei before their decussations in the upper to middle medulla oblongata. This patient suggested that variant decussations of supranuclear facial and hypoglossal fibers may exist on any levels of the medulla oblongata.

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We report a case of pulmonary thromboembolism (PE) in a 43 year-old man who presented with left hemiparesis and dysarthria due to intracranial hemorrhage (ICH). Intermittent pneumatic compression (IPC) and rehabilitation were started on day 0, but IPC was discontinued on day 3 because he complained, without any signs of deep vein thrombosis (DVT), of discomfort with the IPC. On day 13, however, cardiopulmonary arrest occurred due to pulmonary thromboembolism. IPC, elastic stockings (ES), and rehabilitation are recommended as preventive treatments for pulmonary thromboembolism after ICH, although the appropriate start time and the duration of these preventive treatments have been unclear. The safety and efficacy of subcutaneous heparin injection (SHI) from day 2 of ICH onset to prevent DVT/PE have been reported. However, it is difficult to apply this assurance of safety to Japanese patients because the subjects in such reports were not Asians, who have a higher intracranial bleeding rate than Caucasians during anticoagulant therapy. On the other hand, it has been reported that SHI from day 3 is not effective and that the most delayed PE after ICH occurred on day 33. In the present case, appropriately started IPC or substitution with ES should be continued for approximately one month, considering the subclinical DVT resulting in the delayed PE. Moreover, SHI should be considered, even though the evidence of its safety for the Japanese is expected.

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We report a patient with right internal carotid artery (ICA) territory infarction during intravenous recombinant tissue plasminogen activator (rt-PA) therapy for left middle cerebral artery (MCA) territory ischemic stroke. A 79 year-old woman with a history of atrial fibrillation received intravenous rt-PA for left MCA territory infarction. However, a right ICA territory infarction developed 37 min after the start of intravenous rt-PA. This patient is considered to have suffered an early recurrent ischemic stroke (ERIS), which is defined as the early occurrence of new neurological symptoms, suggesting the involvement of initially unaffected vascular territories in the absence of intracranial hemorrhage. Cardiogenic embolism or artery to artery embolism is considered to be the cause of ERIS. It is important to identify cardiac embolism as well as presence of floating plaques in the carotid arteries before intravenous rt-PA treatment to avoid the development of ERIS.

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A 75 year-old man with a history of gastroesophageal reflux disease (GERD) suffered from persistent hiccups the day after he was diagnosed to have middle cerebral artery infarction. Although nasogastric tube feeding was started, he developed a repeated bout of aspiration pneumonia caused by gastroesophageal reflux (GER) accompanied by hiccups. Hiccups were intractable and got worsened in parallel with the symptoms of GER. To relieve the reflux symptoms, we tried half-solidification of nutrients in addition to medical treatment with proton pump inhibitors. As a result, hiccups were improved and there was no recurrence of aspiration pneumonia. For dysphagia after stroke, early enteral feeding with a nasogastric tube is recommended as nutritional management in the acute phase. However, we should be careful that mechanical stimulation by a nasogastric tube can also be a worsening factor for patients with hiccups and that hiccups might be refractory due to iatrogenic injury by long-term tube feeding. It should also be noticed that hiccups are part of the atypical symptoms of GERD and can fluctuate correlated with the reflux symptoms. As asymptomatic GERD is common in the elderly, it should be considered as a cause of intractable hiccups. Furthermore, prevention of GER by half-solid nutrients could also lead to the improvement of hiccups.

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A 69 year-old man, suffering from multiple cerebral embolisms with symptoms of sudden onset aphasia and right hemiparesis, was transferred to our hospital for convalescent rehabilitation on day 38. Cardioembolic stroke was presumed to be the pathogenesis of his stroke, however, embolic sources could not be detected in the initial examinations during acute phase hospitalization. To prevent against recurrence of stroke, anticoagulant therapy was administered considering the possibility of paroxysmal atrial fibrillation. In the process of re-evaluation in the convalescent rehabilitation ward, a mobilizing mass in the left atrium was detected by transthoracic echocardiography on day 40. Suspected as cardiac myxoma, he was transferred for emergency cardiovascular surgery. The mass was surgically resected on day 55, and was confirmed pathologically as myxoma. Although cardiac myxoma is quite rare, it should not be excluded as an embolic source in cases of multiple cerebral embolisms of unknown origin. Repeated evaluation during convalescence and maintenance period is needed for appropriate diagnosis and treatment.

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