Cerebral microbleeds (MBs) originate from hypertensive microangiopathy or amyloid angiopathy. However, small intracerebral bleeds associated with other diseases or head traumas are also reported as MBs, in the absence of MB criteria. MBs are divided into two groups, lobar areas and deep areas including posterior fossae. MBs in these two areas are investigated each for related diseases and risk factors. Recently, apolipoprotein ε4 or inflammation were reported to influence MBs. MBs originate from multiple factors. In people with MBs, the incidence or recurrent rate of strokes, in particular intracerebral hemorrhages or lacunar infarctions, are higher than those without MB. MBs might be a surrogate marker for strokes. However, there are no guidelines for anti-platelet or anti-coagulant drug use, for people with MBs. Further studies are needed to investigate antithrombotic drug uses in patients with MBs. MBs are reported to be associated with neuro-cognitive disorders, including Alzheimer’s disease and vascular dementia.

View full abstract

Background and Purpose: Moyamoya disease has been studied concerning its natural history and treatment. Japanese guidelines for Moyamoya disease were suggested on 2009. We studied the outcome of initial and recurrent patients with Moyamoya disease in our institute.Methods: Between 1982 and 2012, we analyzed the follow up reports on 49 consecutive patients including 37 initial patients and 12 recurrent patients.Results: Twenty-seven patients presented with ischemic disease, and 10 presented with hemorrhagic disease. In the initial treatment group, higher age patients presented with hemorrhagic disease, and poorer prognosis compared with younger patients. In the recurrent group, almost all patients presented hemorrhagic disease, and poorer prognosis compared with the patients of initial group. The ischemic group of patients, treated with surgical anastomosis, presented with a lower recurrence rate.Conclusions: Our study suggests that Moyamoya disease frequently presented with hemorrhagic disease at recurrence, and that surgical anastomosis for ischemia at the initial hospitalization has a possibility of prevention of recurrent cerebrovascular events.

View full abstract

Background and Purpose: Stroke recurrence, often developed in convalescent rehabilitation ward, impairs the functionality of patients and results in QOL deterioration. The aim of this study was to clarify the detailed characteristic and treatment strategy of recurrent cases.Methods: We retrospectively investigated 16 cases with stroke recurrence among 1,301 consecutive stroke patients in our convalescent rehabilitation ward between 2008 and 2012.Results: As the primary stroke type of 16 recurrent cases, 12 were brain infarction and 4 were brain hemorrhage. Further classified into clinical subtypes, the recurrence rate was the highest in cardioembolic stroke. Each stroke type at recurrence was 8 in brain infarction, 2 in TIA, and 6 in brain hemorrhage, with 108.8 days for mean time to recurrence. Early recurrence cases, within 30 days from transference, all presented with ischemic symptoms. Among the recurrence cases due to brain hemorrhage, none have taken dual antithrombotic medication.Conclusion: In management of stroke patients in convalescence and maintenance periods, it is critical to reappraise the prevention strategy for recurrence depending on risks and ADL in each patient.

View full abstract

Background and Purpose: The Scale for the Assessment and Rating of Ataxia (SARA) was developed to evaluate ataxia severity with spinocerebellar degeneration. However, there have so far been few studies regarding ataxia evaluation in stroke patients using the SARA. The purpose of the present study was to investigate the usefulness of the SARA for evaluating ataxic severity of stroke patients.Methods: Eighteen adult patients who underwent physical therapy for ataxia after a posterior circulation stroke were examined between June 2011 and July 2012. The correlations between the SARA or National Institute of the Health Stroke Scale (NIHSS) score and Barthel Index (BI), Functional Ambulation Category (FAC) one week after stroke onset, or length of hospital stay were investigated.Results: The scores on the SARA correlated significantly with the BI scores (p=0.001, r=−0.725), FAC (p<0.001, r=−0.800) and length of stay (p<0.001, r=0.874). The scores on the NIHSS did not correlate with the BI scores, FAC or length of hospital stay.Conclusions: The SARA score was found to closely correlated with the gait status, ADL dependency and length of hospital stay in stroke patients with ataxia and it is therefore considered to be a useful functional measure for such patients, because the SARA provided a compensated evaluation of neurological symptoms that cannot be reflected are not be reflected in the finding of the NIHSS.

View full abstract

Background and Purpose: We investigated the questionnaire survey on management of antithrombotic agents during surgery or kinds of medical procedures with bleeding.Methods: The questionnaire survey was performed for department chiefs of the hospitals or medical centers of National Hospital Organization in Japan. We received available answers from 655 department chiefs of 99 institutions (69%).Results: Surgery or kinds of medical procedures with bleeding were performed under withdrawing or reducing anti-coagulants or anti-platelets by 66% and 58% of respondents respectively. Heparin bridging therapy was performed during withdrawing anti-coagulants or anti-platelets by 54% and 27% respectively. Manuals about the management of antithrombotic agents during surgery or kinds of medical procedures with bleeding were available in 35% of the departments. Only 12% of departments got written informed consents when antithrombotic agents were withdrawn. Nearly 10% of departments have experienced major bleeding events related to continuation of antithrombotic agents or thrombosis or embolism related to withdrawing or reducing antithrombotic agents.Conclusions: Establishing how to manage antithrombotic agents during surgery or kinds of medical procedures with bleeding seems required, because frequency of heparin bridging therapy, preparation of manuals, and obtaining informed consent regarding withdrawing antithrombotic agents were low.

View full abstract

Purpose: We report a questionnaire survey administered to emergency medical technicians (EMTs) to assess the transportation system by using a clinical indicator to thrombolytic therapy.Methods: The same questionnaire survey was administered to EMTs of Kawasaki City Fire Department in 2007 and 2010. The questionnaire consisted of acute stroke therapy, network system for accepting stroke victims, patient transportation, and Maria Prehospital Stroke Scale (MPSS). Quality assurance monitoring of a stroke-bypass transportation protocol was repeated every six months.Results: The response rates were 100% in 2007 (n=235) and 99% in 2010 (n=233). The rate of EMTs who recognized the success of stroke-bypass transportation for intravenous tissue plasminogen activator (iv-tPA) increased from 48% in 2007 to 66% in 2010. There were no significant differences in the rate of refusal of accepting stroke victims (75% in 2007, 81% in 2010) or transfer to hospitals in neighboring cities (42% in 2007, 41% in 2010). Most EMTs revealed a delay in the onset-to-detection and arrival-to-door times were barriers to prompt transportation. The rate of EMTs who completed the evaluation of MPSS within 1 min increased from 79.1% in 2007 to 86.4% in 2010. The rate of iv-tPA based on MPSS was 11–14%, while the rate of a modified Rankin Scale score <2 increased from 24.1% in the second half of 2009 to 39.0% in 2011.Conclusions: Triage of stroke victims by EMTs based on MPSS was conducted smoothly, and the outcome of iv-tPA improved along with EMTs’ recognition of the citywide stroke-bypass transportation system.

View full abstract

Purpose: We investigated inpatient convalescent rehabilitation outcomes of ischemic stroke especially for branch atheromatous disease (BAD).Subjects and Methods: Subjects were 90 lenticulostriate artery territory-BAD (LSA-BAD) and 21 paramedian pontine artery territory-BAD (PPA-BAD) patients. For all patients, National Institutes of Health Stroke Scale (NIHSS) and functional independence measure (FIM) scores, and Brunnstrom stages (BRS) of upper limb, fingers, and lower limb were measured both on admission and discharge.Results: There were no significant differences in clinical scores and characteristics on admission between LSA-BAD and PPA-BAD groups except for the higher proportion of female in PPA-BAD groups (p=0.043). The severities of PPA-BAD patients with NIHSS scores were significantly mild compared with those of LSA-BAD patients on admission (p=0.031) and at discharge (p=0.008). Significant lower improvements with LSA-BAD patients were found in the stages of BRS with upper limb (p=0.009) and fingers (p=0.010) at discharge and recovery changes of BRS with fingers (p=0.031) compared with those of PPA-BAD patients. The improvements of each BRS score with LSA-BAD patients had the tendency of the limitations within two up-grades however both LSA-BAD and PPA-BAD patients basically gained over 100 total-FIM scores at discharge.Conclusion: The investigation of rehabilitation outcomes with BAD patients in the convalescent period can assess the improvements of pure-motor hemiparesis and activities of daily living, because the disturbance of the corticospinal tract by ischemic infarction lesions may be different in LSA-BAD and PPA-BAD.

View full abstract

73-year-old man suddenly experienced drowsiness, dysarthria, and left hemiparesis. He was transferred to our hospital 90 minutes after onset of these symptoms. On admission to our hospital, his neurological deficits disappeared. Diffusion-weighted magnetic resonance imaging (MRI) performed on admission did not show any highsignal lesions, and MRI revealed multiple old infarctions throughout the brainstem, the basal ganglia, both the cerebral hemispheres. At 175 minutes after admission, he suddenly exhibited left facial palsy and hemiparesis, and diffusion-weighted MRI showed a high-signal lesion in the right internal capsule. His condition was diagnosed as lacunar brain infarction. Thrombolytic therapy using intravenous recombinant tissue plasminogen activator (rt-PA) was started 80 minutes after this onset, and the neurological deficits improved. Computed tomography conducted a day after the treatment revealed intracerebral hemorrhages at 3 portions of the right internal capsule, pons, and right temporal lobe. Presence of cerebral microbleeds (CMBs) or cerebral amyloid angiopathy (CAA) is one of the risk factors for extraischemic cerebral hematomas after rt-PA thrombolysis, but T2*-weighted imaging revealed few CMBs in this case. This report shows that in cases with multiple previous cerebral infarctions, intracerebral hemorrhage can occur after rt-PA thrombolysis, even if T2*-weighted imaging shows CMBs. Therefore, rt-PA thrombolysis should be carefully applied even in cases with CMBs and multiple old infarctions.

View full abstract

We describe a case of non-diabetic hemichorea resulting from incomplete ischemic injury of the contralateral lenticulostriate artery region. A 90-year-old woman was admitted because of coarse hemichorea on the right side. She did not have hyperglycemia or a past history of diabetes mellitus, and brain magnetic resonance imaging (MRI) revealed no apparent new lesion. Haloperidol was administered, and her choreic movement gradually improved. Six weeks after the chorea onset, brain MRI revealed a small high-intensity lesion in the left striatum on a T1-weighted image and a perforator branch infarction in the left coronal radiation. These lesions were closely located and estimated to be caused by focal ischemia in the territory of single or multiple lateral lenticulostriate arteries. Diabetic hemichorea is frequently associated with contralateral striatal high-intensity lesions on T1-weighted images, and such lesions have been suggested to be caused by incomplete ischemic injuries. Our case suggests that striatal T1-hyperintensity lesions could occur in association with non-diabetic hemichorea, and the timing of the appearance and the size of T1-hyperintensity lesions do not closely correlate with the severity of the choreic movements.

View full abstract

A rare case of Moyamoya disease associated with an accessory middle cerebral artery (accessory MCA), in which a saccular aneurysm was found at its origin is reported. Neck clipping of the aneurysm was performed along with the superficial temporal artery–MCA bypass. Intraoperative observation revealed that the terminal portion of the ICA, M1 portion and the superior trunk of the MCA, and the A1 portion of the contralateral anterior cerebral artery were affected by Moyamoya disease, while no definite change was found in the accessory MCA. The accessory MCA itself suffers from hemodynamic stress at its origin because of its recurrent configuration. In the present case, as the arteries around the circle of Willis were affected by Moyamoya disease after birth, the accessory MCA worked as an important collateral pathway, which consequently caused additional hemodynamic stress, resulting in an aneurysm formation at its origin.

View full abstract