Background and Purpose: Recently, the number of the patients having atrial fibrillation (AF) is increasing with aging of the population. We screened patients who come to the outpatient department of our hospital and tried to detect proactively patients with asymptomatic AF, which is the main cause of cardiogenic embolism (CE) in brain.Methods: We build the system for early detection of asymptomatic AF. We called it “Find AF” project and publicized it to all the staffs in our hospital. To screen irregular pulse of outpatients before medical examination of the doctor, an automated sphygmomanometer with irregular heart beat (IHB) detection function (hereafter, IHB detection sphygmomanometer) was used. The investigation period spanned for 2 years, from December 2011 to November 2013. We performed electrocardiography on patients who had been detected as having irregular pulse.Results: During these 2 years, the number of AF patients for whom anticoagulation treatment was considered/introduced was 56, including those who were newly diagnosed as AF and those who were having AF untreated. This figure amounts to 0.2% of all outpatients. AF was tended to overlook among patients who were visiting our hospital regularly. Irregular pulse of chronic AF was not detected in 25.7% of patients even with an IHB detection sphygmomanometer.Conclusion: Through this effort, we could detect asymptomatic AF among outpatients and could start anticoagulation treatment to prevent CE. However, there are still possibilities of overlooking AF patients by simply using IHB detection sphygmomanometer. It will be necessary to develop an AF detection device with a higher precision.

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Objective: The aim of this study was to investigate the frequency of pure midbrain infarction, vascular territories, neurological findings, symptom onset, stroke subtype, and embolic source.Methods: We retrospectively enrolled patients who were admitted to our stroke center from April 2006 to August 2012 within 7 days. We investigated the frequency of pure midbrain infarction, vascular territories, neurological findings, stroke subtype, stroke subtype, and embolic source. The vascular territories were classified into median zone (MZ), anterolateral zone (AZ), lateral zone (LZ), and dorsal zone (DZ).Results: Nine patients (3%) were diagnosed as having pure midbrain infarction (mean age: 74 years, 6 males). Vascular territories were MZ in 5 patients, AZ in 3 patients, and LZ combined DZ in 1 patient. Stroke subtypes were undetermined etiology in 5 patients, cardioembolism in 3 patients, and other etiology in 1 patient. Eye movement disorders and ataxia in MZ, hemiparesis in AZ were prominent neurological findings. Embolic sources were found in 6 patients, atrial fibrillation in 2 patients, patent foramen ovale in 2 patients, aortic atheromatous disease in 1 patient, and patent foramen ovale and aortic atheromatous disease in 1 patient.Conclusion: Pure midbrain infarction is very rare, and half of them had embolic sources. Therefore, when we see pure midbrain infarction, a diagnostic workup including transesophageal echocardiography should be performed to detect embolic source.

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Background: Hemiparesis without chest pain could make it complicate to distinguish acute aortic dissection (AAD) and ischemic stroke. We, therefore, investigated the clinical characters in patients with these diseases.Methods: In 334 consecutive patients with ischemic stroke, including cerebral infarction and transient ischemic attack, and 38 patients with stanford type A AAD, we retrospectively analyzed their vital signs, D-dimer, chest radiographs, and the filming conditions at initial visit.Results: Eight patients had AAD with hemiparesis. Compared to patients with ischemic stroke, they showed significant low blood pressure, elevation of D-dimer, and widening of mediastinum on chest radiograph, with or without hemiparesis.Conclusion: Blood pressure, D-dimer, and chest radiograph can be useful to distinguish between AAD and ischemic stroke.

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Background: Previously, cilostazol (CIL) was reported as an alternative drug for acetylsalicylic acid (ASA) in cases with non cardioemboic (CE) stroke. We studied the difference of efficacy for non CE stroke patients between ASA and CIL. Especially, we evaluated the efficacy of these drugs for severity of stroke, functional outcome, and post-stroke depression.Objects and Methods: Patients with non CE stroke, who were admitted into our hospital and affiliated hospitals during April 2010 and December 2012, were objects of our study. We excluded patients who disagreed with our informed consent, already took antiplatelet drugs before onset of ischemic stroke, and had complicated atrial fibrillation. We included 168 patients, and divided these patients into two groups; group ASA and group CIL. We compared stroke severity, functional outcome and post-stroke depression using modified Rankin Scale (mRS), the National Institute of Health Stroke Scale (NIHSS) score, and Self-rating-Depression Scale (SDS) score between group ASA and group CIL. The times of assessment of the scores such as NIHSS, mRS, and SDS were at the time of admission into our hospitals and discharge from our hospitals, and 3 months after onset.Results: Baseline characteristics, NIHSS, mRS, and SDS of two groups were not significantly different. In both groups, functional outcome tended to be poor with advancing age and greater number of complications.Conclusion: The efficacy of ASA and CIL for stroke severity, functional outcome, and post-stroke depression was not significantly different in this study. Higher age and the greater number of complicated diseases were associated with poor functional outcome after ischemic stroke except for CE.

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Background and Purpose: Although hypertension and diabetes are strong predictors for stroke, only few studies have investigated their combined impact on stroke recurrence. We investigated the relationship between clinical characteristics of the ischemic stroke patients and stroke recurrence, and their association with all-cause mortality within 2 years after onset.Methods: A total of 544 ischemic stroke patients, living in the Yamagata prefecture, were enrolled in this study. We evaluated the clinical characteristics of patients on admission, and followed their clinical courses for 2 years.Results: During mean follow up of 22.4 months, 25 incident ischemic stroke events were found. Furthermore, 34 patients died during follow up. On multivariate Cox hazard regression analyses, combination of hypertension, diabetes, hypercholesterolemia (HR 2.72, p=0.033), and past history of stroke (HR 3.69, p=0.001) were independent predictors of stroke recurrence. The results of multivariate Cox hazard regression analyses also showed that age (HR 1.05, per 1-year increase), presence of hypertension and diabetes (HR 2.99), anti-thrombotic therapy (HR 0.18), lacunar infarct (HR 0.14), cardiogenic embolism (HR 2.45), and the scores of modified Rankin scale (HR 2.75, per 1 score increase) were independent predictors of all-cause mortality.Conclusion: The results of the present study indicate that joint effects of diabetes, hypertension, and hypercholesterolemia are at increased risk for ischemic stroke recurrence. Diabetes appeared to be associated with all-cause mortality, and joint effect of hypertension and diabetes are independent risk for all-cause mortality within 2 years after the onset of ischemic stroke.

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Background and Purpose: The characteristics of cases with internal carotid occlusion and ipsilateral supratentorial cerebral hemorrhage were reviewed.Methods: Cases of internal carotid occlusion with an ipsilateral supratentorial cerebral hemorrhage over a 5-year period (2008–2012) were identified in our inpatient database and medical records.Results: Of 313 cases of supratentorial cerebral hemorrhage, 7 (2.3%) had internal carotid occlusion with an ipsilateral supratentorial cerebral hemorrhage. There were no cases of internal carotid occlusion with contralateral cerebral hemorrhage. There were 6 men and 1 woman with an average age of 79 years. The hemorrhagic location was the putamen in 3 and the thalamus in 4, with an average bleeding volume of 6 ml. CT perfusion studies showed decreased hemispheric blood flow on the affected side in 5 cases. One ¹²³I-IMP-SPECT study revealed misery perfusion. One case underwent bypass surgery 2 years and 8 months before the intracranial hemorrhage. Revascularization surgery (bypass 2, carotid endarterectomy 1) was performed at an average of 85 days from hemorrhage onset. Antithrombotic therapy was started or re-started after an average of 55 days after hemorrhage in 5 cases, but intracranial hemorrhage enlarged in one case. None of the 6 patients who could be followed-up showed recurrence during an average follow-up of 2 years and 3 months after hemorrhage.Conclusion: Decreased cerebral blood flow and vascular reserve capacity due to main trunk occlusion seemed to be risks for ipsilateral perforating branch area hemorrhage.

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A 61-year-old male suddenly felt a shooting pain on the left side of his neck when he twisted the neck, and suddenly experienced urinary retention. On admission, we observed few obvious focal neurological signs except for an unsteady gait. Magnetic resonance imaging revealed an acute infarct in the left medulla, which extended posteriorly from the inferior olivary nucleus. Left vertebral angiogram revealed that the left posterior inferior cerebellar artery (PICA) territory was supplied by the right anterior inferior cerebellar artery–PICA trunk and a collateral branch originating from the extracranial left vertebral artery. Cystometry revealed normal voiding sensation and relatively high intravesical pressure during voiding effort. On the 9th day of admission, he was able to void normally without residual urine. He was discharged on the 13th day; he has not shown any signs of recurrence of lower urinary tract symptoms. Lower urinary tract dysfunction (LUTD) associated with medullary infarction is rare. At the medulla level, the descending tract from the pontine micturition center (PMC) is assumed to lie posterior to the inferior olivary nucleus. In our patient, the involvement of this tract might have caused LUTD. The important point in this case is that his medullary infarction developed mainly with LUTD. In contrast to previous reports, the lateral part of the medulla, which is supplied by PICA, was spared in our patient. This characteristic infarct distribution would explain the paucity of focal neurological findings in our patient.

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The patient was a 75-year-old female who developed disturbance of consciousness, right hemiplegia, aphasia, and a high fever and was transported to our hospital by ambulance. On MRI (DWI), high-intensity regions were diffusely present in the splenium of the corpus callosum, hippocampus, and deep white matter of the left temporal lobe. The patient was initially diagnosed with multiple cerebral infarction and treated with general drip infusion and oral drugs. Pneumonia was also present, and treated with antibiotics. After admission, fever was gradually resolved and right hemiparesis improved, but aphasia remained. On MRI, performed to follow the course, the lesions had disappeared on DWI and FLAIR, and no abnormality was noted on MRA. Based on the clinical course and imaging findings, clinically mild encephalitis/encephalopathy with a reversible splenial lesion (MERS) was strongly suspected. MERS should be included in the differential diagnosis even in elderly patients. Transcortical sensory aphasia and acalculia remained in this patient, unlike reported cases, for which we considered the possibility of reduced cerebral blood flow in the left temporal lobe due to the commissural fibers of the splenium of the corpus callosum.

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