Objective: The study was conducted to understand the current state of awareness by the general public in seeking early medical care following stroke, and to find what knowledge or information is required to influence their behavior.Method: A questionnaire survey designed to understand the current state of awareness in seeking early medical care following stroke was mailed to 1059 advisers of Kobe City local government. Factors that may influence general public’s behavior in seeking early medical care were assessed.Results: The response rate was 62%. The largest group of the respondents were in their 60’s (22.5%). 68% of the respondents were categorized as will “seek early medical care” immediately after stroke. With increasing awareness about stroke risk factors and warning signs, the proportion of those who will “seek early medical care” increased. 38.6% of the respondents knew tPA as a treatment option. Results show tPA’s time-limit concept encouraged them to seek early medical care after stroke.Conclusion: In order to influence the behavior of the general public to seek early medical care following stroke, the knowledge to be given must be evaluated focusing on its quality and quantity.

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Background and Purpose: In recent years, clinical practice guidelines related to stroke have been published in Japan and used in medical practice.Methods: We investigated trials which involved issues of stroke and searched the available full-text court records to find those with the term “stroke treatment clinical practice guidelines” in the ruling.Results: 7 cases (8 trials) were enrolled. In the medical negligence cases in which the guidelines were a factor in the guilty ruling, we confirmed the sentence had largely been made in accordance with the guidelines. Several verdicts seemed to emphasize the amount of evidence, as indicated by the guidelines.Conclusion: Although complete medical validity is not necessary in Japanese lawsuits, the guidelines may have some positive effect in terms of guaranteeing medical accuracy in a trial.

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Background and Objective: In the Aso medical region of Kumamoto prefecture, no facilities are capable of providing acute revascularization therapy. Therefore patients for whom this procedure is indicated are thus transferred to another facility outside of the Aso city. However, because transfer takes approximately one hour, intravenous recombinant tissue plasminogen activator (rt-PA) was administered for only one of 11 patients transferred for hyperacute ischemic stroke in 2010. In order to enable rt-PA infusion at the hospital to which these patients were first brought, we aimed to establish a telemedicine system between comprehensive stroke centers and primary emergency model hospitals using smartphones.Methods: When a hyperacute patient is brought to a model hospital, the physician in charge uses the smartphone application “RDICOM” to upload the National Institute of Health Stroke Scale (NIHSS) score and head computed tomography (CT) images to a server. Based on the RDICOM information, a stroke neurologist at the comprehensive stroke center then decides on the indication for rt-PA and instructs for infusion (“drip”) to be carried out. As this treatment is highly specialized, the patient is transferred (“ship”) to the comprehensive stroke center while receiving intravenously rt-PA.Results: During June 2012 to May 2013, a total of 15 hyperacute patients were brought to the model hospital; rt-PA was performed for five of these patients without complications, and the door-to-needle time was almost one hour.Conclusion: Remote support using the present system may enable rt-PA therapy to be performed in regions where it had not been previously possible.

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The Northern Hokkaido Stroke Study (NOHSS) is a population-based study. We started the stroke registration system in this area, and evaluated the type of stroke, risk factors, outcome, and recurrence rate for 9 years. Between July 1, 2002 and June 30, 2011, 2345 patients (56.6% male and 43.4% female) with acute stroke were registered. The mean age (±SD) of patients were 72.2±12.1. The type of stroke distribution was cerebral infarction in 66.1%, intracerebral hemorrhage in 23.5%, subarachnoid hemorrhage in 9.9%. The clinical category of cerebral infarction was lacunar in 38.1%, atherothrombosis in 31.2%, cardioembolism in 26.6%. In total 2345 cases, 197 cases were recurrent strokes. The annual recurrence rate was 3.8%. We divide the patients into 3 groups every 3 years of the registered period and analyzed clinical data among the groups. We found that intracerebral hemorrhage decreases and cerebral infarction increases for the 9 years. In ischemic stroke subtypes, cardioembolism increases statistically. We also found that anticoagulation therapy, as prevention to cardioembolism, is popularized gradually.

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The patient was a 62-year-old female who had acute dizziness and nausea. On brain magnetic resonance imaging (MRI), diffusion-weighted imaging (DWI) and FLAIR showed high-intensity areas mainly in the bilateral insular cortex. Laboratory tests revealed an elevated D-dimer level, and cerebrospinal fluid analysis showed no abnormality. Brain and cervical MR angiography displayed no stenosis of vessels, and ^99mT-ECD SPECT showed decreased blood flow in the areas in which brain MRI showed abnormalities. Gadolinium-enhanced T1-weighted brain MRI showed enhancement in one of the right lesions. Transesophageal echocardiography revealed a patent foramen ovale and right-to-left shunt. Ultrasound of lower extremity veins showed thrombosis in the lateral soleal vein of both sides. Therefore, we diagnosed her as having paradoxical cerebral embolism by deep vein thrombosis. After admission, anti-coagulation therapy was administered, and her symptoms and abnormalities on DWI of brain MRI disappeared. When we encounter a patient who has abnormalities in the bilateral insular cortex on MRI, we should consider brain infarction as one of the differential diagnoses.

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A 39-year-old man visited our hospital presented with a slight sensory disturbance who had a history of resection of left temporal arteriovenous malformation (AVM) and postoperative stereotactic radiosurgery in another hospital. Magnetic resonance (MR) imaging showed multilocular cysts and edema formation in the left temporal lobe. Angiography demonstrated the complete obliteration of the nidus. His speech disturbance deteriorated and MR imaging showed cysts enlargement one year after the first visit. He underwent microsurgical cysts fenestration and cystoperitoneal shunt (C-P shunt), and the symptom was gradually improved and cysts were decompressed up to 3 months after surgery. One year after the initial surgery, he developed speech disturbance and computed tomography (CT) demonstrated the enlargement of the cysts again. He underwent re-surgical opening of the cysts and shunt revision. The cyst had resolved on postoperative CT and the patient remained asymptomatic at 4-year follow-up. Delayed cysts formation after stereotactic radiosurgery for the cerebral AVM is relatively rare but well-described complication. We could achieve complete decompression of the cysts and improvement of the symptom by microsurgical cysts fenestration with C-P shunt. We have to be aware of this complication in the long term after radiosurgery for the AVM.

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We reported on three patients with pure dysarthria. All of them were admitted to our hospital due to sudden onset of dysarthria. On admission, none of the patients showed any neurological abnormality except for dysarthria. Brain MRI of all three patients revealed a small infarct limited to the posterior limb of the internal capsule. In all cases, the clinical symptom completely disappeared in a few days. Pure dysarthria due to a lacunar infarct of the posterior limb of the internal capsule is extremely rare. Our three cases suggest that pure dysarthria may be caused by the disruption of the corticobulbar tract not only in the genu but also in the posterior limb of the internal capsule.

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Limb shaking (LS) is a rare manifestation of transient ischemic attack in patients with high-grade stenosis or occlusion of the internal carotid artery or Moyamoya’s disease. We reported on a 78-year-old man who presented with involuntary movement on the left upper and lower limbs, associated with dysarthria and left hemi-weakness. Although he had oral haloperidol, neurological symptoms did not improve. EEG revealed normal findings. Brain MRI diffusion weighted images showed a high intensity area in the right basal ganglia and insula. Cervical MRA and echocardiography revealed severe stenosis with soft plaque in the right internal carotid artery. SPECT and perfusion CT showed mild reduction of cerebral blood flow (CBF) in both the right middle cerebral artery (MCA) territory and the basal ganglia. Carotid endarterectomy was performed on day 15, followed by improvement of LS and CBF. Since preoperative difference of the CBF between the basal ganglia and MCA cortex was insignificant, derangement in the basal ganglia itself might play an important role for the cause of LS.

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A 71-year-old woman with vascular access for dialysis in her left arm demonstrated subclavian steal syndrome. Although the stenotic left subclavian artery was reconstructed with stent placement, antero-grade filling of the left vertebral artery was not obtained. Two months later, ultrasonography showed excessive flow of the vascular access and worsening of the retro-grade filling of the left vertebral artery. Flow of the vascular access was decreased with “banding technique” until filling of the left vertebral artery normalized. After the flow reduction of the vascular access, symptoms completely resolved. In the cases where the vascular access is present ipsilateral to subclavian artery stenosis, effect upon the subclavian steal syndrome of the vascular access should be considered.

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We report a case of reversible stenosis of the cervical internal carotid artery (CICA) causing stroke associated with Basedow disease. This 26-year-old woman presented with the left motor weakness. She complained of palpitations several days prior to having neurological deficit. Endocrinological examination disclosed hyperthyroidism. MR examination showed a small infarction and severe stenosis of the right CICA. After an appropriate medical treatment, she recovered well. Follow up MRA showed improvement of the stenosis. Basedow disease, we may need to be aware of causing not only intracranial arterial stenosis but also reversible stenosis of CICA as seen in our case.

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