Background and Purpose: Recently, the numbers of stroke patients with cancer have increased. The purpose of this study was to analyze the characteristics of stroke patients with cancer at our hospital.Methods: We reviewed 30 consecutive stroke cases with cancer (11 females and 19 males with a mean age of 69 years) who were admitted in our hospital from January 2011 to December 2012.Results: Lung cancer in 7 (23%) and pancreas cancer in 7 (23%) were the most common primary tumors. Stroke subtypes were infarction in 21 (70%), hemorrhage in 7 (23%), and transient ischemic attack in 2 (7%). Nine of 21 infarction patients had Trousseau syndrome. Patients’ symptoms of stroke were improved in 12, unchanged in 12, and exacerbated in 6.Conclusion: Approximately 10% of stroke patients at our hospital had cancer, and the most common locations of primary lesions were lung and pancreas. Ischemic stroke was most frequent among the patients, and Trousseau syndrome was the main cause of infarction. Stroke could worsen the prognosis of cancer patients, so further studies are needed to identify the pathological associations between cancer and stroke.

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A 30-year-old woman with mild migraine, in her 33 weeks’ gestation, experienced a sudden onset parieto occipital headache, and soon developed motor aphasia and right hemiparesis with right homonymous visual field impairment. When admitted, the NIH stroke scale was 16, and the brain MRI revealed DWI high intensity areas in the left PCA distribution including the thalamus, hippocampus, and corona radiata with no visualization distal to P2 segment. Although eclampsia/preeclampsia was excluded, high-dose intravenous magnesium sulfate (20 g/day) was given together with heparin till successful full-term delivery. Her motor aphasia and hemiparesis totally disappeared with some residual homonymous visual field impairment. High-dose intravenous magnesium sulfate is considered to be a choice for reversible cerebral vasoconstriction syndrome associated with peripartum.

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A 42-year-old man suffering from hypertension was admitted to our hospital following a sudden onset of headache, dizziness, and vomiting. Magnetic resonance imaging (MRI) procedure was performed, revealing an infarction of the left cerebellar hemisphere. There was no apparent sign of dissection. Antithrombotic treatment was started and monitored carefully. On day 9, the patient complained of dysphagia, and an ensuing MRI showed a new right cerebellar hemisphere infarction. MRA and conventional angiography were conducted, revealing dissection of the bilateral posterior inferior cerebellar arteries (PICAs). We proceeded with conservative treatment and there was no recurrence of stroke. In this case, an infarction of the right cerebellar hemisphere appeared in the acute phase of an infarction of the left cerebellar hemisphere due to bilateral PICA dissection. Bilateral PICA dissection is quite rare, and we have not found such a case in the literature.

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We report the case of a patient who suffered from subarachnoid hemorrhage (SAH) from “de novo aneurysm” even though there had been no abnormal findings on head magnetic resonance imaging (MRI) and magnetic resonance angiography (MRA) in the past. A 69-year-old woman had undergone head MRI and MRA at our hospital 6 years previously, but there were no abnormal findings. She later suffered from severe headache, and computed tomography of the head at second admission showed SAH. MRA and digital subtraction angiography showed de novo aneurysm at the right distal anterior cerebral artery bifurcation, so aneurysmal clipping was performed. The postoperative course was good. Although some reports about de novo aneurysm have been published, almost all of them were about cases of de novo aneurysm formation following at another site. Ruptured de novo aneurysm with no abnormal findings in the past is very rare. Because the risk of de novo aneurysm formation remains, long-term follow-up is needed.

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A 74-year-old right-handed man who presented with sudden right hemiparesis was transferred to our hospital an hour after onset of symptoms. Upon admission, he exhibited mild unconsciousness, slurred speech, right hemiparesis, and pyramidal signs in both lower extremities. Computed tomography (CT) and magnetic resonance imaging (MRI) showed no lesions, except for the disappearance of the right vertebral artery in magnetic resonance angiography. However, MRI conducted on the next day showed an area of high intensity in a diffusion-weighted image, which ranged from the medial to the right dorsolateral side of the medulla oblongata. Follow-up MRI conducted on day 19 showed that the lesion ranged from the medulla to the upper cervical spine. CT angiography showed a proximal-dominant narrow area in the right vertebral artery. A neurological examination conducted after the improvement of the patient’s unconsciousness revealed weakness in the right sternocleidomastoid muscle, mild left hemiparesis, and sensory impairment on the left side of the body, in addition to the neurological findings that were observed upon admission. Our observations suggest that the ischemic lesion that occurred due to right vertebral artery occlusion included pyramidal decussation, which caused ipsilateral-dominant quadriparesis by impairing the motor fibers both before and after the crossing.

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We describe a patient who suffered from intracerebral hemorrhage and pseudoaldosteronism caused by the use of glycyrrhizic acid and Yi-Gan San (Yokukan-San in Japanese). An 85-year-old woman with hepatic dysfunction and dementia, who had taken glycyrrhizic acid and Yi-Gan San for more than 6 months, was admitted to our hospital complaining anorexia and aggravation of dementia. Neurological examination revealed loss of muscle strength and left hemianopsia. Brain computed tomography demonstrated subcortical hemorrhage in the right occipital lobe. Additionally, pseudoaldosteronism was diagnosed based on blood test and electrocardiogram. Glycyrrhizic acid and Yi-Gan San was stopped immediately and conservative treatment was initiated. During several subsequent days in the hospital the drug-resistant elevation of blood pressure was noted, however it decreased gradually in parallel with normalization of the serum potassium level. Since glycyrrhiza is one of the components of Yi-Gan San, it can induce drug-resistant secondary hypertension. Therefore, patients who use Yi-Gan San as a part of combination therapy with other drugs, such as glycyrrhizic acid, require special attention. To prevent the possible complications such as the brain hemorrhage, we need regularly to examine the blood test, electrocardiography and to maintain blood pressure.

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A 39-year-old female secondipara patient had an acute otitis media 15 days prior to her third delivery without complications. On the 7th day of puerperal period, she became unconscious and was taken to the hospital. Cerebrospinal fluid showed polynuclear pleocytosis and glucose level at zero. Hydrocephalus and bilateral thalamic infarction were seen on MRI, and cerebral venous thrombosis on MRV. Streptococcus pneumoniae was cultured both from cerebrospinal fluid and blood. The diagnosis of septic dural sinus thrombosis was made. She was treated without surgical intervention, and instead with antibiotics and heparin. The condition was dramatically improved and the expansion of thalamic infarction was prevented. Her consciousness disturbance was improved and she was able to eat and talk before discharge.

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A 69-year-old man was admitted to our hospital with right pleural effusion, ascites, and hypereosinophilia. Ten days later, he developed impaired consciousness and involuntary movement in the right upper limb was noted. A neurological examination revealed muscle weakness in all extremities and negative pyramidal tract signs. Cranial diffusion-weighted images showed multiple hyperintensity lesions in the watershed area of white matter and the cortex, suggesting acute brain infarctions. Cerebrospinal fluid (CSF) analysis revealed pleocytosis and extremely elevated protein level (4,504 mg/dl), while cytology of the CSF showed atypical lymphocytes, leading us to suspect T-cell lymphoma. Cytology of pleural effusion and ascites specimens revealed no apparent malignant cells, though Southern blotting of a pleural effusion sample showed clonal rearrangement of the T-cell receptor Cβ1 gene. The cerebral borderzone infarctions were speculated to have been caused by hypereosinophilia secondary to IL-5 over-production by a T-cell lymphoma. Methyl prednisolone pulse therapy was administered to reduce eosinophils. The patient was diagnosed with progressive disease after one cycle of CHOP chemotherapy (cyclophosphamide, doxorubicin, vincristine, prednisone). Unfortunately, he died of multiple organ failure 58 days after admission. A postmortem examination revealed widespread infiltration of lymphoma cells in various organs including the gastrointestinal tract and brain, though no eosinophils were found in examined brain or heart tissues. Hypereosinophilic syndrome should be considered as a differential diagnosis in patients with multiple borderzone infarctions.

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We report a case of middle cerebral artery dissection onset of ischemic stroke successfully diagnosed by MRA source images at the initial visit. A 75-year-old woman suddenly developed aphasia and right hemiparesis. Although MIP images of MRA revealed left middle cerebral artery M1 stenosis suggestive of atherothrombotic stroke, she was soon underwent an accurate diagnosis of middle cerebral artery dissection based on MRA source images and left carotid angiogram. Although the diagnosis of the intracranial cerebral artery dissection is not easy, it is needed to recognize the possibility of cerebral artery dissection in the intracranial major artery stenosis.

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A 79-year-old man with diabetes mellitus suddenly presented with right hemiparesis. Diffusion-weighted image (DWI) revealed high signal intensity localized in the left posterior limb of the internal capsule. Low plasma glucose level and neurological symptoms recovered after glucose infusion. He was diagnosed with hypoglycemic hemiparesis. He also had right hypoglycemic hemiparesis due to the same lesion 2 years ago. There has not been a report of a case with hypoglycemia that repeatedly presented abnormal signal in the same site. Repeatedly observed DWI abnormal signal in the posterior limb of the internal capsule may be caused by selective vulnerability to hypoglycemia among different brain regions.

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Periodontal disease is an inflammatory disorder and characterized by the destruction of periodontal support tissue which consists of gingiva, periodontal ligament, cementum, and alveolar bone. About 70% of all Japanese people suffered from some degree of periodontal disease. It was traditionally thought that systemic illness such as blood disease, developmental disease, metabolic disorder, and infection aggravated periodontal condition. However, scientific studies regarding the association between oral condition and whole body showed that periodontal disease deeply influences cardiovascular disease, diabetes mellitus, respiratory dysfunction, and preterm low birth weight. It was also reported that patients with periodontal disease had high risk of fatal coronary vascular disease, myocardial infarction, and stroke in comparison to healthy subjects. Periodontal disease increases CRP level in blood and promotes the development of atherosclerotic plaque, which might connect periodontal disease to cardiovascular disease such as stroke.

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Background: Stroke is still a heavy burden to our society. We have developed a stroke databank system since 1999 to standardize stroke therapy in acute stage and verify the evidence of treatment in Japanese stroke patients.Methods: We analyzed the data of more than 100,000 patients with acute stroke registered in Japan Standard Stroke Registry from 1999 to 2012. We focused on the chronological changes in stroke patient data.Results: Ischemic stroke was divided into three subtypes; 31% of patients had atherosclerotic, 29% had lacunar stroke, and 26% had cardioembolic stroke. Only the prevalence of cardioembolic stroke increased over the years. The incidence of cardioembolic stroke was high in aged people; 30% of stroke patients of more than 80 years had cardioembolic stroke. The time interval between stroke onset and hospital visit did not change chronologically except for transient ischemic attack, which showed increased ratio of early visit within 2 hours after stroke onset. The severity of illness became milder in recent years for ischemic stroke, but not for hemorrhagic stroke. On the other hand, modified Rankin Scale at discharge improved only for atherosclerotic stroke in recent years, while other types of stroke did not show improvement in prognosis at discharge.Conclusion: These data indicate the importance for prevention of cardioembolic stroke in aged people and social education for early detection of stroke symptoms and hospital visit.

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