Background and Purpose: The Penumbra System (PS) is a mechanical thrombectomy device for recanalization of a large artery occlusion in acute stroke. The purpose of this study was to clarify the efficacy of PS with MAX system. Methods: We retrospectively reviewed 74 consecutive patients treated by PS at our institution between November 2011 and May 2014. We compared the Penumbra MAX series (MAX) with conventional Penumbra System (CPS) by examining the characteristics of treated patients, procedure contents, and angiographic and clinical outcomes. Results: MAX and CPS were performed in 32 and 42 patients, respectively. Baseline mean National Institutes of Health Stroke Score (NIHSS) was 20 in the MAX group and 18 in the CPS group. The recanalization rate was higher in the MAX group (88%) than in the CPS group (71%). Mean procedure time was shorter in the MAX group (67 min) than in the CPS group (114 min). Completion of the procedure with PS alone was more frequent in the MAX group (66%) than in the CPS group (36%). Symptomatic intracranial hemorrhage occurred only in one patient in the CPS group. The rate of favorable clinical outcome (mRS ≤ 2 at 3 months post-procedure) was 41% and 43% in MAX and CPS groups, respectively. Conclusions: Mechanical thrombectomy with MAX was effective for acute ischemic stroke. Use of MAX with PS increased the rate of recanalization and shortened the procedure time, although it did not improve clinical outcomes because patients’ baseline condition was poor.

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Purpose: We examined the incidence, clinical features, and treatment of deep vein thrombosis (DVT) in patients with cerebrovascular disease (CVD) who were admitted in our convalescence rehabilitation unit. Methods: Two hundred and thirty-seven patients who were treated in acute hospitals and transferred to our hospital for intensive rehabilitation from January 2011 to December 2012 were examined. Results: Twenty-eight patients with DVT (11.8%) were detected in this study. The same study had been also done in 2006 in our unit, showing an incidence of 8.8%. Therefore, the diagnostic rate of DVT increased in these recent years. Apparently, only four patients were diagnosed at other acute care hospitals previously, before they were transferred to our hospital. And 24 patients were diagnosed at our hospital at the time of their admission. DVT was significantly occurred in patients who had severe motor weakness of their legs, and detected in the affected side. In the 24 patients, only 1 patient required implantation of inferior-venacava (IVC) filter, because of the pulmonary thromboembolism. Eighteen patients were treated with warfarin, and five patients were followed up without medical treatment. Conclusion: Many patients of DVT associated with CVD who were transferred to the convalescence rehabilitation unit were not diagnosed adequately at the acute care hospitals, while DVT was considered to be increasing in these recent years. Physicians should take care of the high incidence of DVT in patients with CVD.

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Background and Purpose: The purpose of this study was to clarify the distinct influence of verbal and non-verbal cognitive functions on ADL improvement in stroke patients. Methods: RCPM and the MMSE were administered to examine the factors affecting improvement in ADL in 146 stroke patients who underwent convalescent rehabilitation. Results: Most patients with a decrease in MMSE scores alone (M group) had a language disorder caused by left hemisphere damage, while most patients with a decrease in RCPM scores alone (R group) had visuospatial cognitive impairment caused by right hemisphere damage. No difference in improvement in ADL was seen between the M group and those who had no decrease in scores on both assessments (N group). The R group had a longer hospital stay and lower ADL at discharge than the N group. The group of patients with decrease in scores on both assessments (MR group) had lower ADL at discharge and a lower rate of improvement in ADL than the other groups. Furthermore, the MR group had a longer hospital stay than the N group. Conclusion: The MMSE reflects verbal intelligence while the RCPM reflects non-verbal intelligence. Cognitive function as assessed by RCPM and MMSE may differentially affect ADL at discharge and improvements in ADL.

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We retrospectively analyzed 191 patients who underwent rt-PA treatment, catheter thrombolytic therapy, or thrombectomy from 2005 to 2014. Treated patients were categorized into 4 groups: group A intravenous alteplase (rt-PA) alone, group B underwent thrombolytic therapy with intra-arterial urokinase, group C underwent catheter intervention including mechanical thrombectomy mainly done for patients who were in contraindication with rt-PA, and group D catheter intervention was additionally done following rt-PA(bridging therapy). Patients in group A and group D achieved good outcome (modified Rankin Scale 0 to 2, at 90 days 37% and 40%, respectively). In both groups, patients underwent treatment earlier than the other two groups. In the case of internal carotid artery occlusion, only group D had good outcome, instead group A and C had poor outcome. Our data showed that early intervention resulted in good outcome. Favorable outcome is expected by bridging therapy and further experience is necessary.

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Putaminal-thalamic hemorrhages are located both in the putamen and thalamus and have been included in putaminal hemorrhage group or in the thalamic group for data analysis. However, it is difficult to determine whether the hematomas should be classified in each type, when the size of hematoma is large or it equally extends to putamen and thalamus. Moreover, most patients with putaminal-thalamic hemorrhage have severe neurological deficits because the size of hematoma is large or the internal capsule is destroyed. So, the treatment outcome of putaminal or thalamic hemorrhage might be affected by determining whether putaminal-thalamic hemorrhages are included in putaminal or thalamic type. We investigated the treatment outcome of putaminal-thalamic hemorrhage as one of the intracerebral hemorrhage type. Consecutive 28 patients with putaminal-thalamic hemorrhage from January 2009 to May 2014 were registered. Basically the patients had a medical treatment, but ventricular drainages were performed in cases with hydrocephalus and craniotomies for removal of hematoma were done in severe cases for rescue. Modified Rankin Scale (mRS) as prognosis were 3 in 3 cases, 4 in 2 cases, 5 in 4 cases, and 6 in 19 cases. The home discharge rate of patients with putaminal-thalamic hemorrhage was 17.9%. The prognosis of patients with putaminal-thalamic hemorrhage was poor. So far, putaminal-thalamic hemorrhage has been included in either putaminal or thalamic hemorrhage. We note that putaminal-thalamic hemorrhage should be investigated independently from putaminal and thalamic hemorrhages.

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A 77-year-old right-handed male with symptomatic carotid artery stenosis was treated by carotid stenting. Cerebral angiography revealed a de novo aneurysm in the distal posterior cerebral artery after the procedure. Further investigation documented the vegetation at the posterior leaflet of the mitral valve. The patient was treated by parent artery occlusion with N-butyl-2-cyanoacrylate (NBCA) at 2 days after the carotid stenting because of dual antiplatelet therapy to prevent in-stent restenosis. High-dose antibiotic therapy in the following 6 weeks resulted in resolution of the infectious endocarditis and the patient was discharged to home with quadrantanopsia. Early endovascular treatment should be considered for patients with dual antiplatelet therapy.

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Intravascular large B-cell lymphoma (IVLBCL) is a rare lymphoproliferative disorder characterized by massive intravascular growth of lymphoma cells that commonly affects the central nervous system and skin. Diagnosis is generally delayed by variable clinical presentations and nonspecific laboratory findings. We report herein the case of a 63-year-old man with IVLBCL who showed progressive multiple cerebral infarctions. The patient had a feeling of floating, and diffusion-weighted magnetic resonance imaging of the head showed multiple cerebral infarctions involving several blood vessel regions. Despite anticoagulation therapy, he developed left hemiparesis, urinary retention, and conscious disturbance. He was again found to have multiple cerebral infarctions with abnormal enhancement of brainstem lesion and the meningeal lesions of the right cerebral hemisphere. Serum lactate dehydrogenase (LDH) and soluble interleukin-2 receptor (sIL2R) levels were elevated (LDH 276 IU/l, sIL2R 1,910 IU/ml), which suggested malignant lymphoma. Random skin biopsy showed that blood vessels were infiltrated by CD20-positive atypical lymphocytes. These findings were consistent with IVLBCL. He received R-CHOP and high-dose MTX chemotherapy and achieved a remission. IVLBCL is known as a rapidly progressive disease with poor prognosis. Random skin biopsy should be considered when IVLBCL is highly suspected.

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A 63-year-old female had headache a week ago and developed pyrexia and right-sided hemiplegia 2 days ago while receiving radiotherapy and hormone therapy for breast cancer. MRI diffusion-weighted imaging (DWI) showed high signal intensity regions in the left parietal-occipital lobe and left lateral ventricle. The patient was diagnosed as having a ruptured brain abscess and treated with antibiotics and by external drainage. Two days after the operation, the right hemiplegia and aphasia became aggravated. MRI DWI showed high signal intensity regions in the left frontal-temporal lobe. The patient was diagnosed as having acute cerebral infarction, and treated with intravenous drip infusion. MRA on admission showed an irregular wall and narrowing of the bilateral anterior cerebral arteries and left middle cerebral artery. Follow-up MRA revealed occlusion of the left middle cerebral artery at the onset of cerebral infarction. After antibiotic therapy, the infection signs subsided. However, on computed tomographic angiography (CTA), while the irregular wall of the bilateral anterior cerebral arteries improved, occlusion of the left middle cerebral artery remained. The original image of CTA showed contrast enhancement of the arachnoid membrane and pia mater surrounding the left middle cerebral artery. Since brain abscess penetrating to the lateral ventricle can cause cerebral infarction, we need to give our full attention.

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