Purpose: The aim of this study was to examine the relationship between stress index (SI) calculated by dividing blood sugar (BS) concentration by serum potassium (K) level at the time of initial examination and both severity and outcome of subarachnoid hemorrhage (SAH). Methods: We retrospectively analyzed 108 patients with SAH. Severity of SAH was assessed using the World Federation of Neurosurgical Societies (WFNS) classification system. The moderate group included patients with WFNS grade I–III, with all other patients classified into the severe group. Outcomes at the time of discharge were assessed using the Glasgow Outcome Scale. Good outcome group included patients with good recovery or moderate disability, while others were classified to the poor outcome group. Biochemical factors evaluated at the initial examination included K, BS, and SI. Results: BS and SI were significantly higher in the severe group than in the moderate group (p<0.001). These indicators were also significantly higher in the poor outcome group than in the good outcome group (p<0.001). Some patients in the moderate group fell into the poor outcome group. In those patients, SI was significantly high. Conclusion: SI was significantly high in patients with severe SAH and in patients with poor outcome. Patients with high SI who are classified into the moderate group might show poor clinical outcomes.

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Purpose: The aim of this study is to investigate the relationship between Champagne bottle neck sign (CBNS) and the internal carotid artery (ICA) flow. Methods: We investigated 108 patients with moyamoya and akin-moyamoya disease (216 vessels) from January 2001 to December 2013 who received cerebral angiography and carotid ultrasonography. We retrospectively assessed the relationship between CBNS and stage of moyamoya disease, and the presence of the posterior communicating artery (Pcom) by cerebral angiography, pulsatility index (PI) and mean velocity (MV) of the ICA were measured by carotid ultrasonography. Results: Prevalence of the CBNS was well correlated with stage of moyamoya disease and CBNS was detected more often in patients with stage 3–6 than in those with stage 1–2. PI was higher (1.30 ± 0.34 vs. 1.02 ± 0.12, p=0.027) and MV was lower (33.8 ± 3.6 cm/sec vs. 45.6 ± 3.2 cm/sec p<0.001) in the patients with CBNS positive group than in those without. Conclusions: It seems that CBNS is related to progression of stage of moyamoya disease and to low ICA flow due to increased peripheral resistance by defect of Pcom.

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Background and Purpose: Dysphagia after acute ischemic stroke is frequently associated with aspiration and pneumonia. Thickened liquids have been shown to prevent aspiration in acute ischemic stroke patients with a pseudobulbar palsy. We developed a simple bedside screening test to assess aspiration for thin liquids. The test is a combination of a modified 3-ml water drinking test (MWST) and a 2-ml 1% thickened liquid swallow test (TLST). In this study, we investigated the validity of this screening tool to identify high risk cases in acute ischemic stroke patients. Methods: Subjects included 450 consecutive acute ischemic stroke patients admitted to our hospital, excluding those with somnolence or coma, medullary infarction, and fatality. Screening began with the MWST. When positive for cough (n=104), patients were then given TLST. If cough was noted with TLST (n=22), patients were then considered high risk for developing aspiration pneumonia, and received intensive management. Rehabilitation programs were made according to the risk. We evaluated prognosis of the oral intake by the combined screening test and the rate of pneumonia at discharge. Logistic regression analyses were performed. Results: A total of 424 patients could successfully achieve an oral intake without aspiration pneumonia. The 2-step test, pneumonia, and bilateral lesion were related to the prognosis of the oral intake (p<0.01). The pneumonia rate was 1.1%. Conclusion: The 2-step test of MWST and TLST during the acute stage of ischemic stroke is valid to predict the prognosis of the oral intake.

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Background: We examined the clinical features of cardioembolic stroke in patients with non-valvular atrial fibrillation (NVAF) who developed cardiogenic cerebral embolism during anticoagulant therapy. Methods: Among 760 patients who suffered from cardioembolic stroke caused by NVAF and were hospitalized between April 2007 and July 2015, we retrospectively reviewed 186 who had been receiving anticoagulant therapy. Results: Of the 186 patients, 168 were being treated with warfarin and 18 with non-vitamin K-antagonist oral anticoagulants. Of the 168 warfarintreated patients, 130 had prothrombin time-international normalized ratio (PT-INR) values below the target ranges (age<70:2.0–3.0, ≥70:1.6–2.6); 8 of these patients had suffered cerebral infarction during adjustment (5 patients) or initiation (3 patients) of warfarin therapy. All three newly warfarinized patients had developed cerebral infarctions within the first week of warfarin therapy. Twelve patients had developed cerebral infarction during cessation of anticoagulant therapy. Six of these had stopped their anticoagulants due to poor medication adherence and two had been prescribed cessation by their doctors. The remaining four patients had stopped their anticoagulants for reasons associated with surgery or hospital admission; two of them were on heparin replacement. Conclusions: In oral anticoagulant therapy, special attention needs to be paid to the risk of cerebral infarction during therapy initiation or dosage adjustment. Attention also needs to be given to ensuring medication adherence.

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A 38 year-old woman with a sudden headache was transferred to the ER. Head CT and CT angiography (CTA) revealed subarachnoid hemorrhage without any aneurysm. Multimodality examinations were performed repeatedly during the acute period. On her 14th hospital day, digital subtraction angiography showed a slight protruded change of the right internal carotid artery (C3 portion), which was suspected as a blood blister-like aneurysm. As a result of comparing the MRI and CTA images, the false lumen was speculated to spread around the posterior wall of the ophthalmic artery bifurcation. Balloon occlusion test showed tolerance, however, no intraorbital blood flow was observed through any angiographies during ICA occlusion. We changed the strategy to the stent assisted coil embolization with preserved ophthalmic artery flow because trapping of dissecting lesion carried a very high risk of visual impairment. After this embolization, there was good course with no neurological deterioration, no blurred vision, and no recurrence of this aneurysm. As for the present patient, diagnostic multimodality imaging with MRI and angiography seemed to not only change the determination of therapeutic strategy but also avoid complication risk.

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Purpose: We report a case of a ruptured blood blister-like aneurysm of the internal carotid artery, which was treated with stent-assisted coil embolization using Enterprise VRD. Case: A 70-year-old man was admitted to our hospital because of unconsciousness due to subarachnoid hemorrhage (SAH). WFNS (World Federation of Neurosurgical Societies) SAH grading scale was 4. Head MR angiography and 3D-CT angiography showed a ruptured blood blister-like paraclinoid aneurysm of the left internal carotid artery. On the next day of admission, the patient presented anisocoria. After an emergency ventricular drainage, stent-assisted coil embolization using Enterprise VRD was subsequently performed. Angiography immediately after embolization showed residual aneurysm filling. The modified Rankin Scale score at discharge after about 2 months was 2. The follow-up angiography for 30 months showed progressive occlusion with a tiny neck remnant of the aneurysm and reconstruction of the internal carotid artery. No rerupture occurred during 33 months. Conclusions: Stent-assisted coil embolization can be considered an alternative treatment option for ruptured blood blister-like aneurysms of the internal carotid artery.

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A 34-year-old woman experienced a stroke-like episode and was diagnosed with mitochondrial myopathy, encephalopathy, lactic acidosis, and stroke-like episodes (MELAS). By the end of November 2014, she suffered from cognitive decline, although there had been no recurrence of strokes till then. Her symptoms progressed steadily to the point that her ability to communicate was lost and then she was hospitalized in the beginning of December 2014. On magnetic resonance imaging (MRI) high-intensity areas from the left temporal to the occipital region was shown, which stretched to the left precentral gyrus region within several days, with associated limb-kinetic apraxia. The treatment consisted of daily high-dose L-arginine of 1.0 g/kg/day for 14 days by intravenous administration. After starting the treatment, modest improvement was observed, so the dosage of L-arginine was reduced. But later she experienced the recurrence of symptoms with cortical blindness and agitation, and a right occipital lesion was also identified. So, daily high-dose L-arginine of 1.0 g/kg/day began to be used again. Her neurological symptoms gradually improved, and all the lesions that had been seen on the MR images disappeared. We confirmed from the result that clinical and radiologic reversal of stroke-like episodes in an adult MELAS patient occurred with daily L-arginine.

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Recently four NOACs have become available, which requires us to determine the most appropriate one among the options. Since each NOAC has a specific indication and two different dosages according to various patient criteria including age, weight, renal function, and so on, it is often confusing and troublesome to compare them and select the best one. We developed an electrical medical record template for automatically evaluating and selecting the most suitable candidate among four NOAC candidates. In selecting an adequate NOAC, this system is easy and useful for objective comparison and apparent assessment, avoiding contraindication and off-label use.

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