Background: We focused on the putaminal hemorrhage in a rehabilitation hospital and evaluated the relationships between the frequencies of neglect. Methods: For the 103 patients with putaminal hemorrhage referred to our rehabilitation hospital, Cube-copying test, bisection test, and extinction and inattention were conducted and evaluated relative to the information obtained on computed tomography imaging, including hematoma type and volume. Results: Unilateral spatial neglect was found in 58 of 103 patients. There were significant differences in hematoma volume, neurologic manifestation, cognitive function, and cognitive function between patients with and without unilateral spatial neglect. Conclusion: Unilateral spatial neglect in more than half of patients with putaminal hemorrhage at the time of convalescence rehabilitation. Existence of unilateral spatial neglect after putaminal hemorrhage was influenced not only the hematoma volume but also hematoma type.

A 60-year-old woman with a severe headache and decrease in consciousness, who had been diagnosed with an asymptomatic right middle cerebral artery (MCA) stenosis on magnetic resonance angiography (MRA) at another hospital 7 years ago, was transferred to our hospital. Head computed tomography (CT) showed a diffuse subarachnoid hemorrhage and an intracerebral hematoma in the right mediobasal frontal lobe. Subsequent CT and digital subtraction angiograms revealed a ruptured small aneurysm at the origin of an anomalous collateral artery with twig-like networks that extended from the right A1 segment to the distal end of the M1 segment, bypassing the missing main trunk of the proximal M1 segment of the right MCA. The aneurysm was successfully treated with coil embolization. Recently, Shin et al. described this kind of MCA anomaly as a subtype of aplastic or twig-like MCA, which was named as “twig-like networks of an anomalous collateral artery”. To our knowledge, only six cases of this type of anomaly associated with A1 aneurysm at the origin of the collateral artery have been reported including our case so far. Even though the size of all the aneurysms was small (≤5 mm), five of them (83%) ruptured. These data may indicate the vulnerability of this type of flow-related aneurysms to rupture, probably due to hemodynamic stress and the fragile nature of their immature arterial walls. To prevent such devastating complications, early surgical or endovascular intervention might be justified for these aneurysms, even for those of a small size without symptom.

We report a case of spontaneous internal carotid artery dissection, and discuss the etiology of the dissection. A 30-year-old man usually leaned his head when he slept. One day, he complained of right hemiplegia, motor aphasia, and neck pain after he woke up. MRI demonstrated small infarctions on the left basal ganglia and deep white matter, and MRA demonstrated the pseudo-occlusion of the left internal carotid artery (ICA). We diagnosed the dissection of the left ICA. We treated him medically first, because he was asymptomatic on admission. However, 4 days after onset, the dissection was not improved at all. Then, we decided to perform endovascular stenting for the dissection. After the treatment, the lesion was completely improved. On day 15 after admission, the patient was discharged without any neurological deficit. In this case, the mechanism of dissection of the internal carotid artery seemed to be associated with the lateral extension of the neck when sleeping.

A 68-year-old woman with Fabry disease-associated left ventricular hypertrophy was admitted because of sudden onset left hemiparesis. Her baseline National Institutes of Health Stroke Scale score (NIHSS) was 19. Diffusion-weighted magnetic resonance (MR) imaging of the brain demonstrated hyperintense signals at the right middle cerebral artery (MCA) territory, and Alberta Stroke Program Early CT Score+W (ASPECTS+W) score was 6. MR angiography disclosed the occlusion of the first segment of the right MCA. There was no contraindication to the intravenous application of recombinant tissue-type plasminogen activator (rt-PA) based on the Japanese guidelines for intravenous application of rt-PA edited by guideline committee for intravenous rt-PA in acute ischemic stroke, and we initiated intravenous infusion of rt-PA. The occluded right MCA was successfully recanalized and the patient showed neurological improvement. After hospitalization, paroxysmal atrial fibrillation was detected, and she was diagnosed with cardioembolic stroke. The treatment with intravenous rt-PA may be effective and safe in acute cardioembolic stroke in patients with Fabry disease.

Regional cerebral oxygen saturation (rSO₂) with the evaluation by near-infrared spectroscopy (NIRS) is noninvasive and easy to measure. This rSO₂ might be good for monitoring cerebral blood flow, especially in patients suffering from ischemic cerebrovascular disease. We experienced a case of Moyamoya disease, who is a 17-year-old female suffered from transient right motor weakness. At first, she underwent superficial temporal artery to middle cerebral artery (STA-MCA) bypass with encephalo-myo-synangiosis (EMS) at the left side. Two months later, she suffered from transient left motor weakness induced by standing position. We measured rSO₂ by using NIRS with the probe on the forehead during the alteration of the position. The rSO₂ of the right side fell down 8% following the change of position from laying down to standing position. After we performed STA-MCA bypass with EMS at the right side, the rSO₂ of the right side was stable during the alteration of the position. The change of rSO₂ by head up or orthostatic induction could be useful not only for the screening of cerebral blood flow but also the bed rest level and blood-pressure management in patients with acute ischemic cerebrovascular disease.

We prospectively investigated the cognitive function in patients with cerebral large artery disease (CLAD). We registered 176 patients without severe neurological symptoms who had apparent carotid artery or middle cerebral artery occlusive disease between October, 2011 and December 2013. We excluded those with dementia. The cognitive functions of the patients were measured with Mini-Mental State Examination (MMSE) and Montreal Cognitive Assessment (MoCA). Their white matter lesion and microbleeds evaluated with MRI and cerebral blood flow were also assessed. The factors associated with cognitive impairment were analyzed using univariate and multivariate analyses. Furthermore, the factors associated with sub-scores (ex. executive function, attention, memory) were assessed. Of the patients with carotid stenosis, pre-and post-operative changes of cognition were compared with those performed carotid endarterectomy (CEA) while the cognition was also compared between at initial and at 1 year after. As a result, the cognitive impairment defined with 25 points or less of MoCA reached 77.3 percent. Multivariate analysis indicated that the factors associated with cognitive impairment were older age, drinking habit, decreased cerebral blood flow and the grading of periventricular white matter. Meanwhile, the cognitive function was elevated from 21 before CEA to 23 one year after CEA (P=0.006), while cognitive function at 1 year after did not improve significantly compared with that at initial (P=0.47). Thus, we were able to elucidate the characteristics and factors associated with cognitive function in patients with CLAD.

Cryptogenic stroke is not uncommon, and there is etiological heterogeneity of cryptogenic stroke regarding the underlying embolic source. So far, several potential embolic sources demonstrated on transesophageal echocardiography (TEE) including patent foramen ovale (PFO), and aortic arch plaques (AAPs) have been associated with the pathogenesis of cryptogenic stroke. Embolic stroke of undetermined source (ESUS) has been recently proposed as a new clinical entity with specific diagnostic criteria. In ESUS, diagnostic modalities to investigate cardioembolic etiologies involved 12-lead electrocardiogram, cardiac monitoring for ≥ 24 h, and transthoracic echocardiography. TEE has not been required for the diagnosis of ESUS. Therefore, embolic mechanisms caused by PFO or AAPs could be implicated in the pathogenesis of ESUS. To date, factors related to recurrent vascular events in ESUS have been unknown. In the present study, we investigated the factors, including clinical characteristics and potential embolic sources on TEE related to recurrent vascular events in ESUS patients who were undergoing TEE.

Cerebral microbleeds (MBs) are the surrogate markers of recurrent strokes. However, the types of recurrent strokes associated with deep MBs are still unknown. We investigated the contribution of deep MBs to stroke recurrences in patients with the past histories of deep intracerebral hemorrhages (deep-ICHs) or lacunar infarctions (LIs). As a result, the incidences of all types of strokes, deep-ICHs and LIs presenting as stroke recurrences were significantly larger in LI patients with deep MBs than in those without. However, there was no significant difference between deep-ICH patients with and without MBs in terms of incidences of stroke recurrences. The investigations revealed no significant relationship between deep MBs and athero-thrombotic infarctions, cardio-embolic infarctions or lobar-ICHs presenting stroke recurrences. There are differences among patients with the past histories of strokes in the contributions of MBs to stroke recurrences. And there are differences among recurrent stroke types. In this review article, we discuss the stroke recurrence associated with MBs, with recent reports demonstrating several risk factors associated with MBs.

We evaluated the feasibility and safety protocol of the HAL intervention study to analyze the clinical condition that HAL was effective in the acute phase of stroke, and tested an intervention effect by the HAL. Method: A feasibility and safety as well as physical function and the activities of daily living in the stepped functional recovery program of HAL was evaluated for the 36 patients with stroke in the acute phase. Results: In the comparison between before and after HAL intervention, walking speed, 12-grade hemiplegia functional tests, NIHSS, Barthel index, and motor FIM showed a significant improvement. They were significantly associated with the initiation of the ambulation activity intervention by HAL, and the acquisition of walking speed 25 m/min or more. Discussion and Conclusion: A feasibility and safety of the stepped functional recovery program by HAL was proved in an acute stroke. Physical function and activities of daily living were useful in evaluating an intervention effect of stand- and ambulation- activity by HAL.

Purpose: There are only few stroke specialists in the medically under-served areas of Japan. To correct the specialist shortage in a medically under-served area located in Tokushima Prefecture, the Department of Regional Neurosurgery was established in the Tokushima Prefectural Kaifu Hospital in October 2011. Additionally, a mobile telestroke support system that accesses the internet via a smartphone was introduced in February 2013. We analyzed the effect of the new support system on acute stroke in the medically under-served area of Tokushima. Methods: Acute stroke patients treated in Kaifu Hospital were divided into two groups. Group A comprised 253 patients treated from October 2011 to December 2014, after the introduction of the new support system. Group B comprised 103 patients treated from October 2009 to September 2010, before the introduction of the new support system. We analyzed the time interval from the patient’s home to the start of the treatment, the rate of admission to the hospital for further treatment, and the patient outcome. Results: The average time taken from the patient’s home to the start of the treatment for stroke in Groups A and B were 30 min and 100 min, respectively, with a significant statistical difference (p=0.0068). The admission rate for further treatment decreased significantly in Group A than in Group B (p<0.001). The improvement in the average value of modified Rankin scale at discharge was significantly higher in Group A than in Group B (p<0.0001). We implemented intravenous recombinant tissue plasminogen activator infusion therapy using a drip-and-ship protocol in Kaifu Hospital in 8.6% of patients with acute ischemic stroke after the introduction of the new support system. The telestroke system was used in 50% of the acute stroke patients, and 87% of it was used in off-time period. Conclusion: The new support system for acute stroke in the medically under-served area of Tokushima involves direct medical treatment by a stroke specialist during office hours and indirect specialist support to general physicians using the telestroke system during overtime, night, and holiday work. We observed that the new system could reduce the time interval to start the treatment and contribute to the improvement of patients’ outcome.