In the arbitrary guardianship system in Japan, we will contract with guardians if the judgment ability declines in the future. There is no clear standard for judgment ability necessary for the arbitrary guardian contract. We examined the judgment ability necessary for the arbitrary guardian contract. Even if the judgment ability is declining, the arbitrary guardian agreement will be effective if there is will ability necessary for concluding a contract. A judge evaluates the will ability necessary for concluding a contract with reference to medical evaluation, personal circumstances, etc. Therefore, the medical assessment and the judgment of the court may not necessarily agree.

Background and Purpose: It is well known that Stroke Care Unit (SCU) is effective for improving clinical outcomes of stroke patients. In Japan, SCU is installed in limited hospitals. However, its efficacy has rarely been reported. We compared the clinical outcomes of acute stroke patients in a community hospital in Japan between before and after SCU installation. Methods: From April 2011 to March 2016, acute stroke patients admitted to Neurology/Neurosurgery department in Nagahama City Hospital were enrolled. Age, gender, stroke types, NIHSS on admission, the number of tPA thrombolysis, length of stay in acute care ward, in-hospital mortality, the rate of home discharge, and modified Rankin Scale on discharge of each fiscal year were retrospectively recorded from the medical chart. Parameters of each patient for 2013, 2014, and 2015 were compared with control (those of 2011), by means of chi-squared test, Kruskal-Wallis test, or one-way analysis of variance as appropriate. Bonferroni correction was used as a post hoc comparison. P value less than 0.05 was deemed as significant. Results: Demographic and clinical data of patients did not differ among every year. The number of tPA thrombolysis tended to increase after SCU installation. Length of stay in acute care ward decreased after SCU installation. The rate of discharge home tended to increase after SCU installation. In-hospital mortality finally decreased after SCU installation. mRS 0–2 on discharge has a tendency to increase after SCU installation. Conclusion: Even if a community hospital in Japan was equipped with SCU, clinical outcomes of acute stroke patients tended to improve.

Background and Purpose: Cancer and stroke are the main causes of death in Japan. Some patients with cancer also have stroke. We retrospectively analyzed the clinical features of Trousseau syndrome. Methods: 40 patients with Trousseau syndrome of 2273 consecutive stroke patients except transient ischemic attack were admitted to our hospital between April 2009 and March 2016. We evaluated the origins, histological types, and stages of cancer related to Trousseau syndrome. Trousseau syndrome was defined as multiple cerebral infarctions with cancer-associated hypercoagulability. Results: The patients with Trousseau syndrome accounted for about 1.8% of a total of stroke patients. 27.5% of the patients with Trousseau syndrome were newly diagnosed as having occult cancer after stroke during medical treatment for acute phase. Lung cancer (11 cases) was the most common cancer. Adenocarcinoma (23 cases) was the most common histological type. Stage IV cancer (31 cases) was the most common cancer stage. Conclusions: It is important to search for occult cancer as soon as possible in terms of survival prognosis when we encounter multiple cerebral infarctions with hypercoagulability.

We report a rare case of posterior fossa dural arteriovenous fistula (AVF) presenting as cerebellar hemorrhage with a substantial brain edema. A 75-year-old man presented with imbalance and gait disturbance. He had a 5-year-old history of malignant melanoma of the toe, which was successfully resected and has not recurred ever since. He visited a neurosurgical clinic, but was transferred to our hospital because of his cerebellar dysfunction. Magnetic resonance (MR) images revealed a right tonsillar T2 high-intensity lesion with a small hemorrhage. However, diffusion-weighted images did not suggest any diffusion impairment. Contrast-enhanced MR images revealed an enhanced lesion on the right tonsil. Accordingly, he was diagnosed with a metastatic brain tumor of malignant melanoma, and corticosteroids were administered. One week after the admission, T2 high-intensity area of the right tonsil decreased, the enhanced area shrunk, and his cerebellar symptoms improved. Cerebral angiography demonstrated dural arteriovenous shunt on the tentorium cerebelli between the posterior meningeal branch of the vertebral artery and the right inferior vermian vein. Dural AVF comprised retrograde leptomeningeal venous drainage without draining into the dural sinus. Thus, we could diagnose cerebellar hemorrhage due to dural AVF of the posterior fossa. The abnormal vessels disappeared 3 months after the admission. Hence, this report suggests that tonsillar hemorrhage and diffuse cerebellar edema may indicate the presence of dural AVF, considering a distinctive draining pattern of the cerebellar tonsil.

Stanford type A acute aortic dissection is a disease requiring emergency surgery. Because patients with Stanford type A acute aortic dissection and ischemic stroke do not often complain chest or back pain probably due to consciousness disturbance, amnesia or aphasia, “fatal course following inappropriate intravenous rt-PA therapy” and “delay of appropriate surgical treatment” sometimes occur. When treating stroke-suspected patients, emergency services and initial urgent care doctors should always have suspicion of aortic dissection. Even in the absence of chest or back pain, the initial urgent care doctor need to immediately perform chest contrast CT examination if suspecting aortic dissection from the blood pressure laterality or the upper mediastinal widening on the X-ray. Whenever aortic dissection cannot be denied from initial clinical information, the initial urgent care doctor should evaluate the common carotid artery (CCA). Dissection extension to CCA or flow abnormality of CCA is often detected if aortic dissection is a cause of ischemic stroke or transient ischemic attack. Head CT or MRI including vascular imaging is preferable. D-dimer should be measured in the available hospitals. As soon as aortic dissection is detected, the initial urgent care doctor needs to consult with cardiovascular surgeons or cardiologists for appropriate treatment.

Vertebral artery (VA) dissecting aneurysms presenting with subarachnoid hemorrhage (SAH) require prompt treatment, because they frequently rebleed within 24 hours. Recently, interventional radiology is prevailing in comparison with surgery. However, surgery is necessary for decompression or posterior inferior cerebellar artery (PICA)-involved vertebral artery dissecting aneurysm (VADA). Furthermore, infarction in the area of perforating artery is less frequent in surgery. One of the reasons of decrease of surgery is the blind inheritance of the conventional complex method with lateral position. On the other hand, surgery with prone position have a lot of advantages. The author details this method. The ideal direction of treatment of VADA is keeping a balance between developing intravesical recurrence (IVR) with surgery. For surgery, strategy and method must be rethought again.

Awareness of the warning signs of stroke to the public is essential to shorten the time from stroke onset to hospital arrival. School-based education pertaining to lifestyle-related diseases can help to prevent diseases like stroke. Further, it is also expected for educated family members will act appropriately by calling emergency medical services on encountering an incidence of suspected stroke. We developed educational material to advance stroke awareness for children at junior high school and elementary school, and confirmed that this material helped to improve the knowledge of stroke in children, which in turn was conveyed to their parents. This educational approach can also be applied to other lifestyle diseases like heart attacks and some cancers, and may be a promising strategy to cut the prehospital delay as well as to widely spread stroke awareness via school children.

Cervicocephalic arterial dissection is an important cause of stroke in young patients. In Japan, 0.7% of strokes are caused by dissection, and 71.9% of strokes due to dissection are ischemic strokes. Intracranial vertebral artery dissection is popular in Japan, and the risk of subarachnoid hemorrhage caused by the rupture of a dissected aneurysm is important in antithrombotic treatment. The safety and efficacy of intravenous thrombolysis in ischemic stroke caused by dissection have been reported to be similar to those in non-dissected ischemic stroke, but most dissection sites of the reported series are in the extracranial arteries. The CADISS trial demonstrated that cardiovascular events after dissection are few, and no difference was found between antiplatelet and anticoagulant treatments. The efficacy and safety of antithrombotic agents in intracranial dissection patients is not known. Aneurysm formation is worried about the risk of rupture, so repeated sequential neuroimaging is important in intracranial dissection of patients under antithrombotic treatment.