Background and Purpose: To evaluate the Shizuoka Stroke Network, which is a regional stroke network for stroke prevention with regular specialist consultation, we investigated the long-term persistence rate of regular specialist consultation. Methods: We investigated 346 patients with stroke who registered over 5 years. The patients were classified through ongoing regular specialist consultation or dropout. Results: The mean follow-up time was 84.8 ± 17.0 months, and 38% of the patients were classified into the ongoing group. Patients in the ongoing group were significantly younger (p<0.001), had higher complication of hypertension and dyslipidemia (p=0.001, p<0.001), had carotid artery stenosis or occlusion, malignant tumor and lower scores of modified Rankin Scale (p=0.004, p=0.041, p<0.001) and were discharged to home (p<0.001) than those in the drop-out group. In multivariate logistic regression models, ongoing regular specialist consultation was associated with significantly lower age, higher complication of hypertension or dyslipidemia, and lower scores of modified Rankin Scale (odds ratio [95% confidence interval]: 2.09 [1.24–3.52], 2.23 [1.18–4.22], 2.33 [1.35–4.00], and 2.81 [1.27–6.24]). Conclusion: Our stroke prevention system with regular specialist consultation revealed that 38% of the patients registered over 5 years had regular follow-up. The ongoing regular specialist consultation was associated with younger age, complications of hypertension or dyslipidemia, and lower scores of modified Rankin Scale.

Objective: We had a case of an acute cerebral infarction (ACI), who had a coincidence of an acute myocardial infarction (AMI). It is a rare case and we treated both ACI and AMI simultaneously. Case: An 86-year-old woman admitted to our hospital with severe right hemiparesis and aphasia. Respiratory status and circulatory condition were stable. The electrocardiogram showed mild ST decline in II, III, aVF, and V4. MRI revealed an acute cerebral infarction in the left middle cerebral artery (MCA), MRA showed the left MCA occlusion. We started intravenous tissue plasminogen activator therapy at 80 min after the onset, and then mechanical thrombolysis was administered. The left MCA was successfully recanalized. Immediately after these procedures, the coronary angiography was performed, which revealed a left circumflex artery (LCX) occlusion. We proceeded percutaneous coronary intervention for LCX, which was recanalized successfully. After the surgery, right hemiparesis and aphasia were improved. The patient transferred to a rehabilitation hospital on day 23 after the initial treatment in stable condition. Conclusion: Even though it is a rare case, it is necessary to consider the treatment method and the treatment priority for each case.

The prognosis of the untreated giant upper basilar artery aneurysm is extremely poor. We present a case of complete spontaneous thrombosis of giant upper basilar artery aneurysm without any symptoms. A 22-year-old woman with no medical history suffered from brain stem infarction. Radiological examinations revealed a large (21 mm) partially thrombosis distal basilar artery aneurysm and left mid-brain infarction. On vertebral angiogram, the right posterior cerebral artery (PCA) and superior cerebellar artery (SCA) were not identified and the left PCA and SCA were originated from the aneurysm. She was treated conservatively. The follow-up MRI and cerebral angiogram performed 4 months after the onset showed the rapid progression of thrombosis of an aneurysm and the near occlusion of the left SCA origin without marked enlargement of an aneurysm. However, the 8-month follow-up MRI revealed that the aneurysm became giant (31 mm). The 3DCTA, at the same time, showed the enlargement of the circulating portion of an aneurysm and a protruded change of an aneurysmal wall at the origin of the left PCA. She was admitted for further management and cerebral angiography were performed 9 months after the onset, which demonstrated complete occlusion of an aneurysm and the distal basilar artery without any ischemic lesions. The patient was discharged in good condition and remains neurologically intact. The 2-year follow-up MRI demonstrated dramatic shrinkage without recanalization of an aneurysm. In this case, we speculate that the stepwise near occlusion of SCA and PCA origins plays an important role in complete thrombosis of an aneurysm.

The distribution of atherosclerotic lesions in the cervicocephalic vascular systems is well known to vary among different ethnic groups. In Caucasians, atherosclerosis develops more frequently in the extracranial carotid arteries, whereas intracranial atherosclerosis is the most common cause of stroke in Asians. Patients with intracranial artery stenotic lesion (ICAS) are still at high risk of stroke recurrence despite medical therapy, including antiplatelet therapy and risk factor modification. The annual recurrence rate of ischemic stroke was reported to be as high as 15% in the aspirin arm of the WASID (Warfarin-Aspirin Symptomatic Intracranial Disease) trial. In the SAMMPRIS (Stenting and Aggressive Medical Management for Preventing Recurrent stroke in Intracranial Stenosis) trial, aggressive medical management was superior to balloon angioplasty/stenting with the use of the Wingspan stent system and the 30-day rate of stroke or death was 14.7% in the endovascular group and 5.8% in the medical management group. Aggressive medical management consisted of dual antiplatelet therapy (aspirin of a dose of 325 mg per day and clopidogrel of a dose of 75 mg per day for 90 days after enrollment), management of risk factors targeted a systolic blood pressure <140 mm Hg (<130 mm Hg in the case of patients with diabetes) and LDL cholesterol level <70 mg, and the lifestyle program to the study patients. Considering that ICAS is the major pathological symptoms leading to stroke, further studies are needed to identify the best strategy in patients with ICAS.

Elevated blood pressure (BP) independently predicts poor outcomes for patients with acute intracerebral hemorrhage (ICH). The INTERACT2 trial published in 2013 is found to produce better functional outcomes without harming patients with ICH who underwent early intensive BP lowering (systolic BP target <140 mmHg) within 6 hours of onset. These outcomes resulted in revisions of guidelines for the acute BP management of patients with ICH, in which, intensive BP lowering is recommended as safe and effective for improving functional outcomes. However, the ATACH-II trial found no difference in the frequency of death and disability at 90 days between patients treated with “very early” (<4.5 hours of onset) and “very rapid and intensive” BP lowering (systolic BP <140 mmHg with intravenous nicardipine for 24 hours) and with standard BP management. Therefore, a lower limit of target BP and an optimal method of reducing BP remain to be clarified. Evidence does support the notion that long-term BP lowering is the single most significant intervention for the secondary prevention of ICH. Several guidelines recommend a target BP of <130/80 mmHg after ICH, but this is supported by limited evidence. An ongoing randomized controlled trial (TRIDENT) is aiming to determine the effectiveness of more intensive BP lowering using a fixed low-dose combination of agents such as telmisartan, amlodipine, and indapamide (“Triple Pill” strategy) in addition to standard care, on the time to first occurrence of recurrent stroke among over 4,200 patients with ICH worldwide, including Japan.

To prepare acute revascularization therapy including mechanical thrombectomy and acute stroke imaging are essential to select proper candidate. The components of treatment related acute imaging target (TRAIT) are (1) large vessel occlusion, (2) small core, (3) mismatch (penumbral marker), and (4) collaterals. Even with non-contrast computed tomography (CT) only, occlusion of internal carotid or proximal middle cerebral artery can be diagnosed by hyperdense artery signs. Ischemic core size is commonly evaluated using Alberta Stroke Program Early CT Score (ASPECTS). These signs trigger rapid commencement of thrombectomy. More detailed TRAIT evaluation requires CT-angiography and/or CT-perfusion studies.

Recent advances in stroke treatment, such as tissue plasminogen activator and endovascular treatment, have brought a dramatic reduction in the mortality rate of stroke. Consequently, the number of stroke survivors living with disability has increased. Epilepsy occurs approximately in 5 to 10% of stroke survivors, and therefore, post-stroke epilepsy (PSE) is a significant complication after stroke. We conducted a nationwide questionnaire survey of the 189 stroke centers in Japan to determine how PSE is currently diagnosed, treated, and prevented. This review provides a comprehensive perspective of PSE, including the definition, diagnostic criteria, examination tool, and treatment of PSE.

Alzheimer’s disease (AD) is a neurodegenerative disorder with progressive cognitive decline presenting accumulation of amyloid β (Aβ) and phosphorylated tau (ptau). Cerebral amyloid angiopathy (CAA) is frequently observed Aβ deposits in the small- and mid-size blood vessel walls of the meninges and cerebral cortices in the brains of people with AD and elders. CAA is a deteriorative factor of AD, which has been elucidated its various etiology by recent progresses of neuroimaging techniques. CAA-related inflammation (CAA-RI) has recently attracted lots of attention and investigated its pathogenesis, but remain unknown, although the diagnosis and treatment have been progressed. We consider that the development of treatment for CAA is more important for AD and CAA-related diseases for future.

Intracerebral hemorrhage (ICH) consists of approximately 20% of all strokes and has a high mortality rate and poor functional prognosis. The guidelines derived from randomized control studies and case series clarify surgical benefits in several occasions such as putaminal hemorrhage >31 ml, deteriorating cerebellar hemorrhage, etc. Another role of surgery may be in identifying the otherwise unknown pathology such as a cryptic arteriovenous malformation (AVM) or a tumor. In patients with ICH due to AVM and moyamoya disease, surgical outcomes tend to be better than those of hypertensive ICH. Minimally invasive surgery, especially neuro endoscopic surgery, may be a focus of next advancements.

Evolution of reperfusion therapy in acute stroke has been accelerated after the evolution of the efficacy of endovascular therapy after/without recombinant tissue plasminogen activator (iv rt-PA). Reperfusion therapy has moved into a new era, although certain imaging criteria should have some favorable outcome which has not yet been established. Penumbral imaging has the potential to solve this issue both by CT and MRI scanning. Optimal mismatch ratio between MRI diffusion-weighted image/cerebral blood volume (DWI/CBF) (<30% of the contralateral hemisphere) and perfusion image (PWI) Tmax > 6 s area may predict the favorable outcome. On the other hand, certain large core threshold called malignant profile lead to poor outcomes despite any reperfusion therapies. Several criteria have been discussed but not met the consensus for optimal mismatch ratio and hazardous volume thresholds.