Background and Purpose: To introduce the stroke bypass system in Tokyo for the direct transfer of the patients suffered from emergent large vessel occlusion (ELVO) to endovascular capable center, the present status of the Tokyo Emergency Medical Service (TEMS) was confirmed. Methods: We analyzed eight representative prehospital stroke scales (PSS), TEMS guideline, Prehospital Stroke Life Support (PSLS) guideline of the Japanese Society for Emergency Medicine (JSEM). Results: Enough patient’s information to calculate some PSS had been already collected according to TEMS guideline as equal to PSLS. Conclusion: Stroke bypass system could be already performed in Tokyo if TEMS crews could calculate the PSS to predict ELVO with high precision. To solve this problem, we developed an application to calculate the PSS automatically when they enter the patient’s information on it.

Purpose and Methods: We conducted a retrospective comparative study of the impact of warfarin and direct oral anticoagulants (DOAC) on efficacy and safety events in patients with non-valvular atrial fibrillation. Results: The warfarin group included 359 patients (age, 76.7 ± 9.2 years; mean observation period, 3.5 years; and median time in therapeutic range, 64.8%) and the DOAC group included 357 patients (age, 78.1 ± 9.7 years; mean observation period, 2.0 years, and percentage administered at an appropriate dose, 88%). The incidence of stroke/systemic embolism and intracranial hemorrhage in the DOAC group was significantly lower than the warfarin group (2.3 vs. 3.1/100 person-years, p< 0.001; 0.4 vs. 1.0/100 person-years, p< 0.001, respectively). On the other hand, no differences were noted in the major bleeding incidence between the two groups (2.7 vs. 2.7/100 person-years, p = 0.90). Conclusions: In clinical practice, DOAC administration demonstrated non-inferior efficacy and safety to warfarin therapy for stroke prevention in non-valvular atrial fibrillation.

Background and Purpose: The current status of community medicine for acute stroke was investigated to clarify regional disparities in medical practice in Japan. Methods: Questionnaires concerning the current status of medical practice for acute stroke was sent to members of the Japan Stroke Association and the Miyagi Stroke Association. Results: The first batch of questionnaires asked about the presence of secondary medical service areas with problems. The response rate was 61.4% (81/132), covering all prefectures. Among 329 secondary medical service areas, 32 (9.7%) and 90 (27.4%) lacked hospitals with round-the-clock tissue plasminogen activator (t-PA) therapy and thrombectomy, respectively. These regional disparities were considered due to a shortage of stroke physicians in these areas, and effective method to resolve this problem was combining with medical support systems in other secondary medical service areas. Responses to the second batch of questionnaires asking about row numbers in secondary medical service areas were received from 32 prefectures (68.1%). t-PA therapy was not performed in 21 of 174 areas (12.1%), and thrombectomy in 53 of 145 areas (36.6%). Differences among prefectures and those among secondary medical service areas in a prefecture were evident. Conclusion: The government should play a central role in taking measures to establishing the collaboration system and improving emergency transportation systems to reduce regional disparities in medical treatment and care for patients with acute stroke in Japan.

Background and purpose: In order to conduct intravenous thrombolysis as soon as possible, a pioneer project in Japan, consisting of stroke coordinate nurse (SCNs), was established. The aim of this study was to investigate whether the SCNs was able to reduce door to needle time (DNT) for an acute ischemic stroke patient who received intravenous thrombolysis. Method: From April 2012 to February 2017, acute ischemic stroke patients with intravenous thrombolysis were enrolled. Patients were divided into two groups, DNT within 60 min (s-DNT group) and a 60 min or more time group (l-DNT group). We compared clinical characteristics including presence or absence of ASCNP services between short- and long-DNT groups. Results: A total of 74 patients (54 males, mean age: 68 years) were retrospectively enrolled and the s-DNT group consisted of 19 patients, and the l-DNT group was 55. The s-DNT group more frequently received SCNs service than that of the l-DNT group (52% vs. 18%, p=0.015). Multivariate logistic regression analysis showed that SCNs service was the only independent factor associated with the s-DNT (OR 3.4, 95%CI 1.1–11.5, p=0.043). Conclusion: SCNs service was contributed to s-DNT in acute ischemic stroke patients with intravenous thrombolysis.

An 87-year-old woman suffered sudden onset of right hemiparesis and disturbance of consciousness resulting in a fall. She was admitted to our hospital 30 min after the onset. She presented with disturbance of consciousness (Glasgow Coma Scale score E4V1M5), aphasia, and right hemiparesis. Diffusion-weighted imaging showed an acute ischemic infarct in the territory of the left middle cerebral artery, but detected no signs of hemorrhage or cortical contusion. Intravenous administration of recombinant tissue-type plasminogen activator (rt-PA) was performed. Subsequently, her consciousness level deteriorated rapidly to coma. Computed tomography showed scattered intracerebral hemorrhages in the bilateral hemispheres and posterior fossa. Patient may present with both cerebral infarction and head trauma. Cortical contusion in acute phase can be difficult to detect on neuroimaging. Consequently, emergency physicians should carefully consider the possibility of cerebral contusion before the administration of rt-PA.

A 73-year-old man met with a traffic accident when driving a car. He wore a seat belt and the air bag did not work. He was affected with left hemiparesis when the ambulance arrived. Physical examination did not reveal any trauma on the body. NIHSS score was 18. Body CT was normal. Head diffusion-weighted MRI demonstrated a slightly high signal lesion in the right basal ganglion and occlusion of the right middle cerebral artery (M1 portion). About 90 min after onset, intravenous administration of recombinant tissue-type plasminogen activator (rt-PA) was started. Then, he developed chest pain and dyspnea. Contrast-enhanced body CT showed hematoma in the anterior mediastinum and extravasation of the contrast medium. Angiography demonstrated bleeding from internal thoracic arteries, treated by coil embolization. If the vascular injury is suspected, it is necessary to grasp the disease condition promptly before application of rt-PA thrombolytic therapy for ischemic stroke in case of trauma.

Protracted vomiting in patients with a cerebellar hemorrhage reportedly obstructs rehabilitation and correlates with poorer outcomes. Here, we discuss two cases that highlight the efficacy of perphenazine in treating cerebellar hemorrhage-associated intractable vomiting. Two Japanese males experienced a sudden onset of nausea, vomiting, and unsteady gait. After receiving conservative therapy, they were transferred to our hospital for rehabilitation therapy. In patient 1, a 66-year-old male, the right nodulus and juxtarestiform body were presumably involved in a small hematoma. The patient’s recurrent vomiting was completely resolved with oral perphenazine 12 mg daily and he became able to gait unaided. However, after the 6-week of treatment, he developed akathisia, which completely disappeared after the discontinuation of perphenazine. Patient 2, a 68-year-old male, presented with not only severe truncal ataxia, but also impairment of executive functions and disinhibited sexual behavior, which were consistent with the cerebellar cognitive affective syndrome. Computed tomography revealed a large hematoma in the posterior lobe of the cerebellum principally on the left side. Treatment with an increasing dose of perphenazine (up to 24 mg) completely resolved both persistent vomiting and sexual disinhibition. However, over the next 4 weeks, as he gradually developed Parkinsonism, we tapered off perphenazine. Treatment with levodopa-carbidopa effectively improved akinesia. Approximately 5 months after the onset of stroke, he regained independent gait with a T-cane. Perphenazine is a treatment option for cerebellar hemorrhage-associated intractable vomiting. However, clinicians should be wary of the adverse effects of perphenazine because its chronic administration and high dose tend to cause extrapyramidal side effects.

A 48-year-old woman was admitted to our hospital due to sudden motor aphasia and right hemiplegia with lower limb dominance. Computed tomography angiography (CTA) revealed occlusion of the left anterior cerebral artery (ACA) and multiple stenosis of the bilateral major arteries. MRI showed a new infarct lesion inside the left frontal lobe and subarachnoid hemorrhage around the sulcus. Digital subtraction angiography demonstrated pearl and string sign beyond the left A2 segment. Follow-up CTA showed the improvement of the multiple stenosis. We therefore, diagnosed left ACA dissection accompanied with reversible cerebral vasoconstriction syndrome. This case is valuable because similar cases have not ever been reported.

When a patient’s condition becomes irreversible due to a severe stroke, the decision regarding continuing treatment and care is left to the staff at the clinical site, except in the case of legal brain death determination assuming organ donation. Because of its sudden onset, stroke has a special property that the patient’s premorbid wishes cannot be confirmed in most cases. The Japan Stroke Society has established these guidelines for the purpose of supporting decision-making for treatment and care by the medical team at the clinical site. In these guidelines, “whole brain dysfunction in stroke” is defined as irreversible dysfunction of the whole brain due to stroke, and the patient is in a state in which death is inevitable regardless of any treatment. We also recommend that, if organ donation is not carried out, the final determination of whole brain dysfunction should be made in the way prescribed in these guidelines when a stroke patient is regarded as at a terminal stage and the patient’s family wishes cessation or a change in life-sustaining treatment. When whole brain dysfunction is then finally confirmed, the medical team at the site may stop or withdraw the life-sustaining treatment with the approval of the hospital director after deliberation by the clinical ethics committee of the institution.