Background: The Stroke Liaison Critical Pathway and Stroke Registry have been in operation in Noto district, which is located in the northern peninsular part of the Ishikawa prefecture in Japan (population: 211,000). In total, 111 hospitals and clinics have participated in this program since 2008. In this study, we analyzed the entry patterns for the stroke path registry. Methods and Results: The total number of cases registered between July 1, 2008 and June 30, 2014 was 4,179 (2,216 men and 1,963 women, mean age = 75.4 years). There were 2,945 cases of infarction, 854 of hemorrhage, 283 of subarachnoid hemorrhage, and 97 of other or unspecified types of stroke. The registration rate was 369.5 per 100,000 annually for men, and 293.7 per 100,000 annually for women. Moreover, 197 patients were registered two or more times, and the re-registration rate was 1.39 per person-year (95% CI: 1.20–1.58). At the time of the second registration, most of the patients with prior infarction were re-registered due to an infarction (91%). In contrast, only 31% of patients with prior hemorrhage were re-registered due to hemorrhage. Conclusion: Although not all stroke events were included in the regional stroke path registry, the information obtained from the present study is thought to be valuable for managing the stroke care system in the community. Moreover, this study suggested that most of the second stroke registrations were due to infarctions, regardless of the type of the prior stroke.

Background and purpose: Neurological evaluation using the National Institutes of Health Stroke Scale (NIHSS) is needed to perform thrombolytic therapy via telestroke. Assistance from medical staff in a spoke hospital is inevitable to allow evaluation of NIHSS score by a board-certified doctor in a hub hospital. To improve skills in providing assistance specific to NIHSS evaluation via telestroke, we developed a training video and examined effects on the time for NIHSS evaluation. Methods: We have assessed NIHSS scores for healthy individuals by remote examination and evaluated the time required for measurements. After the first evaluation, we divided participants into two groups: one trained using video teaching materials (Group VT); and the other trained without those materials (Group non-VT). We then evaluated the time required to assess NIHSS scores again. We compared differences in NIHSS evaluation times and the interaction of video training using repeated-measures analysis of variance (ANOVA). Results: Participants were comprised of eight spoke assessors in Group VT and seven in Group non-VT. NIHSS score measurements were significantly quicker in Group VT (88.5 s) than in Group non-VT (19.3 s). In particular, evaluations of visual fields and ataxia were markedly quicker and total examination time was significantly reduced (p = 0.002, 0.007, 0.004, respectively; ANOVA). The interaction effect of the video training was also significant (p = 0.042, ANOVA). Conclusion: Using video training, material reduced the time required for NIHSS score measurements. Education programs for medical staff in spoke hospitals may be useful to shorten the door-to-needle time in telestroke.

Background and purpose: Consistency between face-to-face and remote examination ratings has not been clarified for the NIH Stroke Scale (NIHSS), Barthel Index (BI) and modified Rankin Scale (mRS). We aimed to demonstrate the reliability of NIHSS, BI and mRS assessments via a telestroke system using a tablet device. Methods: Two neurologists assessed 16 stroke patients using NIHSS, mRS and BI scores by both face-to-face and remote examinations. Weighted κ coefficients were used as a measure of consistency between face-to-face and telestroke ratings for each outcome scale. Cronbach’s α was used as a measure of reliability, and intraclass correlation coefficient (ICC) was used as a measure of concordance for total and individual NIHSS, BI and mRS scores between face-to-face and telemedicine-based evaluations. Results: In terms of the weighted κ coefficient, consistency between face-to-face and telestroke ratings for NIHSS, BI and mRS were 0.82, 0.88 and 0.77, respectively. Agreement of total scores for these three scales as assessed by two different methods were evaluated as ‘almost perfect’ by Cronbach’s α and ICC. Conclusion: Remote assessment of NIHSS, BI and mRS using an interactive video conferencing system equipped with a tablet device is feasible and as reliable as face-to-face evaluations, offering high reliability and consistency.

A 57-year-old man was admitted with SAH caused by the ruptured aneurysm of the anterior communicating artery. This saccular aneurysm was successfully treated by coil embolization. On day 6, he had the difficulty of verbal communication, however, he could talk in writing. ABR was normal and the diffusion-weighted image of MRI showed no ischemic change. SPECT revealed hypo-perfusion in both temporal lobes including the auditory cortex. Therefore, we diagnosed that this symptom was caused by cerebral vasospasm. After treatment of cerebral vasospasm, the patient's hearing difficulty improved and SPECT showed the recovery of cerebral perfusion. We experienced a rare case of cortical deafness caused by cerebral vasospasm of bilateral auditory cortex. In this case, the hypoperfusion of the auditory cortex was determined by SPECT. We report here the first case that cerebral blood flow of cortical deafness during vasospasm of SAH was evaluated by SPECT.

A 37-year-old Japanese woman, whose pregnancy course was good, was taken to our hospital in child birthing. She complained severe headache and paralysis at the left side of limbs and head CT revealed intracranial hemorrhage in the right basal ganglia. On the day 14, head MRI showed various regions of vasoconstriction which means reversible cerebral vasoconstriction syndrome (RCVS), and transcranial color flow imaging (TC-CFI) showed highest peak systolic flow velocity (PSV) of middle cerebral artery (MCA: 317 cm/s). As vasoconstriction on MRA became decline without additional neurological deficiency, TC-CFI also showed the decline of the PSV of MCA. We evaluated transitions of images of MRI and TC-CFI, and thought that they linked with each other. We believe that TC-CFI is a non-invasive, repeatable, and useful tool to evaluate the changes of vasoconstriction to follow RCVS.

“Purpose” Cases of subarachnoid hemorrhage due to a ruptured cerebral aneurysm complicated by cerebral hemorrhage are often observed, however, simultaneous occurrence of a subarachnoid hemorrhage due to a ruptured cerebral aneurysm and a non-related cerebral hemorrhage, is rare. We would like to report an experience of a case of simultaneous occurrence of a subarachnoid hemorrhage due to a ruptured aneurysm of the right middle cerebral arterial branch, and a right putaminal hemorrhage. “Case” A 78-year-old woman experienced a sudden pain in the right occipital region and fell down, and was emergency transported to the hospital. During transport, JCS3, right conjugative deviation of eye, dysarthria, left upper and lower limb paresis were observed. According to head CT, a right putaminal hemorrhage and a subarachnoid hemorrhage were observed. According to CTA, brain aneurysm was observed on both sides of the middle cerebral arterial branch. However, no relation to the aneurysm of the right middle arterial branch and the right putaminal hemorrhage was observed. On the following day of hospitalization, coil embolization was performed, and on the 9^th day, endoscopic hematoma removal surgery was performed. “Conclusion” Simultaneous occurrence of a subarachnoid hemorrhage due to ruptured brain aneurysm and non-related brain hemorrhage is rare, and reports of future cases are expected.

A 38-year-old man experienced dizziness and numbness in his right hand. Computed tomography revealed a subarachnoid hemorrhage in the precentral sulcus. T2-star-weighted MR images detected a thrombosis in the superior sagittal sinus (SSS) and in the cortical vein draining into the SSS. Based on these findings, we initiated an anticoagulant therapy at the early stage of the disease. In addition, protein S deficiency was found to be the cause of the cerebral venous thrombosis. Therefore, we continued administering the anticoagulant therapy to prevent a recurrence. In a case of an atypical subarachnoid hemorrhage, cerebral venous thrombosis as the cause of hemorrhage should be considered, which can be diagnosed using T2-star-weighted MR images.

We reported a case of subarachnoid hemorrhage (SAH) in a pregnant female. A-34-year-old woman at 38 weeks gestation presented with sudden headache, vomiting and her consciousness deteriorated into coma immediately after arrival at our hospital. Computed tomography (CT) scan showed a SAH and cerebellar hematoma. CT angiography demonstrated a saccular aneurysm at right posterior inferior cerebellar artery. Her condition was serious because of SAH and cerebellar hematoma and she needed to be performed direct surgery as soon as possible. However, her swollen abdomen prevented her from crouch position. We decided to perform cesarean section followed by clipping the aneurysm. As a result, the fetus was delivered without any complications. The maternal survived and left to another hospital for rehabilitation. If maternal is very serious, it is good to perform cesarean section followed by neurological surgery that could contribute to a good clinical outcome for fetus and maternal.

Introduction: Calcified plaque in the carotid artery is considered less likely to cause embolization than soft plaque. We used carotid endarterectomy (CEA) to treat a patient who developed repeated cerebral infarctions during a short space of time and was diagnosed with calcified cerebral emboli (CCE) resulting from carotid calcifications on the basis of test results. Case Report: A 69-year-old man was admitted after transient ischemic attacks. He was treated with antiplatelet therapy and his condition was subsequently monitored. He suffered from repeated cerebral infarctions five times during an approximately 4-month period after the initial hospitalization. Tests ruled out cardiogenic and aortogenic infarctions, and severely calcified lesions in the internal carotid artery in the right neck were considered as the cause. Although only mild stenosis was present, CEA was performed to prevent further recurrence of cerebral infarction. Results: Intraoperative examination revealed a localized protrusion into the carotid artery lumen of calcified lesions similar to grains of sand. The patient was discharged home with a modified Rankin Scale score of 1. The course has been uneventful, without any signs of recurrence. Discussion/Conclusion: We performed CEA to treat a patient diagnosed with CCE after repeated cerebral infarction. Few reports have described CCE; some cases have been described as a complication of aortic lesions, valvular disease, or surgery, and others as caused by carotid calcifications as described in this report. CEA should be considered for patients with CCE who are resistant to medical treatment and develop repeated cerebral infarctions.

Here we report a case of subarachnoid hemorrhage (SAH) that was treated with neck clipping and coil embolization. A 76-year-old woman presented with multiple cerebral aneurysms, which made it difficult to identify the bleeding source. Cerebral angiography showed one internal carotid-posterior communicating (IC-PC) aneurysm on the left, one IC-PC aneurysm and two internal carotid-anterior choroidal (IC-ACh) aneurysms on the right, and one anterior communicating (Acom) aneurysm. It was determined that either the left IP-PC or Acom aneurysm had ruptured, due to the site of the hematoma on a computed tomography scan, and the size and shape of the aneurysms. We performed neck clippings for these aneurysms using a pterional approach on the left; however, intraoperative findings showed both remained intact. We then performed coil embolization for the IC-PC and IC-ACh aneurysms on the right. After intervention, the aneurysms did not re-rupture, and the patient was transferred to a rehabilitation hospital. After 3 months of rehabilitation, the patient was discharged home with a modified Rankin Score of zero. Multiple aneurysms are found in 15–45% of patients with SAH, and it is often difficult to identify the source of bleeding. It is advantageous to perform neck clipping and coil embolization, especially in elderly patients, where bilateral craniotomies could cause harm. While used retrospectively, computational fluid dynamics analyses can be useful in determining the bleeding source and help guide treatment.

Social reintegration, particularly returning to work (RTW) is one of the most important rehabilitation goals for young patients with stroke from the viewpoint of normalization. Understanding the concepts of the International Classifications of Functioning, Disability and Health has spread, and thus the importance of social interaction has become paramount. Also, the Ministry of Health, Labor and Welfare now have a policy of promoting of RTW after stroke, and this is important for the balanced support of treatment and professional careers associated with employment policy reforms. However, aging, severe disability caused by stroke and increased part-time or short-term employment have inhibited RTW after stroke. Thus, the proportion of stroke victims who have been able to return to work has remained static at 40% for the past 20 years. The ability of patients to return to work after stroke is associated not only with the medical and vocational rehabilitation, but also with the welfare system. Close cooperation among the medical community, the social welfare system and the workplace of the companies are necessary.