In addition to the risk factors including hypertension, cerebral amyloid angiopathy, aging, and gene, cerebral microbleeds (CMBs) are recently reported to be associated with cnm-positive Streptococcus mutans, chronic obstructive pulmonary disease, and migraine. CMBs are divided into two groups, CMBs in deep areas including posterior fossae and lobar areas. Microangiopathies in both deep and lobar areas might make synergistic effects for poor prognoses on cerebrovascular events. In peoples with CMBs, the stroke incidences and stroke recurrences were higher than those without CMB. CMBs might be an important biomarker for the strokes. However, there was no guideline for anti-platelet drug use, or anti-coagulant drug use, for the peoples with CMBs. In peoples with the past histories of ischemic strokes or transient ischemic attacks, in particular the peoples with CMBs ≥5, the recurrent rate presenting as hemorrhagic strokes are higher than those presenting as ischemic strokes. We should reconsider antithrombotic drug uses in patients with CMBs ≥5. Furthermore, the association between CMBs and neuro-cognitive disorders are also investigated carefully. Lobar CMBs are related to Alzheimer’s disease. Whereas, in Japanese peoples, deep CMBs are associated with vascular dementia instead of lobar CMBs. There might be differences between Western and Eastern peoples in the relationships CMBs, and strokes or neuro-cognitive disorders.

Transthoracic echocardiographic assessment of left ventricular diastolic function in atrial fibrillation (AF) patients is difficult because of no atrial contraction wave. The present study aimed to investigate left ventricular diastolic function in 31 cardioembolic stroke patients due to AF within 7 days of onset. First, we examined the frequency and the severity of left ventricular diastolic dysfunction (LVDD) in paroxysmal AF patients who were in sinus rhythm at the time of the echocardiographic examination. LVDD was evident in 11 patients (100%), and moderate or more LVDD was in 8 patients (82%). Next, patients were divided into 2 groups: paroxysmal AF and persistent AF groups, and we compared the differences in background factors between the two groups. There was no significant difference in E/e′ as a parameter of LVDD. Multivariate logistic regression analysis showed the left atrial volume index was the only independent factor associated with persistent AF. Cardioembolic stroke patients due to AF may have moderate or more LVDD.

Background and Purpose: Tissue plasminogen activator (t-PA) is a very important treatment for Acute ischemic stroke (AIS). We aimed to determine the capacity of all hospitals in Tottori Prefecture, Japan, to treat all of the patients who presented with AIS with t-PA over a period of three years. Methods: We determined the total number of patients who presented with AIS at all of the hospitals in the three secondary medical areas in Tottori Prefecture between 2016 and 2018, and assessed the hospitals' capability to deliver t-PA treatment to such patients. Results: The total number of patients treated with t-PA decreased over time (2016: 110 patients, 2017: 90 patients, 2018: 73 patients); however, the number of patients who presented at hospitals in all of the secondary medical areas in Tottori Prefecture for t-PA therapy was above the national average. On the other hand, the number of patients treated at each hospital differed considerably (35~0 patients/year), with more presenting at hospitals that are known to deliver endovascular therapies. Conclusions: The total number of patients treated with t-PA decreased over time between 2016 and 2018, and the number of patients treated with t-PA at each hospital differed.

A case of clipping surgery of a ruptured aneurysm left for a long period after onset is rare. A 77-year-old woman was suddenly developed a headache and was admitted to the hospital 4 days later. Computed tomography (CT) showed thin subarachnoid hemorrhage (SAH) in the hemispheric fissure, but magnetic resonance angiography (MRA) and three-dimensional CT angiography (3-DCTA) showed no aneurysm or vascular anomaly and was diagnosed unverified etiologic SAH. After that MRA was done several times, but no bleeding source were detected. Six years later, a small saccular aneurysm was incidentally pointed out in the distal part of the anterior cerebral artery by MRA. Based on bleeding distribution of onset CT and MRI, it was considered as the cause of SAH and the clipping surgery was performed. In this case, a ruptured aneurysm may have been overlooked at the first admission because SAH was washed out after onset, it was a small aneurysm in the periphery lesion, and the cerebral vasospasm had occurred, etc. In the search by 3-DCTA and MRA, there is a possibility that the peripheral aneurysm may be overlooked, and it is necessary to pay attention to whether the imaging range is limited or not.

A 40-year-old male presented with diplopia and hospitalized with pontine infarction. Because he had thrombocyteopenia and prolonged activated partial thromboplastin time (APTT), we suspected the complication of antiphospholipid syndrome (APS). As a result of investigation, several antiphospholipid antibodies were all positive and thus the diagnosis of APS was confirmed. We initiated warfarin administration to prevent recurrence of infarction. Nevertheless, he had motor aphasia and right hemiplegia 4 months after the first visit. Diffusion-weighted (DW) image of MRI showed a new infarction in the left basal ganglia, and MRA showed an occlusion of the left middle cerebral artery. We deduced that intracranial artery lesion worsened due to the progression of APS, and added hydroxychloroquine to warfarin. One month later from discharge, DW-MRI showed a new asymptomatic infarction in the left thalamus, and MRA showed a stenosis at P₁ segment of the left posterior cerebral artery. We added clopidogrel for 2 months, and the stenosis improved over time and he did well without recurrence. Drug treatments other than anticoagulation may be useful for prevention of recurrent brain infarction in APS patients.

The patient is a 65-year-old man was admitted due to the visual disturbance. Neurologic images including cranial CT and MRI showed a cerebral infarction in the right occipital lobe. This infarction was diagnosed as the embolic infarct, but embolic cause including the paroxysmal atrial fibrillation was not detected in further examinations during the hospital stay. He was diagnosed as embolic stroke of undetermined source, however, he was strongly suspected to have undetected paroxysmal atrial fibrillation. He participated in a disease management program for the ischemic stroke recurrence prevention and received self-management educations lead by the disease management nurse. He was educated to measure and record the pulse and blood pressure for himself every day to detect the arrhythmia, especially paroxysmal atrial fibrillation. On the 86th day after the onset, the patient himself noticed the abnormality of blood pressure and irregular pulse in daily check at home and called the disease management nurse. The disease management nurse suspected paroxysmal atrial fibrillation, and suggested him to have a medical examination immediately. As a result, atrial fibrillation was confirmed with an electrocardiogram, and an anticoagulant therapy was started soon after. For the detection of paroxysmal atrial fibrillation in embolic stroke of undetermined source, the self-management education to the patients was proved to be effective.

We reported a 74-year-old patient with the articulation disorder, which was presented to our hospital. He was suffering from hypertension and diabetes with smoking. Diffusion-weighted imaging of magnetic resonance imaging revealed multiple high-intensity lesions in the internal carotid artery area. In his admission, he was diagnosed with the cerebral infarction due to the artery-to-artery embolization. His condition progressed gradually in spite of increasing two to three kinds of antiplatelet treatments. That indicated that the thromboembolus had been generated from the extremely lower unstable lesion of the common carotid artery. So we finally decided to do surgery for carotid endarterectomy. The efficacy and indications of emergency surgery or best medical medication for patients with unstable carotid artery plaque still remains unclear. The procedure and timing should be carefully considered in the patient’s clinical symptoms. The internal and external carotid bifurcation can be generally recognized as the highest portion, followed by the internal carotid artery in the lesion of plaque in the carotid artery. To the best of our knowledge, the lesion of the proximal common carotid artery like this report is very rare.

A 69-year-old woman presented with consciousness disturbance, and she was admitted to our hospital. She had taken a Xa inhibitor (rivaroxaban) for non-valvular atrial fibrillation. Head computed tomography revealed a large subcortical hemorrhage in the left temporal lobe and uncal herniation. Computed tomography angiography revealed a spot sign in the hematoma. To prevent hematoma expansion, we administered a high-dose four-factor prothrombin complex concentrate (4F-PCC). Immediately after 4F-PCC administration, her prothrombin time (PT) and PT-INR completely normalized. Subsequently, we performed craniotomy and evacuated the hematoma. After the surgery, her consciousness disturbance completely resolved. Eventually, she was transferred to a rehabilitation hospital owing to cognitive dysfunction.

The case is a 67-year-old man attending the internal medicine out-patient clinic nearby for the treatment of hypertension and diabetes for more than 10 years, but his blood pressure and blood sugar has been poorly controlled. The patient was diagnosed with left putaminal hemorrhage associated with right hemiplegia and aphasia, and was admitted to our hospital. The physical examination on the admission suggested acromegaly, leading to a definitive diagnosis of acromegaly at the screening after hospitalization. Since no compression on optic chiasm and severe paralysis were observed, rehabilitation was carried out, followed by the surgery to treat the pituitary tumor. After surgery, he visited hospital again, but cerebral infarction and TIA were recurred, resulting in the need for treatment and rehabilitation. As the underlying cause of cerebral hemorrhage and cerebral infarction in this case, the possible presence of secondary hypertension and diabetes mellitus associated with over-secretion of Growth Hormone (GH) was suggested. Early differential diagnosis should be needed considering the possible presence of secondary disease, which may lead to early treatment of the causative disease and contribute to improved prognosis in patients with hypertension and diabetes. A limited number of studies have reported on the patients with acromegaly accompanied by cerebrovascular dysfunction, whose mortality rate is considered to be higher compared with the general population. The early treatment of hypertension and diabetes may lead to improved prognosis in patients with acromegaly.

A 21-year-old woman was admitted to our hospital with left hemiparesis and sensory disturbance. She presented with a 1-week history of fever, headache, abdominal pain and bloody stools. At admission, computed tomography (CT) and magnetic resonance imaging of the brain revealed hemorrhagic infarction in the right frontal and temporal lobes. Magnetic resonance venography revealed right transverse sinus thrombosis. Systemic contrast-enhanced CT demonstrated superior mesenteric vein thrombosis. Ultrasonography showed thrombus in the right femoral vein. Thrombocytopenia and coagulopathy were observed from initial laboratory tests. Despite early anticoagulation with heparin and glucocorticoid pulse therapy, level of consciousness deteriorated and hemiparesis progressed. On day 3 after admission, presence of lupus anticoagulant was verified. Catastrophic antiphospholipid syndrome (CAPS) was diagnosed. After immediate initiation of plasma exchange, intravenous cyclophosphamide and rituximab, marked improvements in clinical condition and normalization of laboratory findings were observed. In cases of cerebral venous thrombosis with thrombocytopenia and coagulopathy, CAPS needs to be considered. Optimal management of CAPS remains controversial. Early diagnosis and aggressive treatment are central to the successful management of CAPS.