We reviewed literatures and guidelines for acute cerebrovascular imaging to perform acute reperfusion therapy in patients with Acute ischemic stroke (AIS). AIS is treatable with acute reperfusion therapy. Imaging evaluation by CT or MRI is essential for the diagnosis of AIS. We need to promptly determine whether AIS patients are candidates for acute reperfusion therapy with the minimum imaging evaluation. The American Heart Association/American Stroke Association (AHA/ASA) guideline 2018 recommended that brain imaging studies can be performed within 20 minutes of hospital arrival, but Japanese guideline do not recommend the time to brain imaging. MRI is available in most Japanese stroke centers. Immediate evaluation of large vessel occlusion is required to decide indications for mechanical thrombectomy. In selected AIS patients within 6 to 24 hours of last known normal, volumetric evaluation of ischemic core and/or perfusion imaging with CT or MRI is recommended to aid in patient selection for mechanical thrombectomy (the AHA/ASA guideline 2018). In Japan, perfusion imaging and automated imaging analysis are not commonly used so far. Development of diagnostic imaging guidelines for AIS to perform appropriate reperfusion therapy is expected in Japan.

Background and Purpose: Acute ischemic stroke is treatable with acute reperfusion therapy. Imaging evaluation by CT or MRI is essential for the diagnosis of acute ischemic stroke. Recently, the effectiveness of imaging-based selection for reperfusion therapy has been proved in various clinical trials. To clarify the current status of neuroimaging strategy for acute ischemic stroke in Japan, we conducted a nationwide survey. Methods: A web questionnaire on neuroimaging strategy from January to December 2017 was mailed to neurosurgeons and neurologists in 2112 institutes in August 2018. Results: Of 2112 institutes, 556 sites (26%) were responded. Within 556 respondents, 507 (91%) sites were performing medical treatment for acute stroke. Of the 507 respondents, 311 (61%) performed diagnostic imaging of acute stroke with both CT and MRI, and door to imaging time was within 20 minutes in 312 respondents (61%). Three hundred and twenty-two (322) sites were performing endovascular treatment (EVT) for acute ischemic stroke and of these 263 respondents were performing EVT to late presenting cases. Within 263 respondents, only 30 (12%) used perfusion imaging to determine the indication of EVT in late presenting cases. Conclusions: In Japan, diagnosis of acute ischemic stroke using both CT and MRI was mostly common, and perfusion imaging for patient selection was rarely used.

Background and Purpose: The purpose of this study is to investigate the characteristics of economically disadvantaged stroke patients, who underwent treatment for their condition using a publicly funded low-cost medical treatment. Methods: Out of 113 persons who used the low-cost medical treatment model from October 2010 to March 2018, 27 stroke patients who were hospitalized for convalescent rehabilitation comprised the treatment group. Stroke patients who were hospitalized next to the patient and who did not use the low-cost medical treatment model comprised the control group. Results: In the treatment group, the income protection ratio was 64%, the average age was 72.0 years, and the average length of hospital stay was 143.7 days, which was lower than the average age of the control group (78.9 years) and longer than the length of the hospital stay of the control group (95.1 days). Conclusions: People living in poverty are at a higher risk of suffering from cerebrovascular disorders at a younger age than nonpoor people, and the length of hospital stay is prolonged when the disorder occurs.

Background and Purpose: The aim of this study is to evaluate the utility of our unique nutritional supply-demand control system, Nutrition Support Team Manager (NSTManager), in stroke patients who were unable to orally consume food due to disturbances of consciousness or dysphagia early in their hospitalization. Methods: Acute stroke patients with a Glasgow Coma Scale score of ≤12 or who had a meal intake of <70% on hospitalization day 3 and who could be observed for 28 consecutive days were included. Nutritional status, energy intake, fasting periods, and adverse gastrointestinal events were evaluated and compared between before (control group, n=30) and after (NSTManager group, n=39) NSTManager introduction. Results: Significant reduction of fasting periods (p=0.00022), adverse gastrointestinal events (p=0.019), and changes in body weight (p=0.032) were noted in the NSTManager group in contrast to the control group. Higher significant energy intake (day 21, p=0.027 and day 28, p=0.019, respectively) were seen in the NSTManager group than in the control group on hospitalization days 21 and 28. Conclusion: Nutritional support using NSTManager was beneficial for patients recovering from strokes.

A 42-year-old man complained of headache, dizziness, and vomiting. Head magnetic resonance imaging revealed a lack of visualization ranging from the bilateral vertebral artery (VA) to the basilar artery, and the bilateral cerebellum and brainstem infarction. The left VA originated from the aortic arch. The patient followed a stable course with antithrombotic therapy. As the dissected arteries recanalized chronologically, the patient was diagnosed with bilateral VA dissections. To the best of our knowledge, there have been no reports of bilateral VA dissections involving the left VA of aortic origin. The mechanism of bilateral VA dissections was speculated as follows: arterial dissection extends to the contralateral side or flow reduction of the dissected VA increases perfusion of the contralateral VA, thus inducing dissection. In addition, the left VA of aortic origin is at high risk of arterial dissection. Therefore, right VA dissection may induce left VA dissection, especially in cases of aortic origin, and this speculation is compatible with our case.

Thyroid tumors have not been reported to cause common carotid artery dissection so far, and they are considered clinically important not only in stroke departments but also in otolaryngology. A 76-year-old woman was pointed out a left thyroid tumor that gradually increased from the age of 72 years, but was observed without any malignancy findings by fine needle biopsy. At the age of 76, she had a sudden attack with loss of consciousness and right hemiparesis and was transported to emergency. The NIHSS score at the hospital visit was 22 points, and magnetic resonance imaging (MRI) revealed arterial dissection in the left common carotid artery extending into internal carotid artery. However, there was no acute cerebral infarction detected by diffusion-weighted image, and the symptoms spontaneously resolved during the examination. After hospitalization, treatment was started with 10,000 units of sodium heparin per day and she became asymptomatic on the next day, but transient ischemic attack (TIA) showing loss of consciousness and right hemiparesis occurred twice during hospitalization. TIA disappeared from the 5^th hospital day, and improvement of arterial dissection was confirmed by MRI. Finally, thyroid tumor was removed and no carotid artery infiltration was observed, but histopathological thyroid examination revealed follicular carcinoma. In this case, the left common carotid artery was largely displaced by a giant thyroid tumor with a diameter of 5 cm, and it was thought that traumatic carotid artery dissection was caused by hyperextension/flexion and traction force by a giant tumor at the bifurcation of carotid blood vessels.

A 52-year-old female diagnosed with Moyamoya disease in 2013 presented with upper-extremity sensory abnormalities, and was admitted to our hospital. In 2017, brain magnetic resonance imaging detected an aneurysm in the deep white matter near the left lateral ventricle body with a small intracerebral hemorrhage. The incidentally detected peripheral aneurysm of the posterior choroidal artery with asymptomatic cerebral hemorrhage was conservatively treated after elucidating the treatment policy (direct surgery, endovascular treatment, and surgical revascularization). After 5 months, the aneurysm was spontaneously thrombosed on an angiogram without rebleeding. To date, no treatment policy has been established for Moyamoya disease-related peripheral aneurysms. Although prophylactic treatment for bleeding of aneurysms could be recommended for symptomatic cases, it is imperative to judiciously consider the treatment option for asymptomatic cases from the perspective of the invasiveness and potential for complications.

A 29-year-old woman felt abrupt headache. After 3 days, she presented dysesthesia on her left leg and referred to our hospital. Cranial CT showed cerebral hemorrhage with edematous change in the right temporo-parietal lobe and T1-weighted image of brain MRI demonstrated high-intensity area from the right basal vein to straight sinus. We suspected sinus thrombosis by taking oral contraceptive drug and clinical results. Headache gradually improved from onset, in consideration of cerebral hemorrhage, we stopped taking oral contraceptive drug and controlled blood pressure without anticoagulant. Because late arterial phase angiography obtained 1 week after admission revealed right cerebral cortical vein with the umbrella sign led from ipsilateral middle cerebral artery, we suggested cerebral hemorrhage was correlated with the DVA. As angiographic findings of venous congestion was mild, we kept conservative therapy and obtained good clinical course. Although the natural course of DVA is usually good, symptomatic case often corresponding with cerebrovascular malformation or thrombosis. Assessment of clinical status should be carefully considered for deciding on treatment strategy.

It is difficult to diagnose and treat the disease of elderly patient who suffer with coexist dementia. We experienced a case with subarachnoid hemorrhage (SAH) due to ruptured cerebral aneurysm requiring differentiation from traumatic SAH that developed elderly patient with dementia. And at that time, enhanced MR-vessel wall imaging (enhanced MR-VWI) was useful for differential diagnosis. A 74-year-old woman was admitted to our hospital from the practitioner diagnosed with traumatic SAH after fall. Though she was independent, she has suffered from Alzheimer’s disease with severe recent memory disturbance. Her Glasgow Coma Scale was E4V4M6, and had no other neurological deficit. She had contusion on her forehead and no other wound. Head computed tomography (CT) showed SAH on interhemispheric fissure, anterior part of basal cistern, left frontal brain surface. And added 3D-CT angiography revealed anterior communicating artery aneurysm (AcomA). We needed to differentiate the cause of SAH from intrinsic and traumatic mechanism, but she could not elaborate on the cause. We tried to perform enhanced MR-VWI as motion-sensitized driven equilibrium (MSDE) to differentiate the ruptured AcomA. Significant enhancement was observed at the wall of AcomA aneurysm on MSDE images. So we determined the AcomA as the rupture site and performed endovascular coil embolization. Her postoperative course was uneventful and rebleeding was not observed. Identification of the ruptured aneurysm is the most important problem in the treatment of SAH. Differential diagnosis can often be difficult in the elderly patient, especially with severe dementia. Enhancement of the aneurysmal wall on MSDE method can provide a useful finding in the decision of treatment strategies for SAH.

We describe a case of a patient with neurofibromatosis type 1 who developed thrombosed cervical internal carotid artery (ICA) aneurysm combined with subcutaneous hematoma originating from the facial artery. A 25-year-old woman developed airway obstruction due to progressive neck swelling. Computed tomography (CT) showed massive subcutaneous hematoma in the neck and subsequent angiography with arterial catheterization showed extravasation from the left facial artery and a fusiform aneurysm located at the ICA. The left facial artery was embolized with coils. Eleven hours later, the neck swelling in the patient enlarged. CT angiography demonstrated enlargement of the fusiform aneurysm. The aneurysm was trapped by coil embolization of the left ICA. The patient did not develop any ischemic complications in the brain, but suffered in the subcutaneous abscess in the neck. After removal of the lesion, her postoperative course was uneventful.

Background: Bilateral large vessel occlusion is very rare and mortality is high. We report a case of bilateral large vessel (right internal carotid artery and left middle cerebral artery) occlusion treated by simultaneous bilateral mechanical thrombectomy and intravenous alteplase administration. Case presentation: A 69-year-old man not treated by atrial fibrillation was presented with mild disturbance of consciousness, right conjugated deviation, left hemiplegia, and aphasia. He arrived at the hospital 46 min after the onset with an National Institute of Health Stroke Scale (NIHSS) score of 28. DWI showed high intensity in bilateral cerebral hemispheres, and Alberta Stroke Program Early Computed Tomography Score (ASPECTS) was 7/11 in the right hemisphere and 10/11 in the left. MRA showed right internal carotid artery and left M1 occlusion. We treated the right side first because it had a lower ASPECTS score and the main symptoms were due to right cerebral ischemia. Mechanical thrombectomy was performed and bilateral recanalization was achieved (right side modified TICI 3, left side 2a). On the day after onset, MRI did not show progression of cerebral infarction compared with the initial MRI, and NIHSS decreased to 1. After a short rehabilitation period, he was discharged. Conclusion: Bilateral large vessel occlusion is more likely to be severe than unilateral occlusion. However, as in this case, if the treatment order (right or left) is properly selected and the procedure can be quickly performed, a good prognosis can be expected.

Postoperative atrial fibrillation (POAF), which may cause an ischemic stroke, occurred perioperatively. Here, we report that POAF developed after lung cancer surgery; the sinus rhythm was restored rapidly, but atrial fibrillation and an ischemic stroke occurred after approximately 1 year. A 75-year-old woman who underwent left pneumonectomy for lung cancer and experienced transient POAF, which was treated with calcium channel blocker (Verapamil hydrochloride) and beta blocker (Bisoprolol fumarate) approximately 1 year prior, experienced atrial fibrillation recurrence and was started on rivaroxaban treatment. On the following day, she was presented with dysarthria and right hemiparesis. MRI revealed left middle cerebral artery (MCA) occlusion. After using an intravenous tissue plasminogen activator and performing mechanical thrombectomy, the occluded MCA was recanalized. She was discharged from our hospital with a modified Rankin Scale score of 0. Various treatments such as rate control, anticoagulation, and rhythm control can contribute to POAF management after non-cardiothoracic surgery. However, long-term outcomes of POAF remain unclear. Therefore, we assume that careful follow-up and management would be necessary to prevent embolic complications by recurrent AF caused by POAF.