Regional disparities in demographics have occurred due to the effects of the declining birth rate and aging population, and population decline, and a review of the medical provision system in the so-called secondary medical area is being promoted by the regional medical concept. On the other hand, the number of deaths due to stroke and heart disease and the need for long-term care has increased, so the basic law for cardiovascular disease countermeasures was formulated and the cardiovascular disease countermeasures were promoted comprehensively and systematically. Therefore, in this study, we examined “the hospitalization rate and the regional difference in the residential secondary medical zone and the facility location secondary medical zone of patients with subarachnoid hemorrhage” using the data of the DPC team. As a result, there was a significant difference between Yamagata Prefecture, which had the highest completion rate in the secondary medical area, and Yamanashi Prefecture, which had the lowest rate. From this result, it is possible that the facility placement situation and topographical factors have changed compared to when the secondary medical zone was set. Therefore, for acute diseases that cannot be waited for, it is necessary to discuss the appropriate arrangement of medical functions to be provided by setting a wide medical area beyond the secondary medical area set in the medical plan.

Background and Purpose: Ovarian clear cell carcinoma (OCCC) has been reported to have increased risks of thromboembolic events from early stages. However, clinical characteristics of cerebral infarction and thromboembolism, is known as Trousseau syndrome, associated with OCCC have not been clearly elucidated. Therefore, we investigated clinical characteristics of patients with Trousseau syndrome and constituent cerebral infarction associated with OCCC. Methods: We compared cerebral infarction encountered in OCCC with those associated with other malignancies among patients who were admitted to our hospital between January 2012 and December 2017. Plasma D-dimer and CA-125 values, characteristics of cerebral infarction, timing of the onset of cerebral infarction, outcomes etc. were investigated. We identified 21 patients with OCCC in the literature and added them to our analyses. Results: There were four patients with OCCC and other four patients with cancers. Plasma CA-125 levels were high in all patients with OCCC, whereas plasma D-dimer levels were high in all eight patients. All four patients with OCCC had cerebral infarction prior to cancer diagnosis, and three patients survived for more than two years. All four patients with other cancers had cerebral infarction during cancer treatment, and died within four months after the onset of cerebral infarction. Conclusion: The patients with Trousseau syndrome associated with OCCC had acute cerebral infarction prior to the cancer diagnosis and the prognosis tended to be good. Clinical feature of Trousseau syndrome associated with OCCC appears to be different from the same syndrome associated with other cancers.

Background and Purpose: Nontraumatic and traumatic intracranial hemorrhage (ICH) related to oral anticoagulants (OAC) is reported to be more severe compared to patients who did not take OAC. The aim of this study was to evaluate the effect of OAC on hematoma expansion and surgical intervention after follow-up computed tomography (CT) in ICHs occurred in patients taking warfarin or direct OAC (DOAC). Methods: We retrospectively reviewed the medical records of our department after the release of DOAC in Japan. The number of patients who experienced hematoma expansion and surgical intervention after follow-up scan were counted and compared to each other, and logistic regression analysis was performed to compare patients taking OAC and without taking OAC. Results: From Mar 2011 to Apr 2019, 403 patients were admitted to our institute for the treatment of ICH. Hematoma expansion/surgical intervention after follow-up CT was significantly different (P = 0.007/0.002) among patients taking warfarin (N = 28, 40%/26%), patients taking DOAC (N = 10, 20%/0%), and patients without taking OAC (N=365, 17%/6%). Logistic regression analysis for patients taking warfarin and patients without taking OAC revealed that warfarin was a significant risk factor of hematoma expansion and surgical intervention after follow-up CT (odds ratio=4.62/7.03). Conclusions:In our experience, ICH occurred in patients taking warfarin were more likely to show hematoma expansion and require surgical intervention after follow-up CT. Clinicians should closely follow ICH occurred in patients taking warfarin, even if the initial scan did not show surgical indication.

Posterior reversible encephalopathy syndrome (PRES) is known to present with headache, altered mental status, seizure and visual loss. It shows reversible edema in bilateral parietal, temporal, and occipital lobes on magnetic resonance imaging (MRI). Here, we present a rare case of a 69-year-old male who was diagnosed with PRES after bilateral carotid endarterectomy (CEA). Preoperative angiography revealed severe bilateral carotid artery stenosis (>85% stenosis by North American Symptomatic Carotid Endarterectomy Trial). Since the perfusion area of the left internal carotid artery was larger, we first performed left CEA uneventfully, then right CEA 2 months later. Postoperative images showed hyperperfusion in the right hemisphere without any noticeable symptoms. Deterioration of consciousness, convulsion, and left homonymous hemianopia suddenly developed in the 23rd postoperative day (POD). MRI showed edematous signal changes in the right temporal and occipital area. Despite anti-hypertensive therapy with deep sedation, MRI on POD 35 showed globally distributed edematous areas in both hemispheres. Such drastic MRI findings as well as the relevant symptoms gradually improved in the following 2 weeks. These clinically and radiographically reversible characteristics led to the diagnosis of PRES. PRES occurred during prolonged hyperperfusion state and edematous signal changes in MRI spread from the operative side to the contralateral side, suggesting that hyperperfusion after bilateral CEA contributes to inducing PRES.

A 77-year-old male presented with sudden onset right hemiparalysis and total aphasia. The National Institutes of Health Stroke Scale (NIHSS) score was 17 and the magnetic resonance angiography (MRA) showed occlusion in the distal M1 segment of the left middle cerebral artery. The diffusion weighted image (DWI) revealed early ischemic change in the corresponding MRA field with DWI -Alberta Stroke Program Early CT Score (DWI-ASPECTS) of 8. White blood cell count and CRP levels were elevated; however, electrocardiogram did not show atrial fibrillation. The final diagnosis was acute cerebral infarction. We performed mechanical thrombectomy after injection of intravenous recombinant tissue plasminogen activator (rt-PA). The procedure was successful in four passes, attaining Thrombolysis in Cerebral Infarction (TICI) Grade 2b recanalization. Based on pathological and bacteriological examinations of the retrieved emboli, acute cerebral infarction was attributed to infective endocarditis (IE). Antibiotic therapy was initiated; antithrombotic therapy was not given. The patient was transferred to a rehabilitation hospital with modified Rankin Scale (mRS) of 4. There was no recurrence of cerebral infarction during follow-up. Mechanical thrombectomy for the large vessel occlusion due to IE tends to require more passes, and the choice of thrombectomy device, aspiration or stent retriever, is still debated because IE embolus composition differs from usual thrombi. However, pathological and bacteriological diagnosis of emboli may be useful for the choice of post-therapy.

An 84-year-old woman visited our hospital with gastrointestinal bleeding and was hospitalized for suspected colon cancer by abdominal CT. She had a history of atrial fibrillation and she had undergone aortic valve replacement. Warfarin was stopped because PT-INR was excessively prolonged. On the third day of hospitalization, she developed unconsciousness and left hemiplegia, and Magnetic resonance (MR) showed ischemia in the right putamen and corona radiata on diffusion-weighted imaging. MR angiography revealed occlusion of the right middle cerebral artery. T₂＊-weighted imaging showed no susceptibility vessel sign (SVS). She underwent endovascular thrombectomy. As a result, complete recanalization was achieved and white thrombus was retrieved. The pathological diagnosis of the retrieved white thrombus proved that the clump was gram-positive cocci. The pathological examination disclosed the final diagnosis of the embolic stroke due to infective endocarditis, but not atrial fibrillation or malignancy. It is important to predict the characteristics of thrombus from SVS, and if white thrombus is collected, it need to be submitted for pathology.

A 41-year-old man was transferred to our hospital because of sudden nuchal pain just after habitual head rotation, followed by dizziness, speech disturbance, and weakness of right half body. On admission, he had mild consciousness disturbance, right homonymous hemianopsia, dysarthria, right hemiparesis, and cerebellar ataxia in the left upper and lower limbs. Brain MRI showed multiple high intensity lesions in the left cerebellum and left medial thalamus on diffusion-weighted image. Cervical MRA and CT angiography showed right extracranial vertebral artery dissection. We diagnosed him artery-to-artery embolisms due to vertebral artery dissection. Vertebral angiography revealed interruption in-flow of the right vertebral artery on head rotation to the left side. He complained of new nuchal pain on head rotation to the right side under examination. Stenotic changes and flow interruption on head rotation to the right side in the left vertebral artery was newly documented on the angiography. Subsequently, he complained of transient dizziness. On the following day, we diagnosed bow hunter’s syndrome due to bilateral extracranial vertebral artery dissection based on the detection of additional left vertebral artery dissection on MRA. Treatment with antiplatelet and cervical hard collar fixation improved his symptoms immediately and did not lead to any ischemic events. We should pay close attention to the incidence of new vertebral artery dissection caused by neck rotation when we perform an angiography to investigate extracranial vertebral artery dissection in the craniovertebral junction.

Case: A 17-year-old man was brought to our hospital by ambulance due to a severe headache and vomit. The meningeal irritation and right abducens nerve paralysis were found on neurologic examination. Head computed tomography (CT) revealed poor growth of the right mastoid pneumatization and a high absorption area in the sinus sagittalis superior from the right lateral venous sinus. On cerebral angiography, there was no depiction of the right sigmoid sinus, and thrombus was observed in sinus sagittalis superior. Therefore, it was diagnosed as cerebral venous sinus thrombosis. The cause of thrombosis was unknown a blood test. After admission the patient had right otorrhea. After examination, right otitis media cholesteatoma was found. Treatment was commenced with hypothesis thatotitis media cholesteatoma was involved as a cause of cerebral venous sinus thrombosis. Later, the symptoms resolved, and the patient was discharged. In cerebral venous sinus thrombosis, we should consider the possibility of otitis media cholesteatoma as a cause due to poor growth of the mastoid pneumatization as seen on head CT.

A 74-year-old man visited to our hospital due to the complaint of dizziness. Head MRI and Angiography revealed aneurysm on the upper basilar trunk incidentally. We performed stent assisted coil embolization using LVIS stent for this aneurysm in order to prevent aneurysmal rupture. After three hours of operation, the patient presented with left hemiparesis and dysarthria. MRI showed pontine infarction on the right side. Retrospectively, angiographical findings during procedure demonstrated disappearance of the perforating artery in the territory of pons, just after LVIS stent was deployed. It was assumed that the cerebral infarction was caused by stent deployment. Deployment of the stent is one of the useful treatments of dissecting aneurysms. On the other hand this procedure may induce occlusion of perforating arteries by pressing false lumen of dissecting artery. It is necessary to keep in mind that the deployment of stent causes perforator infarction.

We describe a pediatric case undergoing trapping and resection combined with superficial temporal artery (STA) and middle cerebral artery (MCA) bypass for ruptured large aneurysm located at the distal portion of the MCA. A 9-year-old boy presented with sudden onset of headache. Plain computed tomography (CT) scan showed subarachnoid hemorrhage in the right sylvian fissure and intracerebral hematoma in the right temporal lobe. CT scan with contrast enhancement and cerebral angiography with arterial catheterization revealed a thrombosed aneurysm with a diameter of 20 mm which was located at the M3 portion of right MCA. The patient underwent right STA-M4 bypass and resection of the aneurysm after trapping through the right fronto-temporal craniotomy. Histopathological examination of the resected tissue showed disappearance of the internal elastic lamina and infiltration of inflammatory cells and collagen fiber with mucopolysaccharide deposits in the media. These findings were comparable with those of fusiform aneurysm. The patient’s postoperative course was uneventful, and postoperative angiography showed patency of bypass and disappearance of the aneurysm.

Objective: We report a case of transverse-sigmoid sinus junction dural arteriovenous fistula (DAVF) in which selective angiography of each feeder revealed another shunted pouch during embolization. Case Presentation: Head MRA of 72-year-old man, who developed cerebral infarction a year ago showed de novo DAVF. Preoperative angiography demonstrated multiple shunted pouches around the left transverse-sigmoid junction. Transvenous embolization was performed under the control of angiography in the left occipital artery and left vertebral artery. In the process of sequential embolization of shunted pouches, another shunted pouch was newly identified. After the embolization of the newly identified shunted pouch, the cortical reflux and shunt flow was disappeared. Conclusions: It is useful to compare selective angiographies of feeding arteries precisely for identification of various shunted pouches.