Background and Purpose: Subarachnoid hemorrhage (SAH) in an acute phase causes increase in serum catecholamine concentration, which is well associated with stress index (SI) calculated as serum glucose (Glu) divided by potassium (K). The purpose of this study was to analyze the relationship between SI and severity of SAH, and SI and patient’s outcome. Methods: We collected SAH patient’s clinical data (including K and Glu on arrival) from two institutes for the past four years. We divided SAH patients into two groups based on severity of SAH and patient’s outcome. K, Glu, and SI were compared between the two groups. Results: We retrospectively analyzed 122 SAH patients. Glu and SI were significantly higher (p < 0.01 for both Glu and SI) in the severe (n=66) and poor outcome (n=62) groups than in the moderate (n=56) and good outcome (n=60) groups. In World Federation of Neurological Surgeons grade V patients, the receiver operating characteristics assessment revealed that the good outcome group could be detected by SI ≤56.00. Conclusion: SI might be simply used as a prognosis predicting factor in clinical situations.

Background and purpose: The purpose of this study was to determine the factors for delayed diagnosis and treatment of in-hospital stroke. Methods: We retrospectively analyzed the data of consecutive patients with in-hospital stroke. We divided the patients into the early group (within 3 hours) and the delayed group (more than 3 hours) based on the time from the onset to the treatment by a stroke specialist, and analyzed the factors related to the delayed group by multivariate analysis. Results: There were 89 in-hospital stroke patients (mean age 73.6±9.0 years) registered from January 2012 to December 2014. In the early group of 37 patients, 62.2% of them had contraindications to iv-tPA. Compared to the delayed group, the early group included more patients with atrial fibrillation (17 cases, 45.9%) and more nurses as first callers (78.4%). Notably, it took 53.6±31.2 minutes for taking images even in the early group. Multivariate logistic analysis revealed that the “first caller was a doctor” was a significant factor for delay (OR=8.572, 95% CI 2.186–33.617, p=0.002), and the presence of atrial fibrillation was a significant avoidance factor for delay (OR=0.140, 95% CI 0.024–0.801, p=0.027). Conclusions: Three factors were considered to be important factors for delay (the location of discover, job type of the first discoverer, and the response of the primary doctor), suggesting the importance to build an in-hospital triage system and to educate medical staff.

Background: In all, 66.7% of the mechanical thrombectomy (MT) cases were transferred between hospitals in the Atami-Ito medical area. The stroke bypass protocol with the FACE₂AD scale (3 points for cutoff and within 6 hours or unknown onset) for LVO had been deployed since September 2018 (Atami-Ito stroke bypass for LVO:AISB for LVO). Methods: (1) In all, 49 cases underwent MT from June 2015 to April 2020 before and after AISB deployment. (2) In all, 54 patients were directly transported by AISB, and positive predictive value of LVO and increase in the number of emergency transportations were analyzed. Result: (1) The transfer rate between hospitals had significantly decreased from 66.7% to 27.3% (P=0.03). (2) The positive predictive value of our protocol for LVO was 55%. The increase in the number of cases directly transported to hospitals capable of MT was 1.28/month on average. Conclusions: AISB significantly decreased the transfer rate of MT patients between hospitals in the Atami-Ito medical area. The increase in the number of emergency transportations was only 1.28/month.

A 44-year-old man with no past medical history was admitted to our hospital because of non-fluent aphasia. Magnetic resonance imaging of the brain showed embolic stroke in the region of left middle cerebral artery. Transthoracic echocardiography demonstrated intracardiac thrombus at the apex. Left ventricular systolic function was almost normal. After treatment with anticoagulant therapy, the thrombus was finally resolved. Protein C antigen and activity were 43% (normal, 70–150%) and 39% (normal, 64–146%), respectively. Genetic analysis was not performed, but congenital protein C deficiency was strongly suggested considering the patient's age, rare thrombus and protein C activity. This case indicates that congenital protein C deficiency can cause intracardiac thrombus and embolic stroke, although it is so rare.

A-55-year-old woman developed disturbances of consciousness. An emergency CT scan revealed a cerebellar hemorrhage. Transthoracic echocardiology confirmed an ejection fraction of 40%, and left ventricular apical akinesia and basal hyperkinesis were seen. We performed hematoma evacuation on the 1st day. On the 14th day, echocardiography showed complete improvement of heart wall motion. This patient was diagnosed with takotsubo cardiomyopathy based on clinical course and transthoracic echocardiology. A total of 12 patients have been found in whom intra cerebral hemorrhage triggered takotsubo cardiomyopathy. This is the 6th case of cerebellar hemorrhage with takotsubo cardiomyopathy.

A 73-year-old man was diagnosed with arrhythmia in a Ningen Dock about a year ago; he started apixaban 10 mg/day after the diagnosis of atrial fibrillation. He had been taking regular medicine since then. Two days before the consultation, he developed aphasia and visited our department. His symptoms improved, and no neurological abnormalities were noted. Head MRI revealed multiple new infarctions. Blood sampling was performed that showed an abnormally high level of coagulation and fibrinolysis, and a chest CT showed a mass-like lesion. He was admitted to the Department of Respiratory Medicine. After admission, he changed apixaban to low-molecular-weight heparin and switched to subcutaneous injection for home discharge. Biopsy confirmed lung adenocarcinoma. He went to an outpatient clinic with no recurrence of cerebral infarction, and the clotting/fibrinolytic system had also progressed at a low value. In this report, a case of Trousseau’s syndrome that developed cerebral infarction under apixaban is discussed, which was successfully controlled by subcutaneous injection of heparin.

Differentiating acute aortic dissection that develops cerebral ischemic symptoms in stroke practice is very important for avoiding inappropriate IV rt-PA therapy beyond delaying treatment of acute aortic dissection. Although acute aortic dissection with cerebral ischemic symptoms is infrequent, it may exist in patients who are suspected of stroke with neurological symptoms such as unconsciousness and aphasia. Acute aortic dissection can be non-specific and may depend on various symptoms such as where the tear is located in the aorta. In order to not miss out acute aortic dissection that develops with cerebral ischemic symptoms without chest and back pain, it is necessary to understand the clinical findings of acute aortic dissection such as low blood pressure, difference of right and left blood pressure, mediastinal widening on chest X-ray, and high D-dimer. In an auxiliary imaging operation, cervical MRA is useful not only for the evaluation of pathophysiology of cerebral infarction but also to diagnose acute aortic dissection. We report two cases of acute thoracic aortic dissection that developed with cerebral ischemic symptoms without chest pain along with a literature review.

A 77-year-old woman complaining of dizziness was taken to a local hospital by ambulance. Magnetic resonance imaging (MRI) of her head revealed a bilateral cerebellar infarction, and she was admitted. The next morning, she became drowsy, and head CT revealed obstructive hydrocephalus. She was transferred to our hospital, where we immediately performed posterior fossa decompression. After the surgery, her consciousness improved and she returned to the first hospital for rehabilitation. This is a case of a bilateral cerebellar embolic infarction caused by atrial fibrillation. Head MRI revealed a bihemispheric posterior inferior cerebellar artery (PICA), which ran along the midline and bilaterally separated into the cerebellar hemispheres after branching off from the extracranial vertebral artery. There are few previous reports on ischemic stroke patients with a bihemispheric PICA, as it is a rare anomaly. It carries an increased risk of bilateral cerebellar infarctions that may progress to obstructive hydrocephalus. It is important to pay particular attention to patients with cerebellar vascular disease who display this anomaly.

A 62-year-old woman was admitted to our hospital due to a sudden onset of right hemiparesis with lower limb dominance and consciousness disturbance without headache. Magnetic resonance imaging (MRI) of the brain showed ischemic lesions in the territories of the bilateral anterior cerebral arteries. Anterior cerebral artery dissection was suspected because MRI angiography (MRA) revealed a dilation and stenosis in the anterior cerebral artery. Digital subtraction angiography (DSA) and CT angiography (CTA) demonstrated the fusion of both A2 segments of the anterior cerebral artery to form a single artery and a pearl and string sign in the A2 segment. From these findings, she was diagnosed with azygos anterior cerebral artery dissection. Subarachnoid hemorrhage and hemorrhagic infarct were seen during treatment for cerebral infarction. This case indicates that it is important to recognize azygos anterior cerebral artery dissection as a cause of cerebral infarction at bilateral anterior cerebral artery territories, although it is so rare.

An 87-year-old man developed sudden loss of consciousness and left hemiplegia. MRI revealed multiple acute cerebral infarctions in the right thalamus and the right occipital lobe. Atrial fibrillation was noted, but there was no ischemic change indicating acute myocardial infarction was observed. No chest symptoms were noted. After intravenous administration of tissue plasminogen activator (t-PA), cerebral angiography revealed occlusion of the right middle artery in addition to the right posterior cerebral arteries. Bradycardia and ST elevation were observed on ECG during the catheter manipulation. Acute inferior wall myocardial infarction was noted. Following successful thrombectomy for the right middle cerebral artery occlusion, percutaneous coronary intervention (PCI) was performed with the cooperation of a cardiologist. He was hospitalized for eight days due to heart failure and eventually died. Cardiovascular complications in stroke patients do not constitute a common complication and are life-threatening. Therefore, close cooperation with cardiologists and attention to acute coronary complications are required.

Background: The carotid web is an intraluminal shelf-like projection emanating from the posterior wall of the carotid bifurcation. Carotid web is a relatively rare cause of embolic stroke. The optimal medical and surgical strategies for managing these lesions have not been well established. Case report: A 47-year-old female patient was transported to our hospital soon after sudden onset of left conjugate deviation of the eyes, right-sided severe hemiplegia and total aphasia. Magnetic resonance imaging (MRI) showed a proximal occlusion of the M1 segment of the middle cerebral artery (MCA). We performed mechanical thrombectomy, and complete recanalization was achieved. Computed tomography angiography (CTA) of her neck demonstrated a shelf-like filling deficit emanating from the posterior wall of the left internal carotid artery, and this finding was diagnostic of a carotid web. We suspected it as the cause of embolization and performed carotid stenting. The postoperative course was uneventful, and she had no recurrent stroke during the 1.5 year follow-up period. Conclusion: Carotid web stenting should be considered as one choice of the treatment because of its safety.

An 89-year-old woman was transferred to our hospital with a sudden onset of consciousness disturbance. Brain MRI showed basilar artery occlusion. Intravenous tissue plasminogen activator was started, but she did not improve neurologically and thus endovascular treatment was performed. The embolus in the basilar artery was successfully retrieved by using a combined technique with a stent retriever and an aspiration catheter at 172 minutes after the onset. The retrieved embolus was whitish in color and suggested pathologically myxoma. Initially, the cardiac tumor was not detected by transthoracic echocardiography and MRI. One month later, transthoracic echocardiography detected a tumor in her left ventricle, and she underwent cardiac surgery on the same day. The cardiac tumor was identified as myoma. Although the embolus suggested myoma prior to echocardiography, it was not found at the same time. This case shows the importance of a repeat echocardiography for preventing from a recurrent embolism.