Background and Purpose: Successful recanalization and better clinical outcomes of endovascular thrombectomy in acute ischemic stroke (AIS) have been demonstrated in several randomized clinical trials. It is difficult to treat patients with AIS in underpopulated regions where medical resources are limited. We established a new system at our hospital for AIS under the Saitama Stroke Network (SSN). The purpose of the present study was to evaluate the effectiveness of our system for treating patients with AIS employing mechanical thrombectomy. Materials and Methods: The influence of our system was analyzed in AIS patients treated using mechanical thrombectomy during the periods of two years before and after the SSN. The times from door to puncture, from puncture to recanalization, from door to recanalization, and the clinical outcomes were compared. Results: A total of 35 patients were treated between January 2016 and December 2017 (the former group), whereas 27 patients were treated between January 2018 and December 2019 (the latter group). The time from puncture to recanalization was significantly shortened in the latter group. The time from door to recanalization was not significantly different between the two groups. Conclusion: The number of patients treated for AIS by endovascular recanalization therapy was increased following the start of the SSN. Due to improvements in the in-hospital medical care system, the time from puncture to recanalization was significantly shortened. However, the time from door to puncture was not shortened. Making use of past clinical experience and educating the co-medical staff members are important for further improving our system.

Background and Purpose: The aim of this study was to investigate the serial changes in skeletal muscle mass and actual state of sarcopenia in acute ischemic stroke patients. Methods: Between January 2019 and September 2020, we enrolled 101 ischemic stroke patients admitted within 48 hours of onset. Measurement of skeletal muscle mass was performed on admission and 2 weeks after admission (follow-up). Handgrip strength and gait speed were assessed at follow-up. The frequency of sarcopenia and its associated factors were retrospectively investigated. Results: Sarcopenia was identified in 58 patients (57%). Of these, only 3 patients developed low skeletal muscle mass during hospitalization. Multivariate logistic regression analysis showed that age (OR 1.2, 95%CI 1.060–1.267), body mass index (OR 0.7, 95%CI 0.526–0.881), and Food Intake LEVEL Scale (OR 0.3, 95%CI 0.117–0.841) were independent factors associated with sarcopenia. Conclusion: There were a few patients who developed low skeletal muscle mass during hospitalization.

Objective: Recently updated guidelines now allow estimation of the onset of stroke time using DWI-FLAIR mismatch (DFm). We conducted a retrospective study to understand the epidemiology of wake-up stroke (WUS). Patients and Method: We studied 905 patients with strokes in our hospital from 1 March 2015 to 31 March 2019. First, we divided our patients into two groups: WUS and non-WUS. Then, we divided patients with WUS with cerebral infarction into two groups: those with or without DFm. Result: We obtained two results of significant differences. One, cardioembolism occurred at higher frequency in WUS. Two, first-imaging time of patients with DFm was earlier in morning than that of patients without DFm. Conclusion: One of the characteristics of WUS with cerebral infarction was higher cardioembolism occurrence, and ischemic stroke treatment system should be prepared bearing these results.

Background and Purpose: To treat cases of acute stroke on remote islands where there are no stroke specialists, we established a stroke hotline (the Isolated Islands Stroke Hotline system: I-SHOT) in collaboration with an acute care hub center on the mainland. We investigated whether implementation of I-SHOT contributes to an increase in the number of patients treated with intravenous rt-PA using the drip and ship (DS) method. Methods: We compared the number of DS cases, patient background, door to needle (DTN) time, prognosis, and complications before (early period: 2012–16) and after (late period: 2017–19) implementation of I-SHOT. Results: After the introduction of I-SHOT, there was a significant increase in the number of DS cases (early period: 3/197 cases [1.5%] vs. late period: 16/125 cases [12.8%], respectively; p<0.01); there was a decrease in DTN time from before to after the introduction of ISHOT (mean 118 minutes vs. 80 minutes). Two patients (67%) in the early period versus 9 (56%) in the late period achieved favorable outcomes (modified Rankin Scale score at 90 days ≤2). Conclusions: The introduction of I-SHOT led to an increase in the number of DS cases by allowing medical institutions on remote islands in Japan that are staffed exclusively by non-stroke specialists to collaborate with the acute care hub center on the mainland.

A 74-year-old woman was admitted with acute onset paralysis of vertical gaze and bilateral ptosis. On admission, the consciousness was clear and she showed no neurological abnormality except paralysis of vertical gaze and bilateral ptosis. Magnetic resonance imaging (MRI) detected bilateral paramedian thalamic infarction. At the next day of the admission, bilateral ptosis had disappeared and clinical course looked good. However on the fifth day from the onset, she presented an abrupt sleep attack. Since then, she came to have paroxysmal sleep attacks. Each episode lasted about 2 hours, and she was alert in the interictal time. The attacks happened even during walking and eating. The attacks were resolved just after starting oral amantadine. Generally, bilateral paramedian thalamic infarction is well known to present prolonged consciousness disturbance. Reports of episodic sleep attack are only a few, and our case is the first report with the sleep attack in the subacute phase. It has to be known that paroxysmal sleep attacks can appear in the subacute phase in bilateral paramedian thalamic infarction and can be resolved by amantadine.

Objective: We present a rare case of Takayasu arteritis complicated by eosinophilic granulomatosis with polyangiitis (EGPA), followed by common carotid artery occlusion. Case Presentation: A 49-year-old woman with a history of EGPA rapidly developed left hemiplegia. MRI revealed acute infarction in the right middle cerebral artery territory. The right common carotid artery was not visualized on magnetic resonance angiography. She was transferred to our hospital for a detailed examination. Her erythrocyte sedimentation rate and C-reactive protein level were slightly increased. PET-CT showed high uptake in the aortic arch, right innominate artery, and common carotid artery, which supported the diagnosis of Takayasu arteritis. Rest ¹²³I-IMP-SPECT demonstrated low uptake in the right middle cerebral artery territory; therefore, subclavian-carotid bypass for revascularization of the right carotid artery was performed. She eventually recovered well from the surgery and was discharged home. Conclusion: Revascularization for common carotid artery occlusion of Takayasu arteritis with EGPA was safe and effective in improving the neurological status, and it should be performed while the disease is inactive.

We report a case of a ruptured basilar artery dissecting aneurysm that was successfully treated by coil embolization with multiple LVIS stents. A 69-year-old woman, who presented with subarachnoid hemorrhage, was admitted to our institute. On admission, angiography revealed slight dilation of basilar trunk but no apparent bleeding source. One week after the onset, the second angiography demonstrated remarkable aneurysmal dilation on the middle basilar trunk with an irregular stenosis proximal to the dilation, which was diagnosed as basilar artery dissecting aneurysm. We judged that the risk of re-rupture was high and performed multiple stent placements to cover the entire basilar artery dissection and coil embolization for the aneurysmal enlargement. Cerebral angiography showed no recurrence several days after the surgery and even 2 years after the operation. Coil embolization with multiple LVIS stents was considered to be useful for subarachnoid hemorrhage due to dissecting aneurysm.

An 83-year-old man was admitted to our hospital with acute aphasia, left-sided conjugate eye deviation, and right hemiplegia. Brain computed tomography and diffusion-weighted magnetic resonance imaging were unremarkable; however, magnetic resonance angiography revealed proximal occlusion of the left middle cerebral artery (MCA). Blood test results showed severe macrocytic anemia with serum hemoglobin 3.8 g/dl and mean corpuscular volume 144 fl. The patient was not administered intravenous recombinant tissue plasminogen activator because active gastrointestinal bleeding could not be immediately ruled out. He underwent mechanical thrombectomy together with blood transfusion, leading to complete recanalization of the left MCA. Upper gastrointestinal endoscopy revealed chronic atrophic gastritis. Blood test results showed a low serum vitamin B₁₂ level; therefore, the patient was diagnosed with severe macrocytic anemia secondary to pernicious anemia. He received anticoagulation and mecobalamin replacement therapy and was discharged on the 13th day without any sequelae. Clinicians should carefully evaluate underlying diseases, including anemia, before determining the indications for endovascular treatment in patients with acute ischemic stroke.

A 48-year-old woman was admitted to our hospital with motor aphasia, right homonymous hemianopia, and right-sided hemispatial neglect. Her mother and maternal grandmother had a history of deafness and diabetes mellitus. Five years earlier, she was diagnosed with diabetes mellitus. Metformin treatment was started at 6 months before admission, and the metformin dose was increased. From this period, she became aware of hearing difficulties. On day X, she was admitted to another hospital due to motor aphasia, and she was treated for a diagnosis of herpes encephalitis and then discharged on day X + 15. The next day, she was admitted to our department. Brain magnetic resonance imaging showed lesions in the left temporal, occipital, and parietal lobes. Magnetic resonance spectroscopy showed a lactate peak in the lesions. Serum and cerebrospinal fluid showed elevated lactic acid and pyruvic acid levels; the lactate/pyruvate ratio was also elevated. She was diagnosed with MELAS (mitochondrial myopathy, encephalopathy, lactic acidosis, and stroke-like episodes). In this case, hearing difficulty and stroke-like episodes occurred after metformin use, which worsened mitochondrial disease by elevating lactate levels. In patients with maternal inheritance of antibody-negative type 1 diabetes mellitus, hearing loss, short stature, and so forth, lactate or pyruvic acid levels should be measured to assess the possibility of mitochondrial disease.

We describe a rare case of 81-year-old woman who presented repetitive ischemic stroke due to the mechanical stimulation of the hyoid bone. The patient suffered from embolic strokes three times in a year. Although she had several examinations to detect embolic source, a definite embolic source was not detected. Magnetic resonance angiography showed only low-grade internal carotid artery stenosis, but three-dimensional computed tomographic angiography proved clearly the entrapment of the top of common carotid artery due to hyoid bone. We diagnosed embolic stroke due to the mechanical stimulation of the hyoid bone, and the patient underwent carotid endarterectomy. The anatomical position of hyoid bone may be variable and more than expected, and it can be a risk factor for embolic stroke even if low-grade carotid artery stenosis. We should examine carefully the relationship between the carotid artery and the surrounding bone structures in the cases of embolic stroke of undetermined source.

The patient was a 56-year-old man who suffered from cerebral venous thrombosis 4 times. Peripheral blood and bone marrow aspirate smears at onset and during subsequent recurrence did not lead to a diagnosis of a myeloproliferative neoplasm. Later, platelets were elevated and anemia gradually worsened. Four years after onset, abnormal bone marrow findings were noted, and the patient was diagnosed with a myeloproliferative neoplasm associated with the JAK2 V617F mutation. In this case, cerebral venous thrombosis presumably recurred due to the myeloproliferative neoplasm associated with the JAK2 V617F mutation. There are a few reports of patients with the JAK2 V617F mutation who did not have abnormal blood test results when cerebral venous thrombosis developed but who were diagnosed with a myeloproliferative neoplasm several years later. In cases of unprovoked cerebral venous thrombosis, further testing must be performed with a latent myeloproliferative neoplasm associated with a JAK2 gene abnormality in mind.

Although the etiology of acute onset amnesia can involve lesion of the fornices, a few cases of pure fornix infarction have been reported. Here we report a 75-year-old right-handed woman with bilateral fornix infarctions. She presented with acute onset global amnesia. Except for amnesia, her neurological evaluation was unremarkable. Brain 3T MRI showed bilateral cytotoxic edema of the anterior columns of the fornix, predominantly on the left side. Her symptoms had improved by 14 days after the onset of amnesia. We speculated that she had severe recent memory impairment due to damage in the Papez circuits. The subcallosal artery (ScA) is thought to feed the columns of the fornix. In this case, infarction of a branch of the ScA might be the cause. Therefore, cases of acute onset amnesia should be evaluated quickly for the possibility of infarction in the Papez circuit.