Background and purpose: The use of a combination of stroke predictors, such as clinical factors and asymptomatic lesions on head magnetic resonance imaging, may improve the accuracy of stroke risk prediction. Therefore, we attempted to develop a stroke risk score for healthy individuals. Method: We investigated the presence of cerebral stroke in 1,790 healthy individuals who underwent brain dock screening at the Health Science Center, Shimane. We examined the factors contributing to stroke and attempted to determine the risk of stroke by comparing background factors and MRI findings. Results: The following items were found to be significant risk factors for stroke: age (≥65 years), hypertension, subclinical cerebral infarction, deep white matter lesion, and micro cerebral hemorrhage. Each item was assigned 1 point, and the hazard ratios for the risk of developing stroke based on the group with 0 points were 16.8 (P <0.01) for 3 points, 44.0 (P <0.005) for 4 points, and 121.2 (P <0.001) for 5 points. Conclusion: We could create a precise stroke prediction score by combining MRI findings and clinical factors.

Background and purpose: The purposes of this study were to examine the progression of brain edema after MCA infarction and the effect of time of decompressive hemicraniectomy (DHC) on prognosis. Methods: Cases of brain infarction at our institution between 2008 and 2019 were assessed. Twenty-eight cases of ICA or MCA occlusion with a clear onset time and cerebral swelling and without effective recanalization were included in this study. Time from onset and midline shift were investigated in 54 CT images taken during the course of each case. Results: Time from onset and midline shift were positively correlated in the Alberta Stroke Program Early CT Score (ASPECTS) ≥6 and ASPECTS <6 groups on admission (rs = 0.92, 0.78). The midline shift was about 6 mm and 12 mm, respectively, in the two groups after an average of 48 hours, and a 2-fold difference in the progression of brain swelling was found. Anisocoria was observed when the midline deviation exceeded 8 mm. The median mRS at discharge in the ASPECTS ≥6 group was 4 in the 6 cases that underwent DHC and 5 in the 5 conservative treatment cases, with no statistically significant difference (p = 0.479). The median mRS at discharge in the ASPECTS <6 group was 5 in the 13 DHC cases and 5.5 in the 4 conservative treatment cases, showing no statistically significant difference (p = 0.400). The median mRS at discharge was 4.5 in the 8 DHC cases when the midline shift was 8 mm or less (mean 3.7 mm), and the mRS was 5 in the 11 operation cases when the midline shift exceeded 8 mm (mean 12 mm). No significant difference was found (p = 0.371). Conclusion: A positive correlation was found between the time from onset and progression of cerebral swelling. Earlier progression of brain swelling was found in the group with a low ASPECTS at onset.

Purpose: Factors related to the final outcome in patients with acute stroke were investigated using the medical information of stroke patients who were transferred to a convalescent hospital in the first week after onset. Methods: A total of 126 patients were admitted to our hospital because of acute stroke and were transferred using a collaborative path. They were stratified according to their discharge; 90 patients were classified in the home discharge group and 36 patients in the no homes group. The evaluated items were basic information, physical function before and at admission, neurological severity, neurological findings in the first week after onset, and activities of daily living. Multiple logistic regression analysis was performed with the final outcome as the dependent variable. Results: The factors found to affect the final outcome after discharge from the convalescent hospital home were age, NIHSS score, and Stroke Impairment Assessment Set (SIAS) score; these were extracted, and their discriminative predictive value was found to be 83.4%. The cutoff values for these factors were 78 years of age, and an NIHSS score of 5 and an SIAS score of 55 at the first week of onset. Conclusion: Age, NIHSS score, and SIAS at the first week of onset were associated with the final outcome after discharge from a convalescent hospital.

A 68-year-old woman was admitted to our hospital with a diagnosis of recurrent cerebral infarction. She had dysarthria, dysphagia, and incomplete paralysis of the right upper and lower extremities. The laboratory findings including extensive hematology, immunology, and coagulation tests were normal. Brain magnetic resonance imaging showed multiple ischemic lesions in both cerebral hemispheres. Magnetic resonance angiography and the carotid and vertebral artery ultrasonography findings were normal, as were the results of a 24-hour electrocardiogram. Transthoracic echocardiography (TTE) showed no visible vegetations, and repeated blood cultures were also negative. The transesophageal echocardiography revealed a anemone-like vegetation on the aortic valve. She was diagnosed with brain embolisms due to the intracardiac tumor, which was surgically excised and pathologically confirmed as papillary fibroelastoma. The postoperative course was uneventful, with no neurologic complications. This type of tumor is rare but is important as an embolic source, especially in embolic stroke of undetermined source.

A 74-year-old woman presented with right hemiplegia and aphasia (Glasgow Coma Scale E3V2M5). The patient had fever, thrombocytopenia, and abnormal blood coagulation. The acute DIC score was 6 points on the arrival. CT revealed intracerebral hemorrhage, subarachnoid hemorrhage, and acute subdural hematoma. The patient presented acute hydrocephalus after the admission. We performed ventricular drainage and collected the cerebrospinal fluid for the specimen. From the result of bacteriological examination of blood and cerebrospinal fluid showing Neisseria meningitidis, we diagnosed the patient with bacterial meningitis and treated with antibiotics. The patient was transferred to a hospital with modified Rankin scale (mRS) of 5. Though meningitis associated with Neisseria meningitidis is rare, initial treatment has a significant impact on the outcome. Prompt and accurate initial treatment of hemorrhagic stroke with fever needs to be performed in consideration of bacterial meningitis.

A 54-year-old man acutely developed respiratory distress and fever, and could not move 3 days later. Chest CT demonstrated bilateral pneumonia, and nasopharyngeal polymerase chain reaction confirmed SARS-CoV-2 infection. Brain CT showed multiple infarctions in the right frontal lobe, thalamus, midbrain, and cerebellum. Echocardiography revealed a right atrial thrombus and a right-to-left shunt via a patent foramen ovale (PFO), leading to the diagnosis of paradoxical embolism. Although COVID-19-related ischemic stroke has been reported worldwide, accurate pathogenic mechanism remains unclear. This case study suggested that paradoxical embolism is one of the pathogenetic mechanisms in COVID-19-related ischemic stroke. COVID-19-related ischemic stroke may include a certain number of paradoxical embolisms via a PFO.

A case of cervical carotid artery stenosis with persistent primitive hypoglossal artery (PPHA) treated by carotid artery stenting (CAS) with carotid direct puncture is reported. A 65-year-old female presented with an incidentally discovered left cervical internal carotid artery (ICA) stenosis and ipsilateral PPHA during close examination of aortic arch aneurysm. After thoracic endovascular aortic repair (TEVAR) by a cardiovascular surgeon, CAS was performed for ICA stenosis. Two sheaths were inserted by carotid direct puncture, and double distal filter protection was placed on both the distal ICA and the PPHA, respectively. In performing CAS for cervical ICA stenosis with PPHA, it is considered important to select appropriate embolic protection for each case. Furthermore, carotid direct puncture was useful for CAS after TEVAR.

Cerebral air embolism (CAE) is typically associated with diving, trauma, and medical procedures including catheterization and biopsy. Very rarely, some internal diseases can lead to CAE, as opposed to the classic external causes. Here, we report two unusual cases of CAE caused by internal diseases (a pulmonary disease and a bowel one). Case 1 is a 78-year-old male presenting with transarterial CAE led by pneumothorax relating to emphysema and bronchitis based on nontuberculous mycobacterial infection. Case 2 is a 92-year-old male presenting with transvenous CAE arising from hepatic portal venous gas relating to non-occlusive mesenteric ischemia (NOMI). Pulmonary circulation in Case 1 and portosystemic collateral pathways in Case 2 might play an important role in the mechanism of these CAEs, respectively. Although the correct diagnosis of CAE is immediately difficult, it is essential to bear in mind that a pulmonary or bowel disease could be potentially an internal risk of CAE.

Objective: Cerebral air embolism, commonly known as caisson disease, is often observed among divers. Here, we report a case of a man who developed cerebral air embolism after muscle strength training. Patient: A 75-year-old man developed a sudden disturbance of consciousness at home after muscle strength training at a gym and was transferred to our hospital by ambulance. His levels of consciousness were Japan Coma Scale 300 and Glasgow Coma Scale E1V1M1, and he was diagnosed with tonic status epilepticus. Head computed tomography revealed a diffuse low-density area in the right frontal lobe, which led to the diagnosis of cerebral air embolism. Because of the status epilepticus, we did not use hyperbaric oxygen therapy and treated him with anticonvulsants and edaravone. His level of consciousness gradually improved, and he was able to speak and follow instructions. However, the severe left hemiplegia persisted. On day 53 after disease onset, the patient was transferred to a rehabilitation hospital when his condition was graded as modified Rankin Scale 3. Conclusions: The patient had a history of interstitial pneumonia. Thus, air embolism may have been caused by the rupture of the alveoli owing to the increase in the intrathoracic pressure during muscle strength training. Clinicians should recognize that air embolism associated with muscle strength training can cause stroke.

A 23-year-old woman was admitted to our hospital with eosinophilic pneumonia. She developed left hemiparesis on the 3rd day of hospitalization, and magnetic resonance venography revealed superior sagittal sinus occlusion. She was diagnosed with cerebral venous thrombosis and treated with anticoagulant and steroid therapy. She developed acute subdural hematoma 7 days later and underwent emergency craniotomy and recovered without sequelae. Laboratory investigations revealed elevated eosinophils while the steroid was tapered; therefore, we diagnosed the patient with eosinophilia-induced cerebral venous thrombosis. Severe eosinophilia should be considered a risk factor for thrombosis.

We report a rare case of adult pial arteriovenous fistula (PAVF) treated with preoperative embolization and surgical excision. A 26-year-old man presented with sudden headache and vomiting. CT demonstrated a subcortical hemorrhage in the left temporal lobe. Cerebral angiograms revealed a PAVF. He was treated with endovascular embolization by n-butyl-2-cyanoacrylate (NBCA) and surgical excision. Following the sign of NBCA revealed that some fine feeding arteries were directly connected to the drainer veins and the shunts were disconnected safely and reliably. In addition, we reviewed the literatures on adult PAVF from 1979 to 2020 and discussed clinical characteristics and appropriate treatment. A review of the literature showed that 8 of 106 patients received combined endovascular and surgical treatment, of whom 75% achieved a complete obliteration and 88% had a good outcome. This case report suggests that combined endovascular and surgical treatment can be a useful treatment for PAVF.