Two large randomized clinical trials (NAVIGATE ESUS and RE-SPECT ESUS) to compare direct oral anticoagulants (DOACs) and aspirin in patients with embolic stroke of undetermined source (ESUS) did not show superiority of DOACs over aspirin for the prevention of recurrent stroke. These results suggest that covert atrial fibrillation is not a major player and arterial origin is more common than ever thought as a cause of embolism. Therefore, classification of causes into two groups by responding and non-responding to anticoagulation is required as much as possible for decision-making of antithrombotic therapy in ESUS patients. However, etiology is still unknown even after stroke recurrence in the majority of ESUS patients, and thereby, more extensive investigations and new approaches are mandatory. Regarding these issues, we reviewed and analyzed the results of NAVIGATE ESUS and RE-SPECTE EUS trials as well as their subgroup analyses, and described future perspectives.

Background and Purpose: This area is a rare primary stroke center (PSC) blank secondary medical area in Japan, and our hospital is the only designated emergency hospital in the area. In a primary care facility like our hospital, it is necessary to shorten the time from arrival at the hospital to the start of transfer (door-in door-out time [DIDO time]) as much as possible; however, there are very few reports on DIDO in Japan. We therefore conducted a retrospective survey to clarify the current situation in the area. Methods: Among the 25 cases of cerebral infarction with internal carotid artery (ICA) or M1 (horizontal segment of middle cerebral artery) obstruction encountered at our emergency outpatient department from April 2018 to March 2021, the data of 7 cases transferred to an emergency hospital were evaluated and verified. Results: The median DIDO time was 140 minutes (97–180 minutes). Conclusion: Information sharing and cooperation beyond the secondary medical area are required to improve access to thrombectomy therapy.

Background and Purpose: Our aim was to clarify the clinicians’ attitudes and medical trends in patients with cancer and stroke at stroke medical facilities and cancer medical facilities nationwide by a questionnaire survey. Method: A nationwide web questionnaire survey was conducted at primary stroke centers (stroke side, 974 facilities), designated cancer hospitals and Japanese Society of Medical Oncology facilities (cancer side, 584 facilities). Results: The response rate was 54.9% (535/974) on the stroke side and 18.8% (110/584) on the cancer side. Most institutions provided medical care for patients with cancer and stroke (95.5% on the stroke side, 93.6% on the cancer side). On the stroke side, 92.9% of the facilities responded that they were promptly consulted when a cancer patient developed acute stroke, and on the cancer side, they promptly contacted the stroke department at all facilities and have them responded immediately. Conclusion: Medical management for patients with cancer and stroke was provided at almost all facilities. Management of patients with cancer and stroke is a complicated issue to be solved by a single clinical department; therefore, the medical cooperation of cancer and stroke clinicians is required.

Pregnancy-associated intracranial hemorrhage is a serious clinical condition; however, the pathophysiology and effective management method remain unclear, and only a few cases have been reported to date. We here report a case of a pregnant woman in her thirties without any past medical history. She presented with a sudden severe headache, and a head CT scan displayed a subarachnoid hemorrhage. We performed two cerebral angiographies but could not detect any cerebral aneurysms. Conservative management was hence performed, and she was discharged without any neurological deficits. Five months after the subarachnoid hemorrhage, she was admitted to our hospital again for the delivery of her infant. We checked the previous cerebral angiography images again and detected a dissecting aneurysm at the distal region of the right posterior cerebral artery. Owing to this finding, we performed a caesarean section under careful blood pressure monitoring and delivered the infant without any complications. Subsequently, we followed the patient by performing cerebral angiography several times, and the dissecting aneurysm gradually became smaller and eventually disappeared. The dynamic physiological changes that occur to a woman’s body during pregnancy can cause stroke, and it is hence important to cooperate with neurosurgeons and obstetricians for the management of this complicated and life-threatening condition.

Discrimination of a tiny ruptured aneurysm from non-aneurysmal subarachnoid hemorrhage (SAH) is sometimes difficult. We report a case of aneurysm on the basilar apex of a patient with SAH who was treated with stent-assisted coil embolization. A 48-year-old female presented with SAH. A tiny and broad neck aneurysm was detected at the apex of the basilar artery. Because it was uncertain that the aneurysm caused SAH, the patient received conservative therapy under sedation. Follow-up angiography revealed no other aneurysms, and the enhancement of the aneurysmal wall was seen in MRI VWI. We conducted stent-assisted coil embolization on the 17th day after the onset. The postoperative prognosis was favorable, and the patient was discharged without symptoms. MRI VWI was useful in deciding on the treatment. A “horizontal stent” may be suitable for tiny basilar apex aneurysms.

A 38-year-old woman was admitted to our hospital with non-fluent aphasia. She had repeated convulsions several times a day. Neurological examination showed sensory aphasia. Brain MRI showed a left-temporal lesion, which gradually shrank without anti-coagulant agents. Cerebral angiography showed no evidence of vascular malformation or vessel occlusion. Laboratory tests showed iron-deficiency anemia due to uterine myoma detected by pelvic MRI. Cerebral venous thrombosis was suspected according to the clinical course, so 3D-FLAIR was added to conventional MRI sequencing. A funicular high-intensity lesion corresponding with the occluded cortical vein was detected in 3D-FLAIR, which was retrospectively regarded as the same finding in brain CT on admission. The patient was diagnosed with isolated cortical venous thrombosis due to iron-deficiency anemia. 3D-FLAIR may contribute to diagnosis of cryptogenic stroke.

The patient was a 67-year-old woman. She was admitted to our hospital for sudden onset of left hemiparalysis. Based on the diagnosis of right middle cerebral artery occlusion, we performed acute endovascular mechanical thrombectomy after injection of intravenous recombinant tissue plasminogen activator. White thrombus was recovered, and TICI grade was 3 in 1 pass. The postoperative neurological findings improved markedly, and the patient was discharged without any sequelae. Pathological examination of the embolus revealed Gram-positive cocci, and we suspected infective endocarditis and started antibiotic therapy, and performed upper and lower gastrointestinal endoscopy to find the source of Gemella haemolysans infection, which led to the discovery of early stage colorectal cancer, which was cured by endoscopic resection. In this case, we performed upper and lower gastrointestinal endoscopy to find the source of Gemella haemolysans infection.

Objective: Bilateral acute intracranial large vessel occlusion is extremely rare and associated with poor prognosis. We report a case with acute ischemic stroke due to bilateral acute MCA occlusion treated with mechanical thrombectomy. Case Presentation: A 87-year-old male was admitted with unconsciousness (Glasgow Coma Scale 11) and severe left hemiparesis. The NIHSS score was 29. CT showed no early ischemic signs, and intravenous thrombolysis was performed. MRI DWI showed right cerebral infarction, and MRA showed right ICA and right MCA occlusion. Left ICA and MCA were patent. Several minutes after finishing thrombolysis, the condition was deteriorated to coma, tetraparesis and respiratory insufficiency. Emergent endovascular intervention was performed. The initial left carotid angiogram revealed bilateral MCA occlusion. First, mechanical thrombectomy for the left MCA M1 segment occlusion was performed using the combined technique with a stent retriever and an aspiration catheter and leaded to complete recanalization (thrombolysis in cerebral infarction: TICI 3). Right hemiparesis and respiratory insufficiency were improved. Then, the system was transferred to the right ICA, and right carotid angiogram revealed right intracranial ICA and right MCA M1 segment occlusion, which were completely recanalized using the same technique (TICI 3). Although postoperative course was not eventful, his general condition was poor due to heart failure and severe pleural effusion. He was transferred to another hospital with an mRS score of 5. Conclusion: Emergent mechanical thrombectomy is a potentially effective treatment option for acute bilateral MCA occlusion.

A 59-year-old Korean female residing in Japan with a history of hypertension presented to the emergency department of our hospital with a sudden headache, hearing loss, and inability to walk. A CT scan showed Fisher group 3 subarachnoid hemorrhage and intracranial hematoma in the left temporal lobe. A CT angiography confirmed an aneurysm located at the bifurcation of the left middle cerebral artery. We performed surgical clipping via a left-sided pterional approach on the day of hospitalization. Neurological examination revealed motor aphasia and sensorineural hearing loss. We performed conservative treatment, and the hearing ability got better. Hearing loss caused by subarachnoid hemorrhage due to ruptured aneurysm of posterior circulation is well known but that caused by anterior circulation has not been reported. Intracranial hypertension or damage of hematoma in the inner ear may be the cause of hearing loss.

In a healthy 61-year-old man, on September X, 2020 (day of onset 0), general malaise and respiratory distress were observed. On the 7th day after onset, COVID-19 pneumonia was suspected on chest CT, and the patient was transferred to the emergency department of our center for hospitalization, but the SARS-CoV-2 PCR test was negative. On the 8th day after onset, his response became ambiguous, and right hemiparesis appeared on the 10th day after onset, so the patient immediately consulted our stroke center. Left M1 occlusion was observed by CTA, and the recanalization was obtained by emergency mechanical thrombectomy. On the 11th day, renal function deteriorated, and contrast-enhanced CT showed occlusion of the right renal and hepatic arteries, thrombus on the aortic wall, and splenic infarction. Endovascular treatment was performed for right renal artery occlusion. All four PCR tests up to the 12th day were negative, but the SARS-CoV-2 antibody test on the 14th day after onset was positive for both IgG and IgM.We will report the case diagnosed as COVID-19-related thrombosis because it showed a characteristic pneumonia image and the antibody test was positive after developing systemic arterial thrombosis including cerebral infarction, although the PCR test was negative multiple times.

An 86-year-old man with a history of long QT syndrome suddenly collapsed. The radial pulse was palpable at the time of contact with the ambulance crew. However, consciousness disorder with a Japan Coma Scale (JCS) score of III-200, right conjugate deviation, and left paralysis were observed. He was transferred to the department of neurosurgery of our hospital for suspected stroke. After MRI, the JCS score improved to II-20, and his left paralysis gradually improved. Although DWI did not show clear hyperintensity, FLAIR demonstrated vascular hyperintensity in the right MCA region, and magnetic resonance angiography showed poor delineation of the right MCA from its origin. His blood test results showed dehydration. Hemodynamic cerebral ischemia in the right MCA region was suspected. After admission, frequent ventricular premature contraction and torsade de pointes-type ventricular tachycardia (VT) appeared; the symptoms at the onset were attributed to cerebral ischemia caused by VT. Cerebral ischemic attack due to refractory VT might be difficult to identify based on the results of examination at admission because VT may have subsided by then, as observed in our patient. Detailed history taking is necessary at the time of admission, especially if there is a history of QT prolongation syndrome. The possibility of cerebral ischemia due to VT should be considered.

Craniocervical junction dural arteriovenous fistula (CCJ dAVF) has been considered traditionally to be characterized by the development of subarachnoid hemorrhage (SAH). However, CCJ dAVF due to congestion in the brainstem and spinal cord has also been reported in recent years. We report a case of dAVF with intramedullary hemorrhage in the medulla oblongata due to congestion. A 71-year-old man with a history of lumbar disc herniation presented with right thumb dorsiflexion disorder. Lower extremity hyperreflexia was also observed but could not be explained by a lumbar lesion. Lumbar MRI revealed no abnormality, but cervical MRI suggested a medullary lesion, which may have been due to cervical spondylosis. Computed tomography showed hemorrhage on the left dorsal side of the medulla oblongata, and MRI showed high signal intensity at the medulla oblongata on T2WI and hemorrhage on the left dorsal side, with flow void and contrasted palisading structures. We diagnosed the case as CCJ dAVF by angiography and performed a surgical blockade of the outflow vein. Surgery improved his symptoms, and the AV shunt was resolved.

Here, we report the case of a 43-year-old man who presented with transient right visual field loss and numbness and weakness in the right upper and lower limbs in a few days after noticing posterior neck pain while playing golf. Though brain magnetic resonance imaging showed an acute cerebral infarction near the left lateral ventricle, there were no abnormalities identified on brain magnetic resonance angiography. Antithrombotic therapy was initiated; however, 1 week later, the posterior cerebral artery showed segmental stenosis and repeated cerebral infarctions occurred in only the posterior circulation territory over a period of 2 weeks. After lomerizine administration as a treatment for vasoconstriction, the stenosis improved without recurrence. A carotid artery echocardiography revealed markedly decreased blood flow in the right vertebral artery by mechanical stretch, with the probe in a flexed position after leftward rotation, which generally suggested bow hunter’s syndrome. However, the known pathogenetic mechanisms of bow hunter’s syndrome could not explain the present case. Therefore, we presumed that reversible cerebral vasoconstriction syndrome triggered by mechanical stress on the vertebral artery after neck rotation.

An 89-year-old man transferred to our hospital due to sudden-onset disturbance of consciousness, left unilateral spatial neglect, right conjugate deviation of the eyes, dysarthria, left facial paresis and left hemiparesis. Brain MRI and MRA revealed an acute ischemic lesion of the right hemisphere and occlusion of the right middle cerebral artery (MCA), respectively. We diagnosed acute ischemic stroke due to right MCA occlusion caused by cardiogenic embolization (due to atrial fibrillation) or Trousseau’s syndrome (due to advanced lung adenocarcinoma). Immediate intravenous administration of alteplase and mechanical thrombectomy were performed, which resulted in recanalization of the right MCA. Subsequently, we started post-therapy administration of oral anti-coagulants, but bilateral internal carotid artery (ICA) occlusion occurred on day 6, and the patient died due to whole-brain death on day 8. Autopsy revealed primary adenocarcinoma in the right lung, and platelet-rich white clots and fresh thrombi in the bilateral ICA. These findings suggest features of thrombi in Trousseau’s syndrome. We compared the pathological findings of thrombi from Trousseau’s syndrome with cardiogenic emboli and discussed the differential diagnosis between the thrombus from Trousseau’s syndrome and cardiogenic embolization.

Intracranial hemorrhage has been known as one of the major adverse events of rtPA therapy. However, it is usually cerebral hematoma or hemorrhagic cerebral infarction, and subarachnoid hemorrhage (SAH) due to vertebral artery dissection has not been announced. We report a case of a patient who developed fatal SAH from vertebral artery dissection 31 hours after the rtPA therapy for ischemic stroke in corona radiata. Factors that may have contributed are his history of untreated hypertension and initial treatment with double antiplatelet therapy. Here, we discuss these possible causes of the dissecting aneurysm and necessity of optimal blood pressure control considering multiple elements.