Background and purpose: In recent years, the poverty ratio has been increasing due to widening economic disparity. The purpose of this study was to analyze the characteristics of cerebrovascular disease (CVD) in economically challenged patients. Methods: Eight hundred and sixteen patients with CVD from 2014 to 2018 were investigated. Patients who had a low-cost medical care treatment and livelihood protection belonged to the economically challenged group, while the rest of the patients were assigned the control group. The disease type, average age at onset, male-female ratio, living conditions before hospitalization, home discharge ratio, and modified Rankin Scale (mRS) scores at discharge were compared between the control and economically challenged groups. Results: Analyses of the patients with CVD revealed that the economically challenged group had a (1) higher proportion of men than women (especially under 65 years of age), (2) high rate of living alone before hospitalization, (3) lower average age at the onset of ischemic CVD, and (4) deterioration of the mRS score at discharge for intracerebral hemorrhage. Conclusions: In economically challenging conditions, ischemic CVD frequently occurs at an earlier age and the severity of intracerebral hemorrhage tends to increase.

Background and Purpose: Determining the factors associated with post-stroke survival and prognosis in cancer patients is important for treatment selection. However, there has been no clear evidence related to markers that can predict mortality. Therefore, in this study, we analyzed the factors associated with post-stroke mortality in patients with cancer. Methods: Specifically, this was a retrospective cohort study that included cancer patients with acute ischemic stroke hospitalized at Kawasaki Municipal Tama Hospital between January 2009 and March 2021. To evaluate the associations between clinical factors within 24 hours of initial stroke and mortality or stroke recurrence events within 6 months after stroke onset, logistic analysis was used. Further, in each study group, cutoff points for the markers of mortality were determined using receiver operating characteristic (ROC) curve analysis, and cumulative outcome rate was compared using Kaplan-Meier analysis. Results: A total of 94 cancer patients who developed acute stroke were ultimately selected for analysis, wherein 40 (42.5%) subjects died within 6 months following stroke onset. On assessment, high D-dimer levels and deep venous thrombosis (DVT) were independently associated with mortality, in which a higher death rate was significantly confirmed in the group with D-dimer levels ≥4.1 mg/dl. Conclusion: Furthermore, cancer patients with stroke, high D-dimer levels, and DVT would be associated with the risk of mortality within 6 months after stroke onset.

Background and Purpose: This study aimed to examine the factors affecting the promotion or inhibition of return to work among stroke patients using a database of cases managed by the health and employment support coordinator. Methods: We analyzed 337 stroke patients out of 401 patients registered in the database between February 2017 and March 2019, excluding 64 cases of unknown outcomes, ongoing treatment, and non-stroke. The database consisted of 69 items belonging to six factors: patients, family, economy, workplace, medical care, and return to work, and each item was evaluated on a 2 to 5 scale. A univariate analysis was performed by the χ² test to see if there was a difference between “return to work” and “non-return to work” for each variable. Results: The results revealed that the possibility of returning to work was influenced by physical functions, higher brain function, desire to return to work, self-management skills, and income; however, no significant effects of gender and age were found. The rate of return to work (67.7%) was considerably high. Conclusion: Functional improvement and psychological support are important for reinstatement support, and continuous rehabilitation and consultation support system construction are desired.

We experienced a case of transverse-sigmoid sinus dural arteriovenous fistula (TSS-DAVF) with low radiation exposure using various devices. A 45-year-old woman with left temporal lobe hemorrhage was diagnosed with left TSS-DAVF. Using a navigation system and indocyanine green (ICG) angiography, sinus was punctured directly. DAVF disappeared by sinus packing without any complication. Direct puncture is a long-standing procedure, but now that various medical devices can be used, it is considered to be safer with low exposure and one of the options.

Objective: We present an extremely rare case of an unruptured aneurysm arising from a fenestrated anterior cerebral artery (ACA) and associated with the accessory middle cerebral artery (MCA), the accessory ACA, and a quasimoyamoya disease of neurofibromatosis type 1 (NF 1). Case: A 65-year-old man with NF 1 was brought to our hospital after a head injury. Computed tomography showed an abnormality at the top of the basilar artery. Angiography revealed a saccular aneurysm arising from the proximal end of the fenestrated ACA. It was also associated with the accessory MCA, accessory ACA, and abnormal moyamoya vascular networks at the MCA (distal M1). A saccular aneurysm was also detected in the right basilar artery-superior cerebellar artery (BA-SCA). Coil embolization was performed for these aneurysms because of the association with aneurysm of the posterior circulation. Conclusion: This is a literature review of two cases of fenestrated ACAs with accessory MCAs, in one of which an aneurysm arose from the fenestration. The present case is the first to report on an aneurysm arising from the fenestrated ACA associated with the accessory MCA, accessory ACA and the quasi-moyamoya disease of NF 1. Embryologically, the aneurysm may be related with these vassal variations, especially hemodynamic stress. Considering the location of the aneurysm and the complexity of these vassal variation, coil embolization may be a better treatment choice than clipping.

A 58-year-old man developed left unilateral spatial neglect and hypoxemia during hospitalization for postoperative adjuvant chemotherapy for lung adenocarcinoma. Brain MRI revealed acute cerebral infarction in the right frontal lobe. In addition, contrast-enhanced CT showed pulmonary embolism and deep vein thrombosis. The diagnosis of cancer-associated thromboembolism was made on the basis of cerebral infarction, deep vein thrombosis, and increased coagulation, and he was treated with DOAC. However, symptoms of TIA and recurrence of cerebral infarction were observed. Although DOAC administration was switched to warfarin, recurrence of pulmonary embolism was observed. He was transferred to a higher level medical institution, and subcutaneous heparin therapy was started. The general condition of the patient improved without any recurrence of thromboembolism. He received cancer treatment with an immune checkpoint inhibitor (pembrolizumab). The treatment with subcutaneous heparin and pembrolizumab has continued for over two years without any recurrence of thromboembolism. Cancer-associated thromboembolism will likely increase with continued improvements in cancer survival. Therefore, secondary stroke prevention including subcutaneous heparin therapy may become more important.

Objective: We examined the effectiveness of 3D variable refocusing flip angle turbo spin echo (3D VRFA TSE) in the evaluation of restenosis after carotid artery stenting. Case Presentation: We examined 23 patients who underwent carotid artery stenting at our hospital. In all cases, in-stent lumen observation by the 3D VRFA TSE after stenting was possible. In-stent restenosis was observed in 5 cases, and the restenosis site was well visualized in all cases. The three representative cases are presented with images. Conclusion: The 3D VRFA TSE is effective as a follow-up to restenosis after carotid artery stenting.

An arterial dissection limited to the basilar artery is rare, and the treatment is not established. We report a case of basilar artery dissection diagnosed with high-resolution MRI and treated with antithrombotic agents. A 46-year-old man was emergently transported to our hospital because of sudden onset vertigo, tinnitus, headache, and dysarthria. Brain MRI diffusion-weighted image showed shower embolism in the right occipital lobe, and MR angiography demonstrated high-grade stenosis at the midportion of the basilar artery. High-resolution T1-weighted image revealed high signal along with the vessel wall indicating arterial dissection and the part was enhanced with a contrast medium. We concluded a diagnosis of basilar artery dissection and treated with antithrombotic agents. The neurological symptoms were improved but minor stroke recurred. Basilar artery dissection was confirmed with angiography. High-resolution MRI is useful for the diagnosis of basilar artery dissection with ischemic manifestation.

A 66-year-old man suddenly presented with dysphagia, dysarthria, right-sided ataxia, and marked hypertension. MRI showed acute ischemic stroke in the right medulla oblongata due to an occlusion of the right vertebral artery. Scattered edematous lesions were also present in the cerebral cortex and thalamus bilaterally, and subarachnoid hemorrhage was observed in the left cerebral convexity. The patient had a generalized seizure on day 2 of admission. Edematous lesions were completely improved over time by antihypertensive therapy. Clinical diagnosis of posterior reversible encephalopathy syndrome (PRES) was made. Rapid marked hypertension due to an impaired baroreceptor reflex and an excitatory reaction of sympathetic nervous system after medullary infarction including the solitary nucleus may be the underlying mechanism in the development of PRES.

A patent foramen ovale (PFO) is generally present in around 25% of healthy individuals. Embolic stroke of undetermined sources (ESUS) accounts for 20% of all strokes. It has been reported that PFO is present in 50% of ESUS; thus, making the accurate diagnosis of PFO is essential for neurologists. In particular, with the approval of percutaneous closure of PFO in 2019, the diagnosis of PFO is becoming more and more important. In our hospital, the right to left shunts are examined by transcranial doppler and bedside transthoracic echocardiography and after that transesophageal echocardiography is performed. In this case, we performed transesophageal echocardiography after proving a right-left shunt by bedside echocardiography; however, PFO was not confirmed initially but became evident only in a latero-supine position. On review of the current available literature, we are unaware of similar identified cases and therefore believe that this case may be very rare and worth reporting.

The patient was a 70-year-old man who had undergone lobectomy and was diagnosed with pulmonary pleomorphic carcinoma three years ago. The cancer spread to the lymph nodes and brain, despite use of combination chemotherapy; therefore, nivolumab was started a year before. The patient was hospitalized due to embolic ischemic stroke in the same year, but no embolic source was found in transthoracic echocardiography. He was discharged without neurological deficit and the cancer was markedly shrunk. However, 5 months later, he was readmitted with a seizure, and recurrence of ischemic stroke was observed. Transthoracic echocardiography revealed a mobile mass attached to the mitral valve and resection of the mass was performed. The mass was pathologically diagnosed as non-bacterial thrombotic endocarditis (NBTE). In this case, although nivolumab was able to control cancer progression, embolic stroke due to NBTE occurred. This indicates the need to pay attention to the NBTE as complication, even in a case in which nivolumab is effective.

We describe a case where internal trapping performed for ruptured vertebral artery dissecting aneurysm on the proximal side of the posterior inferior cerebellar artery resulted in infarctions due to basilar artery fenestration. A 53-year-old woman sustained subarachnoid hemorrhage. Radiographic examinations revealed ruptured left vertebral artery dissecting aneurysm on the proximal side of the posterior inferior cerebellar artery with basilar artery fenestration. Although internal trapping was performed, it caused infarction on the left cerebellar and medulla oblongata. These results could be attributable to the anatomical features of basilar artery fenestration. The embolization of ruptured vertebral artery dissecting aneurysm with basilar artery fenestration should be performed with care while paying attention to its anatomical features and perfusion.

We describe four cases (an 82-year-old, a 96-year-old, and two 78-year-old women) of cerebral amyloid angiopathy-related inflammation who showed unique brain MRI features. Their chief complaints were consciousness disorder in two cases, acute exacerbation of cognitive decline, and difficulty in moving. Seizures in the acute phase were also observed in three cases. An antiepileptic drug was administered to all four cases during their clinical course. A T2*-weighted image of a brain MRI revealed innumerable cortical multiple microbleeds. FLAIR imaging revealed diffuse white matter hyperintensity, suggesting inflammation. Immunotherapy was effective for cerebral amyloid angiopathyrelated inflammation, but only one patient was treated with a steroid, while the remaining three cases showed improvement with only initial treatment for epilepsy. Furthermore, in one case, white matter lesion improved without immunotherapy.

A 60-year-old woman who had aphasia and right hemiparesis was transferred to our hospital with the diagnosis of cerebral infarction. Her initial National Institutes of Health Stroke Scale (NIHSS) score was 30 points. MRI revealed an acute infarction at the left putamen and left corona radiata due to left internal carotid artery (ICA) occlusion After intravenous administration of tissue plasminogen activator (rt-PA), cerebral angiography revealed an occlusion of left ICA. Finally, we achieved thrombolysis in cerebral infarction (TICI) 2b recanalization after percutaneous transluminal angioplasty (PTA). Her symptoms gradually improved; her NIHSS score reduced to 2 points 24 hours after PTA. She was discharged home on postoperative day 18 with mRS 1. However, 1 month after PTA, she was aware of discomfort in the right upper limbs. DWI and fluid-attenuated inversion recovery (FLAIR) revealed a new high-signal lesion in white matter on the treated side. Since there was no worsening of symptoms, the imaging findings showed a tendency to improve after six months. Delayed white matter lesion rarely occurs after recanalization for intracranial artery occlusion. Although delayed hypoxic leukoencephalopathy and granulomatous lesions due to polymer coating embolisms have been suggested as possible causes, further studies are needed to elucidate the cause.