Japanese Journal of Stroke
Online ISSN : 1883-1923
Print ISSN : 0912-0726
ISSN-L : 0912-0726
Volume 44, Issue 5
Displaying 1-12 of 12 articles from this issue
Originals
  • Osamu Kawakami, Yasuo Koike, Makoto Sugiura, Hiroko Kato, Toshiyasu Ka ...
    2022 Volume 44 Issue 5 Pages 505-511
    Published: 2022
    Released on J-STAGE: September 25, 2022
    Advance online publication: March 25, 2022
    JOURNAL OPEN ACCESS

    Background and Purpose: In order to clarify the clinical features and risk of developing acute symptomatic seizures (ASS) associated with cerebral infarction, we retrospectively examined a large number of cases of cerebral infarction in our hospital. Methods: We extracted 2152 patients with acute cerebral infarction (excluding TIA) who were admitted to our hospital with ASS, which developed into epileptic seizures within 7 days. The endpoints were age, sex, history, presymptomatic mRS and discharge mRS, admission NIHSS, cerebral infarction type (NINDS), and seizure type. Results: ASS developed in 42 cases (2%). Convulsive onset was observed in 83% of cases, nonconvulsive in only 17%, and status epilepticus to nonconvulsive status epilepticus (NCSE) in 32%. The majority of the patients developed ASS within 24 hours of the onset of cerebral infarction. As for the independent risk of developing ASS, NIHSS ≥10 at admission, infection, and prehospital mRS 3–5 were independent risk factors for the ASS group. Conclusion: In the acute phase of cerebral infarction, EEG measurement should be actively considered for early diagnosis of ASS.

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  • Kenichi Irie, Kaori Miwa, Hajime Ikenouchi, Tetsuya Chiba, Satoshi Hos ...
    2022 Volume 44 Issue 5 Pages 512-517
    Published: 2022
    Released on J-STAGE: September 25, 2022
    Advance online publication: May 18, 2022
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    Objectives: This study aimed to describe the clinical and radiologic characteristics and functional outcome of medullary infarction with vertebral artery dissection (VAD) compared with medullary infarction without VAD. Methods: We investigated patients treated for acute medullary infarction from November 2011 to March 2018. The infarct location was classified based on MRI. Functional outcome was assessed using the modified Rankin scale (mRS) at 3 months after onset. Results: The cohort comprised 57 patients (mean age 65±14 years, 75% men) with isolated acute medullary infarction (15 with VAD and 42 without VAD). In the VAD group, 15 patients had lateral medullary infarction (LMI) and none had medial medullary infarction (MMI). LMI was more common in the VAD group than in the non-VAD group (100% vs. 71%, p=0.02). The main symptom was sensory dysfunction (84%) in patients with LMI and limb weakness (93%) in those with MMI. An mRS of 3–6 at 3 months after onset was more common in the non-VAD group than in the VAD group (24% vs. 0%, p=0.04). Conclusions: VAD may more frequently cause LMI rather than MMI. Patients with medullary infarction with VAD had a better 3-month functional outcome than those with medullary infarction without VAD.

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Case Reports
  • Masahiro Kanatani, Shota Matsumoto, Yuko Yoshimoto, Masayoshi Kusumi
    2022 Volume 44 Issue 5 Pages 518-523
    Published: 2022
    Released on J-STAGE: September 25, 2022
    Advance online publication: March 11, 2022
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    An 80-year-old man was admitted to our hospital with a disorder of consciousness, nystagmus, dysarthria, and right hemiplegia after bathing. Brain MRI showed acute small subcortical infarction in the left parietal lobe, and magnetic resonance angiography revealed left internal carotid stenosis that suggested atherosclerotic infarction. On the day after admission, his level of consciousness suddenly worsened to JCS-300, and he developed respiratory arrest during sputum aspiration. He received endotracheal intubation and was ventilated. His level of consciousness improved gradually, but quadriplegia persisted. On the fourth day of admission, brain and cervical spine MRI showed a longitudinally extensive lesion from the right medulla to the upper cervical cord, and computed tomography angiography showed right vertebral artery occlusion. We diagnosed medullary and cervical spinal cord infarction. In conclusion, it is important to consider that unilateral vertebral artery occlusion can occur with upper cervical spinal cord infarction, which requires appropriate care.

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  • Kazuma Sahara, Nobuhisa Matsushita, Yuichi Satoh, Atsuhiko Suzue, Ayat ...
    2022 Volume 44 Issue 5 Pages 524-529
    Published: 2022
    Released on J-STAGE: September 25, 2022
    Advance online publication: March 25, 2022
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    The frequency of true posterior communicating artery (PcomA) aneurysm is relatively rare. A case of a 73-year-old woman with a ruptured true aneurysm of the left PcomA, 17 years following after occlusion of the left ICA, is presented herein. This patient developed vomiting 6 days prior to admission and was assessed to have worsened expressive aphasia due to vasospasm. A left VA angiogram demonstrated a true left PcomA aneurysm, with collateral flow from the left PcomA to the left ICA. Six days from the onset, we performed coil embolization, partially occluding the PcomA; however, no thalamic infarction was detected due to collateral perfusion from the anterior circulation. Because long-term hemodynamic stresses possess risk of developing an aneurysm, long-term follow-up of the ICA occlusion is necessary.

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  • Ryogo Ikemura, Hideaki Ueno, Satoshi Adachi, Yasuaki Nakao, Takuji Yam ...
    2022 Volume 44 Issue 5 Pages 530-533
    Published: 2022
    Released on J-STAGE: September 25, 2022
    Advance online publication: March 31, 2022
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    We present an extremely rare case of a hypokalemic myopathy with motor hemiparesis that is a stroke-like episode indicating rt-PA therapy, although the hypokalemic myopathy often causes tetraparesis. A 69-year-old man was admitted to our hospital with sudden right motor hemiparesis. He did not have any particular past histories, except for a habit of drinking. Hemiparesis caused by acute stroke was suspected in the primary diagnosis, but any ischemic and hemorrhagic lesions could not be detected in both magnetic resonance imaging (MRI) and CT. The laboratory analysis showed that the level of potassium in serum (K+) was decreased to 1.8 mEq/l and CPK was abnormally elevated to 2,403 U/l. We diagnosed him with a hypokalemic myopathy like stroke mimics. His motor weakness had gradually recovered with an improving K+ level. In the present case, the myopathy should be caused by alcoholic hypokalemia because the alcoholic drinker tends to develop chronic hypokalemia. The presence of electrolyte imbalance should be considered, especially when the patient with alcoholism behavior complaint of symptoms like stroke.

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  • Dai Ichikawa, Hiroshi Fukaya, Toshiya Ishida, Masato Sageshima, Satosh ...
    2022 Volume 44 Issue 5 Pages 534-540
    Published: 2022
    Released on J-STAGE: September 25, 2022
    Advance online publication: April 05, 2022
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    A 56-year-old man was admitted due to left lower quadrant homonymous hemianopsia. Brain magnetic resonance imaging showed new and old embolic infarctions in multiple cortical areas including the right visual cortex. The D-dimer level was normal, and no embolic source was detected on various examinations. He experienced recurrence of embolic infarction causing motor aphasia a month later. Computed tomography showed a tumor on his bladder wall. After resection, the tumor was pathologically identified as urachal cancer harboring a large amount of mucins. There was no recurrence with administration of heparin during the hospitalization, and he has had no recurrence of the infarction for a long time after the tumor resection. These clinical courses suggest that his embolic infarctions were due to stroke associated with the urachal cancer. Although cancer-associated stroke without elevated D-dimer level is atypical, there is a possibility that the mechanism of thrombus formation via abundant mucins may have predominated over activation of the coagulation system in our case. The pathogenesis of venous thromboembolism and cerebral infarction in cancer-associated thrombosis may not necessarily be the same. In this complicated syndrome, further studies are expected to establish new indices other than D-dimer for diagnosis and provide evidence for stroke treatment.

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  • Yoshihiro Sunada, Kenji Yagi, Shunji Matsubara, Masaaki Uno
    2022 Volume 44 Issue 5 Pages 541-545
    Published: 2022
    Released on J-STAGE: September 25, 2022
    Advance online publication: April 14, 2022
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    We herein report the case of a patient who experienced a spontaneous thrombosed large aneurysm and underwent follow-up assessments involving computed tomography angiography (CTA). Our patient was a 71-year-old woman who presented with a large aneurysm of the anterior communicating artery (Acom). The aneurysm had a calcified base and bleb. We recommended a surgical intervention; however, the patient did not give consent. She did, however, gave consent to annual follow-up assessments with CTA. During the 3-year follow-up assessment, we observed stenosis of the proximal parent artery (i.e., the A1 segment of the right anterior cerebral artery), but the aneurysm remained stable. By the 4-year follow-up timepoint, the aneurysm had completely disappeared, and the stenosis of the right A1 segment had become less severe. Over the course of 5 years of follow-up, our patient experienced no neurological sequelae, and magnetic resonance imaging (MRI) did not reveal any cerebral infarctions. In conclusion, this case history shows that long-term follow-up with CTA, MRI, and magnetic resonance angiography is essential for patients with spontaneous thrombosed cerebral aneurysms.

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  • Shoko Ito, Masateru Katayama, Kimihiro Matsumoto, Dai Kamamoto, Satosh ...
    2022 Volume 44 Issue 5 Pages 546-551
    Published: 2022
    Released on J-STAGE: September 25, 2022
    Advance online publication: April 14, 2022
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    A 63-year-old male with asymptomatic idiopathic thrombocytopenic purpura (ITP) was presented to the emergency department with mild disturbance of consciousness and was diagnosed with left internal carotid artery occlusion by head MRI/MRA. Intravenous thrombolysis was not chosen for the treatment because of his low platelet count (1.9×104/µl). MRA showed a flow to the left MCA from the anterior communicating artery. Therefore, we decided to give a platelet transfusion followed by mechanical thrombectomy (MT) with a reperfusion of TICI3. He was placed on anticoagulation therapy as a secondary prevention, and discharged ambulatory on the 17th hospital day.

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  • Jo Matsuzaki, Tomoko Yoshida, Jumpei Nishii, Akihiro Tsuji, Takehiko Y ...
    2022 Volume 44 Issue 5 Pages 552-558
    Published: 2022
    Released on J-STAGE: September 25, 2022
    Advance online publication: April 14, 2022
    JOURNAL OPEN ACCESS

    A 69-year-old woman came to our hospital because of a sudden-onset of speech and behavior disturbances. Brain CT, MRI, and MR venography revealed cortical subarachnoid hemorrhage, superior sagittal sinus (SSS) occlusion, and cortical venous congestion. We performed a diagnosis of cerebral venous sinus thrombosis (CVST) of SSS, and immediately started with intravenous heparin and proceeded with neuroendovascular therapy, which was difficult but resulted in slim recanalization of the SSS. Although we started oral warfarin (target PT-INR=2.0–2.5) after the neuroendovascular procedure, SSS occlusion recurred on day 244 with PT-INR in a target therapeutic window. Intravenous administration of heparin and neuroendovascular therapy were carried out with resulting slim recanalization of the SSS again. The neuroendovascular procedure was even more difficult for recanalization of the SSS than before. Afterward, we started oral warfarin (target PT-INR=2.5–3.0), and she has been free of recurrence for about 2 years. With regard to the cause of thrombosis, we suspected congenital antithrombin deficiency, because the antithrombin activity was reduced to 58% and we found heteromutation in the antithrombin gene. The neuroendovascular procedure for CVST caused by congenital antithrombin deficiency was difficult, but we could anticipate neurologically satisfactory outcome using neuroendovascular therapy combined with adequate anticoagulation therapy.

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  • Shun Aritake, Kentaro Hayashi, Kenichi Iwasa, Yukie Kanai, Nao Tahara, ...
    2022 Volume 44 Issue 5 Pages 559-563
    Published: 2022
    Released on J-STAGE: September 25, 2022
    Advance online publication: April 25, 2022
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    Cerebral artery dissection can be a cause of cerebral infarction, especially in the young people. It is difficult to diagnose the arterial dissection since the deformity is very little in the early stage. A 40-year-old man presented with visual field disturbance. MR diffusion-weighted image showed multiple high-intensity lesions in the posterior circulation. Vascular abnormality was not detected by MR angiography. In spite of administration of antithrombotic therapy, cerebral infarction repeated in the posterior circulation. An antiphospholipid antibody was positive. Neither ultrasound study nor radiological study could show the cause of cerebral infarction. Finally, conventional vertebral angiogram revealed dilatation at the V2-3 portion of the right vertebral artery, and we made a diagnosis of the right vertebral artery dissection. In case of repeated cerebral infarction in the same vascular territory, radiological study including conventional cerebral angiography is needed.

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  • Yasushi Ejima, Yoshiko Inaishi, Yoichi Kaneko
    2022 Volume 44 Issue 5 Pages 564-569
    Published: 2022
    Released on J-STAGE: September 25, 2022
    Advance online publication: May 18, 2022
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    Background: We herein report two cases of cerebrovascular disease following methamphetamine abuse. Case 1: A 36-year-old man with a history of methamphetamine abuse for several years suddenly experienced weakness of the right upper and lower limbs shortly after inhalation of methamphetamine. The patient was transported to the emergency department in a comatose state. Computed tomography was performed and revealed a massive hematoma in the left cerebral hemisphere. He had a cardiopulmonary arrest 3 h after admission and died 69 days later. Case 2: A 57-year-old man had been a methamphetamine addict since he was in his twenties. He started complaining of general malaise and difficulty in moving after intravenous injection of methamphetamine. Two days later, the patient was hospitalized for altered state of consciousness with a temperature of 38.7°C. Urine analysis using the triage system showed positive reaction for amphetamines. Magnetic resonance imaging revealed multiple cerebral infarcts in the thalamus, brainstem, and bilateral cerebellar hemispheres. A diagnosis of sepsis and cerebral infarction due to bacterial embolus was made, and antibiotic treatment was initiated. However, his general condition gradually deteriorated, and he died 10 days after admission. Conclusions: It is necessary to consider methamphetamine abuse as a cause of cerebrovascular disease in young adults with no underlying diseases such as hypertension and diabetes mellitus.

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  • Yuki Inoue, Mami Ogawara, Hiroshi Kiduki
    2022 Volume 44 Issue 5 Pages 570-574
    Published: 2022
    Released on J-STAGE: September 25, 2022
    Advance online publication: May 18, 2022
    JOURNAL OPEN ACCESS

    The patient was a 52-year-old man who had an acute cerebral infarction due to occlusion of the basilar artery (BA). Intravenous rt-PA and mechanical thrombectomy (MT) were performed, which resulted in recanalization of the BA. At the time of onset, there were no symptoms or findings suggestive of infection. However, shaking chills appeared during the MT procedure. We suspected bacteremia, and cultured the embolus and blood obtained during the MT, as well as performed echocardiography. We diagnosed a large vessel occlusion (LVO) caused by infective endocarditis (IE) due to Streptococcus sanguinis (S. sanguinis). S. sanguinis is a commensal organism important in promoting oral health but may cause subacute IE. The existence of subacute IE, its symptoms, and its risk of LVO may not be well recognized. Therefore, the possibility of subacute IE due to S. sanguinis should be given attention in acute stroke practice.

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