Background and Purpose: The aim of this study was to investigate the factors that influence the improvement in the language modalities: writing, speech, and comprehension in aphasia patients with left putaminal hemorrhage in the subacute phase. Methods: Age, gender, admission days, hematoma type and volume, National Institutes of Health Stroke Scale (NIHSS), Raven’s Colored Progressive Matrices (RCPM), types of aphasia, and severity of aphasia were retrospectively investigated from the medical records of 70 patients. The severity of aphasia was assessed using scores of the Standard Language Test of Aphasia and its subitems of writing, speech, and comprehension. Factors influencing the improvement in the subitem score were compared between the improved and non-improved groups. Results: In both groups, speech showed significant differences in age, NIHSS, and RCPM, and writing showed significant differences in hematoma volume in addition to the same factors as of speech. Meanwhile, no difference was found for comprehension. Conclusion: Our results suggested that the improvement in writing and speech may be related to age and intellectual functions, and comprehension is likely to be improved regardless of factors.

Background and Objectives: In December 2019, we started a vocational rehabilitation program for patients with stroke who expressed an expectation to return to work (RTW). We report here the results of the program for these patients up to December 2021. Method: The program strengthens the four conditions necessary for RTW: independence in home life, walking function for commuting, general office work function, and cognitive function to process work in an accurate and timely manner. Results: Among 81 patients registered in the program, 61 patients who had completed the program at least two months previously were included in this study. The RTW rate was 85.2% in all patients: 92.3% (n=26), 77.8% (n=9), and 80.8% (n=26) in cases with modified Rankin Scale (mRS) 2, 3 and 4, respectively. The RTW rate of 80.0% in patients with moderate stroke (mRS 3 and 4, n=35) exceeded the previously reported rate of <50%. Conclusion: Stroke patients with mRS 3 and 4, if they have a strong self-expectation to RTW, can benefit from a vocational rehabilitation program in a convalescent rehabilitation hospital that provides extensive rehabilitation for a sufficient period. We suggest that this kind of program should be incorporated into the stroke treatment system.

A 57-year-old woman consulted a local doctor because of a sudden onset of severe bilateral headache. Head magnetic resonance imaging (MRI) revealed no acute intracranial abnormalities. Thirteen days after the onset, she presented with sudden deterioration of consciousness. A large subcortical hematoma was observed in the left parieto-occipital lobe, and emergency hematoma removal was performed at our hospital. Preoperative MRI revealed cerebral infarction in the bilateral parieto-occipital lobes, and pathological examination revealed melting necrosis, suggesting hemorrhagic infarction. Furthermore, multiple stenoses were found in the bilateral middle cerebral arteries and posterior cerebral arteries, which improved later. Based on these findings, we concluded that the hematoma was caused by hemorrhagic infarction due to reversible cerebral vasospasm syndrome (RCVS). Although most patients with RCVS have a good prognosis, some patients, as in this case, have a poor prognosis. Therefore, it is important to consider the possibility of RCVS when treating patients with a sudden severe headache with unknown etiology.

An eighty-seven-year-old woman presenting with disturbance of consciousness and right hemiplegia was transported to our institution. Head CT and CT angiography revealed acute ischemic stroke due to occlusion of the left middle cerebral artery (MCA). To recanalize the occlusion, mechanical thrombectomy after intravenous tissue plasminogen activator was performed. A horizonal segment of the left MCA (M1) was recanalized after one pass with a stent retriever and an aspiration catheter, but an insular segment of the left MCA (M2) was difficult to recanalize because of repeated reocclusion during the procedure. Her left M2 could not be sufficiently recanalized after a total of three passes with the stent retriever. Her left cerebral hemisphere showed extensive infarction, diagnosed by postoperative CT. Despite medical treatment, she died on day 4 from brain herniation. Pathological autopsy revealed severe arteriosclerotic changes in multiple intracranial arteries and coexistence of atheromatous plaque and arterial dissection in the distal left M1. The mechanism of dissection was regarded as iatrogenic dissection due to the use of the stent retriever for vessels with severe arteriosclerosis. We should keep in mind iatrogenic cerebral arterial dissection if occluded vessels repeated reocclusion during mechanical thrombectomy, especially in aged stroke patients, which is severe arteriosclerosis.

In the diagnosis of hypoxic encephalopathy, feasibilities of magnetic resonance images (MRI), particularly diffusion-weighted images (DWI), have been well documented. In this report, we describe a case in which MR perfusion image with pulsed arterial spin labeling (ASL) was useful to evaluate the pathology of hypoxic encephalopathy after cardiopulmonary resuscitation. A 72-year-old female with diabetes and fractures of humerus and olecranon was admitted to our hospital (Day 0). She suddenly developed cardiopulmonary arrest in the next morning and cardiopulmonary resuscitation (CPR) was promptly performed (Day 1). She presented with a persistent consciousness disorder, although her vital signs were maintained stable after CPR. On Day 11, the first MRI evaluation was performed and ASL showed an apparent increase in blood flow in the bilateral striatum, while DWI showed only a slight hyperintensity in the same area. In the T1-weighted images of Day 33 and Day 61, hyperintensities appeared stepwise in the striatum on both sides, while the blood flow in the same area decreased in ASL. Fujioka et al. previously reported the pathophysiology of T1 hyperintensity in the striatum after ipsilateral hemispherical transient or mild ischemia in animal models and clinical cases. The pathology of our case was considered to be consistent with their observations and occurred in both sides after hypoxia due to cardiac arrest. Addition of ASL to the conventional MRI method may improve the accuracy of image evaluation for hypoxic encephalopathy.

We describe a 74-year-old man with cervical epidural hematoma manifesting as transient hemiparesis. The patient complained of a sudden onset of left hemiparesis and mild posterior cervical pain, and was transferred to our hospital. On admission, 1 hour after the onset, his motor weakness had completely resolved, and initial CT and MRI of the brain showed no abnormalities. At first, we suspected that he developed the left hemiparesis due to transient ischemic attack (TIA). We reevaluated the posterior cervical pain, which was mild but persistent, and MRI of the cervical spine was performed. The MRI revealed a fusiform mass lesion from C4 to C7 with compression of the left cervical cord, suggesting the presence of cervical epidural hematoma. Repeat MRI showed regression of hematoma in 3 days, which may be correlated with rapid improvement of clinical symptoms. Cervical epidural hematoma may manifest as transient neurological symptoms like transient ischemic attack. Among patients with posterior cervical pain suspicious of TIA, it is important to give consideration to cervical epidural hematoma, which is rare but the treatment for which is completely different from that for ischemic cerebrovascular disease.

In intensive care hospitals, language disorders owing to the presence of cerebellar disorders are not typically noticed. We present a case of aphasia-like language disorder associated with right cerebellar hemorrhage. It was considered necessary to pay attention to not only ataxic dysarthria and difficulty in writing caused by upper limb ataxia but also paraphasia, paragraphia, and difficulty in recalling words.

A 57-year-old woman was hospitalized for fever and left hemiparesis. She was diagnosed with infective endocarditis by echocardiography, and with cerebral infarction and subarachnoid hemorrhage (SAH) by brain MRI. Antibiotic therapy was given for one week, but cardiac function worsened gradually due to complication of mitral regurgitation, and the patient was transferred to our hospital for open-heart surgery. Brain MRI at arrival showed new lesions of ischemic stroke and SAH, and hematoma in the left occipital lobe. Emergency angiography revealed a cerebral aneurysm of the distal segment of the left posterior cerebral artery (PCA). The patient was diagnosed with cerebral hemorrhage due to rupture of intracranial mycotic aneurysm (IMA). Early surgical intervention was necessary to prevent rerupture of the aneurysm before cardiac surgery because administration of a high dose of heparin was required during extracorporeal circulation. Given the general condition, parent artery occlusion of the distal left PCA with a platinum coil was chosen as minimally invasive surgery and was performed on the same day. The ruptured aneurysm was occluded completely, and cardiac surgery was then performed on the next day. Head CT after both surgeries revealed neither enlargement of the hematoma in the left occipital lobe nor new lesions in the other territory. After treatment with antibiotics for two months, the patient was discharged without neurological deficits. This case suggests that coil embolization could be a treatment option for a ruptured IMA in a serious case of infective endocarditis that requires open-heart surgery.

A 54-year-old man was referred to our hospital due to asymptomatic carotid web (CW), which was noted during a neurological evaluation. He was an otherwise healthy patient with no past medical history. The stenosis was severe, and we performed carotid artery stenting (CAS) at the request of the patient. There were no complications from the operation, and the postoperative course was uneventful. CW is a shelf-like projection located in the posterior wall of the proximal internal carotid artery and is recognized as a cause of ischemic stroke. Symptomatic lesions are often resistant to medical treatment, and carotid revascularization (CR) is considered as a treatment option. However, almost no asymptomatic cases treated with CR has been reported. CAS is less invasive even for asymptomatic CW; thus, it might be an effective treatment option.

Here, we report a case of acute MCA occlusion in a patient who underwent thoracic endovascular aortic repair (TEVAR) for a thoracic aortic aneurysm 2 years ago. An 83-year-old man presented with sudden right hemiparesis and aphasia. CT with contrast revealed occlusion of the left MCA, and MRI revealed mild hyperintense signals in the left MCA area. The aortic arch stent graft partially overlapped the origin of the left common carotid artery on the contrast CT. Therefore, we decided not to perform mechanical thrombectomy via the transaortic approach. Instead, the patient underwent a surgical embolectomy with frontotemporal craniotomy. His symptoms improved remarkably, and he was discharged with only mild aphasia, dysarthria, and disorientation. In a case where mechanical thrombectomy via the transaortic approach is expected to be difficult, surgical embolectomy can be an alternative choice.