Background and Purpose: The current study investigated whether hypo-osmotic non-ionic contrast media, which is remaining after cerebral angiography, could be used to perform swallowing videofluorography safely and effectively. Methods: The study included five ischemic stroke patients who underwent cerebral angiography and swallowing videofluorography on the same day. They underwent swallowing videofluorography using a hypo-osmotic non-ionic contrast agent immediately after cerebral angiography. Results: All five patients completed the evaluation without any problems. Subsequent chest computed tomography indicated aspiration in one patient after swallowing videofluorography, but no clinical symptoms suggesting pneumonia were observed in that patient. The other four patients completed evaluations with no early or delayed complications. Conclusion: The current study suggests that swallowing videofluorography can be performed using residual contrast media after cerebral angiography, minimizing residual contrast media disposal, thereby reducing medical costs and facilitating safe and effective evaluation of swallowing function with non-ionic iodine contrast media.

Background and Purpose: New-onset stroke has been observed in patients with coronavirus disease 2019 (COVID-19). The aim of this study was to investigate the characteristics of new-onset stroke in patients with COVID-19. Methods: We retrospectively investigated the clinical characteristics, laboratory findings on admission, and outcomes in 1101 patients with COVID-19 who were admitted to our hospital between March 1, 2020, and September 30, 2021, according to whether or not they developed stroke. Results: Eight patients developed acute ischemic stroke and one had an intracerebral hemorrhage. Patients with COVID-19 who developed stroke were significantly older than those who did not and had pre-existing cardiovascular risk factors, including hypertension, diabetes, and chronic renal failure. There was a significant correlation between severity of COVID-19 and new-onset stroke. Mortality was higher in the group with stroke. Laboratory values on admission indicated a significant inflammatory response and an elevated D-dimer level. Conclusion: We have investigated the characteristics and risk factors of new-onset stroke in patients with COVID-19. More research is needed on how to prevent, diagnose, and treat new-onset stroke in patients with COVID-19.

Background and Purpose: Cardioembolic stroke with atrial fibrillation plays an important role in cerebral infarction. Although anticoagulant therapy is required to prevent cardioembolic stroke, many patients with atrial fibrillation do not receive appropriate anticoagulant therapy. The purpose of this study was to analyze the anticoagulant therapy before the onset of cardioembolic stroke due to fibrillation. Methods: Among patients admitted to our hospital with a diagnosis of acute cerebral infarction between January 1, 2017, and December 31, 2019, we selected cardioembolic stroke patients with atrial fibrillation and analyzed their anticoagulant therapy. Results: We identified 366 cases of cardioembolic stroke with atrial fibrillation. Among them, 124 cases received anticoagulant therapy. There were 71 cases of warfarin use and 53 cases of DOAC use. Of the warfarin use cases, prothrombin time–international normalized ratio (PT-INR) reached the therapeutic range in 16 cases. Of the DOAC use cases, 35 received the appropriate dose. There were 236 cases without anticoagulant therapy, and at least 73 cases had been diagnosed as atrial fibrillation before admission. The prescriptions in 6 cases were unknown. Conclusion: Only few of the cases of cardioembolic stroke with atrial fibrillation received appropriate anticoagulant therapy. In addition, there were many cases in which anticoagulant therapy was not prescribed despite a diagnosis of atrial fibrillation.

Background and Purpose: A hub and spoke model for telestroke has been increasingly utilized for the treatment of acute ischemic stroke (AIS) with intravenous recombinant tissue plasminogen activator (IV rtPA). We aimed to compare the outcomes of IV rtPA therapy in patients with AIS between hub and spoke hospitals. Methods: We retrospectively investigated consecutive 203 patients with AIS following IV rtPA treatment between April 2012 and October 2021 using medical records from an ongoing stroke registry at our institution. The patients were classified as the islands group (transfer using the drip/ship method from spoke hospitals) and the mainland group (direct transfer to the hub hospital). We analyzed the patient characteristics and outcomes between the two groups. Results: Among 203 rtPA-treated patients, all the patients in the islands group (61 cases=30.0%) were transferred to the hub after IV rtPA treatment. No significant differences between the two groups were seen in patient characteristics, rates of symptomatic intracranial hemorrhage, and a good functional outcome (mRS, 0–2) at 30 days. No patient underwent hematoma evacuation. Conclusion: No differences were noted in patient outcomes between the hub and spoke hospitals. Our findings indicated that the IV rtPA use via telestroke at spoke hospitals was safe, and patient transportation to the hub for post-rtPA care may not always be necessary.

A 54-year-old woman experienced a thunderclap headache during defecation and bathing. On the eleventh day, she experienced weakness in her right foot. She was admitted to our hospital because of acute cerebral infarction in the left frontal lobe (identified on a magnetic resonance imaging scan of the head) and multiple cerebral vascular stenoses in the bilateral anterior cerebral arteries, bilateral posterior cerebral arteries, and basilar artery (identified on magnetic resonance angiography). She was diagnosed with reversible cerebral vasoconstriction syndrome (RCVS) and was started on nicardipine. However, the cerebral infarction spread to both the occipital lobes, and temporal lobes, and she presented with Balint syndrome. She had intracerebral hemorrhage, subdural hemorrhage, and subarachnoid hemorrhage of the right frontal, right temporal, and occipital lobes on the sixteenth day. We started verapamil on the seventeenth day, but vasogenic edema was observed in the corpus callosum on the twenty-first day. Fasudil was started, following which her symptoms and vascular stenosis improved. This is the first report to show that fasudil is effective for RCVS and can be considered clinically important for treatment.

Nontraumatic acute subdural hematomas can arise from various causes. Clinical diagnosis of a ruptured cerebral aneurysm is important because it influences the treatment. When a patient presents with coma at onset or without subarachnoid or intracerebral hemorrhage, traumatic acute subdural hematomas may be diagnosed and treated initially. Ruptured aneurysms may be overlooked, and re-rupture would result in a poor prognosis.

Here, we report two cases of ruptured distal anterior cerebral artery aneurysms that presented as nontraumatic acute subdural hematomas. Clinical diagnosis was difficult to obtain based on history and imaging findings. Nevertheless, after definitive diagnosis, the endovascular treatment was performed, and the prognosis was excellent.

A 51-year-old woman underwent stent-assisted coiling for an unruptured left intracranial carotid artery aneurysm. She developed headache and abdominal pain 3 months after the treatment, and an interview for these unidentified complaints revealed her history of metallic allergy. MRI showed vasogenic focal edema and small enhancing lesions in the ipsilateral cerebral white matter. Although not confirmed with biopsy, clinical course and imaging evidence suggested that she probably developed delayed leukoencephalopathy that is reported as a rare complication after coiling. Oral prednisolone (30 mg tapering to 0 mg over 5 weeks) was successful; however, small ischemic lesions were observed in the edematous core. We reviewed the pathophysiological mechanism of this delayed complication, and we enlightened the noteworthy phenomenon after endovascular treatment.

A 76-year-old woman was transferred to our hospital with sudden-onset of impaired consciousness, conjugate eye deviation to the right, and left hemiplegia. MRI showed intraarterial sign, suggestive of occlusion in the right middle cerebral artery. 40 minutes after her visit, she showed dramatic improvement of symptoms by spontaneous recanalization. After improvement of symptoms, she vomited, and 10 mg of metoclopramide was intravenously injected in a bolus. After 1 hour of injection, dyskinesia was present on her oral tongue and limbs. Clinical diagnosis of metoclopramide-induced acute dyskinesia was made. Dyskinesia was improved over time by biperiden. Metoclopramide is a typical antiemetic drug frequently used in daily practice, and it can cause tardive dyskinesia when administered for a long period. Rarely, acute extrapyramidal disorders including dyskinesia may occur by intravenous injection even in a single and a normal dose of metoclopramide. Vomiting is a common symptom in stroke care. When administering metoclopramide, the past history and the family history of similar symptoms should be confirmed, and slow drip infusion is desirable to prevent acute extrapyramidal disorders.

A 30-year-old pregnant woman developed hyperemesis gravidarum in the 6th week, headache in the 7th week, and right hemiparesis in the 8th week of pregnancy. Neurological examinations represented mild disturbance of consciousness and right hemiparesis with right hemispatial neglect. Brain MRI on FLAIR and T2 star-weighted image showed low-intensity lesions suggestive of thrombus in the superior sagittal sinus, right transverse sinus, and right sigmoid sinus, where brain MRV demonstrated blood flow disruptions, diagnosed with cerebral venous sinus thrombosis (CVST). Laboratory investigations revealed protein S deficiency and transient hyperthyroidism during pregnancy as the causes of CVST. The initiation of continuous intravenous heparin rapidly resolved her neurological symptoms and abnormalities of brain images, resulting in independence at discharge. We changed the route of heparin administration from continuous infusion to subcutaneous injection in the 11th week of pregnancy. However, infiltrative erythemas with induration and pruritus appeared at injection sites in the 27th week of pregnancy, diagnosed as a delayed hypersensitivity reaction to subcutaneous heparin injection. We could continue heparin treatment using topical steroids with heparin dose reduction and frequent changes in the injection site. She delivered transvaginally in the 38th week of pregnancy with no problems to the mother or child. She discontinued heparin at 46 days after delivery, and there has been no recurrence of CVST or skin manifestations. In this case, we should consider alternative drugs carefully based on transferability to the placenta or breast milk and teratogenicity, since anticoagulation therapy will be expected to be necessary for future pregnancies.

COVID-19 has been reported to increase the risk of thrombosis because of abnormal coagulation. A 72-year-old woman had a positive PCR test for SARS-CoV-2, was diagnosed with COVID-19, and was treated at home for 10 days. Two days later, she developed a consciousness disorder, and subcortical hemorrhage in the right temporal and parietal lobes, an extensive perfusion defect (brush sign), and cerebral venous sinus thrombosis were observed. After treatment with anticoagulant and antiepileptic drugs, the symptoms improved and the brush sign disappeared, and magnetic resonance venography (MRV) showed recanalization from the left transverse sinus to the sigmoid sinus. Cerebral venous sinus thrombosis associated with COVID-19 has been reported to occur within 47 days after the onset of COVID-19, regardless of disease severity. Although the in-hospital mortality rate is higher than that of cerebral venous sinus thrombosis without COVID-19, in this case, early diagnosis and treatment were achieved by MRI/MRV, resulting in the recanalization and the improvement of her symptoms.