Background: The current status of the system for providing acute stroke rehabilitation in Japan still remains unknown, since no fact-finding survey regarding this issue has been conducted in the past. Methods: During the period between February 7, 2022, and April 21, 2022, a nationwide, cross-sectional web-based questionnaire survey was administered to 959 primary stroke centers (PSCs) in Japan. In the survey, mainly the current provision status of acute stroke rehabilitation at PSCs was asked. In addition, we questioned providers about the influence of the pandemic of 2019 novel coronavirus (COVID-19) on the provision system and the contents of the rehabilitation. Results: Responses were obtained from 639 hospitals (66.6%). Board-certified rehabilitation doctors and certified nurses in stroke rehabilitation nursing were involved in acute stroke rehabilitation in 41% and 45% of the hospitals, respectively. Irrespective of the type of stroke, 40-minute rehabilitative training was provided as an initial session of acute rehabilitation for stroke patients at many hospitals in Japan. In 37% of the hospitals, the rehabilitative training was not provided on the closed days of the hospitals. In 61% of the hospitals, the pandemic of COVID-19 influenced the provision status of acute stroke rehabilitation. At many hospitals, the daily duration of acute stroke rehabilitation was reduced due to the pandemic. Conclusion: Currently, the provision of acute stroke rehabilitation might be insufficient at some PSCs in Japan. In the future, the equalization and standardization of acute stroke rehabilitation should be promoted throughout Japan.

Background and Purpose: Off-label underdosing and poor adherence to medication have been pointed out as causes of ischemic stroke in patients taking direct-acting oral anticoagulants (DOACs). However, ischemic stroke may occur even in patients with on-label appropriate dosing and good adherence. The aim of this study was to determine the clinical features of ischemic stroke in patients with on-label appropriate dosing and good adherence to DOACs. Methods: Of 2,186 consecutive patients with acute ischemic stroke admitted within 7 days of onset between April 2014 and March 2020, 126 patients with non-valvular atrial fibrillation (NVAF) who developed ischemic stroke despite taking DOACs were studied. Patients were classified into two groups: the appropriate DOAC group (on-label appropriate dosing and good adherence) and the insufficient DOAC group (off-label underdosing or poor adherence). The frequency of embolic sources other than NVAF was compared between the appropriate DOAC group and NVAF patients without anticoagulants (no anticoagulant group). Results: Sixty-four patients were in the appropriate DOAC group and had more potential embolic sources other than NVAF compared to those in the no anticoagulant group (40.6% vs. 18.6%, p=0.0002). Conclusion: In NVAF patients, potential embolic sources other than NVAF may underlie the pathogenesis of ischemic stroke despite taking DOACs with on-label appropriate dosing and good adherence.

Background and Purpose: Intravenous thrombolytic therapy significantly improves the outcomes of acute ischemic stroke (AIS) patients in a time-dependent manner. Moreover, timely implementation of protocol in AIS relates to reducing the door-to-needle time (DNT). The purpose of this research was to identify the effect of triage nurse on self-visited AIS patients. Methods: This is a single-center retrospective observational study conducted from January 2016 to January 2022. Self-visited AIS patients in the emergency department were enrolled. We compared specific stroke metrics before and after the initiation of the triage nurse. The following metrics were included: number of stroke protocols, number of rt-PA, and DNT. Results: A total of 79 AIS patients were analyzed in this study. After the implementation of nurse triage measures, the proportion of stroke protocol increased from 2 cases to 12 cases (P<0.05), and the median DNT was shortened from 115 min to 73 min (P<0.05). Conclusion: A nurse triage is an important factor in significantly increasing stroke protocol and shortening DNT, reducing the delay of intravenous thrombolysis in the hospital.

The patient was a 13-year-old woman. At five years of age, she had a cerebral infarction with right-sided motor and sensory disturbance. She was diagnosed with cerebral infarction with unknown etiology and treated with oral aspirin. Aspirin was discontinued after 3 years, and the patient has had no recurrence since then. At 12, she developed sudden onset of right upper and lower limb paralysis, and her head MRI showed cerebral infarction lesions in the left basal ganglia. Various investigations revealed no cardiac disease, thrombogenicity, or vascular abnormality. She was referred to our hospital for further investigation. The patient presented with a left forehead to the parietal skin lesion with skin laceration and thinning and atrophy of adipose tissue in the same region, which was consistent with scleroderma en coup de sabre. Scleroderma en coup de sabre is focal scleroderma that occurs on one side of the face to the frontal region and is sometimes associated with intracranial lesions. Our case was unique in that there was no evidence of skin lesions at the initial onset, and skin symptoms appeared afterward.

A 68-year-old female visited a local hospital complaining of right hearing loss and dizziness. Head MRI revealed acute ischemic infarction at the right anterior inferior cerebellar artery (AICA) territory. The patient was diagnosed with atherosclerotic cerebral infarction, and antithrombotic therapy was initiated. However, one month later, a high-intensity mass lesion was demonstrated at the right side of lower basilar artery on MRA. Right AICA was not shown on DSA and basi-parallel anatomical scanning (BPAS) did not demonstrate connectivity between AICA and the mass lesion. However, thin-sliced heavily T2 weighted image (heavily T2WI) proved connection between AICA and the mass lesion. Therefore, we diagnosed the cause of the infarction as the occlusion of AICA due to the thrombosed aneurysm; if the thrombosed AICA aneurysm is suspected, thin-sliced heavily T2WI is useful for diagnosis.

We experienced a case of vertex epidural hematoma (VEDH) as a manifestation of dural arteriovenous fistula in the superior sagittal sinus (SSS-dAVF) with no history of head trauma, successfully treated with endovascular surgery. A 28-year-old male presented to our department with headache; emergent head CT scans revealed acute VEDH. He had no history of trauma. Cerebral angiography showed SSS-dAVF, and he was diagnosed with secondary VEDH by the rupture of SSS-dAVF. The feeder of this dAVF was the middle meningeal artery. The patient was treated conservatively in the acute phase. However, to prevent rebleeding of the dAVF, we decided to perform endovascular treatment (transarterial embolization) for it at the subacute phase of the VEDH. Endovascular treatment eliminated the shunt flow, and his postoperative course was excellent. To our knowledge, this is the first report of the VEDH caused by the rupture of SSS-dAVF without history of head trauma. Cerebral angiography is especially helpful for accurate diagnosis of VEDH with no history of trauma. In cases of VEDH caused by the rupture of SSS-dAVF, endovascular treatment is a safe and effective treatment option for eliminating shunt lesions.

An 86-year-old woman was admitted to our hospital with impaired consciousness and right hemiplegia. We diagnosed her with left MCA occlusion and administered intravenous alteplase (rt-PA). Her condition improved immediately thereafter, and left MCA recanalization was observed by magnetic resonance angiography. However, she developed hemichorea on the fifth day of hospitalization. Cranial magnetic resonance imaging showed no lesions in the left corpus striatum, and ¹²³I-N-isopropyl-p-iodoamphetamine single-photon emission computed tomography revealed decreased blood flow in the left MCA and the left putamen. We treated her with haloperidol and the hemichorea immediately improved. Seven cases to date have been reported of hemichorea and hemiballismus caused by MCA recanalization. We suspected that the hemichorea associated with hypermetabolism within the contralateral basal ganglia after recanalization might affect the cortico-basal ganglia loop. We must recognize that t-PA recanalization may cause hemichorea.

We describe an 86-year-old woman with right hemiparesis and double vision. MRI revealed a 25.1-mm basilar tip thrombotic aneurysm. The right vertebral artery was dominant, and we performed a balloon occlusion test (BOT) in the right vertebral artery and ischemia resistance was confirmed. We performed right vertebral artery occlusion by coil embolization. After surgery, right hemiparesis and double vision were gradually improved, and MRI revealed the loss of blood flow signal in the aneurysm and improved peripheral edema. Flow alteration by endovascular treatment can be a useful treatment for basilar tip thrombotic giant aneurysm with careful examination of hemodynamics.

Cerebral amyloid angiopathy (CAA) rarely occurs under the age of 55. An association between neurosurgical procedure in childhood and CAA has been reported. We experienced a case of juvenile CAA having presented as subcortical hemorrhage, and here report it with literature reviews. The patient was a 37-year-old man who underwent reconstruction of the dura mater using cadaveric dural graft in head trauma surgery at the age of 1. Since no specific abnormality was found for scrutinization of the cause of brain hemorrhage, we performed hematoma evacuation in the left temporoparietal region. He was diagnosed with CAA pathologically by the biopsy in the secondary operation. The brain surgery using cadaveric dural graft was thought to be related to the deposition of Aβ.

A 37-year-old male presented to the emergency department of our hospital with a frontal headache and repeated tonic–clonic convulsions, having a convulsion lasting a few minutes the day before. We administered general anesthesia to control status epilepticus. A CT scan revealed cerebral venous sinus thrombosis (CVT) in the superior sagittal sinus. His father had a history of deep venous thrombosis. The protein C activity level was markedly reduced. The patient was diagnosed with protein C deficiency, and genetic analysis revealed a heterozygous mutation at exon7 c.631C>T, p.Arg211Trp (CGG→TGG) on the protein C gene. We started anticoagulation therapy with continuous intravenous heparin injection immediately, and warfarin was administered a few days later. After administration of warfarin, D-dimer levels increased rapidly and he developed pulmonary embolism. We administered an additional intravenous bolus of 3000 units of heparin and increased the dosage of warfarin gradually. The thrombus disappeared, and he remains fully recovered with no adverse events for two years. The risk of developing a transient hypercoagulable state possibly leading to microthrombi and skin necrosis has been reported in patients with protein C deficiency due to the rapid saturation of warfarin. Frequent D-dimer measurement should be considered in the initial phase of warfarin therapy for CVT caused by protein C deficiency.

We report a rare case of a ruptured dissecting aneurysm of the MCA treated using endovascular therapy in a 56-year-old woman with a subarachnoid hemorrhage. CT angiography on admission suggested right MCA dissection. DSA revealed an arterial wall irregularity accompanied by a blister-like aneurysm of the M1 segment of the MCA, and the patient was diagnosed with a ruptured dissecting aneurysm. Following conservative treatment using deep sedation and antihypertensive management, we performed single stent-assisted coil embolization on the 18th day of admission. Blood flow of the MCA and branch artery was maintained after embolization. Four weeks later, DSA revealed complete occlusion of the aneurysm and healing of the MCA dissection. The patient could walk after 3 months. DSA after 1 year showed no recurrence. A ruptured dissecting aneurysm of the MCA M1 segment invariably involves the lenticulostriate artery. Therefore, simple parent artery occlusion is ineffective as a therapeutic strategy. Few studies have reported successful surgical treatments that ensure the preservation of these arteries. Recent advances in endovascular treatment with stents have facilitated parent artery and branch preservation. Although the optimal timing of the acute phase treatment differs depending on the characteristics of each case, stent-assisted coil embolization is considered to be a promising option.