Background: Poststroke epilepsy affects 10% of stroke patients and is known to be a factor contributing to poor functional outcomes. However, clear criteria for selecting anti-seizure medications have not yet been established. We investigated the long-term therapeutic effects of perampanel in poststroke epilepsy. Subjects and Methods: We studied 28 cases of poststroke epilepsy treated with perampanel at the Epilepsy Center and Neurosurgery Department of Tokyo Medical and Dental University and Tsuchiura Kyodo Hospital from June 2016 to April 2022. We examined patient backgrounds, drug dosages, concomitant drug use, side effects, seizure freedom, and tolerability rates at 3, 6, 12, and 24 months. Results: Of the 28 patients, 18 were male and ten were female, with a mean age of 55.8 years (range: 17–97 years). The stroke etiology was hemorrhagic in 20 patients (71.4%) and ischemic in 8 (28.6%). At the start of perampanel treatment, the mean number of concomitant drugs was 1.1 and the mean maintenance dose was 3.6 mg. Seizure freedom was 77%, 80%, 83%, and 80% at 3, 6, 12, and 24 months, respectively. Tolerability remained consistently above 80%. Favorable outcomes were particularly observed in patients with focal to bilateral tonic-clonic seizures. There were no significant differences in treatment outcomes based on etiology or the number of previous medications. Conclusion: Perampanel demonstrated high therapeutic efficacy and tolerability in poststroke epilepsy.

Background and Purpose: Information on the clinical picture of aneurysmal SAH (aSAH) occurring while driving may be useful to strokologists. A retrospective study was conducted using the Keio Brain Aneurysm Registry database. Methods: We used a dataset of 623 aSAH patients (204 men and 419 women) registered on the database between January 2019 and December 2021. Demographic variables were compared between patients who sustained aSAH while driving (Driving group) and those who sustained aSAH during other activities. Results: Ten patients (7 men and 3 women) sustained an aSAH while driving, with an overall frequency of 1.6%. Although male:female ratio was significantly higher in the Driving group, there were no significant intergroup differences, including the aSAH severity and outcomes at discharge. The frequency in the hospitals located in the metropolitan areas was lower than that in those located in the suburban/rural areas; the difference was not significant (1.0% vs. 2.0%, p=0.36). Conclusion: This study is one of the first studies to report the frequency of aSAH occurring while driving. Car drivers may experience stress-induced blood pressure elevation, and it remains to be observed closely whether causal relationship between driving and aSAH exists or not.

An 86-year-old man presented with a 1-week history of headache and visual disturbance. Computed tomography showed intracerebral haemorrhage involving the right occipital lobe, and the patient was admitted for conservative treatment. He developed recurrent episodes of fever secondary to aspiration pneumonia and was treated with antibiotics during each episode. He presented with apraxia 35 days after admission. Diffusion-weighted magnetic resonance imaging performed 41 days after admission showed high signal intensity in the area of haemorrhage with spread into the subdural space and right lateral ventricle. Postoperatively, we diagnosed the patient with a brain abscess based on our surgical findings. Cultures of the surgical specimen and blood yielded Bacteroides fragilis, and the patient was treated with a 6-week course of antibiotic and transferred to a nursing home. This is the first case report that describes identification of the same bacteria in both cultures of a brain abscess and blood. Furthermore, to date, no study has reported B. fragilis as the causative organism of a brain abscess following intracerebral haemorrhage; we present this rare case with a literature review.

Angio-Seal (Terumo Corp., Tokyo, Japan) is a vascular closure device that has been used in many institutions, but bleeding and occlusive complications have been observed with its use. We report a case of delayed occlusion of the femoral artery one week after hemostasis of the femoral artery puncture site with the use of an Angio-Seal. The patient is an 80-year-old man. He has always been independent in ADL and has a history of atrial fibrillation, cerebral infarction, and hypertension. Sudden loss of muscle strength in the left upper and lower extremities and impaired consciousness led to the diagnosis of acute occlusion of the right internal carotid artery. Intravenous tissue plasminogen activator (t-PA) was administered with no improvement, so mechanical thrombectomy was performed and complete recanalization was achieved. Hemostasis was obtained using an 8 Fr Angio-Seal at the puncture site of the right femoral artery. One week after hemostasis of the puncture site, pain, pallor, and poor palpation of the dorsal pedis artery were noted, and a contrast-enhanced CT scan of the lower extremity was performed, which revealed occlusion of the right femoral artery. Emergency thrombectomy was performed by our cardiovascular surgeon and flow restoration was achieved.

A 70-year-old woman visited our hospital with a chief complaint of headache. T2-weighted and fluid-attenuated inversion-recovery magnetic resonance imaging (MRI) showed a leptomeningeal lesion in the right temporal lobe and many enlarged perivascular spaces in the centrum semiovale. Follow-up MRI performed 6 months later revealed cortical microbleeds and cortical superficial siderosis. Three years later, the patient presented with right lower quadrant homonymous hemianopsia and disturbance of consciousness. MRI showed diffuse leptomeningeal and significantly increased hemorrhagic lesions. A brain biopsy confirmed diagnosis of amyloid β-related angiitis. Disturbance of consciousness persisted despite steroid treatment. We concluded that vasculitis-induced inflammation preceded bleeding secondary to vascular fragility in our patient. Inflammatory cerebral amyloid angiopathy should be included in the differential diagnosis in patients with early-onset leptomeningeal lesions and enlarged perivascular spaces without hemorrhagic lesions.

We report two cases of subarachnoid hemorrhage due to a ruptured cerebral aneurysm, in which a hematoma far from the intracranial aneurysm enlarged after coil embolization. Case 1: A 47-year-old female underwent coil embolization for a ruptured left internal carotid artery–posterior communicating artery (IC–PC) aneurysm. Due to the enlargement of the hematoma seen in the left insular cistern following the procedure, a decompressive craniectomy was performed on the third day. Case 2: An 80-year-old female underwent coil embolization for a ruptured right IC–PC aneurysm. Following the procedure, the hematoma in the right insular cistern enlarged, and the patient died on the fourth day. Both cases were regarded as enlargements of subpial hematomas. In addition, there was no prolongation of intraoperative activated clotting time, and protamine was intravenously administered after the operation for heparin reversal. No antiplatelet agents were administered during the perioperative period. If subpial hematoma is discovered following preoperative evaluation, it is important to be mindful of the treatment strategy due to the risk of hematoma enlargement in the acute phase.

An 82-year-old man with a history of spinal stenosis and no significant family history presented with altered consciousness (JCS-II-30), left spatial neglect, conjugate deviation to the right, dysarthria, and left-sided facial hemiplegia. Head MRI revealed acute cerebral infarction in the posterior branch of the right MCA area, and an MRA revealed an occlusion in the right M2 posterior branch. Electrocardiography revealed atrial fibrillation, transthoracic echocardiography revealed severe diastolic dysfunction with apical sparing, and ^99mTc myocardial pyrophosphate scintigraphy indicated Grade 3 uptake by the heart. Cardiac amyloidosis, complicated by a cardiogenic cerebral embolism, was diagnosed. ATTR cardiac amyloidosis may coexist with cardiogenic cerebral embolism, and thus, a thorough examination should be conducted while considering ATTR cardiac amyloidosis.

We report a case of acute cerebral infarction in which a patient had with a complaint of drooping hand and had a good outcome with thrombolytic therapy. A 75-year-old man suffered from sudden weakness of peripheral muscles from the right wrist. MRI scan of the brain showed acute cerebral infarction confined to the left motor cortex, and he was treated by intravenous thrombolytic therapy with rt-PA. The neurological symptoms had rapidly been improved. Thereafter, there was no recurrence of neurological deficit and the patient was discharged back to his home without any neurological deficits (m-RS: 0). Cerebral infarction with weakness of distal limbs is rare, and differentiating it from peripheral neuropathy is challenging. Since finger function greatly affects daily life, early intervention of appropriate treatment would extremely be important if the cause were cerebral ischemia. In this case, early diagnosis and therapeutic intervention resulted in a favorable outcome.

Ischemic stroke is a severe complication of cardiac catheterization surgery, but few reports have examined the risk of perioperative stroke in left ventricular endocardial ablation. Our case is a 74-year-old man. He was referred to our cardiologist for ablation after a ventricular tachycardia attack with hypotension. The ablation was performed under local anesthesia, and the patient was referred to our department because aphasia appeared immediately after the transarterial catheter was inserted into the left ventricle. He presented with total aphasia and right upper limb paralysis; his NIHSS score was 19. After performing cerebral angiography, which showed distal occlusion of the left MCA M1 segment, we performed a mechanical thrombectomy using a combined technique. After the first pass, we obtained thrombolysis in cerebral infarction (TICI) Grade 3. Symptoms improved immediately, and the NIHSS score was 0 the next day. The pathology of the embolus was fibrin thrombus, and a subsequent transesophageal echocardiogram showed a movable plaque in the aortic arch. We considered it essential to collaborate with the cardiologist and share the stroke risk, including considering the access route when performing left ventricular endocardial ablation.

This report describes the case of a 78-year-old female who presented with subarachnoid hemorrhage and had a history of two gamma knife radiosurgery (GKS) treatments for right trigeminal neuralgia. Computed tomography angiography on admission revealed a 3-mm aneurysm at the bifurcation of the common trunk of the right anterior inferior cerebellar artery (AICA) and posterior inferior cerebellar artery. The patient underwent surgical trapping of the right AICA and was subsequently discharged (with a modified Rankin Scale score of 1). The aneurysm was located adjacent to the GKS treatment field and was considered to have been a result of radiation exposure during the treatments. GKS-related aneurysms are often pseudoaneurysms and carry a high risk of rupture, even when their size is small. Careful planning is therefore essential to ensure that critical vessels are not included in the radiation field. Moreover, most GKS-related aneurysms that require trapping of the parent artery are associated with a risk of ischemic complications, and careful consideration is required to decide whether endovascular or direct surgery would be the safer and more secure approach.