Purpose: In our rapidly aging society, the number of ischemic stroke patients who are living alone may also be rapidly increasing. To investigate whether there had been chronological change in the frequency and mode of rescue request of living-alone ischemic stroke patients, a single-center retrospective study was conducted. Methods: Demographic variables and frequency of living-alone were compared between ischemic stroke patients who had been treated in 2011–2012 and those who had been treated in 2021–2022. Furthermore, the mode of rescue request (who had requested for rescue) was compared between the two groups. Results: In the 2011–2012 group, the frequency of living-alone ischemic stroke patients was 6.7%. In contrast, the frequency of living-alone ischemic stroke patients in the 2021–22 group was 11.5%. The difference was statistically significant ( p=0.01). Regarding the mode of rescue request, there was nonsignificant decrease in the frequency of those who could make rescue request by themselves and increase in the frequency of those whose rescue request had been made by third parties. Mechanical thrombectomy had been performed in 30% of patients with large vessel occlusion only in the 2021–22 group. Conclusion: The marked increase in the frequency of living-alone ischemic stroke patients is alarming. To achieve earlier therapeutic intervention, especially mechanical thrombectomy, of living-alone ischemic stroke patients with large vessel occlusion, construction of public safety networks as well as development of mobile trackable devices to enable earlier detection of symptoms and prompter transportation to the hospitals is warranted.

Objectives: This single-center retrospective study aimed to investigate temporal variations in mortality and explore factors influencing ischemic stroke-related mortality in patients with atrial fibrillation (AF). Methods: Patients with AF were categorized into three groups based on treatment phases: patients treated during the early phase of anticoagulation therapy (January 1, 1983, to December 31, 1999; n=968), patients treated during the establishment phase of warfarin therapy (January 1, 2000, to March 24, 2011; n=566), and patients treated during the introduction phase of direct oral anticoagulation therapy (March 25, 2011, to December 31, 2022; n=479). The cumulative mortality in each phase was analyzed using the Fine and Gray proportional hazards model. Results: Significant increases were noted in all-cause mortality over time, whereas a significant decrease was observed in ischemic stroke-related mortality. Multivariate analysis revealed that ischemic stroke-related mortality was positively correlated with age, female sex, persistent/permanent AF, and history of ischemic stroke but negatively correlated with anticoagulation therapy. Conclusion: Ischemic stroke-related mortality in patients with AF decreased over time, with anticoagulation therapy being considered a contributing factor.

Twisted carotid bifurcation (TCB) occurs when the internal carotid artery runs inside the external carotid artery in the neck. Both congenital and acquired predispositions, such as arteriosclerosis, have been considered as the cause, although further clarification is required. We report a case in which a TCB was repeatedly formed due to mobility of the hyoid bone. A 69-year-old woman was followed up for moderate left internal carotid artery stenosis. At the initial examination, the angle of the right common carotid artery bifurcation was normal; however, 1 year later, it was twisted approximately 90°, forming a TCB. The following year, the findings returned to normal. However, 1 year later, the TCB was formed again. A review of the images confirmed that the carotid artery was located outside the hyoid bone under normal conditions and inside the hyoid bone under TCB conditions. Hence, mobility of the hyoid bone might have been the cause of TCB in this case.

The patient was a 52-year-old man who had developed left vertebral artery dissection at the age of 37 and received conservative treatment. Although the fusiform enlargement of the left vertebral artery remained, no imaging changes were observed. At the age of 51, he underwent partial gastrectomy for advanced gastric cancer. Postoperative chemotherapy consisted of tegafur, gimeracil, and oteracil, but multiple liver metastases were detected; hence, the combination therapy was switched to ramucirumab, which is a molecularly targeted drug that inhibits angiogenesis, plus nab-paclitaxel. After starting the new chemotherapy regimen with ramucirumab, he developed a severe headache, and head MRI revealed a new dissection of the contralateral right vertebral artery. The patient did not experience bleeding or ischemia, and occlusion of the right vertebral artery was confirmed, so the patient was followed up with conservative treatment. Although there has been a report of aortic dissection associated with anti-VEGF drugs, such as ramucirumab, there have been no reports of vertebral artery dissection in patients on ramucirumab. The present patient had a history of unilateral vertebral artery dissection, and ramucirumab administration was suspected to be related to the onset of contralateral vertebral artery dissection.

Residual ulceration (RU), characterized by contrast leakage outside the stent, frequently persists following carotid artery stenting (CAS) for ulcerative plaques. While it has been reported that approximately half of these disappear within 6 months, they can also potentially cause cerebral embolism postoperatively. This study aims to investigate the rate of RU disappearance and the incidence of thromboembolic complications in the case of using double-layer micromesh stents for ulcerative lesions. From April 2021 to March 2022, among 20 cases that underwent CAS, we used CASPER stents in 11 cases identified with preoperative ulcer formation. Cerebral angiography was performed 3 months postoperatively, and we evaluated the disappearance of RU and clinical symptoms. RU was observed in 10 out of 11 cases immediately after CAS. In the 9 cases who underwent follow-up angiography after 3 months, the RU disappearance rate at 3 months was 78% (7/9 cases). During a 1-year follow-up, none of the 9 cases experienced symptomatic cerebral infarction. In CAS for ulcerative lesions, the use of a double-layer micromesh stent resulted in a high rate of RU disappearance.

A woman in her 50s presented with left upper extremity sensory disturbance after an afternoon nap. She was diagnosed with acute ischemic stroke in the right M2 region by MRI and MRA; t-PA and thrombectomy were not indicated and she was treated conservatively. She had an MRA the next day and her occluded site had recanalized. She had no obvious embolic source or arrhythmia on transthoracic echocardiography, trunk CT, and Holter ECG. Her cervical MRA showed no apparent stenosis and carotid artery ultrasound was not performed. Hormone and various antibody tests were all normal. Embolic stroke was suspected and DOAC was initiated. She was discharged home with mild sensory impairment. Three months later, she had a recurrence of embolic ischemic stroke at the same site as the previous one, and she was hospitalized. Carotid web (CW) was suspected in her right internal carotid artery by echocardiography and CTA of her carotid artery, and cerebral angiography was performed and CW with stasis of blood flow was detected. She was diagnosed with recurrent embolic ischemic stroke due to CW and underwent DAPT and carotid artery stenting at a later date. She has been without recurrence since then. Embolic ischemic stroke caused by CW is considered to have a high recurrence risk. In this case, recurrence occurred during anticoagulant therapy. In young patients with embolic ischemic stroke, it seems important to treat CW appropriately without overlooking it.

We present a case of rheumatoid meningitis with transient ischemic attack (TIA)-like episodes. A 53-year-old woman with a 3-month history of rheumatoid arthritis arrived at our hospital presenting transient right hemiparesis and aphasia. Fluid-attenuated inversion recovery and diffusion-weighted magnetic resonance imaging showed a hyperintense lesion in the frontoparietal subarachnoid space. Leptomeningeal enhancement was also revealed from gadolinium-enhanced T1-weighted images. The levels of anticyclic citrullinated peptide antibodies in the cerebrospinal fluid were elevated. Her medical history, symptoms, laboratory tests, and neuroradiological findings supported the diagnosis of rheumatoid meningitis. Her neuroradiological findings improved immediately after the commencement of corticosteroid treatment. Rheumatoid meningitis should be considered during the process of differential diagnosis of TIA mimics.

A 75-year-old man suddenly developed vertigo and gait disturbance, and was taken to our hospital by ambulance. On arrival, hypercapnia was observed. Neurological examination revealed dysarthria, horizontal gaze-evoked nystagmus, left facial paralysis, dysphagia, left curtain sign, hyperesthesia of the left side of the face and the right side of the body, left cerebellar ataxia, and left Horner syndrome. Brain magnetic resonance imaging revealed lateral medullary infarction with a large lesion extending vertically from the left lateral medulla to the dorsal part of the left pontomedullary junction. Magnetic resonance angiography showed occlusion of the left vertebral artery. Approximately 9 hours after onset, he developed aspiration pneumonia, and about 24 hours later, he suddenly developed respiratory arrest, requiring mechanical ventilation. In cases of lateral medullary infarction involving lesions extending more rostrally than the obex level, respiratory control mechanisms can be compromised and the risk of aspiration can be increased. This case exhibited a vertically extensive lesion, and presented with severe early onset central respiratory impairment and aspiration pneumonia. We consider our case as valuable for understanding the mechanism of respiratory failure associated with lateral medullary infarction.

A 43-year-old man with a sudden onset of severe headache followed by epileptic seizures was admitted to our hospital. CT showed subarachnoid hemorrhage predominantly located in the left Sylvian fissure and a low-density area in the left parietal lobe with slight subarachnoid hemorrhage. The source of the hemorrhage was undetected; however, cerebral angiography revealed a tumor stain and an early venous filling in the left parietal region. Contrast-enhanced MRI showed a ring-shaped enhancement in the left parietal lobe. A malignant glioma was suspected, and surgical resection was performed. The diagnosis was malignant glioma, and the patient underwent postoperative chemoradiotherapy. Although rare, malignant glioma is an important differential diagnosis for “angiogram-negative SAH.”

A 88-year-old woman was admitted to our hospital with exacerbation of chronic heart failure and urinary tract infection. She received antimicrobial agents through a peripheral venous catheter. On 12th day of hospitalization, she presented with sudden loss of consciousness and right hemiplegia. MRI revealed restricted diffusion in the border-zone territories between the left anterior cerebral artery (ACA) and middle cerebral artery (MCA). Furthermore, multiple hypointense signals were found in the cortices and the sulci of the border-zone territories on T2*-weighted imaging (T2*WI). CT showed air shadows almost matched on the hypointense signals on T2*WI, leading to the diagnosis of cerebral air embolism. On the following day, she showed the improvement of consciousness and hemiplegia. Air shadows on CT disappeared, simultaneously with vanishing of multiple hypointense signals on T2*WI. Some cases of cerebral air embolism in patients with peripheral venous catheter have been reported. Only few reports indicate the presence of multiple hypointense signals on T2*WI, as observed in the present case. Cerebral air embolism should be considered when hypointense signals in the cortices and the sulci are present on T2*WI, even if only a peripheral venous catheter is placed and invasive procedures have not been performed.