A man in his fifties was being monitored for the challenge of addressing an unruptured cerebral arteriovenous malformation. Nevertheless, the patient began to experience gait disturbances and cognitive decline. Eventually, the patient was referred to our medical center for further examination and treatment. Magnetic resonance imaging (MRI) of the head revealed high T2WI signals in the bilateral basal ganglia, indicating potential edema in the basal ganglia resulting from impaired venous return caused by cerebral arteriovenous malformation. Given the patient’s symptomatic status, therapeutic intervention was recommended, but the option of craniotomy was not advisable. Therefore, a combination of endovascular therapy and stereotactic radiotherapy was considered an appropriate treatment regimen. After the treatment, the cerebral arteriovenous malformations were no longer visible on imaging scans, and the T2WI hyperintensities in the bilateral basal ganglia showed improvement. Despite these positive outcomes, the patient continued to experience extrapyramidal symptoms such as limping. It is crucial to exercise caution when treating unruptured cerebral arteriovenous malformations, as irreversible neurological symptoms may develop over time, which should be taken into consideration.

A 74-year-old man with no medical history was admitted to the emergency department because of sudden sensory aphasia and dysarthria. Diffusion-weighted imaging (DWI) showed a slight high-intensity signal in the left temporal lobe. Magnetic resonance angiography did not detect large vessel occlusion. Perfusion image showed no ischemic core by CBF, and the time to maximum (Tmax) extended lesion was in the same area as the DWI slightly high-intensity area. The patient received intravenous thrombolysis for acute ischemic stroke and had intracranial hemorrhage the following day. We diagnosed Borden type 3 transverse-sigmoid sinus dural arteriovenous fistula (dAVF) by DSA and transarterial embolization was performed. Nonhemorrhagic dAVF mimicking stroke is rare and could cause hemorrhagic events by intravenous thrombolysis; therefore, we should focus on the differential diagnosis. Here, we determined the abnormal perfusion pattern on the temporal lobe retrospectively, the coexistence of hypoperfusion and hyperperfusion. The paradoxical finding suggests that the symptom was nonconvulsive status epilepticus, and ictal hyperperfusion existed in the hypoperfusion area due to venous congestion with dAVF.

We report two cases of cerebral hemorrhage with ipsilateral hemichorea-hemiballism (HCHB). Case 1 is a 50-year-old woman. She presented with dysarthria and left hemiplegia, and right capsular hemorrhage was observed on the head CT. On admission, HCHB was observed in the right upper and lower limbs. Case 2 is a 78-year-old woman. She presented with right hemiparesis and left hemiplegia, and head CT showed subcortical hemorrhage in the right frontal to parietal lobes. On admission, she had HCHB in the right upper and lower extremities similar to that in Case 1. In both cases, the HCHB disappeared about two weeks later. Ipsilateral HCHB is a very rare symptom. Noncrossing corticospinal tract effects have been postulated to be a possible mechanism.

Acute isolated internal carotid artery occlusion (isolated ICAO) often results in favorable neurological outcomes because of collateral circulation via the circle of Willis. Thrombectomy for this type of occlusion requires careful consideration because of the potential for rapid symptom worsening caused by distal thrombus migration. A 75-year-old woman presented with mild disturbance of consciousness, right conjugate deviation, left hemiplegia, facial paralysis, sensory disturbance, and dysarthria. Her symptoms progressed, with an NIHSS score of 17 and a DWI-Alberta stroke program early computed tomography score of 8 at 12 hours after onset. The patient was found to have isolated ICAO, and thrombectomy was performed with a flow reversal technique to prevent distal migration. Successful reperfusion was achieved (modified Thrombolysis in Cerebral Infarction 2c). However, her neurological status subsequently deteriorated, revealing extensive cerebral infarction and edema. The findings of angiography and arterial spin labeling supported the diagnosis of the no-reflow phenomenon as the cause of symptom exacerbation. Furthermore, microcirculatory disturbances associated with hyperglycemia were considered to be the primary cause of the no-reflow phenomenon. A comprehensive understanding of the no-reflow phenomenon seems essential even in cerebrovascular reconstruction procedures.

We report a successful case of stent-assisted coil embolization (SAC) for blood blister-like aneurysm (BBA) on the lateral wall of the upper basilar artery. A 53-year-old male was admitted to the hospital because of headache, and head CT revealed a subarachnoid hemorrhage. The bleeding source was unclear. Follow-up DSA revealed gradual swelling of the lateral side of the superior wall of the basilar artery, which was finally diagnosed as the bleeding source, and SAC was performed for BBA on the hospital day 25. Immediately after endovascular treatment, no contrast filling of the bleb was observed, and follow-up DSA showed a white collar sign on the vessel wall after 6 months. The patient was judged to be cured completely. In this case, we performed SAC and believe that a complete cure was achieved due to coil embolization and the flow diversion effect of the neck bridge stent.

The CT attenuation of the brain parenchyma in non-contrast brain CT images is linearly correlated with the blood hemoglobin (Hb) concentration. The cerebral CT attenuation is proportional to the amount of cerebral Hb, which is calculated by multiplying the cerebral blood volume (CBV) by the cerebral blood Hb concentration. In other words, the cerebral Hb volume is linearly correlated with the CBV and blood Hb concentration, and is reflected in the non-contrast CT images. Since the blood Hb concentration is constant for each individual, the CT attenuation of non-contrast cerebral CT images is proportional to the CBV. However, the change in CT attenuation due to the alteration of CBV is very slight and cannot be recognized due to CT noises and human visibility limits. Therefore, we devised an image processing method to visualize changes in the CBV and observed brain CT images of various pathologies. In hyperacute cardiogenic cerebral embolism, the ischemic area can be confirmed from the extent of CBV reduction. In cases of chronic cerebral ischemia, its stage and distribution can be inferred from changes in the CBV due to autoregulation. The image processing of the cerebral non-contrast CT images and its clinical applications are reviewed.

Objective: We aimed to assess the impact of constipation on activities of daily living (ADL) at discharge in patients with acute cerebral infarction (ACI). Methods: This retrospective cohort study included 144 patients with ACI. We estimated the independent relationship between constipation (no defecation for ≥3 days) and the Barthel index (BI) score at discharge using multiple linear regression analysis. Results: The mean BI score was 63.4 points and the incidence of constipation was 54%. In multiple linear regression analysis, constipation showed a significant independent relationship with the BI score (β=−0.137, P=0.047). Conclusion: Constipation has an independent relationship with ADL after ACI.

Objective: Statins are the recommended treatment course for dyslipidemia in patients with ischemic stroke. However, it remains unclear whether statins are effective and safe for use in very elderly patients. Therefore, we performed a retrospective study to elucidate this. Methods: All participants were enrolled between January 2017 and December 2021 in our hospital. The hospitalized patients who were aged ≥80 years and had atherothrombotic cerebral infarction or lacunar infarction were enrolled. Patients were eligible to participate if they could be followed for 1 year after the study onset. Outcomes were assessed for the mRS, hospital stay, LDL-C, and adverse events after statin initiation. Results: In total, 102 patients were included: 33 received statins and 69 did not receive statins. In the statin group, the mRS was 2.6 at discharge, and there were no in-hospital deaths. The length of hospital stay was significantly shorter in the statin group than in the untreated group (27.6 days vs. 38.6 days, p=0.023). The LDL-C on admission was approximately 115 mg/dl in both groups; it decreased to 84 mg/dl after 12 weeks in the statin group. There were no major adverse events at 48 weeks of statin therapy. Conclusions: Although patient background should be noted, we found that elderly patients who were able to begin statin treatment tended to have milder neuromotor function due to cerebrovascular disease and a shorter hospital stay at discharge.

A 43-year-old man presented with sudden-onset severe headache and was admitted to our hospital. At admission, computed tomography (CT) and CT angiography (CTA) revealed subarachnoid hemorrhage caused by a ruptured anterior communicating artery (A-com) aneurysm. CTA also revealed stenotic changes at the terminal portions of the bilateral internal carotid artery (ICA), occlusion of the bilateral middle cerebral artery (MCA), and accompanying typical moyamoya vessels. We performed coil embolization for the A-com aneurysm and the aneurysm was completely occluded. The postoperative course was uneventful and the patient was discharged home with no significant disability on day 21. Computational fluid dynamics (CFD) analysis using intraoperative 3D angiography data revealed increased hemodynamic stress at the aneurysm site due to the narrowing of MCA. The progression of arterial stenosis in limited lesions, in this case MCA, could cause a dynamic change in cerebral blood flow, which results in aneurysm formation and rupture.

A 56-year-old woman experienced a thunderclap headache after swimming. Cranial CT showed no new lesion except the old cerebral infarction. A few days later, the headache did not improve and she was examined again. MRI showed a similar old infarction as demonstrated by the CT. MRA showed an obscure image of MCA. The headache continued, and a repeated MRI showed a new cerebral infarction and she was hospitalized. A duplicated MCA was shown by cerebral angiography. Another vessel with irregular stenoses proved to be the main MCA. The diagnosis was profoundly confused because we misunderstood the duplicated MCA as a single MCA in the early clinical course. The headache and a new cerebral infarction had a possibility to be caused by dissection of the main MCA trunk. A normal variation of the MCA should be considered when we encounter with atypical headache and infarction.

Pediatric pial arteriovenous fistula (AVF) is a rare condition that can cause intracranial hemorrhage and cerebral edema due to increased venous pressure. Therefore, prophylactic treatment should be considered. Here, we report a case of pediatric pial AVF presented with headache followed by subarachnoid hemorrhage. A 6-year-old girl underwent a head MRI for the investigation of headaches. MRI showed abnormal dilated vessels in the posterior space of the brainstem. DSA revealed a pial AVF fed by the left posterior inferior cerebellar artery and drained to the petrosal vein. During formulating the treatment strategy for the pial AVF, she developed a subarachnoid hemorrhage and was admitted to our hospital. We perfomed urgent open neurosurgery, which involved the ligation of the feeder and the drainer, and excision of the varix. Her postoperative course was uneventful. The patient underwent rehabilitation for her gait disturbance and was discharged home with an mRS score of 1. The preoperative evaluation of detailed vascular architecture and secure shunt point occlusion is crucial in successful open neurosurgery for pial AVF.

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 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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.