A 72-year-old woman presented with sensory aphasia and left-sided hemiparesis. Brain MRI revealed cortical hyperintensities in the right MCA territory on both DWI and FLAIR sequences. MRA showed no evidence of large-vessel occlusion. To differentiate non-convulsive status epilepticus (NCSE) from acute ischemic stroke, we performed a headset electroencephalogram (HS-EEG), which demonstrated rhythmic slow waves at 1.5–2 Hz predominantly over the right hemisphere. Based on these findings, a diagnosis of NCSE was made. HS-EEG may serve as a valuable tool for distinguishing NCSE from acute stroke in cases where conventional imaging is inconclusive.

A 28-year-old man presented with a severe headache, and imaging revealed an arteriovenous malformation located in the right occipital lobe. He underwent embolization of the feeding arteries using n-butyl-2-cyanoacrylate (NBCA), followed by surgical resection of the arteriovenous malformation. His postoperative course was initially uneventful, with no neurological deficits or radiological abnormalities. However, 9 days after undergoing embolization, he developed a headache, followed by left lower quadrantanopia on postoperative day 12, which were attributed to perilesional cerebral edema and subdural/extracerebral fluid collection. These symptoms and findings gradually resolved with conservative management. Considering the patient’s atypical postoperative course, which did not suggest infection or reperfusion complications, an allergic reaction was suspected. A skin patch test was performed for various surgical and embolic materials, including Spongel and Lipiodol, which had been used in this case. Based on the strong positive reaction to NBCA, the delayed-onset cerebral edema was suspected to be caused by an allergic reaction to NBCA. Histopathological examination of the resected tissue revealed perivascular lymphocytic infiltration, predominantly CD3-positive T cells, indicating a delayed-type hypersensitivity reaction. Although such cases have been rarely reported to date, our case highlights the importance of considering allergic reactions to various surgical or embolic materials, including NBCA, in patients presenting with unusual postoperative courses.

The composition of atherosclerotic plaques in cervical internal carotid artery stenosis is an important factor in assessing the risk of cerebral infarction. We investigated the pathological findings of plaques obtained through CEA. We included eight patients who underwent CEA. The relationship between pathological plaques and preoperative CT, MRI, and angiography findings was examined. Pathological plaques were stained with hematoxylin and eosin and elastica van Gieson. In the results, no cases showed elastic fibers within atherosclerotic plaques. CEA was selected for cases exhibiting surface roughness, coral-like calcification, and high intensity on T1WI and T2WI.

Background and Purpose: In the Japanese National Plan for Promotion of Measures Against Cerebrovascular and Cardiovascular Disease, the establishment of a support system for the promotion of health and employment support is being proposed. However, the employment status of stroke patients is influenced by numerous unknown factors. Methods: Overall 34,809 stroke patients hospitalized for treatment in Rosai Hospitals between April 2013 and March 2023 were investigated in terms of age, outcomes, discharge destinations, and employment status at the time of onset (occupation, industry classification, and employment type). Results: Of all stroke patients, 7,333 (21%) were employed, regardless of their employment status. Stroke types were 9.8%, 64.3%, and 26.0% subarachnoid hemorrhage, cerebral infarction, and intracerebral hemorrhage. Hemorrhagic stroke was more common among employed people than unemployed individuals; subarachnoid hemorrhage was especially common in women. In all age groups, regular employees were predominantly male; however this gender disparity became particularly pronounced after 30 years of age. Differences in job type, industry, and employment status were recognized based on stroke type. The estimated percentage of support recipients under 64 years of age was 7.2% when limited to regular employees, and 10.3% when non-regular employees were included. Conclusion: Prevention of early departure from work in stroke patients and implementation of return-to-work support are desirable in acute care medical institutions.

Background and purpose: Cerebral cavernous malformations (CCMs) are hamartomatous vascular lesions. A part of CCMs is estimated to occur after cranial irradiation. However, there have been no reports documenting clinical picture of such CCMs. This study aimed to explore it. Methods: A total of 51 patients with multiple CCMs who visited our hospital between 2006 and 2024 were examined. Among them, five were considered to have radiation-induced CCMs, four developing after cranial irradiation and one after endovascular therapy. Results: The male-to-female ratio of radiation-induced CCM cases was 3 : 2. The mean time from radiation exposure to identification of CCM mutation was 31.2 years. Four patients developed symptomatic meningioma and underwent surgical resection. In all cases, the pathological diagnosis was meningothelial meningioma. Genomic analysis of CCMs confirmed a CCM1 mutation in five patients. In four cases, the mutation was located in exon 5. In contrast, it was found in only one of the 46 patients with CCMs who did not have previous radiation exposure. Conclusion: Radiation-induced CCMs may occur through a mechanism different from non-radiation-induced CCMs, showing a stable clinical course, and are incidentally found with symptomatic secondary tumors. Exon 5 of chromosome 7 may be more sensitive to radiation than other genomic loci.

A rare case of subarachnoid hemorrhage caused by a ruptured dissecting aneurysm of the left posterior inferior cerebellar artery (PICA) in a 53-year-old woman is presented. Upon arrival at our hospital, the patient exhibited a rapid decline in consciousness. Cerebral angiography revealed thrombosis within the dissecting PICA aneurysm and an acute embolic occlusion of the basilar artery. Emergency mechanical thrombectomy with aspiration successfully restored complete basilar artery perfusion. The PICA aneurysm was no longer visible, suggesting spontaneous thrombosis. However, on day 3, computed tomography angiography demonstrated recanalization of the aneurysm. Given the high surgical risk associated with its anterior medullary location, endovascular parent artery occlusion was performed. Follow-up T1-weighted black-blood magnetic resonance imaging confirmed aneurysm thrombosis, and cerebral angiography on day 26 demonstrated complete occlusion. The patient’s consciousness gradually improved, although cerebellar ataxia persisted. She was transferred to a rehabilitation facility on day 63. This case highlights the rare occurrence of basilar artery embolic occlusion secondary to a dissecting PICA aneurysm and emphasizes the importance of close imaging follow-up and timely endovascular intervention.

Background and Purpose: This study examined stroke recurrence and outcomes in an aging, rural area using a regional stroke critical path. Methods: We analyzed 7,905 cases (4,195 men, 3,710 women; mean age, 76.1 years) from 2008 to 2020 in the Noto district of Ishikawa Prefecture, Japan (population 179,000；43.1% aged 65+ in 2020).

Results: Stroke subtypes were ischemic (72%), intracerebral hemorrhage (20%), and subarachnoid hemorrhage (6.3%), with an annual incidence of 323 per 100,000. A total of 720 re-registrations (616 individuals, up to five per person) were noted, with an increased proportion of ischemic strokes. Re-registration intervals were under one year in 38% and under two years in 58%. Home discharge rates and favorable outcomes (mRS 0–3) declined with recurrences up to the third but improved at the fourth. Conclusion: The study revealed frequent stroke recurrence, especially ischemic, within a short period, among elderly patients in this region.

In surgery for craniocervical junction-arteriovenous fistula (CCJ-AVF), intraoperative angiography is often required to identify the abnormal vessels. However, conventional intraoperative angiography poses challenges related to sheath fixation and catheter manipulation. In this study, we present a novel method for intraoperative angiography for CCJ-AVF using an ultra-long sheath inserted via the brachial artery and positioned at the subclavian artery to perform vertebral artery angiography (VAG). We evaluated patient demographics and complications in cases where this angiography method was employed. VAG was successfully performed in all four intended cases, and no complications were observed. This method enables us to change patient positions easily and provides a clear visualization of the puncture site. The catheter is also simply manipulated, allowing us to perform VAG with ease. Furthermore, there is no concern about the interference between the C-arm and the surgical field. This angiography method appears to be effective.

Objective: The aim of this study was to obtain real-world data on medical care for patients with Cerebral Autosomal Dominant Arteriopathy with Subcortical Infarcts and Leukoencephalopathy (CADASIL) in Japan. Methods: We conducted a questionnaire survey among members of the Japan Stroke Society to investigate the number of CADASIL patients who visited each hospital between January 2019 and December 2023. Results: A total of 315 patients with CADASIL were identified. The highest number was in Osaka Prefecture (133), followed by Kyoto (52), Kumamoto (19), Kanagawa (16), and Tokyo (12). One hospital in Osaka reported 120 patients, while another in Kyoto reported 50 patients. Conclusion: This study demonstrated a concentration of CADASIL patients in a few hospitals in Japan. It also showed that there are few stroke physicians with significant clinical experience in treating CADASIL patients in other hospitals.

A 24-year-old woman presented to our hospital with occipital pain after urination at 16 weeks and three days of gestation. Simple magnetic resonance imaging revealed a subarachnoid hemorrhage (WFNS grade I, Hunt–Hess grade II, Fisher group 3), and the patient was treated together with an obstetrician and an anesthesiologist. Computed tomography angiography (CTA) revealed a suspected aneurysm in the anterior communicating artery, but it was not definitively diagnosed; therefore, cerebral angiography was conducted to evaluate the aneurysm. An extra-small aneurysm of the anterior communicating artery measuring 1.9 mm in maximal diameter was treated with coil embolization via the brachial artery approach to minimize radiation exposure in the lower abdomen. The treatment was completed without intraoperative rupture or cerebral infarction. The patient was discharged on the illness day 20. She delivered a healthy baby by cesarean section at 38 weeks and three days of gestation as scheduled without reoperation, and the mother and infant had an uneventful postoperative course. Examination and coil embolization of an extra-small cerebral aneurysm that ruptures during pregnancy can be a viable treatment option because it is a less invasive treatment for mothers and infants without the significant side effects of radiation and contrast media.

Objective: Simultaneous acute occlusion of bilateral cervical ICA is extremely rare but represents a critical condition with a poor prognosis unless promptly diagnosed and treated. We report a case of acute bilateral cervical ICAs occlusion treated with revascularization. Case presentation: An 81-year-old woman presented with impaired consciousness and was transported to our emergency department. On arrival, she exhibited JCS 300 with tetraplegia, NIHSS was 40, and ECG showed atrial fibrillation. The head CT scan showed an Alberta Stroke Program Early CT Score of 10 in both hemispheres, and CT perfusion imaging revealed extensive time-to-maximum delays and decreased cerebral blood volume in both cerebral hemispheres. Four-dimensional CT-Angiography showed no depiction of the anterior circulation and hypoplasia of the bilateral posterior communicating arteries. Following the administration of intravenous rt-PA, mechanical thrombectomy was initiated. Recanalization was achieved with modified thrombolysis in cerebral infarction (mTICI) grade 3 in the left ICA and mTICI grade 2a in the right ICA. However, neurological recovery was not observed, and the patient developed severe cerebral edema in both hemispheres, ultimately leading to death on the fifth postoperative day. Conclusion: This case highlights the narrow therapeutic window for acute bilateral ICA occlusion and underscores the critical importance of rapid diagnosis and intervention to improve outcomes.

Background and Purpose: This study retrospectively investigated the impact of a history of cerebral infarction on mortality among patients with nonvalvular atrial fibrillation (NVAF). Methods: Patients with NVAF receiving oral anticoagulant therapy were divided into two groups: 383 with a history of cerebral infarction and 838 without. All-cause and cause-specific mortality rates were calculated during the observation period. Results: All-cause mortality was significantly higher in patients with a history of cerebral infarction compared to those without (8.2 vs. 4.7/100 person-years, p<0.001). Even after adjusting for background factors, a history of cerebral infarction remained a significant risk factor for all-cause mortality (hazard ratio: 1.61; 95% confidence interval: 1.34–1.93; p<0.0001). Additionally, cause-specific mortality revealed that deaths due to cardiovascular disease, cerebral infarction, and infection were significantly higher in patients with a history of cerebral infarction (p<0.05, p<0.001, and p<0.001, respectively). At the same time, there was no significant difference in mortality due to neoplasm or major bleeding. Conclusion: Among patients with NVAF receiving anticoagulant therapy, a history of cerebral infarction is associated with increased all-cause mortality and has varying effects on mortality based on the cause of death.

We report a case of a patient with neuromyelitis optica spectrum disorder (NMOSD) who developed delayed multiple brain lesions following stent-assisted coiling (SAC) of a concomitant unruptured cerebral aneurysm. A woman in her 50s presented with impaired consciousness and right hemiparesis, and MRI revealed multiple FLAIR hyperintense lesions in the brain. Serum testing was positive for aquaporin-4 antibodies, confirming the diagnosis of NMOSD. Her symptoms and radiological findings improved following treatment with steroids and immunoglobulins, and two years later, an interleukin-6 receptor inhibitor, satralizumab, was initiated. Four years later, the patient underwent SAC of an unruptured left internal carotid artery aneurysm. No neurological changes were observed post-operatively; however, MRI performed 34 days after embolization revealed new multiple FLAIR hyperintense lesions in the territory of the left internal carotid artery. Gadolinium-enhanced MRI showed nodular enhancement in the new FLAIR lesions, leading to a diagnosis of granulomatous inflammatory changes due to the fragmentation of the hydrophilic coating on the catheters. The new lesions resolved after medical treatment, and treatment with satralizumab was resumed. To the best of our knowledge, this is the first reported case of foreign body granuloma after coil embolization in a patient with NMOSD. Given the complexity of diagnosis and management, we provide a detailed discussion of the literature.