Stent Retriever Angioplasty for Acute Restenosis of the Middle Cerebral Artery: A Case Report.

We present a case of ischemic stroke treated by stent retriever angioplasty for restenosis during mechanical thrombectomy. An 85-year-old man was admitted to our hospital because of left hemiplegia and left-sided hemispatial neglect caused by an occlusion at the origin of the right middle cerebral artery. Although mechanical thrombectomy transiently resulted in recanalization of the occluded lesion, restenosis immediately occurred and recurred repeatedly. On an angiogram, the stent retriever appeared poorly dilated at the stenosis and showed a contrast deficit. We concluded that restenosis was due to a secondary thrombus resulting from a ruptured atherosclerotic plaque. The stent retriever was kept deployed for 15 minutes. After the stent was retrieved, restenosis did not occur. Stent retriever angioplasty may be effective for determining the cause of restenosis after mechanical thrombectomy as well as for the treatment of restenosis.

[Transient neurological deficits in a patient with chronic subdural hematoma].

A 62-year-old, right-handed man was diagnosed with asymptomatic bilateral chronic subdural hematomas and underwent hematoma removal on the left side only. At 1 month after surgery, he was admitted to our hospital because he began to have one or two attacks/day of apraxia of speech and dysesthesia of the right hand with a duration of approximately 5 |min. The left hematoma had not re-expanded, but fluid-attenuated inversion resonance imaging showed hyperintense lesions in the sulci adjacent to the hematoma. Moreover, single-photon emission computed tomography revealed low-uptake lesions in the left cerebrum adjacent to the hematoma. Electroencephalogram showed no abnormalities, and CT angiography showed a slight deviation of the left middle cerebral arteries due to the hematoma. The attacks disappeared within 10 days, although the volume of the hematoma was unchanged. It was suggested that his transient neurological deficits were caused by cerebral ischemia related to chronic subdural hematoma.

Stent-retriever characteristics and strategies associated with recanalization in thrombectomy for acute ischemic stroke.

INTRODUCTION: Predictive factors for successful reperfusion in mechanical thrombectomy for acute ischemic stroke, and especially technical factors, remain controversial. We investigated various techniques for better angiographic outcomes. METHODS: In this retrospective study, acute ischemic stroke patients with large vessel occlusion treated with mechanical thrombectomy with combined technique were included. Scoring of the reperfusion grade for each attempt was conducted, and each attempt was divided into two groups based on successful reperfusion, which was defined using the presence or absence of modified thrombolysis in cerebral infarction 2b-3. The following characteristics were evaluated: the choice of stent-retriever, its length, occlusion site, thrombus position relative to deployed stent-retriever, methods of thrombectomy, and successful advancement of the distal access catheter to the proximal end of the thrombus. RESULTS: Among 251 patients who underwent mechanical thrombectomy, 154 patients (255 attempts: mTICI 0-2a group, n = 119; mTICI 2b-3 group, n = 136) were included in the analysis. The thrombus position relative to the deployed stent-retriever was likely associated with successful reperfusion, although it was not statistically significant (proximal two-thirds 56.8 %; distal one-third 44.3 %, p = 0.09). Successful advancement of the distal access catheter was related to successful reperfusion both in univariate analysis (success 57.9 %; fail 35.8 %, p < 0.01) and in multivariate regression analysis (odds ratio 2.45; 95 % confidence interval: 1.30-4.61, p < 0.01). CONCLUSIONS: Successful advancement of the distal access catheter to the proximal end of thrombus might be a key component for successful reperfusion in mechanical thrombectomy.

Carotid Free-Floating Thrombus Treated With a Combined Technique Using Embotrap III for Distal Protection.

Carotid free-floating thrombus (FFT) is a rare condition in patients with acute ischemic stroke. Recently, endovascular therapy for carotid FFT has been increasingly reported, but the strategy has not yet been established. We report a case of an acute stroke patient with a carotid FFT, who was successfully treated with a combination of the direct aspiration first-pass technique (ADAPT) and the Embotrap III (Cerenovus, Irvine, CA), specifically designed to prevent distal embolization. We propose the utility of distal embolic protection with Embotrap III for the treatment of patients with carotid FFT. A 71-year-old man who presented with sudden left hemiparesis was admitted to our hospital. Ultrasonography on admission revealed severe stenosis and an FFT at the origin of the right internal carotid artery. Thrombectomy with an aspiration catheter, accompanied by a stent retriever with distal basket Embotrap III for distal protection, was performed. After the FFT was safely aspirated, a carotid Wallstent (Boston Scientific, Marlborough, MA) was deployed in the stenosis. Follow-up ultrasonography showed neither FFT nor in-stent protrusion. The patient did not experience recurrence, as per clinical or radiological findings, and was discharged on day 11 without any neurological deficits. Embotrap III may be useful for a patient with a carotid FFT as distal protection during mechanical thrombectomies.

[Dystypia in a patient with subcortical ischemic stroke].

A 58-year-old, right-handed man noticed difficulty in typing and speech. On day 3 after onset, the day of admission, he had frontal lobe dysfunction including verbal fluency impairment and impairment of recent memory, although he did not have apraxia or visual agnosia. Moreover, he had difficulty typing in romaji, especially words containing contracted or double consonant sounds, although he was able to do this before onset by visually checking the keyboard. He had mild dysgraphia. MRI showed an infarct in the genu and posterior limb of the left internal capsule. SPECT revealed low-uptake lesions in the left frontal lobe. In the present case, we consider that the subcortical infarction disrupted the network between the thalamus and frontal lobe, resulting in dystypia due to difficulty with recalling romaji spelling.

Cortical Involvement of a Recent Infarct Contralateral to Early Focal Seizures in Ischemic Stroke.

Objective To investigate the frequency and clinical characteristics of ischemic stroke patients with early seizures, especially with cortical involvement contralateral to their focal seizures. Methods We retrospectively studied patients with ischemic stroke admitted to our hospital. We compared the clinical characteristics of patients with and without early seizures (occurring within seven days of the stroke onset). In addition, we divided the patients with early focal seizures into two groups (patients with and without cortical involvement of a recent infarct contralateral to their focal seizure) and compared the clinical characteristics of the groups. Results Of the 5,806 patients with ischemic stroke, 65 (1.2%) were diagnosed with early seizures. A history of ischemic stroke [odds ratio (OR) 1.71], a history of seizures (OR 27.58), and a National Institutes of Health Stroke Scale score on admission (OR 1.07) were significant and independent factors associated with the presence of early seizures. Of these 65 patients, 56 had focal seizures, while the others had generalized or undetermined seizures. Cortical involvement of a recent infarct contralateral to their focal seizures was observed in 24 of these 56 patients (43%). Glucose and hemoglobin A1c levels were significantly higher in patients with cortical involvement of a recent infarct contralateral to their focal seizures than in those with infarcts in other regions. Conclusion These findings suggest that recent infarcts play a role as systemic causes of acute symptomatic seizures as well as an epileptogenic lesion in ischemic stroke patients with early focal seizures.

Tremor-like grasp phenomenon: case series study.

OBJECTIVE: Tremor-like movements in patients with the grasp phenomenon are reported rarely. METHODS: We clinically and neuroradiologically studied four patients with tremor-like movements related to the grasp phenomenon. RESULTS: All of the patients were women aged between 61 and 98 years. In the present cases, tremor-like movements were observed in the right arm and/or leg. The movements occurred suddenly in three of the patients and chronically in one. The movements were stereotypic, often rhythmical, tremor-like, and accompanied with groping or picking-like movements. All of the patients displayed the grasp phenomenon, including grasp reflex and/or instinctive grasping reaction ipsilateral to the movements. Two patients had a recent broad infarct ipsilateral to the movements. One patient had meningioma contralateral to the movements, which had been surgically resected. The other patient did not have any radiologically proven cerebral lesions, although she had a history of focal seizures contralateral to the movements. CONCLUSIONS: It was suggested that their abnormal movements were closely related to the grasp phenomenon. We concluded that their characteristic tremor-like movements, a "tremor-like grasp phenomenon," was a variation of the grasp phenomenon that was due to hyperexcitation of the frontal lobe contralateral to the movements.

Reversible Periventricular Hyperintensity Lesions in Cerebral Amyloid Angiopathy: A Case Mimicking Cerebral Amyloid Angiopathy-related Inflammation.

A 59-year-old man with progressive cognitive decline and mood disturbances was admitted to the hospital. Brain magnetic resonance imaging revealed marked white matter hyperintensity (WMH) and widespread lobar cerebral microbleeds. Because he had untreated hypertension, we started antihypertensive treatment and found a significantly improved cognitive function and WMH regression. We diagnosed him with cerebral amyloid angiopathy (CAA) based on the modified Boston Criteria with the rare apolipoprotein E (ApoE) ε2/ε4 genotype. The mechanism underlying reversible leukoencephalopathy in CAA may be related to the loss of autoregulation of brain circulation: cerebrovascular amyloid ß deposits damaged the blood-brain barrier of the capillaries, which led to vasogenic edema induced by blood pressure surges.

Underdosed Direct Oral Anticoagulants in Atrial Fibrillation Patients Reduce Stroke Severity and Improve Outcome.

BACKGROUND AND PURPOSE: Anticoagulant drugs, including vitamin K antagonist (VKA) and direct oral anticoagulants (DOACs), can reduce stroke severity and are associated with good functional outcomes. Some patients are prescribed lower-than-recommended doses of DOACs; whether these have similar effects has not been clarified. METHODS: We retrospectively evaluated 1,139 consecutive ischemic stroke and transient ischemic attack patients with atrial fibrillation. Patients were divided into 5 groups according to their preceding anticoagulant drug therapies: no anticoagulant therapy (ACn), undercontrolling VKA doses (VKAuc), recommended, controlling VKA doses (VKArec), prescribed underdoses of DOAC (DOACud), and recommended doses of DOAC (DOACrec). We investigated the associations between these anticoagulant drug therapies and patients' initial stroke severity and 3-month outcomes. RESULTS: Median National Institutes of Health Stroke Scale scores at admission were as follows: ACn: 16, VKAuc: 15, VKArec: 9, DOACud: 5, and DOACrec: 7. When the ACn group was used as a reference, regression analysis showed that VKArec (odds ratio [OR] 1.49, 95% confidence interval [CI] 1.01-2.21), DOACud (OR 2.84, 95% CI: 1.47-5.66), and DOACrec (OR 1.83, 95% CI: 1.23-2.74) were associated with milder stroke severity, while VKAuc was not. Median 3-month modified Rankin Scale scores were 2 in the DOACud and DOACrec groups and 4 in all other groups. After adjusting for confounding factors, DOACud (OR 3.14, 95% CI: 1.50-6.57) and DOACrec (OR 1.67, 95% CI: 1.05-2.64) were associated with good 3-month outcomes while VKAuc and VKArec were not. CONCLUSIONS: In patients with atrial fibrillation, recommended doses and underdoses of DOACs reduced stroke severity on admission and were associated with good 3-month outcomes.

[Tactile hallucination and delusion associated with broad brain infarction in the right middle cerebral artery territory: a case report].

A 64-year-old woman experienced a broad brain infarction in the right middle cerebral artery territory with left hemiparesis and left unilateral spatial neglect. She was treated by endovascular thrombectomy and decompressive craniectomy. During the subacute phase of the brain infarction, she became alert and insisted, "My eldest daughter is at my feet and I can touch her body with my feet." The patient's abnormal experience was accompanied by visual information, such as her daughter's physical characteristics and clothing, which could not be directly confirmed, and a false ideation that she had two eldest daughters. Although the patient was aware that her experience was abnormal, she was unable to deny her strong beliefs regarding the experience. We concluded that a series of the patient's abnormal experiences consisted of both tactile hallucinations and delusions. In this case, the subjects of the delusions associated with the patient's tactile hallucinations were limited to close relatives. Finally, it was clinically important that introspection by the patient revealed details of the nature of her hallucinations.

Preceding direct oral anticoagulant administration reduces the severity of stroke in patients with atrial fibrillation - K-PLUS registry.

BACKGROUND: Stroke severity can be mitigated by preceding anticoagulant administration in acute ischemic stroke patients with atrial fibrillation (AF). We investigated if such mitigative effects are different between warfarin and direct oral anticoagulants (DOACs). MATERIAL AND METHODS: We collected data from a regional multicenter stroke registry. Ischemic stroke or transient ischemic attack patients with AF were included. Background characteristics, National Institutes of Health Stroke Scale (NIHSS) score on admission, lesion characteristics, and in-hospital death were analyzed according to preceding antithrombotic agents at onset. RESULTS: A total of 2173 patients had AF; 628 were prescribed warfarin, 272 DOACs, 429 antiplatelets alone, and 844 no antithrombotics. The NIHSS score on admission was lowest in the DOACs group compared to the other groups. In neuroimaging analysis, small ischemic lesions were observed more frequently in the DOACs group, while large ischemic lesions were less frequent in this group. When the no antithrombotics group was used as a reference, the adjusted odds ratio for moderate to severe stroke was 0.56 (95% confidence interval, 0.40-0.78) in the DOACs group, while it was 0.98 (0.77-1.24) in the warfarin group and 0.94 (0.72-1.22) in the antiplatelets group. In-hospital mortality was lowest in the DOACs group compared to the other groups. CONCLUSION: Preceding DOAC administration might mitigate the severity of stroke in AF patients more strongly than other antithrombotics, possibly leading to a better outcome in patients with stroke.

[Paraneoplastic sensorimotor neuropathy with anti-Hu antibody associated with gallbladder carcinoma].

A 78-year-old woman experienced gait disturbance. She became unable to walk within a month. On admission, her cranial nerves were normal. She had motor weakness in the arms and legs, dysesthesia of the peripheral extremities, impaired deep sensation in the legs, and hyporeflexia in the arms and legs. She was initially diagnosed with Guillain-Barré syndrome; therefore, she was treated with intravenous immunoglobulin therapy and steroid mini-pulse therapy, however improvements of her neurological deficits were minimal. Anti-Hu antibody was positive in serum and gallbladder carcinoma was detected. She was treated with chemotherapy but neurological symptoms worsened progressively. Gallbladder carcinoma can rarely cause anti-Hu associated paraneoplastic sensorimotor neuropathy.

Aphasia Induced by Infratentorial Ischemic Stroke: Two Case Reports.

Aphasia induced by an infratentorial stroke has rarely been reported, and its mechanism has not been fully identified. We evaluated two individuals who had been admitted to Saiseikai Kumamoto Hospital in Kumamoto, Japan, due to acute ischemic stroke in order to determine whether their aphasia was induced by an infratentorial stroke. The first patient, a 59-year-old man with a history of left parietal embolic stroke with very mild sequelae of anomia, developed Wernicke's aphasia, nonfluent speech, and right limb ataxia as a result of the stroke. The second patient, a 76-year-old woman with a history of chronic renal failure, experienced transcortical sensory aphasia and right one-and-a-half syndrome as a result of the stroke. Both patients' recent ischemic lesions were limited to the right cerebellar hemisphere and the right medial portion of the midbrain. However, SPECT showed low-uptake lesions in both patients' left cerebral hemisphere that did not include the recent ischemic lesions but that had spread to an extent that was difficult to be explained by the old or recent ischemic lesions and that might be responsible for their recent aphasia. We believe that the aphasia experienced by these two patients may have been caused by crossed cerebello-cerebral diaschisis.

[Non-aphasic misnaming: a case report and literature review].

A 71-year-old, right-handed woman was admitted to our hospital due to a sudden difficulty with conversation. On admission, she was alert, but had a euphoric mood, disorientation, and a disturbance of recent memory. Her speech was fluent. Her repetition and auditory word cognition were excellent, but she had a slight difficulty with naming visual objects. She frequently showed word-finding difficulty and irrelevant paraphasia during free conversation and a word fluency task. Her irrelevant paraphasia was observed more frequently when she was asked to explain her outbreak of anger at the hospital, i.e., it was situation-dependent. She also had anosognosia. MRI showed an infarct in the territory of the left tuberothalamic artery. Single-photon emission computed tomography revealed low-uptake lesions in the left thalamus and orbital frontal, medial frontal, and medial temporal lobes. The patient was diagnosed with non-aphasic misnaming. The clinical characteristics of patients with non-aphasic misnaming in the literature were reviewed. All of the patients with non-aphasic misnaming had word-finding difficulty and irrelevant paraphasia. Additionally, they had either emotional disturbance or anosognosia.

Clinical characteristics of patients with ischemic stroke after the 2016 Kumamoto earthquake, a multi-center study.

OBJECTIVE: To investigate the clinical characteristics of patients with ischemic stroke following the 2016 Kumamoto earthquake. METHODS: We retrospectively studied patients with ischemic stroke admitted to 5 stroke centers for 1 year after the earthquake. We compared clinical characteristics in these patients (the post-earthquake group) to those in the patients with ischemic stroke admitted during the same period from the previous 3 years (the pre-earthquake group). Additionally, we analyzed the trend of the incidence rate of stroke before and after the earthquake. RESULTS: A total of 1979 patients were admitted after the earthquake; 5670 (1,890/year on average) patients were admitted before the earthquake. A first-ever ischemic stroke (71 vs. 75%) and premorbid modified Rankin Scale > 1 (26 vs. 29%) were found significantly more frequently in patients after the earthquake. National Institutes of Health Stroke Scale score ≤ 2 at discharge (60 vs. 65%) was found more frequently in patients after the earthquake, although non-discharge to home (65 vs. 70%) was more frequent in patients after the earthquake. Trend analysis revealed a decrease of small vessel occlusion and large artery atherosclerosis in the month after the earthquake. CONCLUSIONS: The 2016 Kumamoto earthquake may have affected the characteristics of stroke during the early phase of the earthquake and increased the difficulty in returning home.

Transient total locked-in syndrome due to vertebral and basilar artery dissection.

A 52-year-old woman suddenly presented with right conjugate eye deviation, anarthria and quadriplegia, and appeared to be in a deep coma. MRI revealed a new infarct in the left cerebellar hemisphere and stenosis in the distal portion of the basilar artery caused by arterial dissection. Her deficits improved within 6 hours of onset. Moreover, on day 1, she described that she had been alert and her vision, hearing and somatic sensation had been preserved during the illness. Total locked-in syndrome should be considered while assessing patients with total immobility who are unable to communicate.

Reliability of the Modified Rankin Scale Assessment Using a Simplified Questionnaire in Japanese.

OBJECTIVES: We developed a Japanese version of the simplified modified Rankin Scale questionnaire, of which the agreement between patients or their family members and neurologists was verified in a previous single-center study. In the present study, the reliability of the questionnaire was evaluated in another hospital. MATERIALS AND METHODS: The participants were prospectively-registered patients with acute ischemic stroke admitted to Saiseikai Kumamoto Hospital. The questionnaire was administered to the patients or their family members at discharge. At the same time, the attending physician assessed the Japanese version of a guidance scheme for the modified Rankin Scale. The agreement rate between the scores from both assessments was examined using the κ statistic and weighted κ statistic. We examined the factors related to disagreement between the modified Rankin Scale score by the attending physicians and the questionnaire score by patients/family members. RESULTS: A total of 146 patients (age 77 ± 12 years; 53% men) were included. Agreement between the raters was 39%; the κ statistic was 0.27, but the weighted κ statistic, taking into account the extent of disagreement, was 0.81. In multivariate analysis, the disagreement between the modified Rankin Scale score and the questionnaire score was negatively associated with a modified Rankin Scale score of 5 at discharge (odds ratio, 0.02 per score point; 95% confidence interval, 0.00-0.34). CONCLUSION: The questionnaire showed decent reliability and similarity to the modified Rankin Scale assessed by physicians. The questionnaire could be a reliable indicator for assessing stroke functional outcomes even when implemented by non-medical staff.

Nonconvulsive Status Epilepticus With Neuropsychological Symptoms: Two Case Reports.

Nonconvulsive status epilepticus with neuropsychological symptoms other than aphasia or amnesia is rare. We report two such cases. Case 1, a 62-year-old man with a history of a subcortical hemorrhage in the right lateral temporal lobe and a brain infarct in the left medial temporo-occipital lobes, suddenly developed left unilateral spatial neglect and visual object agnosia. Diffusion-weighted imaging indicated status epilepticus, not stroke. His deficits resolved immediately after treatment with diazepam and phenytoin sodium. Case 2, a 61-year-old man with a history of brain infarcts in the right lateral temporal and left medial temporo-occipital lobes, suddenly developed global aphasia and cortical deafness. An MRI revealed no new lesions, including infarcts. An EEG revealed lateralized periodic discharges in the left temporo-parieto-occipital area, and single-photon emission computed tomography revealed a transient high-uptake lesion in the left temporoparietal lobes, indicating status epilepticus. His deficits also resolved immediately after treatment with diazepam and phenytoin sodium. The two patients' neuropsychological symptoms-visual object agnosia and cortical deafness-were associated with focal nonconvulsive status epilepticus and were successfully treated with anti-epileptic medications. It is suggested that individuals with acute neuropsychological symptoms be diagnosed with MRI and/or EEG as well as CT for differential diagnoses other than cerebrovascular diseases.

Pre-Hospital Delay in Patients with Acute Ischemic Stroke in a Multicenter Stroke Registry: K-PLUS.

PURPOSE: There is scant data related to prehospital delay in cases of acute ischemic stroke from multicenter studies conducted after change of the therapeutic window of intravenous tissue plasminogen activator (iv-tPA) administration to within 4.5 h of onset. We investigated factors causing prehospital delay and their associations with clinical outcomes using data from a regional multicenter stroke registry. METHODS: Data from the multicenter regional stroke registry were analyzed. Patients admitted within 24 h of the last known well time were categorized according to whether their admission was early (≤ 4 h; n = 2350) or delayed (> 4 h; n = 2752). We then compared patients' backgrounds and outcomes between the two groups. RESULTS: Five-thousand, one-hundred two patients presented at hospitals within 24 h of onset. On multivariate analysis, atrial fibrillation, higher NIHSS score on admission, anterior circulation stroke, detection of symptoms immediately after onset, and emergency system use were positively associated with early admission, whereas modified Rankin Scale (mRS) score before onset, onset at home, diabetes, current smoking, dementia and symptom detection between 00:00 and 06:00 h were negatively associated. Early admission was associated with mRS scores of 0-2 at discharge independent of backgrounds, stroke severity, and thrombolytic therapy (odds ratio, 1.56; 95% confidence interval, 1.32-1.84). CONCLUSIONS: Certain patient factors relating to prehospital delay, such as lack of awareness of onset or non-cardioembolic etiology, are crucial but often inevitable. However, earlier admission was associated mRS scores of 0-2 independent of other factors. This study may help to plan educational activities to general population or public awareness campaigns.

Spinal epidural hematoma as a stroke mimic.

PURPOSE: Spinal epidural hematoma is a rare but important disease as it can be a stroke mimic. Our aim was to investigate the clinical characteristics of patients with an activated stroke code and spinal epidural hematoma. METHODS: Patients with an activated stroke code were examined retrospectively. Patients with spinal epidural hematoma were evaluated with further neurological examinations and neuroimaging. RESULTS: Of 2866 patients with an activated stroke code, spinal epidural hematoma was detected in 5 (0.2%, 63-79 years, 2 men). In all 5 cases, hematoma was located in the unilateral dorsal region of the spinal canal and spread to 5-9 vertebral segments at the C1-T3 level. None of the patients had a medical history of head or neck injury, coagulopathy, or use of anti-thrombotic agents. All of the patients had occipital, neck, and/or back pain, and their hemiparesis occurred simultaneously or within 1 h after the onset of pain. Hyperalgesia ipsilateral to the hematoma was observed in 1 patient, hypoalgesia contralateral to the hematoma was observed in 1, and quadriparesis and bilateral hypoalgesia were observed in 1. The hematomas spontaneously decreased in size in 4 patients, and cervical laminectomy was performed in the other patient. In the 1860 patients with an activated stroke code and spontaneous eye opening, the sensitivity of pain as a predictor of spinal epidural hematoma was 100%, with a specificity of 88.7%, and positive predictive value of 2.3%. CONCLUSION: Patients with spinal epidural hematoma could present with clinical characteristics mimicking ischemic stroke. Spinal epidural hematoma should be differentiated in patients treated under stroke code activation.