The relationship between the pre-admission CHA2DS2-VASc score and proximal artery occlusion in patients with acute stroke and atrial fibrillation.

BACKGROUND AND PURPOSE: The CHA2DS2-VASc score is associated with severity and outcome of ischaemic stroke in patients with atrial fibrillation (AF). It was hypothesized that a high CHA2DS2-VASc score was related to severity and outcome because of its association with proximal artery occlusion (PAO). This study aimed to elucidate the relationship between the CHA2DS2-VASc score and PAO and to determine whether the effect of the CHA2DS2-VASc score on severity or outcome is independent of PAO. METHODS: Acute stroke patients with AF were retrospectively enrolled. PAO was defined as occlusion at the internal carotid artery or proximal middle cerebral artery on admission magnetic resonance angiography. Multivariable analyses were performed to identify independent factors associated with PAO and determine the associations of the CHA2DS2-VASc score with the initial National Institutes of Health Stroke Scale (NIHSS) score and poor functional outcome (discharge modified Rankin scale score 4-6). RESULTS: In all, 213 patients [102 women; median age 80 (interquartile range 71-86) years; NIHSS score 16 (9-22)] were enrolled. On multivariable analysis, the CHA2DS2-VASc score (odds ratio 1.40, 95% confidence interval 1.12-1.76 per 1 point) was independently associated with PAO and correlated with the initial NIHSS score (standardized coefficient 0.198, P = 0.017). This association was not significant after further adjustment for PAO (0.080, P = 0.241). The CHA2DS2-VASc score was independently related to poor outcome even adjusted for PAO (odds ratio 1.39, 95% confidence interval 1.03-1.88). CONCLUSION: The CHA2DS2-VASc score was associated with PAO in acute ischaemic stroke patients with AF. The CHA2DS2-VASc score may be correlated with the NIHSS score through the presence of PAO and with poor functional outcome independently of PAO.

Intravenous thrombolysis for patients with reverse magnetic resonance angiography and diffusion-weighted imaging mismatch: SAMURAI and NCVC rt-PA Registries.

BACKGROUND AND PURPOSE: The characteristics of reverse magnetic resonance angiography and diffusion-weighted imaging (MRA-DWI) mismatch (RMM), defined as a large DWI lesion in the absence of major artery occlusion (MAO), remain unknown, especially in patients treated with intravenous recombinant tissue plasminogen activator (rt-PA). METHODS: Patients with stroke in the middle cerebral artery territory were included. Early ischaemic changes (EIC) were assessed with the Alberta Stroke Program Early CT Score on DWI (DWI-ASPECTS). All patients were divided into four groups based on the presence of MAO and a DWI-ASPECTS cut-off value of <7. RMM was defined as DWI-ASPECTS <7 without MAO. Clinical characteristics, symptomatic intracerebral hemorrhage (sICH) and favorable functional outcome (modified Rankin Scale score 0-2) at 90 days were compared amongst the four groups. RESULTS: Of the 486 patients enrolled (167 women, median age 74 years, median initial National Institutes of Health Stroke Scale score 13), reverse MRA-DWI mismatch was observed in 24 (5%). Of the clinical characteristics, cardioembolism was the only factor that was independently associated with RMM [odds ratio (OR) 5.49, 95% confidence interval (CI) 1.25-24.1]. Multivariable analyses revealed that patients with RMM more commonly had sICH than those with DWI-ASPECTS ≥ 7 irrespective of the presence (OR 5.44, 95% CI 1.13-26.1) or absence (13.1, 2.07-83.3) of MAO, and they had a more favorable functional outcome than those with DWI-ASPECTS < 7 plus MAO (7.45, 2.39-23.2). CONCLUSION: RMM was observed in 5% of patients treated with rt-PA and associated with cardioembolism. Patients with RMM may benefit from thrombolysis compared with those with EIC with MAO, although increment in the rate of sICH is a concern.

Simple clinical predictors of stroke outcome based on National Institutes of Health Stroke scale score during 1-h recombinant tissue-type plasminogen activator infusion.

BACKGROUND AND PURPOSE: An index for predictors of stroke outcome was determined based on the National Institutes of Health Stroke Scale (NIHSS) scores during 1-h intravenous administration of recombinant tissue-type plasminogen activator (rt-PA). METHODS: Stroke patients with baseline NIHSS score ≥8 and occlusion at the internal carotid or middle cerebral arteries (ICA, MCA) were retrospectively studied from a prospective single-center registry. NIHSS scores and inverse change from baseline scores (ΔNIHSS) were assessed at 30 min and 1 h after rt-PA infusion. Patients were divided into two groups according to arterial occlusion sites: group P, ICA or proximal M1; and group D, distal M1 or M2. A modified Rankin Scale score of 2-6 at 3 months was defined as an unfavorable outcome. RESULTS: In all 108 patients, the cutoff NIHSS score predicting unfavorable outcome was ≥12 and cutoff ΔNIHSS scores were ≤2 at both 30 min and 1 h. In group P (n = 36), the cutoff NIHSS score was ≥14 at both 30 min and 1 h and cutoff ΔNIHSS scores were ≤1 at 30 min and ≤2 at 1 h. Unfavorable outcome was seen in all patients with NIHSS1 h ≥ 14, ΔNIHSS30 min ≤ 1 and ΔNIHSS1 h ≤ 2. In group D (n = 72), the cutoff NIHSS scores were ≥12 at both 30 min and 1 h, and cutoff ΔNIHSS scores were ≤2 at 30 min and ≤7 at 1 h; 90% of patients with unfavorable outcome showed ΔNIHSS1 h ≤ 7. CONCLUSION: NIHSS and ΔNIHSS during 1-h rt-PA infusion seemed predictive of 3-month outcome when the site of arterial occlusion was identified prior to rt-PA.

Run-up to participation in ATACH II in Japan.

Intracerebral hemorrhage (ICH) is a major cause of morbidity and mortality in Japan. Seventeen Japanese institutions are participating in the Antihypertensive Treatment for Acute Cerebral Hemorrhage (ATACH) II Trial (ClinicalTrials.gov no. NCT01176565; UMIN 000006526). This phase III trial is designed to determine the therapeutic benefit of early intensive systolic blood pressure (BP) lowering for acute hypertension in ICH patients. This report explains the long run-up to reach the start of patient registration in ATACH II in Japan, including our preliminary study, a nationwide survey on antihypertensive treatment for acute ICH patients, a multicenter study for hyperacute BP lowering (the SAMURAI-ICH study), revision of the official Japanese label for intravenous nicardipine, and construction of the infrastructure for the trial.

Arterial occlusion sites on magnetic resonance angiography influence the efficacy of intravenous low-dose (0.6 mg/kg) alteplase therapy for ischaemic stroke.

AIMS: To determine the predictors of efficacy, including magnetic resonance imaging information, for low-dose intravenous alteplase therapy for stroke patients. METHODS: Seventy-eight patients were prospectively enrolled in a single Stroke Unit (SU) receiving alteplase at a dose of 0.6 mg/kg during the initial 27 months after its approval in Japan. Ischaemic changes and vascular lesions were identified using computed tomography, diffusion-weighted magnetic resonance imaging, and magnetic resonance angiography. Early ischaemic signs were assessed using the Alberta Stroke Program Early CT Score. RESULTS: The median baseline National Institutes of Health Stroke Scale score of 78 patients was 12. In 19 patients (24%), the National Institutes of Health Stroke Scale score improved by >or=8 points at 24 h. After multivariate adjustment, occlusion at the internal carotid artery (odds ratio 11.82, 95% confidence interval 1.73-142.74), Alberta Stroke Program Early CT Score on diffusion-weighted imaging

Frontal bone window improves the ability of transcranial color-coded sonography to visualize the anterior cerebral artery of Asian patients with stroke.

The frontal bone window (FBW) is a promising approach in evaluating the anterior cerebral artery. The goal of the present study was to determine the rates of detection of the basal cerebral arteries by using the FBW alone and a combination of the FBW with the temporal bone window (TBW) in 163 patients. The combined application improved detection rates of A1 (58.6% versus 46.0%, P = .001) and A2 (43.6% versus 6.7%, P < .001) compared with the TBW alone.

Eccentric stenosis of the carotid artery associated with ipsilateral cerebrovascular events.

BACKGROUND AND PURPOSE: Eccentric stenosis of the coronary artery is associated with plaque disruption and acute coronary syndrome. The purpose of the present study was to determine whether eccentric stenosis of the carotid artery contributes to cerebrovascular events. MATERIALS AND METHODS: Of 6859 patients with vascular diseases who underwent duplex carotid ultrasonography, we studied 512 internal carotid arteries in 441 patients who had a maximum area stenosis at or more than 70%, which corresponds with approximately 50% or more by the NASCET method. The maximal (A) and minimal wall thicknesses (B) were measured on cross-sectional sonography images, and an eccentricity index was calculated using the following formula: (A - B)/A. Arteries in the lowest quartile of the eccentricity index (<0.69) were defined as having a concentric stenosis, whereas the others were defined as having eccentric stenosis. The underlying clinical characteristics and plaque morphologies, as well as the occurrence of ipsilateral ischemic stroke or transient ischemic attack in the preceding year, were compared between patients with eccentric and concentric stenosis. RESULTS: Patient characteristics and plaque morphology were similar between the 2 groups. Cerebrovascular events occurred more frequently ipsilaterally to the artery with eccentric stenosis (13.5%) than to the artery with concentric stenosis (5.5%; P = .013); the difference was more evident when cerebrovascular events of presumed carotid arterial origin were assessed (P = .005). After adjusting for risk factors and plaque morphology, eccentric stenosis was independently related to the presence of recent cerebrovascular events (odds ratio = 2.76; 95% confidence interval = 1.19-6.40). CONCLUSIONS: In patients with an area carotid stenosis of 70% or more, eccentric plaque was associated with a significantly increased incidence of ipsilateral cerebrovascular events compared with patients with concentric stenosis.

How to improve repetition ability in patients with Wernicke's aphasia: the effect of a disguised task.

Dissociation "automatico-voluntaire" is a symptom observed in aphasic patients. We elucidated the difference between voluntary and involuntary speech output in a quantitative manner using the same task materials in nine patients with Wernicke's aphasia. All the patients exhibited better ability and less paraphasias in a repetition task elicited in a disguised condition than in an ordinary repetition condition. This result indicates that the output difficulty in Wernicke's aphasia might be a disability of volitional control over the language system.

Homonymous defect of macular vision in ischemic stroke.

It is generally believed that a homonymous defect of macular vision (HMV) is caused by a small lesion restricted to the occipital lobe tip and rarely results from ischemic stroke. The incidence of HMV was studied retrospectively in 54 patients with infarction of the posterior cerebral artery territory who underwent Goldmann's visual field test. HMV was found in 6 patients (11%). In all of them, HMV was first dismissed due to a confrontation test of visual fields at the bedside and later detected by Goldmann's visual field test. All had a relatively large infarction extending from the occipital lobe tip to the posterior part of the calcarine cortex and/or the neighboring subcortical regions. Stroke-induced HMV can be caused by a large lesion involving the occipital pole and may not be so rare as generally considered.

Blood flow in the left atrial appendage and embolic stroke in nonvalvular atrial fibrillation.

It is unclear if low flow velocity in the left atrial appendage (LAA) is a predisposing factor to stroke in patients with nonvalvular atrial fibrillation (NVAF). We investigated flow velocity in the LAA in NVAF patients in relation to a past history of stroke and other potential embolic sources. We measured and analyzed peak flow velocities into (FV-in) and out of (FV-out) the LAA in a middle portion of the LAA in 35 NVAF patients by transesophageal echocardiography (TEE). We divided the NVAF patients into 3 groups: the Eaf group had a history of embolic stroke without any other potential embolic sources; the Emulti group had other potential embolic sources, and the control group had no embolic history. FV-in and FV-out in the Eaf group (12.3 +/- 6.7 and 10.2 +/- 7.3 cm/s) were significantly lower than those in the control group (24.3 +/- 11.3 and 19.9 +/- 8.8 cm/s; multicomparison Scheffé's test, p = 0.0123 and 0.0395, respectively). The Emulti group varied in those values from less than 5 to above 35. Low flow velocity in the LAA seems to be a predisposing factor for stroke in NVAF patients without any other sources of emboli.

Prospective comparative study of brain protection in total aortic arch replacement: deep hypothermic circulatory arrest with retrograde cerebral perfusion or selective antegrade cerebral perfusion.

BACKGROUND: The purpose of this study was to compare the results of total aortic arch replacement using two different methods of brain protection, particularly with respect to neurologic outcome. METHODS: From June 1997, 60 consecutive patients who underwent total arch replacement through a midsternotomy were alternately allocated to one of two methods of brain protection: deep hypothermic circulatory arrest with retrograde cerebral perfusion (RCP: 30 patients) or with selective antegrade cerebral perfusion (SCP: 30 patients). Preoperative and postoperative (3 weeks) brain CT scan, neurological examination, and cognitive function tests were performed. Serum 100b protein was assayed before and after the cardiopulmonary bypass, as well as 24 hours and 48 hours after the operation. RESULTS: Hospital mortality occurred in 2 patients in the RCP group (6.6%) and 2 in the SCP group (6.6%). New strokes occurred in 1 (3.3%) of the RCP group and in 2 (6.6%) of the SCP group (p = 0.6). The incidence of transient brain dysfunction was significantly higher in the RCP group than in the SCP group (10, 33.3% vs 4, 13.3%, p = 0.05). Except in patients with strokes, S-100b values showed no significant differences in the two groups (RCP: SCP, prebypass 0.01+/-0.04: 0.05+/-0.16, postbypass 2.17+/-0.94: 1.97+/-1.00, 24 hours 0.61+/-0.36: 0.60+/-0.37, 48 hours 0.36+/-0.45: 0.46+/-0.40 microg/L, p = 0.7). There were no intergroup differences in the scores of memory decline (RCP 0.74+/-0.99; SCP 0.55+/-1.19, p = 0.6), orientation (RCP 1.11+/-1.29; SCP 0.50+/-0.76, p = 0.08), or intellectual function (RCP 1.21+/-1.27; SCP 1.05+/-1.15, p = 0.7). CONCLUSIONS: Both methods of brain protection for patients undergoing total arch replacement resulted in acceptable levels of mortality and morbidity. However, the prevalence of transient brain dysfunction was significantly higher in patients with the RCP.

Microembolic signals and diffusion-weighted MR imaging abnormalities in acute ischemic stroke.

BACKGROUND AND PURPOSE: The clinical significance of microembolic signals (MESs) detected by transcranial Doppler sonography (TCD) in acute ischemic stroke remains unclear. The purpose of the present study was to assess the findings of diffusion-weighted MR imaging (DWI) and other clinical characteristics in patients with acute ischemic stroke and MESs. METHODS: We performed TCD and DWI within 48 hours and 7 days, respectively, after stroke onset in 28 patients with acute brain infarction. The relationship between the number of MESs and DWI findings, risk factors for stroke, National Institutes of Health Stroke Scale (NIHSS) score on admission, and arterial disease was examined. RESULTS: Ten patients had MESs detected by TCD (MES group) and 18 had no MESs (control group). The frequency of hypertension, diabetes mellitus, hyperlipidemia, and smoking; NIHSS score; blood-coagulation parameters; and interval between stroke onset and DWI study did not differ between the two groups. However, arterial disease was more frequent in the MES group than in the control group. Small, multifocal ischemic lesions (<10 mm in diameter) on DWI were more frequent in the MES group than in the control group. Conventional CT and MR imaging often failed to show these lesions. CONCLUSION: Small, often asymptomatic DWI abnormalities were more frequent in patients with MESs detected by TCD and with large-vessel occlusive diseases than in stroke patients without MESs. TCD and DWI may provide early clues to the mechanism of stroke in the acute phase.

[A case of agnosia for streets and houses unaccompanied by prosopagnosia of familiar faces due to the right occipital lobe infarction].

We reported a patient who showed agnosia for streets and homes unaccompanied by prosopagnosia of familiar faces following infarction in the right occipital lobe. A 70-years-old right-handed man admitted to our department because of sudden development of visual impairment. He had left hemianopsia, left unilateral spatial neglect and slight visual memory disturbance but no other neurological abnormalities. His verbal memory was maintained intact. He was, however, unable to distinguish the sceneries of buildings and streets regardless of their familiarities and often got lost in the hospital. His topographical abilities in map-sketching and route-description were partially impaired depending upon the familiarity of targets; the disability was observed toward unfamiliar targets. His ability in facial recognition was also partially impaired depending upon the familiarity of persons. The patient was unable to distinguish faces of unfamiliar persons, such as nurses and doctors whom he met following stroke, whereas he was able to distinguish faces of familiar persons, such as his family and friends. The brain MRI demonstrated infarction in the right medial occipital lobe including parahippocampal gyrus, lingual gyrus and fusiform gyrus. In general, the manifestation of agnosia for streets and houses is associated with prosopagnosia. The present case, however, exhibited only the former in association with the partial manifestation of the latter. The fact suggests that those two are independent syndromes. The present case also showed a dissociation in the abilities of topographical and facial recognition according to the familiarity of targets. The process for the retrieval and reference of acquired information and that for the acquirement of new visual information may work in an independent manner.

[A case of antiphospholipid antibody syndrome showing a neurological deterioration and infarct development over a month].

A 67-year-old man was admitted to our hospital because of a sudden onset of gait disturbance and behavioral abnormalities. On the admission, he had a moderate consciousness disturbance and right hemiparesis with left internal carotid artery occlusion. Eight days after the stroke, the patient further developed left hemiparesis in association with right internal carotid artery occlusion. Despite anticoagulation therapy and plasma volume loading, neurological symptoms deteriorated over a month, during which CT scan demonstrated a progressive expansion of infarct size. Laboratory tests revealed the presence of lupus anticoagulant. Antiphospholipid antibody syndrome may be associated with a progression of ischemic stroke.

Successful application of three-dimensional transcranial power Doppler imaging in two stroke patients.

We applied a new technique of three-dimensional (3-D) transcranial power Doppler imaging to demonstrate the middle cerebral artery (MCA) in the 2 stroke patients. In the first patient, the 3-D power Doppler study clearly showed the horizontal portion, bifurcation, proximal portion of the upper and lower trunks, and the major branches of the lower trunk of the MCA. In the second patient, the 3-D power Doppler clearly revealed the proximal bifurcation of the left MCA. The 3-D transcranial power Doppler seems to be useful in making clear 3-D images of the MCA.

[Right-to-left shunt and atrial septal aneurysm in stroke patients: a contrast transesophageal echocardiographic study].

BACKGROUND: Transesophageal echocardiography (TEE) has been used to detect cardiac abnormalities including right-to-left shunt (RLS) and atrial septal aneurysm (ASA). The aim of this study was to elucidate frequency of RLS and ASA detected by contrast-TEE, and to evaluate the role of these abnormalities in stroke patients. METHODS AND RESULTS: We investigated prevalence of RLS and ASA in 504 patients suspected of stroke by using TEE. (mean age 62 +/- 12 y.o., stroke 491, non-stroke 13). The RLS was detected in 64 patients (12.7%), in whom 49 patients (9.7%) had the patent foramen ovale (PFO). The ASA was demonstrated in 10 patients (2.0%), and accompanied well with the RLS (six of the 10, 60%). The prevalent ratios of the RLS (33.8%), the PFO (26.8%), and the ASA (11.3%) in 71 patients with embolic stroke (brain embolism or TIA) of unknown cause were significantly higher than those in the other 433 patients (9.2%, 6.9%, 0.5%, respectively, p < 0.0001). Multiple logistic regression analysis showed that both the PFO and the ASA were independent risk factors (odds ratio: 3.8: p = 0.0002 and 16.6: p = 0.0008, respectively) for embolic stroke of unknown cause. CONCLUSION: It seems that the RLS, PFO and the ASA play a roll in developing embolic stroke of unknown cause.

Transoral carotid ultrasonography.

BACKGROUND AND PURPOSE: We attempted ultrasonographic evaluation of the distal extracranial internal carotid artery (ICA) using the transoral method (transoral carotid ultrasonography [TOCU]). METHODS: The subjects consisted of five healthy volunteers and seven stroke patients. Examinations were performed with a color Doppler flow imaging system equipped with convex array transducers (7 or 9.5 MHz), originally designed for transrectal use. After local anesthesia of the pharynx, we inserted a probe covered with thin gum transorally, touching the tip to the pharyngeal posterolateral wall. We then attempted to detect the ICA and measure flow velocity of the distal extracranial ICA using principal images obtained by TOCU. RESULTS: TOCU was successfully performed in all subjects without any difficulty. In the healthy volunteers, the ICA was identified at a depth of 2.2+/-0.6 cm and visualized as a vertical linear vessel 2.9+/-0.3 cm in length and bent slightly backward. The diameter and mean flow velocity of the distal extracranial ICA were 4.7+/-0.2 mm and 50+/-7 cm/s, respectively. In the stroke patients, some remarkable findings were obtained, including a narrow ICA with low flow velocity in a patient with possible ICA dissection, a lucent echo without flow signal in a patient with acute cardioembolic ICA occlusion, and decreased ICA flow velocity in a patient with ipsilateral MCA stenosis. CONCLUSIONS: These preliminary data demonstrate the potential applicability of TOCU to the evaluation of flow in the far distal extracranial ICA. TOCU definitely warrants further investigation in patients with carotid artery disease.

Side-to-side differences of the common carotid artery diameter in presence of asymmetry of the circle of Willis or different vasculopathies.

Based on angiographic and carotid ultrasonographic findings in 60 patients with stroke or other diseases, we studied what factors affected the side-to-side differences of the common carotid artery diameter (CCAD). The side-to-side differences of the CCAD were within 0.7 mm in patients with normal cerebral angiogram, but a difference above 0.7 mm was found in many patients with asymmetry of the circle of Willis or different vasculopathies, such as the carotid artery occlusion, cerebral arteriovenous malformation and aortitis.

[Detection of microemboli by transcranial Doppler sonography after carotid endarterectomy].

Transcranial Doppler sonography (TCD), a non-invasive monitoring technique, has potential for detecting microemboli caused by the extracranial internal carotid artery. Many previous reports have shown that TCD-detected microemboli may be a risk factor for stroke. The main purpose of this study is to verify whether microemboli cease after carotid endarterectomy (CEA). TCD monitoring was performed in 43 cases before and after CEA. TCD monitoring was carried out for an hour at the ipsilateral middle cerebral artery of each case using a 2-MHz pulse-wave transcranial Doppler device, and high intensity transient signals were counted as microemboli. Microemboli were detected preoperatively in 10 cases (23.3%). Microemboli were not detected in any case immediately after CEA, in either the subacute stage (from 14 to 21 days after CEA) or in the chronic stage (more than 3 months after CEA). In the acute stage (from 3 to 7 days after CEA), microemboli were detected in three cases (7.0%). The rate of TCD-detected microembolic was always significantly reduced after CEA. TCD monitoring can be helpful in assessing the effect of CEA for prevention of stroke by removing the suspected source of microemboli.

[Analysis of factors related to microemboli in cases with internal carotid artery stenosis].

Transcranial Doppler ultrasound (TCD) has been used to detect microemboli in cases with extracranial internal carotid artery stenosis. However, the mechanism causing microemboli has remained unclear. The purpose of this study is to clarify clinical characteristics and circumstances associated with the genesis of TCD-detected microemboli. Ninety-one cases with more than 30% stenosis of the internal carotid arteries were studied. TCD monitoring was carried out for an hour at the ipsilateral middle cerebral artery of each case using a 2-MHz pulse-wave transcranial Doppler device, and high intensity transient signals were counted as microemboli. Digital subtraction angiography, magnetic resonance imaging (MRI) and single photon emission computed tomography (SPECT) were also performed in all cases. Microemboli were detected in 30 of 91 cases. Microemboli were significantly well detected in cases with a history of ischemic event and/or cerebral infarction recognized by MRI. Detection of microemboli had no relation to sex, age or clinical risk factors (hypertension, hypercholesterolemia, diabetes mellitus and smoke habituation). In contrast, detection of microemboli was significantly related to decrease in cerebral blood flow recognized by SPECT, severity of stenosis and wall irregularity of lesion recognized by angiography. Microemboli can be found in a significantly high percentage of these clinical conditions, which may be risk factors for embolic stroke caused by extracranial internal carotid artery stenosis.