Transient Hemichorea-hemiballism Induced by a Combination of Postprandial Hypotension and Severe Stenosis of the Innominate Artery Concomitant with Left Carotid Occlusion.

Hemichorea-hemiballism (HCHB) due to transient ischemic attacks (TIAs) is rare. An 83-year-old woman had repeated episodes of right-sided HCHB for 3 months. Magnetic resonance (MR) angiography demonstrated occlusion of the left carotid and middle cerebral arteries and severe stenosis of the innominate artery, and 24-hour ambulatory blood pressure monitoring showed a blood pressure decrease of >20 mmHg after each meal. We speculated that HCHB developed as TIAs due to hemodynamic failure in the left cerebral hemisphere, caused by a combination of severe stenosis of the innominate artery concomitant with occlusion of the left carotid and middle cerebral arteries as well as postprandial hypotension.

Endovascular Embolization with n-Butyl Cyanoacrylate for Ruptured Distal Posterior Inferior Cerebellar Artery Dissecting Aneurysm.

Parent artery occlusion is a definitive treatment method for preventing rebleeding of dissecting aneurysms. We herein report a case of a ruptured distal posterior inferior cerebellar artery (PICA) dissecting aneurysm treated with internal trapping using n-butyl-2-cyanoacrylate (NBCA). A 65-year-old man visited our hospital with a complaint of headache and neck pain that began 1 week before his arrival. He had a history of spontaneous subarachnoid hemorrhage of unknown cause. Computed tomography of the brain revealed a small amount of subarachnoid hemorrhage, and distal subtraction angiogram showed a distal PICA dissecting aneurysm. We placed a guiding catheter in the left vertebral artery and an intermediate catheter in the PICA. A microcatheter was guided toward the proximal side of the aneurysm and was wedged into the parent artery. The dissecting aneurysm was treated with parent artery occlusion using 50% NBCA. The postoperative course was uneventful, and the patient was discharged 3 weeks after treatment without any neurological deficit. Parent artery occlusion with internal trapping using NBCA could be a safe and definitive treatment method for distal PICA dissecting aneurysms. Angiographical evaluation of the collateral network in the distal branch of PICA before embolization and wedged microcatheter technique in the parent artery are important for successful embolization using NBCA.

Parent Artery Occlusion for Symptomatic Large Internal Carotid Artery Aneurysm with Primitive Trigeminal Artery Variant: A Case Report.

Objective: To report a case of symptomatic large cerebral aneurysm of the internal carotid artery (ICA), associated with a primitive trigeminal artery variant (PTAv), which was treated with a balloon occlusion test (BOT) to evaluate ischemic tolerance. Case Presentation: A 79-year-old woman was diagnosed with a symptomatic large cerebral aneurysm of the ICA bifurcating the PTAv due to diplopia. After confirming the ischemic tolerance of the perfusion area and PTAv by BOT, we performed ICA parent artery occlusion with selective embolization of the PTAv. Postoperative MRI showed no ischemic lesion and the diplopia was resolved. Conclusion: ICA parent artery occlusion with PTAv selective embolization after evaluation by BOT is useful in the treatment of large aneurysms.

A Ruptured Aneurysm in Aplastic or Twig-like Middle Cerebral Artery: A Case Report with Histological Investigation.

Aplastic or twig-like middle cerebral artery (Ap/T-MCA) is a rare vascular anomaly that can cause a hemorrhagic or ischemic event. We report a 38-year-old man who presented with intracerebral hemorrhage from a ruptured aneurysm associated with an Ap/T-MCA. After aneurysm trapping and resection, histopathological examination revealed an internal elastic lamina (IEL) disruption and a thin aneurysmal wall. The patient recovered well after surgery and rehabilitation. No hemorrhagic or ischemic events have occurred during 2 years of follow-up. Ap/T-MCA-associated aneurysms exhibit a disrupted IEL and thin wall, which demonstrates the fragility of the "twig-like" vessels.

A Case of Acute Embolic Occlusion of the Common Carotid Artery in Which a Giant Thrombus Was Retrieved Using the Parallel Stent Retriever Technique.

Objective: We report a case of embolic occlusion of the common carotid artery (CCA) in which a giant thrombus was retrieved using the parallel stent retriever technique. Case Presentation: An 84-year-old woman without anticoagulant therapy despite a history of cardioembolic stroke presented to our hospital because of left hemiparesis after developing sudden vision loss in her right eye. Emergency angiography revealed a giant thrombus in the right CCA. After arresting flow in the CCA using a balloon-guided catheter (BGC), we deployed two stent retrievers in parallel from the internal carotid artery to the CCA, and slowly retrieved them simultaneously under manual aspiration through the BGC. As a result, complete recanalization was achieved. Conclusion: Thrombi causing acute embolic occlusion of the CCA are often too large to be completely retrieved using conventional thrombectomy techniques. The parallel stent retriever technique may be effective in such cases.

Efficacy and Safety Study of Wearable Cyborg HAL (Hybrid Assistive Limb) in Hemiplegic Patients With Acute Stroke (EARLY GAIT Study): Protocols for a Randomized Controlled Trial.

We hypothesized that gait treatment with a wearable cyborg Hybrid Assistive Limb (HAL) would improve the walking ability of patients with hemiparesis after stroke. This study aims to evaluate the efficacy and safety of gait treatment using HAL versus conventional gait training (CGT) in hemiplegic patients with acute stroke and establish a protocol for doctor-initiated clinical trials for acute stroke. We will enroll patients with acute stroke at the University of Tsukuba Hospital. This study is a single-center, randomized, parallel-group, controlled trial (HAL group, n = 20; control group, n = 20) that will include three phases: (1) pre-observation phase (patient enrollment, baseline assessment, and randomization); (2) treatment phase (nine sessions, twice or thrice per week over 3-4 weeks; the HAL and control groups will perform gait treatment using HAL or CGT, respectively, and finally (3) post-treatment evaluation phase. The Functional Ambulation Category score will be the primary outcome measure, and the following secondary outcome measures will be assessed: Mini-Mental State Examination, Brunnstrom recovery stage of lower limbs, Fugl-Meyer assessment of lower limbs, 6-min walking distance, comfortable gait speed, step length, cadence, Barthel Index, Functional Independence Measure, gait posture, motion analysis (muscle activity), amount of activity (evaluated using an activity meter), stroke-specific QOL, and modified Rankin Scale score. The baseline assessment, post-treatment evaluation, and follow-up assessment will evaluate the overall outcome measures; for other evaluations, physical function evaluation centered on walking will be performed exclusively, excluding ADL and QOL scores. This study is a randomized controlled trial that aims to clarify the efficacy and safety of gait treatment using HAL compared with CGT in hemiplegic patients with acute stroke. In addition, we aim to establish a protocol for doctor-initiated clinical trials for acute stroke based on the study results. If our results demonstrate the effectiveness of the proposed treatment regarding outcomes of patients with hemiplegic acute stroke, this study will promote the treatment of these patients using the HAL system as an effective tool in future stroke rehabilitation programs. The study protocol was registered with the Japan Registry of Clinical Trials on October 14, 2020 (jRCTs032200151).

Carotid Artery Stenting Using the Snake Hunt Technique for Highly Tortuous Carotid Artery Stenosis: A Technical Note.

In carotid artery stenting (CAS) for highly tortuous carotid stenosis, it is often difficult to guide rigid devices such as carotid stents. There are various adjunctive techniques using a guidewire: the buddy wire technique, the sheep technique, and the stiff guide technique. We report a case in which the tortuous vessel was straightened and a stent could be inserted. A 64-year-old man with amaurosis had highly tortuous left carotid stenosis. Despite the best medical treatments, he often had transient cerebral ischemic symptoms, so we planned CAS. We could insert the first stent, but the proximal vessel was kinked by the placement of the stent. It was so tortuous that the second stent could not be inserted by adjunctive techniques. Therefore, the proximal balloon was inflated and pulled back to straighten the tortuous vessel, and then we could insert the stent. We named this technique the "snake hunt technique" because it was just like catching a snake given that the tortuous vessel was stretched. This technique could be a troubleshooting step when it is difficult to insert a stiff device such as a stent or balloon even with the use of various adjunctive techniques.

Effectiveness of Near-Infrared Spectroscopy (NIRO-200NX, Pulse Mode) for Risk Management in Carotid Artery Stenting.

BACKGROUND: Near-infrared spectroscopy (NIRS) is an alternative monitoring method during carotid artery stenting (CAS). NIRS has been reported to be effective in emergency care; however, it is unknown whether it can predict intraoperative ischemic intolerance and cerebral hyperperfusion during CAS. Perioperative ischemic intolerance and cerebral hyperperfusion are potential events during CAS for carotid artery stenosis. We evaluated whether perioperative monitoring of the tissue oxygenation index (TOI) using NIRS with the NIRO system can predict the occurrence of ischemic intolerance and cerebral hyperperfusion. METHODS: The TOI of 27 patients was measured during CAS. The relationship between the TOI and ischemic intolerance or cerebral hyperperfusion was analyzed, and the cutoff TOI was calculated to predict their occurrence. RESULTS: Ischemic intolerance occurred in 5 patients during balloon protection. The TOI in the presence of ischemic intolerance was significantly lower than that without ischemic intolerance. The cutoff TOI to detect ischemic intolerance was 50% and that of the TOI change rate before and after balloon protection was 80%. The ischemic symptoms in all patients had resolved immediately after balloon deflation. The cerebral hyperperfusion phenomenon was detected using single-photon emission computed tomography in 4 patients. These patients showed a transient increase in the TOI immediately after CAS; however, none of these patients showed symptomatic cerebral hyperperfusion phenomenon. The cutoff TOI to detect cerebral hyperperfusion was 109% compared with the TOI before CAS. CONCLUSION: Monitoring of the TOI using the NIRO system could be useful for the detection of ischemic intolerance and cerebral hyperperfusion during CAS and to prevent perioperative adverse events.

Effects of Gait Treatment With a Single-Leg Hybrid Assistive Limb System After Acute Stroke: A Non-randomized Clinical Trial.

We hypothesized that a single-leg version of the Hybrid Assistive Limb (HAL) system could improve the gait and physical function of patients with hemiparesis following a stroke. In this pilot study, we therefore compared the efficacy of HAL-based gait training with that of conventional gait training (CGT) in patients with acute stroke. Patients admitted to the participating university hospital were assigned to the HAL group, whereas those admitted to outside teaching hospitals under the same rehabilitation program who did not use the HAL were assigned to the control group. Over 3 weeks, all participants completed nine 20 min sessions of gait training, using either HAL (i.e., the single-leg version of HAL on the paretic side) or conventional methods (i.e., walking aids and gait orthoses). Outcome measures were evaluated before and after the nine training sessions. The Functional Ambulation Category (FAC) was the primary outcome measure, but the following secondary outcome measures were also assessed: National Institutes of Health Stroke Scale, Fugl-Meyer Assessment (Lower Extremity), comfortable walking speed, step length, cadence, 6-min walk distance, Barthel Index, and Functional Independence Measure. In total, 22 post-stroke participants completed the clinical trial: 12 in the HAL group and 10 in the CGT group. No serious adverse events occurred in either group. The HAL group showed significant improvement in FAC after nine sessions when compared with the CGT group (P = 0.014). However, secondary outcomes did not differ significantly between the groups. Our results demonstrate that HAL-based gait therapy may improve independent walking in patients with acute stroke hemiplegia who are dependent on ambulatory assistance. A larger-scale randomized controlled trial is needed to clarify the effectiveness of single-leg HAL therapy. Clinical Trial Registration: UMIN Clinical Trials Registry, identifier UMIN000022410.

Spreading Awareness of Stroke through School-Based Education: A Pooled Analysis of Three Community-Based Studies.

BACKGROUND: Advancing school-based education is a promising means to spread knowledge pertaining to stroke. The aim of the current study was to clarify whether stroke lessons provided by schoolteachers could deliver stroke knowledge to children (aged 9-11 years) and their parents, at a similar level to when taught by medical staff. METHODS: Schoolteachers conducted lessons on stroke for school children using the educational materials we prepared (i.e., the teacher group; 1051 children and 719 parents). This was compared with our previous data from Akashi city and Tochigi prefecture, in which the stroke lessons were conducted by medical staff (i.e., the medical group; 1031 children and 756 parents). Three campaigns were conducted between September 2014 and May 2016. Each child was given education materials to take home to discuss stroke with their parents. The children and their parents answered questionnaires on stroke knowledge, at baseline, immediately after the lesson, and at 3 months after the lesson. RESULTS: Compared with the time point before the lesson, both children and parents instructed by the teacher group showed significant increases in the scores about stroke symptoms and risk factors, immediately and at 3 months after the lesson (P < .001). The combined analysis for the group instructed by medical personnel showed no significant differences in the stroke knowledge scores between the 2 groups at 3 months. CONCLUSIONS: Teacher-led lessons, using our educational material, adequately delivered knowledge of stroke to children and parents, in a manner that was similar to when medical staff delivered this information.

Improving Call-to-Door Time Using School-Based Intervention by Emergency Medical Technicians: The Akashi Project.

BACKGROUND: Identification of stroke signs by emergency medical technicians (EMTs) is important for initiating the "stroke chain of survival." The aim of the present study was to clarify the effect of EMT-led lessons on stroke awareness for schoolchildren in the Akashi project on the transportation time to arrive at the hospital. METHODS: Stroke lessons were given by EMTs to 887 elementary school children in elementary schools between September 2014 and October 2015. Data on transportation times from prehospital records and final diagnoses at discharge were collected from both pre- (period 1; January-June 2014) and posteducation (period 2; January-June 2016) periods. Transportation time or onset-to-door time was divided into two parts: the onset-to-call time and the call-to-door time. RESULTS: One hundred forty-four patients in period 1 and 143 in period 2 were transported with potential strokes identified by EMTs. Among these, 119 (83%) in period 1 and 114 (80%) in period 2 had final diagnosis of stroke or transient ischemic attack. The mean age in period 2 was older than that in period 1 (75 years old versus 72 years old); however, there were no significant differences in gender and consciousness level between the 2 periods. The median call-to-door time of 28 minutes for period-2 patients was significantly shorter than that for period-1 patients (32 minutes, P = .0057). There were no differences in median onset-to-door times and onset-to-call times between the 2 periods. CONCLUSIONS: School-based education about stroke conducted by EMTs may be a promising strategy to cut the prehospital delay and to widely spread stroke awareness via school children and EMTs.

Effects of a school-based stroke education program on stroke-related knowledge and behaviour modification-school class based intervention study for elementary school students and parental guardians in a Japanese rural area.

OBJECTIVES: This study aimed to determine the effect of a stroke education programme on elementary school students and their parental guardians in a rural area in Japan that has high stroke mortality. DESIGN: School class based intervention study. SETTING: Eleven public elementary schools in Tochigi Prefecture, Japan. PARTICIPANTS: 268 students aged 11-12 years and 267 parental guardians. INTERVENTIONS: Students received lessons about stroke featuring animated cartoons and were instructed to communicate their knowledge about stroke to their parental guardians using material (comic books) distributed in the lessons. Stroke knowledge (symptoms, risk factors and attitude towards stroke) and behavioural change for risk factors were assessed at baseline, immediately after the programme and at 3 months. We also evaluated behavioural change for risk factors among parental guardians. RESULTS: The percentage of students with all correct answers for stroke symptoms, risk factors and the recommended response to stroke was significantly increased at 3 months P<0.001). We observed a significant increase in the percentage of guardians who chose all correct symptoms (P<0.001: 61.0% vs 85.4%) and risk factors (P<0.001: 41.2% vs 59.9%) at 3 months compared with baseline. The percentage of parental guardians with a high behavioural response to improving risk factors was significantly increased at 3 months compared with baseline (P<0.001). CONCLUSIONS: In a rural population with high stroke mortality, stroke education can improve knowledge about stroke in elementary school students and their parental guardians. ETHICS AND DISSEMINATION: We conducted the intervention as a part of compulsory education; this study was not a clinical trial. This study was approved by the Ethics Committee of the National Cerebral and Cardiovascular Center (M27-026).

Effects of school-based intervention by emergency medical technicians on students and their parents: a community-based prospective study of the Akashi project.

OBJECTIVE: Stroke lessons for youth provided by emergency medical technicians (EMTs) may be an effective strategy to facilitate early intervention for patients with stroke. The aim of this study was to examine how effective EMT-led lessons on stroke awareness for schoolchildren were at disseminating stroke information. SETTING, PARTICIPANTS AND OUTCOME MEASURES: The study was performed in the city of Akashi, Hyogo, Japan (Akashi project). Children (aged 9-10 years old) at 11 public elementary schools and their parents were enrolled in this study. EMTs from the firefighting headquarters provided lessons on stroke to the children using our educational materials between September 2014 and October 2015. Each child was given our educational materials to take home and discuss stroke with their parents. The children and their parents answered questionnaires on stroke knowledge before, immediately and at 3 months after the lesson. RESULTS: A total of 763 children and 489 parents were enrolled (ie, 64% of children). The scores of either stroke symptoms or risk factors were significantly higher immediately and at 3 months after the lesson, compared with before the lesson, both in children and the parents (p<0.01). Compared with the baseline in both groups (58% in children, 83% in parents), the meaning of the FAST mnemonic at 3 months (88%, 94%), as well as at immediately after the lesson (90%, 89%), was significantly higher (p<0.001). CONCLUSION: Stroke education by EMTs was effective in increasing stroke awareness in elementary school children, as well as their parents.

Binding of 11C-Pittsburgh compound-B correlated with white matter injury in hypertensive small vessel disease.

OBJECTIVE: 11C-Pittsburgh compound-B (11C-PIB) positron emission tomography (PET) is used to visualize and quantify amyloid deposition in the brain cortex in pathological conditions such as Alzheimer's disease (AD). Intense 11C-PIB retention is also observed in the white matter (WM) of both healthy individuals and AD patients. However, the clinical implications of this retention in brain WM have not been clarified. We investigated the relationship between the extent of white matter lesions (WMLs) and the binding potential of 11C-PIB (BPND) in the WM in patients with hypertensive small vessel disease. We further examined the relationship between the extent of WMLs and BPND in WML and in normal-appearing white matter (NAWM). METHODS: Twenty-one hypertensive vasculopathy patients, without AD and major cerebral arterial stenosis and/or occlusion, were enrolled (9 women, 68 ± 7 years). Regions of WML and NAWM were extracted using magnetization-prepared rapid gradient-echo and fluid-attenuated inversion recovery of magnetic resonance images. Volumes of interest (VOIs) were set in the cortex-subcortex, basal ganglia, and centrum semiovale (CS). BPND in the cortex-subcortex, basal ganglia, CS, WML, and NAWM were estimated on 11C-PIB PET using Logan graphical analysis with cerebellar regions as references. The relationships between WML volume and BPND in each region were examined by linear regression analysis. RESULTS: BPND was higher in the CS and basal ganglia than in the cortex-subcortex regions. WML volume had a significant inverse correlation with BPND in the CS (Slope = -0.0042, R 2 = 0.44, P < 0.01). For intra WM comparison, BPND in NAWM was significantly higher than that in WML. In addition, although there were no correlations between WML volume and BPND in WML, WML volume was significantly correlated inversely with BPND in NAWM (Slope = -0.0017, R 2 = 0.26, P = 0.02). CONCLUSIONS: 11C-PIB could be a marker of not only cortical amyloid-ß deposition but also WM injury accompanying the development of WMLs in hypertensive small vessel disease.

Delivering Knowledge of Stroke to Parents Through Their Children Using a Manga for Stroke Education in Elementary School.

BACKGROUND: School-based intervention would be promising to spread stroke knowledge widely. This study aimed to clarify the effectiveness of our new educational aids that were developed for elementary school children to impart information about stroke to children and their parents in 2 different ways: with or without stroke lessons by a neurologist. METHODS: We enrolled 562 children (aged 11 to 12 years) and their parents (n = 485). The students were divided into 2 groups: 323 received a lesson on stroke by a stroke neurologist without watching an animated cartoon (Group I), and 239 watched an animated cartoon without the lesson (Group II). All of the children took the manga home, and talked about stroke with their parents. Questionnaires on stroke knowledge were administered at baseline (BL), immediately after the lesson (IL), and 3 months (3M) after the lesson. RESULTS: There were significant increases in the adjusted mean scores for risk factors as well as stroke symptoms at 3M in both groups compared with BL scores, although the children in Group I scored significantly better than those in Group II at IL and 3M (P < .05). In both children and parents, the correct answer rates of the FAST mnemonic at 3M were around 90%, with no significant differences between groups. CONCLUSIONS: Stroke education for elementary school children using our educational aids provided knowledge of stroke symptoms to the children as well as their parents even without lessons on stroke, although a better understanding of stroke was obtained from lessons led by stroke neurologists.

Cerebral blood flow and metabolism associated with cerebral microbleeds in small vessel disease.

OBJECTIVE: Cerebral microbleeds (CMBs), probably reflecting microangiopathy, have not yet sufficiently been examined in association with cerebral blood flow (CBF) and metabolism. We investigated the relationships between CMBs, and CBF and metabolism in symptomatic small vessel disease. METHODS: We enrolled 22 patients with symptomatic small vessel disease without severe stenosis (>50 %) in major cerebral arteries. Volumes of white matter lesions (WMLs) and number of CMBs were assessed on images of fluid-attenuated inversion recovery and gradient-echo T2*-weighted magnetic resonance imaging, respectively. Patients were divided into two groups according to the median number of CMBs (group I <5, n = 10; group II ≥5, n = 12). Parametric images of CBF, cerebral metabolic rate of oxygen (CMRO2), oxygen extraction fraction and cerebral blood volume were estimated using positron emission tomography and (15)O-labeled gases. The functional values in the cortex-subcortex, basal ganglia, and centrum semiovale were compared between the two groups. RESULTS: Volumes of WMLs of group II were larger than those of group I (median: 38.4; range: 25.1-91.5 mL vs. median: 11.3; range: 4.2-73.4 mL, p = 0.01). In the centrum semiovale, the mean CBF of group II was significantly lower than that of group I (12.6 ± 2.6 vs. 15.6 ± 3.3 mL/100 g/min, p = 0.04). In the other regions, there were no significant differences in either CBF or CMRO2 between the two groups. CONCLUSIONS: Our study indicated that increases in the number of CMBs with larger volumes of WMLs were associated with cerebral ischemia in the deep white matter in patients with symptomatic small vessel disease.

Intracranial subdural hematomas with elevated rivaroxaban concentration and subsequently detected spinal subdural hematoma: A case report.

A 79-year-old lean man with a height of 157cm and weight of 42kg (body mass index, 17.2kg/m(2)) receiving rivaroxaban developed an intracranial subdural hematoma and was treated conservatively. Because he had a reduced creatinine clearance of 44mL/min, his dosage of rivaroxaban was reduced from 15 to 10mg daily according to official Japanese prescribing information. However, he developed bilateral intracranial subdural hematomas 2weeks later. Plasma rivaroxaban concentration on anti-factor Xa chromogenic assay was elevated at 301ng/mL, suggesting excessive accumulation. He underwent burr hole drainage and resumed anticoagulation with warfarin. Subsequently, he developed a lumbosacral hematoma. He was treated conservatively and discharged without neurological sequelae. The main cause of the increased concentration of rivaroxaban was believed to be his older age and low body weight. The etiology of the spinal hematoma was suspected to be the migration of intracranial hematoma to the spinal subdural space.