Stroke Systems of Care During the COVID-19 Epidemic in Kobe City.

BACKGROUND: The novel coronavirus disease 2019 (COVID-19) outbreak raised concerns over healthcare systems' ability to provide suitable care to stroke patients. In the present study, we examined the provision of stroke care in Kobe City during the COVID-19 epidemic, where some major stroke centers ceased to provide emergency care. METHODS: This was a cross-sectional study. The Kobe Stroke Network surveyed the number of stroke patients admitted to all primary stroke centers (PSCs) in the city between March 1 and May 23, 2020, and between March 3 and May 25, 2019. In addition, online meetings between all PSC directors were held regularly to share information. The survey items included emergency response system characteristics, number of patients with stroke hospitalized within 7 days of onset, administered treatment types (IV rt-PA, mechanical thrombectomy, surgery, and endovascular therapy), and stroke patients with confirmed COVID-19. RESULTS: During the period of interest in 2020, the number of stroke patients hospitalized across 13 PSCs was 813, which was 15.5% lower than that during the same period of 2019 (p = 0.285). The number of patients admitted with cerebral infarction, intracerebral hemorrhage, and subarachnoid hemorrhage decreased by 15.4% (p = 0.245), 16.1% (p = 0.659), and 14.0% (p = 0.715), respectively. However, the rates of mechanical thrombectomy and surgery for intracerebral hemorrhage were slightly increased by 12.1% (p = 0.754) and 5.0% (p = 0.538), respectively. PSCs that ceased to provide emergency care reported a decrease in the number of stroke cases of 65.7% compared with the same period in 2019, while other PSCs reported an increase of 0.8%. No case of a patient with stroke and confirmed COVID-19 was reported during the study period. CONCLUSION: Kobe City was able to maintain operation of its stroke care systems thanks to close cooperation among all city PSCs and a temporal decrease in the total number of stroke cases.

Characteristics and Quality of Japanese Traditional Fermented Soybean (Natto) from a Low-phytate Line.

The Japanese traditional fermented soybean or "natto", a cheap and nutrient-rich food, is very popular in Japan. The low-phytate (LP) soybeans exhibit higher mineral bioavailability; however, their use in preparing natto has not been reported. Therefore, in this study, characteristics and quality of natto prepared using LP soybean were investigated. The findings revealed a better color, lower stickiness, and lower hardness and taste of LP natto with lower phytate and higher inorganic phosphorus (Pi) concentrations than those in the normal-phytate (NP) natto. However, the Ca, Mg, and K concentrations were not significantly different between LP and NP natto, whereas the protein level in NP natto was slightly higher than that in LP natto. These findings indicate that the lower phytate content in LP natto than that in NP natto, could facilitate a higher bioavailability of P and other minerals. Moreover, the improved color and lower stickiness, in addition to lower hardness and taste of LP natto, imparted through improved manufacturing process could increase its acceptability overseas, thereby increasing its commercial value. These improved qualities of LP natto could contribute to improving human health as well as increasing sustainable food and nutrient security.

Implementation of Intravenous Drip Infusion Therapy with Peripheral Venous Catheters and the Incidence of Related Complications in Home-Based Medical Care Settings in Japan.

BACKGROUND/AIMS: Home-based medical care is rapidly expanding in Japanese health care settings. We aimed to clarify the implementation status of drip injection with peripheral venous catheters (PVCs) and the incidence of related complications. METHODS: We investigated the number of patients who required intravenous drip infusion therapy at home. We also examined the incidence rate of PVC-related complications and their statistical correlation with patients' characteristics. RESULTS: Of 139 patients, 30 (21.6%) received intravenous drip infusion therapy through PVCs at home. Patients' activities of daily living (bed-ridden) and the presence of underlying disease (terminal cancer) were significantly correlated with the requirement for drip infusion therapy (p < 0.0001 and p < 0.0001, respectively). A high incidence of PVC-related complications (75%: 15 out of 20 patients) was observed. More than 50% of patients experienced multiple needling due to difficulty in securing venous access. CONCLUSIONS: This is the first report to reveal the relatively high incidence of PVC-related complications in home-based medical care settings. Safer vascular devises should be incorporated for more stable intervention.

[Clinical Features and Treatment Strategy of Vertebral Artery Injury Associated with Cervical Spine Trauma].

OBJECTIVE: Vertebral artery injury(VAI)associated with cervical spine trauma has the potential to cause catastrophic vertebrobasilar stroke. However, there are no well-defined treatment recommendations for VAI. The purpose of this study was to identify an effective treatment strategy for VAI following cervical spine trauma. METHODS: Ninety-seven patients with blunt cervical spine trauma were treated at Hyogo Prefectural Kakogawa Medical Center between January 2013 and September 2017. Of these patients, 49 underwent computed tomographic angiography or magnetic resonance angiography for evaluation of the vertebral artery. Eighteen patients(36.7%)had a diagnosis of VAI. We retrospectively analyzed the clinical features, treatment, and outcomes in these 18 patients. RESULTS: Seven patients(38.9%)had bilateral VAI, 16(88.9%)had cervical dislocation, and 2(11.1%)had transverse process fractures extending into the transverse foramen. Surgical reduction was performed in 14 patients. Five patients with either bilateral or unilateral occlusion underwent parent artery occlusion before reduction. There were no complications after this procedure. Two patients with bilateral VAI had a stroke before treatment. There were no infarctions in the distribution of the vertebrobasilar artery after intervention. The perioperative stroke rate was relatively good, and almost all Glasgow Outcome Scale scores were related to the degree of spinal cord injury. CONCLUSIONS: Aggressive screening for VAI is important in patients with cervical spine trauma in order to ensure adequate treatment. Although the treatment strategy described here could yield good results, it may require modification according to the needs of the individual patient.

Machine Learning to Predict Three Types of Outcomes After Traumatic Brain Injury Using Data at Admission: A Multi-Center Study for Development and Validation.

The difficulty of accurately identifying patients who would benefit from promising treatments makes it challenging to prove the efficacy of novel treatments for traumatic brain injury (TBI). Although machine learning is being increasingly applied to this task, existing binary outcome prediction models are insufficient for the effective stratification of TBI patients. The aim of this study was to develop an accurate 3-class outcome prediction model to enable appropriate patient stratification. To this end, retrospective balanced data of 1200 blunt TBI patients admitted to six Japanese hospitals from January 2018 onwards (200 consecutive cases at each institution) were used for model training and validation. We incorporated 21 predictors obtained in the emergency department, including age, sex, six clinical findings, four laboratory parameters, eight computed tomography findings, and an emergency craniotomy. We developed two machine learning models (XGBoost and dense neural network) and logistic regression models to predict 3-class outcomes based on the Glasgow Outcome Scale-Extended (GOSE) at discharge. The prediction models were developed using a training dataset with n = 1000, and their prediction performances were evaluated over two validation rounds on a validation dataset (n = 80) and a test dataset (n = 120) using the bootstrap method. Of the 1200 patients in aggregate, the median patient age was 71 years, 199 (16.7%) exhibited severe TBI, and emergency craniotomy was performed on 104 patients (8.7%). The median length of stay was 13.0 days. The 3-class outcomes were good recovery/moderate disability for 709 patients (59.1%), severe disability/vegetative state in 416 patients (34.7%), and death in 75 patients (6.2%). XGBoost model performed well with 69.5% sensitivity, 82.5% accuracy, and an area under the receiver operating characteristic curve of 0.901 in the final validation. In terms of the receiver operating characteristic curve analysis, the XGBoost outperformed the neural network-based and logistic regression models slightly. In particular, XGBoost outperformed the logistic regression model significantly in predicting severe disability/vegetative state. Although each model predicted favorable outcomes accurately, they tended to miss the mortality prediction. The proposed machine learning model was demonstrated to be capable of accurate prediction of in-hospital outcomes following TBI, even with the three GOSE-based categories. As a result, it is expected to be more impactful in the development of appropriate patient stratification methods in future TBI studies than conventional binary prognostic models. Further, outcomes were predicted based on only clinical data obtained from the emergency department. However, developing a robust model with consistent performance in diverse scenarios remains challenging, and further efforts are needed to improve generalization performance.

Incidence and Outcomes of Aneurysmal Subarachnoid Hemorrhage: A Multicenter Retrospective Registry-based Descriptive Trial in Kobe City.

The current study aims to evaluate the incidence and results of aneurysmal subarachnoid hemorrhage (aSAH) throughout Kobe City. Based on a multicenter retrospective registry-based descriptive trial involving all 13 primary stroke centers in Kobe City, patients with aSAH treated between October 2017 and September 2019 were studied. A total of 334 patients were included, with an estimated age-adjusted incidence of 11.12 per 100,000 person-years. Curative treatment was given to 94% of patients, with endovascular treatment (51%) preferred over surgical treatment (43%). Of the patients, 12% were treated by shunt surgery for sequential hydrocephalus with a worse outcome at 30 days or discharge (14% vs. 46%, odds ratio (OR): 0.19, 95% confidence interval (CI): 0.088-0.39, p-value <0.001). As for vasospasm and delayed cerebral ischemia, most patients were given intravenous fasudil infusion (73%), with endovascular treatment for vasospasm in 24 cases (7.2%). The fasudil group had more good outcomes (42% vs. 30%, OR: 1.64, 95% CI: 0.95-2.87, p-value = 0.075) and significantly less death (3.3% vs. 35%, OR: 0.064, 95% CI: 0.024-0.15, p-value <0.001) at 30 days or discharge. Mortality rose from 12% at 30 days or discharge to 17% at 1 year, but neurological function distribution improved over time (modified Rankin Scale 0-2 was 39% at 30 days or discharge, 53% at 60 days, and 63% at 1 year). Our retrospective registered trial presented various statistics on aSAH, summarizing the current treatment status and prognosis.

Putamen Atrophy Is a Possible Clinical Evaluation Index for Parkinson's Disease Using Human Brain Magnetic Resonance Imaging.

Parkinson's disease is characterized by motor dysfunction caused by functional deterioration of the substantia nigra. Lower putamen volume (i.e., putamen atrophy) may be an important clinical indicator of motor dysfunction and neurological symptoms, such as autonomic dysfunction, in patients with Parkinson's disease. We proposed and applied a new evaluation method for putamen volume measurement on 31 high-resolution T2-weighted magnetic resonance images from 16 patients with Parkinson's disease (age, 80.3 ± 7.30 years; seven men, nine women) and 30 such images from 19 control participants (age, 75.1 ± 7.85 years; eleven men, eight women). Putamen atrophy was expressed using a ratio based on the thalamus. The obtained values were used to assess differences between the groups using the Wilcoxon rank-sum test. The intraclass correlation coefficient showed sufficient intra-rater reliability and validity of this method. The Parkinson's disease group had a significantly lower mean change ratio in the putamen (0.633) than the control group (0.719), suggesting that putamen atrophy may be identified using two-dimensional images. The evaluation method presented in this study may indicate the appearance of motor dysfunction and cognitive decline and could serve as a clinical evaluation index for Parkinson's disease.

Brain imaging modality before systemic thrombolysis for ischemic stroke within three hours.

OBJECTIVE: In Japan, MRI-based thrombolysis after CT screening is the most common imaging strategy prior to intravenous thrombolysis (IVT) with tissue plasminogen activator (tPA) within 3 h after ischemic stroke. A choice of MRI with MR angiography (MRA) provides a higher diagnostic accuracy, but may delay an initiation of thrombolysis. METHODS: In our neuro-unit, brain CT is the first screening image for suspected stroke. We retrospectively examined a delay to thrombolysis, imaging modality, diagnostic accuracy, and clinical outcomes at 3 months by the modified Rankin Scale in patients receiving IVT within 3 h. RESULTS: Among 67 patients receiving IVT with tPA, brain imaging prior to IVT was solely CT in 10 (15%) patients and CT + MRI/MRA in 57 (85%) patients. Final diagnosis of brain ischemia was 100%. Patients receiving CT + MRI had significantly shorter pre-hospital delay (mean 54 vs. 83 min; p = 0.012), but longer door-to-needle time (mean 90 vs. 57 min; p = 0.019) than those receiving CT only. Finally, time from onset to thrombolysis was not different between the two groups and clinical outcomes were also comparable. The earlier patients arrived, the longer door-to-needle times were (p < 0.001). CONCLUSIONS: The imaging strategy of initial CT screening with optional MRI/MRA scans prior to IVT was feasible. However, it resulted in an additional 30 min in-hospital delay of tPA administration, which may affect clinical outcomes.

A very unusual case of fibromuscular dysplasia with multiple aneurysms of the vertebral artery and posterior inferior cerebellar artery.

Fibromuscular dysplasia (FMD) is a noninflammatory and nonatheromatous arteriopathy that commonly affects the renal and cervical internal carotid arteries and sometimes the vertebral arteries (VAs). The association of FMD with intracranial aneurysms is widely known. The authors describe a rare case of FMD presenting with subarachnoid hemorrhage due to the rupture of 1 of 10 aneurysms located in the extra- and intracranial vertebral and posterior inferior cerebellar arteries. The FMD was treated successfully using flow reversal therapy, consisting of proximal occlusion of the VA with Guglielmi detachable coils, and was diagnosed histopathologically using a biopsy specimen of the distal superficial temporal artery. Originally FMD may be caused by a fragile arterial wall that may progress to the formation of an aneurysm due to hemodynamic stress. For this reason, FMD may be treatable by reducing this hemodynamic stress.

Post-licensed 1-year experience of systemic thrombolysis with tissue plasminogen activator for ischemic stroke in a Japanese neuro-unit.

OBJECTIVE: In Japan, intravenous thrombolysis with tissue plasminogen activator (tPA) for ischemic stroke within 3h of onset was officially approved in October 2005. METHODS: We report initial 1-year clinical experience of intravenous alteplase at 0.6mg/kg in a Japanese neuro-unit. RESULTS: Twenty patients received intravenous tPA, corresponding to 12% of all ischemic strokes (n=166) and 38% of ischemic strokes within 3h of onset (n=52). The mean age was 68 years old and 15% had pre-morbid dependency with modified Rankin Scale (mRS) of 3 or 4. The median baseline National Institute of Health Stroke Scale score was 19 points (range; 5-37). Average time from stroke onset to tPA delivery was 136 min (range; 87-180). Of 18 (90%) patients receiving pretreatment vascular imaging, 16 (80%) patients had a large arterial occlusion. At 3 months, excellent outcome with mRS of 0 or 1 was 25%, and good outcome with mRS of 0-2 was 35%. One patient (5%) developed symptomatic intracranial hemorrhage within 36 h. Mortality rate was 15%. CONCLUSIONS: Intravenous tPA within 3h was safe and feasible, and possibly effective in clinical practice. The higher stroke severity in our cohort precluded to compare the sufficient effectiveness with clinical trials. In Japan, a post-licensed national surveillance is currently under way.

Endovascular treatment for a unusually large mycotic aneurysm manifesting as intracerebral hemorrhage - case report.

A 62-year-old male presented with an unusually large mycotic aneurysm mimicking a saccular aneurysm manifesting as coma and hypotension. Computed tomography showed intracerebral and intraventricular hemorrhage. He was in septic shock due to acute infectious endocarditis. Cerebral angiography disclosed a large distal anterior cerebral artery aneurysm. The diagnosis was mycotic aneurysm based on the morphological features and associated endocarditis. The aneurysm and the parent artery were successfully occluded by endovascular embolization. High-dose antibiotic therapy in the following 6 weeks resulted in resolution of the infectious endocarditis. Early exclusion of ruptured mycotic aneurysm is mandatory because of the high risk of rerupture. Endovascular treatment is an effective alternative for mycotic aneurysms, especially if the patient's general condition is poor. Parent artery occlusion can be safely tolerated if the aneurysm is located distally.

Rapid tumor growth with glial differentiation of central neurocytoma after stereotactic radiosurgery.

Although stereotactic radiosurgery (SRS) is effective for central neurocytoma (CN), the long-term outcome of SRS remains unclear. We present a case of recurrent CN that was diagnosed 10years after surgical resection and consecutive stereotactic radiotherapy. The patient was treated with SRS for the recurrent tumor, but underwent two-staged surgery once again due to rapid tumor growth. Histological features of the recurrent tumor were consistent with the diagnosis of CN. However, an increased Ki-67 proliferation index (3.4%), aberrant angiogenesis and glial differentiation of the tumor cells were observed, which were not identified in the initial CN. In addition, vascular endothelial growth factor (VEGF) and VEGF receptor were highly expressed in the recurrent tumor cells, as well as in the vascular endothelial cells. Our case suggests that malignant transition with aberrant angiogenesis and glial differentiation may be attributable to SRS.

Unruptured Cerebral Aneurysm Detected after Intravenous Tissue Plasminogen Activator for Stroke.

Therapeutic guidelines of intravenous thrombolysis with tissue plasminogen activator (tPA) for hyperacute ischemic stroke are very strict. Because of potential higher risk of bleeding complications, the presence of unruptured cerebral aneurysm is a contraindication for systemic thrombolysis with tPA. According to the standard CT criteria, a 66-year-old woman who suddenly developed aphasia and hemiparesis received intravenous tPA within 3 h after ischemic stroke. Magnetic resonance angiography during tPA infusion was performed and the presence of a small unruptured cerebral aneurysm was suspected at the anterior communicating artery. Delayed cerebral angiography confirmed an aneurysm with a size of 7 mm. The patient did not experience any adverse complications associated with the aneurysm. Clinical experiences of this kind of accidental off-label thrombolysis may contribute to modify the current rigid tPA guidelines for stroke.

Emergent surgical repair for penetrating injury of the cervical carotid artery associated with shock.

A 41-year-old male presented with penetrating carotid artery injury after being stabbed in the left neck with a knife. He had profuse bleeding from the wound and was in hemorrhagic shock. No neuroimaging evaluation was possible, so emergent surgery was begun with continuous manual compression of the left neck. Graft reconstruction of the injured carotid artery was performed. He recovered well without neurological deficits. Urgent hemostasis is required for patients with penetrating carotid artery injury presenting with shock. Surgical reconstruction of the carotid artery with a vascular graft is a safe option.