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.

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.

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.

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.

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.

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.

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.

Associations between Uric Acid Level and 3-Month Functional Outcome in Acute Ischemic Stroke Patients Treated with/without Edaravone.

BACKGROUND: Uric acid (UA), an antioxidant with neuroprotective effects, favorably affects stroke outcome. However, the effect has not been examined in patients treated with edaravone, a frequently used free radical scavenger. We investigated whether the use of edaravone affected the relationship between UA levels and outcome in acute ischemic stroke. METHODS: We retrospectively evaluated 1,114 consecutive ischemic stroke patients with premorbid modified Rankin Scale (mRS) scores <2 admitted within 24 h of onset (mean, 74 years; median UA levels, 333 µmol/L). We divided the patients into 2 groups using the median UA value as a cutoff, a low UA group (≤333 µmol/L; n = 566) and a high UA group (>333 µmol/L; n = 548), and compared their clinical characteristics and favorable outcomes (mRS <2) at 90 days. We investigated the associations between UA levels and 90-day stroke outcome in patients with and without edaravone treatment. RESULTS: The high UA group had a higher proportion of men, hypertension, atrial fibrillation, and cardioembolic stroke than the low UA group. The high UA group also had a higher proportion of patients with mRS <2 at 90 days (61.5 vs. 54.1%, p = 0.013), but the significance was diminished in multivariate analysis (OR 1.30, 95% CI 0.94-1.71). In subgroup analysis, the high UA group without edaravone exhibited a higher proportion of patients with mRS <2 at 90 days than the low UA group (OR 2.87, 95% CI 1.20-7.16). The high UA group with edaravone did not exhibit this difference. CONCLUSIONS: In acute ischemic stroke, the favorable association between high UA levels and outcome at 90 days was not evident in patients treated with edaravone.

Is the Occlusion Site of the Lenticulostriate Artery Identified on Admission Related to Clinical Prognosis in Patients with Lacunar Stroke?

BACKGROUND: The mechanism of lacunar stroke (LS) is rather speculative due to the lack of neuropathological evidence in clinical practice. To explore the significance of the occlusion site of the lenticulostriate artery (LSA) to this mechanism, we investigated the characteristics and prognosis of patients with LS with proximal occlusions. MATERIALS AND METHODS: We studied 202 patients with acute LS in the region of the LSA. The presumed occlusion site of the LSA was assessed on coronal, diffusion-weighted magnetic resonance images. Based on the distance from the basal surface of the hemisphere to the proximal site of the lacunar infarct, patients were divided into 3 groups: proximal, middle, and distal site occlusions, and their characteristics and outcomes were compared. RESULTS: White blood cell counts, blood glucose, hemoglobin A1c, low-density lipoprotein cholesterol, triglyceride, and admission National Institutes of Health Stroke Scale score were statistically different among the 3 groups. In multivariate analysis, both high levels of white blood cells (odds ratio [OR], 1.16; 95% confidence interval [CI], 1.01-1.33) and triglyceride (OR, 1.31; 95% CI, 1.09-1.61) were positively related to the proximal occlusion site. Proximal occlusion (OR, 3.98; 95% CI, 1.06-16.11) was related to poor outcome at discharge. CONCLUSIONS: Proximal occlusion of the LSA was independently related to elevated triglyceride and white blood cell counts. Patients with LS with proximal LSA occlusion had severe neurological deficits both on admission and at discharge.

Ipsilateral Tremor-Like Grasp Reaction in a Patient With Ischemic Stroke.

Reports of involuntary ipsilateral movements after a stroke are rare, and none have described a patient with both an instinctive grasp reaction and tremor-like movement ipsilateral to the acute stroke lesion. We here report such a patient. A 76-year-old right-handed woman with a past history of left thalamic hemorrhage developed left hemiparesis, an instinctive grasp reaction, and a peculiar involuntary movement of her right arm. This involuntary movement was stereotyped and sometimes rhythmical, with a groping or picking-like action. The lesion responsible for her motor deficits was a broad infarct in the right internal carotid artery territory. We suggest that her characteristic involuntary tremor-like movement was a variation of the instinctive grasp reaction caused by an ipsilateral ischemic lesion that included the frontal lobe. We illustrate her movements with a video, Supplemental Digital Content 1, http://links.lww.com/CBN/A65.

Calcified Amorphous Tumor Causing Shower Embolism to the Brain: A Case Report with Serial Echocardiographic and Neuroradiologic Images and a Review of the Literature.

An 89-year-old woman with chronic atrial fibrillation, hypertension, chronic heart failure, and dementia was admitted to our hospital due to multiple small cerebral and cerebellar infarctions. Transthoracic echocardiogram revealed a floating calcified mass lesion arising from the endocardium of the posterior portion of the mitral annulus with mitral annular calcification. Furthermore, the mass had a heterogeneity of the echogenicity. The mass was diagnosed as a calcified amorphous tumor based on specific echocardiographic features. Serial echocardiograms showed shrinkage and disappearance of the mass, and magnetic resonance image revealed new infarction in the left occipital lobe. Embolization of the mass appeared to cause systemic embolism.

Reappearance of free-floating carotid thrombus after discontinuation of anticoagulant therapy.

A 73-year-old woman who suddenly developed left hemiparesis was admitted to our hospital. Ultrasonography on admission showed a free-floating thrombus (FFT) attached to an ulcerative plaque in the right common carotid artery. The FFT almost disappeared during treatment with intravenous anticoagulation therapy for acute stroke, but it reappeared when the therapy was discontinued. She underwent endarterectomy on day 13, after which she was free from stroke recurrence.

Contralateral recurrence of carotidynia during steroid therapy.

A 44-year-old woman presented with contralateral recurrence of carotidynia during steroid therapy at 1 month after onset. Carotidynia can present with a multiphasic clinical course and can affect the neck bilaterally. Therefore, patients with carotidynia should be observed even after remission.

Cerebral infarction in both carotid and vertebrobasilar territories associated with a persistent primitive hypoglossal artery with severe dilated cardiomyopathy.

A persistent primitive hypoglossal artery (PPHA) is a relatively rare vascular anomaly of a persistent carotid-basilar anastomosis. A 76-year-old man with severe dilated cardiomyopathy suddenly lost consciousness. A magnetic resonance imaging scan of his brain revealed extensive infarction in the carotid and vertebrobasilar territories. Magnetic resonance angiography revealed a PPHA and occlusion of the left internal carotid artery and vertebrobasilar artery. Cardioembolic infarction associated with a PPHA should be recognized as a possible cause of multiple infarctions in both the carotid and vertebrobasilar distributions in the absence of stenotic ICA lesions.

Nontraumatic convexal subarachnoid hemorrhage concomitant with acute ischemic stroke.

BACKGROUND: Nontraumatic convexal subarachnoid hemorrhage (cSAH) rarely occurs subsequent to acute ischemic stroke. The incidence, clinical background characteristics, and outcomes in acute ischemic stroke patients with cSAH were investigated. METHODS: Our stroke center database was reviewed to identify patients with acute ischemic stroke/transient ischemic attack (TIA) who demonstrated acute cSAH within 14 days of admission between 2005 and 2011. Background characteristics, clinical course, and outcomes at discharge and 3 months after onset were investigated in these patients. RESULTS: Of 4953 acute stroke/TIA patients, cSAH was observed in 8 (.14%) patients (7 men, mean age 71 years): 7 were detected incidentally, and the other was found immediately after a convulsion. Two patients died during their hospital stay, 1 died after discharge, and 3 were dependent at 3 months. Major artery occlusion or severe stenosis was observed in 5 patients. Two patients subsequently developed subcortical hemorrhage. On gradient echo imaging, lobar cerebral microbleeds were observed in 2 patients, and chronic superficial siderosis was observed in 2 patients. CONCLUSIONS: In this retrospective review of cases with ischemic stroke and cSAH, over half of patients had occlusion of major arteries. Cerebral amyloid angiopathy was suggested by magnetic resonance imaging findings and subsequent events in 3 patients. The overall outcome was unfavorable although the causal relationship with cSAH was unclear.

Loading dose of clopidogrel in combination with other antithrombotic therapy for capsular warning syndrome.

A 66-year-old man had repeated stereotypical transient ischemic attacks (TIAs) of dysarthria and left hemiparesis. His symptoms were considered capsular warning syndrome (CWS), for which the responsible lesion was found on magnetic resonance imaging to be in the right putamen expanding to the corona radiata. Although administration of antithrombotic therapy including aspirin was ineffective, no further TIAs occurred after a loading dose of clopidogrel was added. A loading dose of clopidogrel combined with other antithrombotic therapy might be an effective treatment for CWS.

Discrimination of acute ischemic stroke from nonischemic vertigo in patients presenting with only imbalance.

Some patients who present with an acute feeling of imbalance are experiencing an ischemic stroke that is not evident on computed tomography (CT) scans. The aim of this study was to compare ischemic stroke and nonischemic vertigo patient groups and to investigate independent factors associated with ischemic stroke. We examined 332 consecutive patients with an acute feeling of imbalance who showed no neurologic findings or responsible lesions on CT scan at the hyperacute phase. We examined their clinical backgrounds, physical findings, and laboratory examinations, with ischemic stroke diagnosed by later CT and/or magnetic resonance imaging (MRI). We identified 41 (12.3%) ischemic stroke patients. Atrial fibrillation (odds ratio 4.1; 95% confidence interval 1.4-11.5), white blood cell count (10(3)/µL, 1.4; 1.2-1.6), head and/or neck pain (4.6; 2.1-10.3), first attack of imbalance feeling (3.3; 1.1-12.2), and dizziness (3.7; 1.7-8.3) were significant and independent factors associated with ischemic stroke among patients with an acute feeling of imbalance. We used these factors to calculate an "imbalance score"; 1 point was given for the presence of each factor and a score of 3-5 points was independently associated with ischemic stroke. An awareness of these factors may indicate that further examinations including MRI are necessary to rule out ischemic stroke.

[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.

[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.