The incidence of hemorrhagic stroke in Japan is twice compared with western countries: the Akita stroke registry.

The purpose of this study is to find out new knowledge about stroke among huge Japanese stroke registry involving complete brain images. The first stroke events from 1995 to 2004 in the Akita stroke registry (28,781 cases) were included in this study. According to brain images, we classified them into three types; cerebral infarction (CI 18,018 cases, 62.6 %), cerebral hemorrhage (CH 7,423 cases, 25.8 %), and subarachnoid hemorrhage (SAH 3,340, 11.6 %). CI and CH were classified according to the lesional areas, respectively. SAH was divided into three types according to arterial sites of ruptured aneurysm. The proportion of hemorrhagic stroke in Japan (37.4 %) was two times higher than in Western countries. Among CI group; lacunar infarction, cortical infarction, and infratentorial infarction occupied 5,437 (30.2 %), 6,121 (34.0 %), and 2,703 (15.0 %) cases, respectively. Among CH group; putamen, thalamus, and subcortex occupied 1,379 (18.6 %), 2,251 (30.3 %), and 1,204 (16.2 %) cases, respectively. According to ruptured cerebral aneurysm site, they were obviously different between men and women, proportion of internal carotid artery was the most (40.8 %) in women and that of anterior communicating artery was the most (46.8 %) in men on the contrary. The incidence of hemorrhagic stroke in Japan is twice as much as in the western countries.

Alcohol is a risk factor not for thalamic but for putaminal hemorrhage: the Akita Stroke Registry.

BACKGROUND: Although the risk factors of cerebral hemorrhage were established long ago, there is little agreement as to the risk factors for the site of cerebral hemorrhage. METHODS: We obtained mass health screening data collected between 1990 and 2000 regarding 151,796 subjects from the Akita Prefectural Federation of Agricultural Cooperative for Health and Welfare. A first-ever cerebral hemorrhage occurring <3 years after the screening examination was defined as an event. Stroke events were determined from the Akita stroke registry between 1990 and 2003. Clinical risk factors for stroke, such as age, blood pressure, severe obesity (body mass index >30 kg/m(2)), low serum total cholesterol, hepatic disorder, renal disorder, and drinking habits were then assessed. RESULTS: Cerebral hemorrhage developed in 344 cases in the study population. The distribution of subtypes (putaminal hemorrhage [PH], thalamic hemorrhage [TH], and subcortical hemorrhage [SH]) were 122 cases (35.5%), 110 cases (32.0%), and 44 cases (12.8%), respectively. We evaluated the risk factors by multiple logistic regression analysis among these 3 groups. Age was a significant risk factor among these 3 groups, but blood pressure was not a risk factor in SH. Low serum cholesterol and drinking habits were significant risk factors only in PH. Hepatic disorder was a strong risk factor in PH and a weak risk factor in TH. Interestingly, a drinking habit was a significant risk factor only in PH. CONCLUSIONS: Drinking habits had been a risk factor for cerebral hemorrhage, but it was a risk factor not for PH and not for TH or SH.

Left ventricular apical and atrial appendage thrombus with hypertrophic cardiomyopathy in sinus rhythm: a case report.

A 47-year-old female with a history of untreated hypertension and diabetes mellitus was referred because of a left ventricular echocardiographic mass with congestive heart failure. At the time of admission, she had already had a cardio-embolic stroke with loss of recent memory and slight paralysis of the right upper arm. It was difficult to distinguish between thrombus and tumor. However, her clinical condition required surgical resection as soon as possible. We performed cardiac CT to evaluate the coronary arteries and to scan the mass at the left ventricular apex. This CT evaluation revealed another mass at the left atrial appendage. Thus, these two masses were highly suggestive of thrombi. Subemergency surgical resection of the two masses and a part of the myocardium at the left ventricular apex was successfully performed. The pathological results showed that both the mass in the left ventricular apex and the mass in the left atrial appendage were thrombi, and the myocardial disarray confirmed the echocardiographic diagnosis as hypertrophic cardiomyopathy.

Prospective multicentre cohort study of heparin-induced thrombocytopenia in acute ischaemic stroke patients.

Acute ischaemic stroke patients sometimes receive heparin for treatment and/or prophylaxis of thromboembolic complications. This study was designed to elucidate the incidence and clinical features of heparin-induced thrombocytopenia (HIT) in acute stroke patients treated with heparin. We conducted a prospective multicentre cohort study of 267 patients who were admitted to three stroke centres within 7 d after stroke onset. We examined clinical data until discharge and collected blood samples on days 1 and 14 of hospitalization to test anti-platelet factor 4/heparin antibodies (anti-PF4/H Abs) using an enzyme-linked immunosorbent assay (ELISA); platelet-activating antibodies were identified by serotonin-release assay (SRA). Patients with a 4Ts score ≥4 points, positive-ELISA, and positive-SRA were diagnosed as definite HIT. Heparin was administered to 172 patients (64·4%: heparin group). Anti-PF4/H Abs were detected by ELISA in 22 cases (12·8%) in the heparin group. Seven patients had 4Ts ≥ 4 points. Among them, three patients (1·7% overall) were also positive by both ELISA and SRA. National Institutes of Health Stroke Scale score on admission was high (range, 16-23) and in-hospital mortality was very high (66·7%) in definite HIT patients. In this study, the incidence of definite HIT in acute ischaemic stroke patients treated with heparin was 1·7% (95% confidence interval: 0·4-5·0). The clinical severity and outcome of definite HIT were unfavourable.

Blood pressure and total cholesterol level are critical risks especially for hemorrhagic stroke in Akita, Japan.

BACKGROUND AND PURPOSE: Stroke risk factors differ depending on the subtype of stroke; moreover, the distribution of risks is different among countries and races. METHODS: Mass health screening data were collected from the Akita Prefectural Federation of Agricultural Cooperative for Health and Welfare from 1991 to 1998. Cerebrovascular events were determined from the Akita stroke registry from 1991 to 2001. Then, clinical risk factors for stroke, such as hypertension, hyperlipidemia and diabetes mellitus, were assessed in the different subtypes of stroke. RESULTS: A total of 156,892 persons were included in this study (76,330 men and 80,562 women), and 1,323 subjects had a stroke during the 3 years of the screening period. The distribution of subtypes such as cerebral hemorrhage (CH), cerebral infarction (CI) and subarachnoid hemorrhage (SAH) was 27.3, 55.9 and 16.8%, respectively. Mean age and systolic and diastolic blood pressures (BPs) were significantly higher in stroke cases. CH and CI occurred more frequently in men, whereas SAH occurred more frequently in women. Serum total cholesterol (TC) <160 mg/dl was a risk factor for hemorrhagic stroke (CH and SAH), whereas TC >280 mg/dl increased the risk of CI. A multivariable analysis revealed that the lower TC level (<160 mg/dl) and the higher BP increased the relative risk of hemorrhagic stroke. CONCLUSIONS: BP was the strongest risk factor for any subtype of stroke. High BP and low TC (<160 mg/dl) were critical risks of hemorrhagic stroke.

Advantages and limitations of antihypertensive treatment for stroke risk in a general population: the Akita Stroke Registry.

BACKGROUND: Although the association between stroke risk and blood pressure (BP) levels related to antihypertensive medication has been an object of study for a long time, there is little agreement as to the relationship in a general population study. METHODS AND RESULTS: We obtained mass health screening data regarding 156,847 (142,989 untreated and 13,858 treated) subjects from the Akita Prefectural Federation of Agricultural Cooperative for Health and Welfare from 1991 to 1998. Stroke events were determined from the Akita stroke registry between 1991 and 2001. A Poisson regression model, adjusting for possible confounding factors, was used to investigate the risk of first stroke among six BP-based categories (BP defined according to JNC-6), with or without antihypertensive medication. Stroke developed in 1,323 (0.8%) individuals in the study population within 3 years after the health examination. Among untreated groups, the relative hazard linearly increased with elevation of the BP grade. In the untreated group, stroke risk was significantly higher (relative hazard 2.1, 95% confidence interval (CI) 1.6-2.7) in the subjects with high-normal BP levels than with optimal BP levels. In the treated group, stroke risk was significantly higher in patients with high-normal BP levels (relative hazard 2.0, 95% CI 1.0-4.2) than with optimal BP levels. Furthermore, stroke risk was significantly higher in the treated groups with normal BP levels (relative hazard 3.1, 95% CI 2.0-4.9) compared with the untreated group with optimal BP levels. CONCLUSIONS: Although antihypertensive medication can reduce stroke risk, treated patients within non-hypertension levels may still have a higher risk compared with untreated subjects of the same categories.

Differentiation between Stroke Subtypes and the Causes of Monthly Variations: The Akita Stroke Registry.

Objective It has been established that stroke occurrence is influenced by seasonality. Stroke is divided into three subtypes: cerebral hemorrhage (CH), cerebral infarction (CI), and subarachnoid hemorrhage (SAH). The purpose of this paper was to analyze stroke events by subtype and month, in order to clarify the biggest factors that affect seasonal differences and thereby gain insight into stroke prevention. Methods Initial stroke events in the Akita Stroke Registry from 1991 to 2010 (58,684 cases; male 30,549, female 28,135) were classified by subtype and the month of onset, and correlations were estimated based on 115 healthy volunteers' monthly mean resting blood pressure (BP) at home and outdoor temperature measured by the Akita Meteorological Observatory in 2001. Results Systolic BP showed monthly variation in both morning and evening measurements. BP and outdoor temperature showed significant correlations with hemorrhagic stroke events by month (CH: r=0.87, r=-0.82; SAH: r=0.68, r=-0.82). Among the stroke subtypes, seasonal differences were the greatest in CH. Systolic BP was the most important factor for monthly and seasonal variation in stroke events. By comparing monthly BP variations with CH incidence throughout the year, we concluded that a decrease in home BP of 5 mmHg can reduce the risk of CH by 35%. Conclusion Our findings suggest that lowering BP would be the best strategy for CH prevention. Simple daily actions may be affected by cold stress. As physicians, we must strive to help patients lower their BP throughout the year not only with medication but with lifestyle guidance, especially in winter.

[Is hyperdynamic therapy possible for elderly patients with vasospasm following subarachnoid hemorrhage?].

BACKGROUND: Recently we have an increased number of elderly patients with subarachnoid hemorrhage (SAH) to be treated. Elderly patients are expected to have a worse cardiac function than that of younger patients. A question arises whether management for elderly patients in the vasospasm period can be performed as safely as it is for younger patients. The aim of this study is to examine the cardiac function of the elderly patients (> or =75 y.o.) with SAH correlated with various complications in the vasospasm period. MATERIALS: We retrospectively analyzed consecutive 356 patients with SAH encountered in our institute since 2000 to 2006. Seventy-three patients (20.5% of all) are 75 or more than 75-year-old. Their mean age is 80.4 +/- 4.43 (16 male, 57 female). Cardiac function was examined by trans-thoracic echocardiography (CTE) in 40 patients (54.8%). RESULT: Average value of their ejection fraction (EF) and rates of perioperative complications were not so different from those of the younger patients. But among patients of > or =75 y.o., certain patients in whom EF was under 0.6 significantly have experienced cardiopulmonary complications and longer hospitalization. In a multiple logistic analyses, only EF is significantly related with cardiopulmonary complications (P = 0.013). CONCLUSIONS: Among elderly SAH patients > or =75 year of age, some have experienced more cardiopulmonary complications than younger patients and have needed longer hospitalization. For such patients hyperdynamic therapy must be carefully carried out. TTE is effective to predispose and help eliminate their cardiopulmonary complications in the pre- and postoperative period.

[Wilson's disease presenting as Asperger syndrome].

A 24-year-old man, who had been treated for 3 years as Asperger syndrome in adolescence due to behavioral disturbances, lack of social awareness and inability to socialize, was referred to our hospital shortly after tremors developed. On the basis of clinical features, laboratory findings and the brain MRI, a diagnosis of Wilson's disease (WD) was made. WD was further confirmed by genetic testing (the mutation of ATP7B gene). He was started with trientine hydrochloride 500 mg/day, and after 1 year of follow-up, his psychiatric symptoms have improved. Since psychiatric symptoms may precede the neurological symptoms, the possibility of WD should be always considered in the differential diagnosis of psychiatric disorders in young adults.

Fatal necrotizing myositis from fulminant Streptococcus dysgalactiae subspecies equisimilis (SDSE) infection: A case report of autopsy images.

Over the past few decades, Streptococcus dysgalactiae subspecies equisimilis (SDSE) have been considered as weak pathogenicity compared with S. pyogenes (GAS). Some recent reports argue that SDSE may bring severe soft tissue infection as same as GAS. No reports have been tried to reveal the clinical characteristics and autopsy images of fulminant SDSE infection. In this case report, we aimed to present a case of fatal necrotizing myositis from fulminant SDSE infection at iliopsoas, including autopsy appearance.

Necrotizing enterocolitis associated with Clostridium butyricum in a Japanese man.

Case: Necrotizing enterocolitis (NEC) caused by Clostridium butyricum is common in neonates; however, a case of NEC in adults has not been previously reported. An 84-year-old Japanese man developed C. butyricum-related NEC during hospitalization for treatment of stab wounds to the left side of the neck and lower abdomen, without organ damage, and concomitant pneumonia. Outcome: The patient developed acute onset of emesis accompanied by shock during his admission; partial resection of the small intestine was carried out due to necrosis. Pathologic findings showed mucosal necrosis and extensive vacuolation with gram-positive rods in the necrotic small intestine. Blood culture tests revealed C. butyricum infection. The patient's condition improved after the surgery. He was moved to a rehabilitation hospital on day 66. Conclusion: This study suggests that hospitalized adult patients who receive antibiotic treatment are at risk for NEC.

Takotsubo cardiomyopathy as a delayed complication with a herbicide containing glufosinate ammonium in a suicide attempt: a case report.

Background. Glufosinate ammonium has a famous delayed complication as respiratory failure, however, delayed cardiogenic complication is not well known. Objectives. The aim of this study is to report a takotsubo cardiomyopathy as a delayed complication of glufosinate ammonium for suicide attempt. Case Report. A 75-year-old woman ingested about 90 mL of Basta, herbicide for suicide attempt at arousal during sleep. She came to our hospital at twelve hours after ingesting. She was admitted to our hospital for fear of delayed respiratory failure. Actually, she felt down to respiratory failure, needing a ventilator with intubation at 20 hours after ingesting. Procedure around respiratory management had smoothly done with no delay. Her vital status had been stable, however, she felt down to circulatory failure and diagnosed as Takotsubo cardiomyopathy at about 41 hours after ingestion. There was no trigger activities or events to evoke mental and physical stresses. Conclusion. We could successfully manage takotsubo cardiomyopathy resulted in circulatory failure in a patient with glufosinate poisoning for suicide attempt. Takotsubo cardiomyopathy should be taken into consideration if circulatory failure is observed for unexplained reasons.

Successful management of aortic thrombi resulting in spinal cord infarction in a patient with antiphospholipid antibody syndrome and acute cholecystitis.

A 74-year-old man with coronary artery disease was suffering from acute nonobstructive cholecystitis and was admitted to a nearby hospital. Dual antiplatelet (aspirin and ticlopidine) therapy was discontinued before preparation for surgical resection of the gall bladder. During his time in hospital he was aware of lumbar pain and weakness in both legs. He was transferred to our hospital for further evaluation and therapy. Diffuse intra-aortic thrombi were revealed by computed tomography with contrast media, and magnetic resonance imaging showed spinal cord infarction. However, computed tomography scans of the descending aorta obtained 4 months before admission exhibited no signs of atherosclerotic plaques or intra-aortic thrombi. Laboratory data suggest that antiphospholipid antibody syndrome might have caused these acute multiple intra-arterial thrombi. By restarting dual antiplatelet therapy and increasing the dose of heparin (from 10,000 IU/day to 15,000 IU/day) we successfully managed the patient's clinical condition and symptoms. It is important to understand that stopping antiplatelet therapy may rapidly grow thrombi in patients with a hypercoagulative state.