Effect of direct oral anticoagulant for acute major cerebral artery occlusion in cardioembolic stroke/transient ischemic attack patients with non-valvular atrial fibrillation.

BACKGROUND: Direct oral anticoagulants (DOACs) can reduce the frequency of cardioembolic stroke with non-valvular atrial fibrillation as well as or better compared to vitamin K antagonists (VKAs). However, whether taking DOACs prior to stroke can prevent acute major cerebral artery occlusion (MCAO) has not been fully elucidated. METHODS: We enrolled patients who underwent cardioembolic stroke or transient ischemic attack with non-valvular atrial fibrillation who were admitted to our hospital between April 2011 and February 2017. The patients were classified into four groups based on anticoagulant medications prior to stroke: no oral anticoagulant (No OAC), VKA below therapeutic range on admission, VKA within therapeutic range on admission, and the DOAC group. We compared clinical backgrounds, National Institutes of Health Stroke Scale (NIHSS) scores, and MCAO prevalence on admission. We identified those patients with MCAO and investigated factors related to MCAO. RESULTS: A total of 287 patients were enrolled in the study (200 No OAC; 49 VKA below therapeutic range; 21 VKA within therapeutic range; and 17 DOAC). Median and interquartile range of NIHSS scores for each group were 10.5 (4-22) for No OAC; 14 (4-22) for VKA below therapeutic range; 8 (6-17) for VKA within therapeutic range; and 3 (1-9) for DOAC (P = 0.041). The prevalence of MCAO in each group was 40% in No OAC; 35% in VKA below therapeutic range; 29% in VKA within therapeutic range; and 6% in DOAC (P = 0.040). In total, 103 patients were identified with MCAO on admission. Multivariate analysis revealed that taking DOACs prior to stroke was significantly associated with MCAO (OR, 0.09; 95% CI, 0.004-0.75; P = 0.023). CONCLUSIONS: DOACs were an independent factor negatively correlated with MCAO in acute cardioembolic stroke with non-valvular atrial fibrillation.

Cerebral infarction associated with accessory middle cerebral arteries: two case reports.

We herein present two cases of cerebral infarction in the middle cerebral artery (MCA) territory associated with an accessory middle cerebral artery (AMCA), which is a rare anomalous vessel arising from the anterior cerebral artery that coexists with the main trunk of the MCA. Cerebral infarction occurred in both patients: due to occlusion of the MCA main trunk in one patient and occlusion of the AMCA in the other patient. These cases suggest the importance of recognizing an AMCA when interpreting neuroradiological findings in patients with MCA ischemic stroke, especially in the hyperacute phase.

Hospital cost of ischemic stroke and intracerebral hemorrhage in Japanese stroke centers.

BACKGROUND: In Japan, the healthcare expenditure has increased to 8.0% of the gross domestic products in 2001. Stroke care is costly. OBJECTIVE: To examine hospital costs and clinical outcomes of ischemic stroke (IS) and intracerebral hemorrhage (ICH) in Japanese stroke centers. DESIGN: A prospective non-interventional multi-center study. SETTING: Ten Japanese stroke centers. STUDY PERIOD: Fourteen months between October 2000 and December 2001. PATIENTS: Patients were those who were consecutively hospitalized with acute IS or ICH within 72 h of onset, excluding subarachnoid hemorrhage. Stroke was defined as focal neurological deficits lasting more than 24 h and the relevant lesions were to be confirmed by brain CT and/or MRI. METHODS: We examined demography, in-hospital cares, length of hospital stay, clinical outcomes at discharge, and direct hospital medical costs including physician's fees. The hospital medical cost data were collected from official hospital medical cost charts for reimbursement to the healthcare insurance systems. RESULTS: There were a total of 1113 patients with a mean age of 70 years, of whom 913 (82%) patients had an IS and 200 (18%) patients had an ICH. The 317 patients (28%) experienced a recurrent stroke. Patients with ICH had the higher baseline stroke severity, resulting in longer hospitalization (39 days for IS and 46 days for ICH; P<0.001), lower independence rate at discharge (55 and 40%; P<0.001), higher mortality rate (5 and 10%; P=0.03), and higher medical costs (US dollar 8662 and US dollar 10,260; P<0.001) than those with IS. Patients with recurrent stroke had significantly older age, higher stroke severity, and lower independence rate at discharge than those with first-ever stroke. The length of stay, in-hospital mortality, and hospital medical costs were similar among first-ever and recurrent strokes. In subtype of IS, patients with cardioembolic stroke had the worst neurological deficits, poorest outcomes, and highest medical costs. The hospital costs had a greatest association with length of stay. CONCLUSIONS: Stroke care is costly in Japan. ICH is more likely to impose substantial physical and economic burden than IS. Because the cares of both first-ever and recurrent stroke were costly, primary and secondary prevention of stroke is important on the healthcare aspects.

Hyponatremia upon resumption of paroxetine therapy.

We present a 79-year-old woman with severe hyponatremia secondary to resumption of treatment with paroxetine, a selective serotonin-reuptake inhibitor antidepressant. Confusion and fatigue followed re-initiation of paroxetine after a 3-month hiatus. Hyponatremia, serum hypoosmolality, and urine hyperosmolality strongly suggested the syndrome of inappropriate secretion of antidiuretic hormone. Hyponatremia was quickly resolved after discontinuation of paroxetine and initiation of intravenous normal saline infusion together with oral fluid restriction. This case underscores the importance of monitoring serum sodium in elderly patients taking paroxetine, whether this represents a new prescription or reintroduction of the drug.

Role of thrombin in CNS damage associated with intracerebral haemorrhage: opportunity for pharmacological intervention?

Intracerebral haemorrhage (ICH) results in high mortality and morbidity. The most important causes of neurological deterioration after ICH are progression of oedema and injury to nerve cells and axons surrounding the haematoma, as well as haematoma enlargement. Recent studies have indicated that thrombin, formed upon clotting of the haematoma, plays an important role in these processes. As opposed to conventional therapeutic approaches, administration of a thrombin inhibitor could effectively limit oedema formation and neuronal damage, improving survival and functional outcome. A small, preliminary clinical trial has suggested that antithrombin therapy with intravenously administered argatroban may be useful in treatment of ICH. Randomised, controlled studies are needed to confirm these initial findings.