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Background: Although double tract reconstruction after proximal gastrectomy (PGDT) is commonly performed for proximal gastric or esophagogastric junction cancer, the impact of the procedure on postoperative quality of life (QOL) has not been clarified. We aimed to clarify the optimal PGDT procedure in terms of postoperative QOL. Methods: Postoperative QOL was analyzed in 172 patients who underwent PGDT for proximal gastric cancer and were enrolled in the PGSAS-NEXT study, a multicenter cross-sectional study in Japan (UMIN000032221), in relation to the remnant stomach size, length of interposed jejunum between the esophagojejunostomy (E-J) and jejunogastrostomy (J-G), and size of the J-G. Results: The remnant stomach size was approximately one-third in 13, half in 97, and two-thirds in 60 patients. Dissatisfaction scores for symptoms, diet, work, and daily life subscales were lower in patients with a larger stomach (p < 0.05). These patients also scored better in terms of weight loss (− 13.5%, − 14.0%, and − 11.2%, respectively) and amount of food ingested per meal (52%, 62%, and 66%). The length of the interposed jejunum was ≤ 10 cm in 62 and ≥ 11 cm in 97 patients. Weight loss (− 11.3% and − 13.8%) and dissatisfaction scores were better in the ≤ 10 cm group (p < 0.05). J-G size was ≤ 5 cm in 27 and ≥ 6 cm in 135 patients. The amount of food ingested (56%, 64%) and dissatisfaction scores were better in the > 6 cm group (p < 0.05). Conclusions: Larger remnant stomach, shorter length of interposed jejunum, and longer J-G might contribute to better postoperative QOL after PGDT. [ABSTRACT FROM AUTHOR]

Indications for adjuvant chemotherapy for advanced gastric cancer are determined based on the pathological diagnosis. However, macroscopic diagnoses have been reported as predictors of peritoneal recurrence and survival. This study investigated the predictability of peritoneal recurrence and survival based on macroscopically (sT) and pathologically (pT) diagnosed serosal invasion to identify more sensitive predictors of peritoneal recurrence. This study included 396 patients who underwent R0 resection without adjuvant chemotherapy with S-1 in the JCOG0110 study. Tumor depth limited to the subserosa (SS) was defined as serosal invasion negative (T-), while tumors with serosal invasion (SE, SI) were defined as serosal invasion positive (T+). The predictability of peritoneal recurrence based on sT and pT was evaluated using the Fine and Gray model. Cox regression analyses were performed for overall survival (OS) and relapse-free survival (RFS) with sT or pT as covariates. A total of 150 patients (37.9%) were sT+ and 82 (26.3%) were pT+. Sixty-two patients (15.7%) were sT+/pT+, 88 (22.2%) were sT+/pT-, 20 (5.1%) were sT-/pT+, and 226 (57.1%) were sT-/pT-. Both sT and pT were found to be independent predictors of peritoneal recurrence, OS, and RFS. The 5-year RFS rates of sT+/pT+, sT+/pT-, sT-/pT+, and sT-/pT-patients were 45.2%, 63.6%, 55.0%, and 81.8%, respectively. Intraoperatively diagnosed macroscopic serosal invasion showed a similar predictive value for peritoneal recurrence as pathologically diagnosed serosal invasion. The establishment of a novel staging system incorporating macroscopic serosal invasion is recommended. [ABSTRACT FROM AUTHOR]

• Characteristics of high-risk patent foramen ovale (PFO) in elderly are unclear. • High-risk PFO had specific clinical characteristics and mechanistic associations. • This trend was consistent among CS patients aged ≥60 years. High-risk patent foramen ovale (PFO) could be pathological in cryptogenic stroke (CS), but its clinical characteristics have not been fully studied, especially in elderly patients. Patients with CS were enrolled in the CHALLENGE ESUS/CS registry, a multicenter registry of CS patients undergoing transesophageal echocardiography. Clinical characteristics were compared among three groups: high-risk PFO group, large shunt PFO (≥25 microbubbles) or PFO with atrial septal aneurysm (ASA); right-to-left shunt (RLS) group, RLS including PFO with <25 microbubbles or without ASA; and no-RLS group. In total, 654 patients were analyzed: 91, 221, and 342 in the high-risk PFO, RLS, and no-RLS groups, respectively. In multinomial logistic regression analysis, the male sex (odds ratio [OR] 1.825 [1.067–3.122]) was independently associated with high-risk PFO, but hypertension (OR, 0.562 [0.327–0.967]), multiple infarctions (OR, 0.601 [0.435–0.830]), and other cardioaortic embologenic risks (OR, 0.514 [0.294–0.897]) were inversely associated with high-risk PFO compared with non-RLS. In 517 patients aged ≥60 years, multiple infarctions (OR, 0.549 [0.382–0.788]) and other cardioaortic embologenic risks (OR, 0.523 [0.286–0.959]) were inversely associated with high-risk PFO. High-risk PFO had specific clinical characteristics and possible mechanistic associations, and this trend was consistent among CS patients aged ≥60 years. http://www.umin.ac.jp/ctr/ (UMIN000032957). [ABSTRACT FROM AUTHOR]

Background: Intracranial arteriosclerotic disease (ICAD) is common in Asians and has been presumed to be largely associated with metabolic syndrome (MetS), but the risks for asymptomatic ICAD detectable in examinations of the brain, among other tests, are not well known. The present study is aimed at identifying the risks for asymptomatic ICAD using data on risk factors obtained in health checkups, including data from magnetic resonance imaging (MRI), chest computed tomography (CT), and neck echography.Methods: Subjects comprised 103 examinees more than equal to 40 years old (56.9 ± 4.7 years, 93 men) who underwent head MRI, chest CT, and carotid echography in the same period in a workplace health checkup between April and September 2014. Subjects were evaluated for ICAD based on stenosis of bilateral middle cerebral arteries and the basilar artery on previously reported scores from magnetic resonance angiography. Evaluations for extracranial arteriosclerotic disease (ECAD) were based on findings from carotid echography, and total calcium scores were calculated based on the number, areas, and peak Hounsfield computed tomographic numbers of the aortic arch calcified lesion detected.Results: ICAD, including mild cases with stenosis less than 50%, was seen in 21 subjects (20.3%); and MetS was evident in 12 subjects (11.7%). Logistic regression analysis with multivariate adjustment for major vascular risk factor demonstrated that echogenic of plaque was significantly associated with the ICAD (OR 3.69, 95%CI 1.02-13.3), however age was significant predictor of the risk profile in patients with ECAD.Conclusions: Carotid atherosclerosis could predict intracranial atherosclerosis in middle-aged people. However, further study with large sample size is warranted. [ABSTRACT FROM AUTHOR]

Background: Nonvitamin K antagonist oral anticoagulants (NOACs) are considered superior, or at least noninferior, to warfarin in preventing stroke or systemic embolism in patients with nonvalvular atrial fibrillation. Here, we recruited acute ischemic stroke patients with nonvalvular atrial fibrillation and at least one cerebral microbleed (CMB), and evaluated the proportion of patients who had an increased number of CMBs (%) after receiving anticoagulant therapy with NOACs or with warfarin for 12 months.Methods: This was a multicenter, prospective, observational cohort study at 20 centers, conducted between 2015 and 2017, in which we recruited 85 patients with at least one CMB detected by 1.5T magnetic resonance imaging (T2*WI) at baseline, who received NOACs or warfarin for at least 12 months. We compared the proportions of patients with increased numbers of CMBs in the NOACs and warfarin treatment groups.Results: The proportions of patients with increased numbers of CMBs at month 12 of treatment were 28.6% and 66.7% in the NOACs and warfarin groups, respectively. The new CMBs showed no specific regional localization in either group. In the NOACs and warfarin groups, physicians prescribed lower-than-standard dosing in 13.3% and 50% of the cases, respectively. The administration of reduced doses at physicians' discretion did not appear to alter the incidence of new CMBs.Discussion: This is the first evidence to suggest efficacy of NOACs for preventing further CMBs in patients with at least one CMB, although no statistical evaluation was carried out. [ABSTRACT FROM AUTHOR]

Background: Dizziness is the most common posterior circulation symptom; however, diagnosing a posterior circulation infarction is difficult due to a lack of typical symptoms. We aimed to investigate the frequency of misdiagnosis of a posterior circulation infarction in patients who presented with dizziness and to develop a new stroke scale that increased the diagnostic accuracy for stroke among these subjects.Methods: We retrospectively analyzed consecutive data from subjects hospitalized with ischemic stroke who presented with dizziness (the developmental phase). Based on these results, we created a novel stroke scale, which was used as a diagnostic procedure in the prospective validation phase. We compared the rate of misdiagnosis of ischemic stroke between phases.Results: During the development phase, 115 subjects were hospitalized for ischemic stroke accompanied by dizziness. Six ischemic stroke subjects were not properly diagnosed (6/115, 5.2%). We created the new DisEquilibrium, Floating sEnsation, Non-Specific dizziness, Imbalance, and VErtigo (DEFENSIVE) stroke scale to prevent underdiagnosis of a posterior circulation infarction. During the validation phase, 949 subjects with dizziness were examined with the DEFENSIVE stroke scale; among these subjects, 100 were hospitalized for ischemic stroke accompanied by dizziness. No subject with ischemic stroke was overlooked. The new DEFENSIVE stroke scale had a sensitivity of 100% and decreased the rate of improper diagnosis of stroke (5.2% versus 0%; P = .022).Conclusions: Our new stroke recognition instrument for a posterior circulation infarction presenting with dizziness and related symptoms (the DEFENSIVE stroke scale) is easy to administer and has good diagnostic accuracy. [ABSTRACT FROM AUTHOR]

Background and Purpose: This study aimed to investigate factors associated with stroke recurrence and new-onset atrial fibrillation (AF) in patients with embolic stroke of undetermined source (ESUS).Methods: Between January 2005 and March 2012, a total of 1514 consecutive patients were admitted to our hospital with a diagnosis of acute ischemic stroke within 7 days after onset. Of these, 236 patients met the diagnostic criteria for ESUS. A retrospective analysis was performed of the following characteristics of these ESUS patients: medical history, comorbidities, and magnetic resonance imaging (MRI) findings including the deep and subcortical white matter hyperintensity (DSWMH) grade, drugs used for preventing recurrence, and clinical information such as NIH Stroke Scale scores on admission and outcomes evaluated by modified Rankin scale. The rate of recurrence after discharge and the frequency of new-onset AF were also determined.Results: There were 236 ESUS patients (141 men, mean age 70.2 ± 12.1 years). During the follow-up period, ranging from 7 days to 12.9 years (median 54.3 months), 32 (13.6%) and 44 (18.6%) of these patients had a recurrent ischemic stroke and new-onset AF, respectively. The most prevalent subtype of recurrent ischemic stroke was ESUS itself; this type of stroke occurred in 19 (59.3%) patients. AF was observed at stroke recurrence, but only 2 patients were diagnosed with cardioembolism. Multivariate analysis with a Cox proportional hazard model demonstrated that DSWMH grade greater than or equal to 3 was significantly associated with both recurrent ischemic stroke (hazard ratio 3.66, 95% confidence interval 1.69-7.92, P = .001) and new-onset AF (2.00, 1.03-3.90, .04).Conclusions: MRI classification of white matter hyperintensity could be effectively used as a predictor for recurrent ischemic stroke and new-onset AF in patients with ESUS. [ABSTRACT FROM AUTHOR]

Carotid artery atherosclerosis is one of the major risk factors for ischemic stroke. Intraplaque neovascularization (IPN) is one of the steps toward the development of vulnerable plaque. Superb microvascular imaging (SMI) is a new ultrasonographic technique for visualizing low-velocity and microvascular flow by clutter suppression to extract flow signals from large to small vessels and enables visualization of intraplaque microvascular flow (IMVF) without echo contrast media. We aimed to investigate the association between IMVF signal in SMI and MRI plaque imaging among patients with atherosclerotic carotid stenosis. We prospectively enrolled patients (>18 years old) with mild to severe carotid stenosis (more than 50% in cross-sectional area) diagnosed by carotid ultrasonography between August 2017 and April 2018, irrespective of sex and history of stroke. A total of 40 patients (31 men, 9 women; mean age, 75.1 ± 10.0 years) were enrolled. SMI revealed IPN findings in 21 patients. SMI clearly visualized the direction of pulsatile flow movement in microvessels and IPN was easily classified into the two types of Type V (n=2) and Type E (n=19). Multivariate logistic regression analysis presented that microvascular flow signal in carotid plaque on SMI was identified as a significant predictor of intraplaque hemorrhage as evaluated by MRI (OR, 8.46; 95%CI, 1.44-49.9; p=0.018). This study demonstrated a significant association between the presence of IMVF signal in SMI and intraplaque hemorrhage characterized by high-intensity lesions on MRI T1-FFE images. [ABSTRACT FROM AUTHOR]

Background: Faster time to recanalization leads to better clinical outcomes in patients treated with endovascular thrombectomy. Whether the association between time to recanalization and clinical outcomes depends on cerebral blood volume (CBV) obtained from pretreatment computed tomography (CT) perfusion (CTP) imaging was investigated.Methods: In consecutive patients with acute ischemic stroke who achieved recanalization by endovascular thrombectomy for intracranial internal carotid artery or M1 occlusion, the effects on clinical outcome of time to recanalization and the relative CBV value (rCBV) assessed by pretreatment CTP were evaluated. The patient population was divided into 2 groups according to rCBV: normal rCBV group (rCBV ≥ .9) and low rCBV group (rCBV < .9). In each group, time to recanalization was compared between the good and the poor clinical outcome groups.Results: Sixty-four patients were eligible for this study. Twenty-six patients (40.6%) achieved good clinical outcomes. In the normal rCBV group, no association was found between clinical outcome and time to recanalization. In the low rCBV group, time to recanalization from CTP (101 minutes versus 136 minutes, P = .040) was significantly shorter in the good clinical outcome group. On binary logistic regression modeling, CTP to recanalization time (odds ratio 1.035 [1.004-1.067], P = .025) was an independent predictor of good clinical outcome only in the low rCBV group.Conclusions: The association between time to recanalization and clinical outcomes depends on rCBV obtained from pretreatment CTP. Time to recanalization is more important for good clinical outcomes in patients with low rCBV than in patients with normal rCBV. [ABSTRACT FROM AUTHOR]

Background: A transient visual symptom (TVS) is a clinical manifestation of transient ischemic attack (TIA). The aim of this study was to investigate differences in clinical characteristics among subtypes of TVS using multicenter TIA registry data.Materials and Methods: Patients with TIA visiting within 7 days of onset were prospectively enrolled from 57 hospitals between June 2011 and December 2013. Clinical characteristics were compared between patients with 3 major subtypes of TVS (transient monocular blindness [TMB], homonymous lateral hemianopia [HLH], and diplopia).Results: Of 1365 patients, 106 (7.8%) had TVS, including 40 TMB (38%), 34 HLH (32%), 17 diplopia (16%), and 15 others/unknown (14%). Ninety-one patients with 1 of the 3 major subtypes of TVS were included. Symptoms persisted on arrival in 12 (13%) patients. Isolated TVS was significantly more common in TMB than in HLH and diplopia (88%, 62%, and 0%, respectively; P < .001). Duration of symptoms was shorter in patients with TMB than those with HLH (P = .004). The ABCD2 score was significantly lower in patients with TMB compared with those with HLH and diplopia (median 2 [interquartile range 2-3] versus 3 [2-4] and 4 [2-5], respectively; P = .005). Symptomatic extracranial internal carotid artery stenosis or occlusion was seen in 14 (16%) patients, and was more frequent in TMB than in HLH and diplopia (28%, 9%, and 0%, respectively; P = .015).Conclusions: TVS was an uncommon symptom in our TIA multicenter cohort. Some differences in clinical characteristics were found among subtypes of TVS. [ABSTRACT FROM AUTHOR]

Future predictions are imperative for environmental planning decisions as ecosystem changes take time to have an effect. In this paper, on the basis of a scenario approach to expose common frameworks and legitimacy, we quantitatively and qualitatively reviewed scientific papers to assess the future condition of ecosystem services. Of the 464 recent papers on biodiversity and ecosystem service changes, we extracted 106 papers by excluding papers that only examined climate change and/or carbon dioxide. Of the 106 papers, most used three scenarios to assess changes in from two to four ecosystem services over the next 20 to 30 years. Overall, not all of the scenarios were used in a predictive capacity, and of the ecosystem services examined, regulating and provisioning services were analyzed more frequently than cultural services. In practice, when using the outcomes of this scenario approach, either an administrative unit or a basin approach is an advisable scale for decision making. As a basin includes various micro ecosystems and various stakeholders, a participatory approach is the most favored. [ABSTRACT FROM AUTHOR]

The growth rate of broiler chickens has increased by 400% over the past 50 years, and breast yields continue to increase. This has led to an increase in thoracic muscle abnormalities in broilers, with wooden breast becoming a major issue worldwide. The etiology and the mechanism underlying the etiology of wooden breasts have not yet been elucidated; however, it occurs due to oxidative stress. Reactive oxygen species, which cause oxidative stress, are mainly produced in mitochondria. Thus, in this study, we investigated the relationship between the severity of wooden breast in broilers and the characteristics of mitochondria as the source of reactive oxygen species. Sampling of the pectoralis major muscle at the ventral cranial position was conducted in 50-day-old broilers. The severity of wooden breast was classified into three groups based on the muscle fiber roundness and wing–wing contact test, with highest severity in severe wooden breast and lowest severity in normal breast. Nicotinamide adenine dinucleotide tetrazolium reductase staining revealed an increase in darkly stained muscle fibers, indicating high severity of wooden breast. The mitochondria were swollen in severe wooden breast cases, with highest swelling in severe wooden breast and lowest swelling in normal breast. The expression levels of the mitochondrial antioxidant enzyme genes superoxide dismutase 1 and superoxide dismutase 2 were significantly lower in wooden breast-severe tissue than in normal tissue. These results suggest that when the levels of reactive oxygen species in muscle fibers, which should be constant, are increased, mitochondrial homeostasis is not maintained and the damage levels increase in various membranes of the cell, leading to the disruption of normal physiological functions. [Display omitted] • Wooden breast affected muscle fibers were rounded as severity higher. • More myofibers were stained with dark and intermediate colors in wooden breast by NADH-TR staining. • Anti-ATPB immune staining were larger mitochondrial particles in severe cases compared with those in normal and mild cases. • The gene expression levels of SOD1 and SOD2 in wooden breast were significantly low. [ABSTRACT FROM AUTHOR]

Background: Symptoms of transient ischemic attack (TIA) persist on arrival and subsequently resolve in some patients admitted to hospitals early after onset. Differences in clinical characteristics between patients with acute TIA whose symptoms do and do not persist on arrival remain unclear.Methods: We retrospectively extracted data of consecutive TIA patients with an onset-to-door time (ODT) of 24 hours or less and without a history of stroke from a multicenter TIA database. Clinical characteristics were compared between patients with and without persisting symptoms on arrival.Results: Two hundred sixty-six patients (158 men, 68.0 ± 12.9 years) were included. Of the total number of patients, 105 (39.5%) had persisting symptoms with a mean National Institutes of Health Stroke Scale score of 2.4 (median, 1.0). Patients with persisting symptoms were more likely to have sensory disorder, ambulance-transported admission, long-duration TIA (≥60 minutes), and shorter ODT than those without. Multivariate analysis showed that sensory disorder (odds ratio [OR] 2.52, 95% confidence interval [CI] 1.35-4.77), ambulance-transported admission (OR 1.80, 95% CI 1.00-3.28), and long-duration TIA (OR 3.96, 95% CI 2.12-7.71) were positively associated and that an ODT of more than 12 hours (OR .18, 95% CI .04-.63) was inversely associated with the presence ofpersisting symptoms. Patients with persisting symptoms were more likely to be examined by a stroke physician at first (69% versus 57%, P = .049) and then hospitalized in a stroke unit (59% versus 43%, P = .010).Conclusion: Clinical manifestations and management after admission might differ between patients with acute TIA whose symptoms do and do not persist on arrival. [ABSTRACT FROM AUTHOR]

Background: Japan has the highest number of magnetic resonance imaging units in the world, and citizens can freely choose medical care at any hospital or clinic. We aimed to investigate the triage of patients with suspected transient ischemic attack (TIA) or minor stroke in this unique Japanese healthcare system. Methods: In this cohort study, patients with suspected TIA or minor stroke (National Institutes of Health Stroke Scale score <4) within 7 days after onset were prospectively enrolled and followed for 1 year. The high-risk group was defined as having at least one of the following 5 items at the initial visit: (1) atrial fibrillation, (2) carotid stenosis, (3) crescendo TIA, (4) definite focal brain symptoms, or (5) ABCD2 score of 4 or higher. After the initial assessment, the patients were diagnosed as having acute ischemic cerebrovascular syndrome (AICS) or stroke mimic. AICS was classified into 3 categories including definite, probable, and possible AICS, based on evidence of neurological deficits and brain infarction on the imaging study. Results: A total of 353 patients were enrolled and 89.8% of the patients were examined by diffusion-weighted imaging at the initial visit. Kaplan-Meier analyses demonstrated a statistically significant difference in subsequent stroke risk when the patients were triaged by the ABCD2 score (P = .031), 5-item high-risk categorization (P = .032), or AICS classification (P = .001). Conclusions: This study demonstrates that hospitals and clinics with imaging facilities play a major role in triage and that the ABCD2 score, 5-item high-risk categorization, and AICS classification are useful as triage tools for patients with suspected TIA or minor stroke. [ABSTRACT FROM AUTHOR]

Background and Purpose: In-stent restenosis (ISR) caused by in-stent intimal hyperplasia (ISH) may develop after carotid artery stenting (CAS), and often necessitates re-stenting. We investigated whether new ultrasound technique is useful for detecting carotid artery plaques prone to ISR.Purpose: Superb micro-vascular imaging (SMI) is a new color Doppler imaging technique for assessing low velocity blood flow such as neovascularization in carotid artery plaques. In this study, we attempted to identify associations between findings from carotid ultrasonography with SMI performed prior to CAS and in-stent restenosis after 6 months of CAS.Methods: This study investigated 19 patients (18 men; mean age, 72.4 years). Preoperative plaque evaluation was performed by magnetic resonance imaging, ultrasonography, and carotid angiography. Follow up angiography was performed in all patients at 6 months after CAS. ISR was defined as ISH resulting in >50% stenosis based on European Carotid Surgery Trialists criteria. We investigated whether SMI was useful as a predictor of ISR by chi-square test.Results: Preoperative mean stenosis rate according to North American Symptomatic Carotid Endarterectomy Trial methods in 19 patients was 61.3%. Neovascularization was observed on SMI in 10 patients (52.6%). Carotid angiography at 6 months after CAS revealed ISR in 4 patients, all of whom had shown neovascularization on SMI. A significant association was seen between findings of neovascularization on SMI and development of ISR (p = 0.033). In predicting ISR, neovascularization findings on SMI offered 100.0% sensitivity and 60.0% specificity.Conclusions: Preprocedural plaque characterization by carotid ultrasound with SMI appears useful for predicting ISR at 6 months after CAS. [ABSTRACT FROM AUTHOR]

Rationale: Anticoagulants are widely used to prevent recurrence of ischemic stroke in patients with nonvalvular atrial fibrillation, but in some patients, they also cause bleeding, particularly intracranial hemorrhage. One of the independent predictors of intracerebral hemorrhage is the presence of cerebral microbleeds (CMBs); a high incidence of intracerebral hemorrhage is reported in warfarin-treated patients with multiple CMBs. Longitudinal study suggested that the presence of CMBs at baseline is a predictor of new CMBs in warfarin-treated patients. However, there has been no study on the progression of CMBs in patients receiving the non-vitamin K antagonist oral anticoagulants (NOACs).Aims: This study tests the hypothesis that the incidence of hemorrhagic stroke is lower in patients receiving NOACs (dabigatran, rivaroxaban, apixaban, and edoxaban) than in those receiving warfarin, and this difference reflects the difference in the effects of warfarin and NOACs on the progression of CMBs.Design: We will enroll 200 patients with at least 1 CMB detected by 1.5 T magnetic resonance imaging (T2(∗)-weighted imaging) at baseline and who have received NOACs or warfarin for at least 12 months. Primary end point is the proportion of subjects with an increased number of CMBs at month 12 of treatment with NOACs or warfarin. If the results of this study support the efficacy of NOACs for preventing increase of CMBs, this would be of great interest to domestic and overseas clinicians, in view of the potential therapeutic impact, including that on primary prevention of ischemic stroke. [ABSTRACT FROM AUTHOR]

Background The effect of renal dysfunction on intracerebral hemorrhage (ICH) remains unclear. We investigated associations of renal dysfunction assessed by estimated glomerular filtration rate (eGFR) with clinical courses and outcomes in ICH patients. Methods From a prospective, multicenter, observational study, 203 patients who had supratentorial ICH within 3 hours of onset were included. Patients were classified into 3 groups based on eGFR: Group 1 (eGFR <60 mL/minute/m 2 ), Group 2 (60-89), and Group 3 (≥90). Outcomes included neurologic deterioration within 72 hours, hematoma expansion (>33% in volume) at 24 hours, and favorable (modified Rankin Scale [mRS] ≤2) or unfavorable (mRS ≥5) outcome at 3 months. Results Thirty-seven patients (16 women, 74.6 ± 13.2 years) were assigned to Group 1, 99 (34 women, 65.2 ± 11.4 years) to Group 2, and 67 (30 women, 61.3 ± 9.4 years) to Group 3. Significant differences were found in age ( P < .001) and initial systolic blood pressure among the groups (208.4 ± 18.0, 201.9 ± 15.1, and 198.1 ± 14.2 mm Hg for Group 1, 2, and 3, respectively; P = .006). Similar rates of neurologic deterioration (14%, 6%, and 6%) and hematoma expansion (16%, 14%, and 18%) were observed among the groups. However, in Group 1, favorable outcome was less frequent (17%, 48%, and 42%; P = .002) and unfavorable outcome was more frequent (24%, 7%, and 6%; P = .013) than in the other groups. After adjustment for confounders, eGFR <60 mL/minute/m 2 was independently associated with both favorable outcome (odds ratio [OR], .21; 95% CI, .07-.54) and unfavorable outcome (OR, 5.64; 95% CI, 1.80-18.58). Conclusions Renal dysfunction (eGFR <60 mL/minute/m 2 ) was associated with poor clinical outcome after ICH. [ABSTRACT FROM AUTHOR]

Background Stroke-bypass transportation to the stroke center by paramedics is important to maximize the efficiency of intravenous tissue plasminogen activator (iv-tPA) therapy. To improve access to stroke thrombolysis, a citywide protocol was launched on January 2007 in Kawasaki City (population 1.4 million) using the Maria Prehospital Stroke Scale (MPSS), and quality assurance monitoring has been performed every 6 months. The aim was to identify whether the citywide quality assurance monitoring improves the process and outcome of iv-tPA therapy. Methods All of the MPSS-based transportation data prospectively recorded by the Kawasaki City Fire Department and the associated clinical data in the 11 hospitals that accept stroke-bypass transfers were merged every 6 months for the quality assurance monitoring. Clinical indicators such as ambulance call-to-door time, onset-to-needle time, door-to-needle time, frequency of thrombolytic use, and outcome of thrombolytic therapy were analyzed. These clinical indicators were also compared between patients transferred on weekdays and on weekends. Results A total of 2049 patients was registered from April 2009 to March 2013. Their mean age was 70.4 ± 13.2 (range, 24-98) years, and 64.3% were male. Ambulance call-to-door time decreased gradually from 37.5 ± 12.5 minutes to 33.9 ± 11.7 minutes over 4 years ( P = .000, analysis of variance with the post hoc Dunnett test). Onset-to-needle time and door-to-needle time were similar over the 4 years. Good outcome (modified Rankin Scale score <2) after iv-tPA therapy increased from 24.1% to 35.3% ( P = .045, 2010 vs. 2012). No deleterious effect of weekend admission was observed based on these clinical indicators. Conclusions A citywide MPSS-based transportation protocol significantly decreased the delay in the ambulance call-to-door time. The implementation of standardized cross-institutional quality assurance programs for acute stroke therapy may improve the process and outcome of iv-tPA therapy in the community. [ABSTRACT FROM AUTHOR]

Background: Intravenous nicardipine is commonly used to reduce elevated blood pressure in acute intracerebral hemorrhage (ICH). We determined factors associated with nicardipine dosing and the association of dose with clinical outcomes in hyperacute ICH.Methods: Hyperacute (<3 hours from onset) ICH patients with initial systolic blood pressure (SBP) greater than 180 mm Hg were included. All patients initially received 5 mg/hour of intravenous nicardipine. The dose was adjusted to maintain SBP between 120 and 160 mm Hg. Associations of maximum hourly and total doses with early neurologic deterioration (END), hematoma expansion (>33%), and modified Rankin Scale score 4-6 at 3 months were assessed.Results: Two hundred six patients (81 women, 65.8 ± 11.8 years) were studied. Initial SBP was 201.9 ± 15.9 mm Hg. Maximum and total nicardipine doses were 9.1 ± 4.2 mg/hour and 123.7 ± 100.2 mg/day, respectively. Multivariate analyses revealed that men (standardized regression coefficient [β] = .20, P = .0030 for maximum dose; β = .25, P = .0002 for total dose), age (β = -.28, P = .0002; β = -.25, P = .0005), and initial SBP (β = .19, P = .0018; β = .18, P = .0021) were independently associated with both maximum and total doses. Body weight (β = .20, P = .0084) was independently associated with total dose. After multivariate adjustment, maximum dose (per 1 mg/hour; odds ratio [OR], 1.25; 95% confidence interval [CI], 1.09-1.45) was independently, and total dose (per 10 mg/day; OR, 1.06; 95% CI, .998-1.132) tended to be independently, associated with END. Nicardipine dose was not associated with hematoma expansion or 3-month outcome.Conclusions: Nicardipine dose is roughly predictable with sex, age, body weight, and initial SBP in acute ICH. The maximum dose was associated with neurologic deterioration. [ABSTRACT FROM AUTHOR]

The concept of telestroke networks has been proposed to overcome regional disparities in stroke treatment. Such networks do not yet operate in Japan. We aimed to determine the specific needs for telestroke networks and to estimate the effects on the number of thrombolytic therapies. Five of the 47 Japanese prefectures with various population densities to estimate the nationwide effect of telestroke networks were selected. The questionnaire survey was administered at hospitals in these prefectures that are authorized to admit patients with acute stroke. Low-volume hospitals that annually treated fewer than 12 patients with acute stroke had never used tissue plasminogen activator (tPA). The number of days when telestroke support might have been needed varied depending on the size of the population aged 65 years or older within a 30-minute-driving-time area of a hospital and the annual number of patients treated within 3 hours of onset. The geographic information system analysis showed that .6%-8.3% of the population lived in areas where they could not reach a hospital for acute stroke treatment within 60 minutes. If 24/7 full telestroke support was introduced to the existing hospitals, 6.8-69.3 more patients could be treated by intravenous (IV) tPA annually. These numbers exceeded the estimated annual increases of .8-13.7 more patients if a drip-and-ship telestroke network was introduced into an underserved area outside the 60-minute-driving-time area. This study uncovered that many Japanese stroke hospitals, especially low-volume facilities located in rural areas, do not perform IV tPA therapy in 24/7 fashion and telestroke support to these hospitals may be highly effective compared with the drip-and-ship network in an underserved area. [Copyright &y& Elsevier]

The over-65 population stands at 29 million, more than 20% of the total population in Japan. This is the highest rate in the world. One-person households and older couple households will be increasing. The aim of the present study was to identify whether life and family background are significant factors for delayed presentation to hospital after stroke onset. A total of 253 patients (mean age, 70.7 ± 13.2 years) with stroke was examined. Patients who presented to hospital within 3 hours of onset were categorized as the early presentation group, and the other patients were categorized as the late presentation group. Life and family background were classified into 3 categories, namely 1-person households, 2-person households, and patients living with 3 or more persons. Two-person households were further subdivided by the age of family members. Multivariate logistic regression analysis demonstrated that 1-person households (odds ratio [OR]: 2.980, 95% confidence interval [CI]: 1.108-8.011) and 2-person households with individuals 65 years and older (OR: 3.059, 95% CI: 1.297-7.217) were significant independent factors for delayed presentation, in addition to stroke subtype, time of stroke onset, and route of admission. Onset-to-door time in patients with night-time onset was significantly different among different types of households. Significant delay was demonstrated in 2-person households with 2 individuals 65 years and older compared with that in patients living with 3 or more persons (P = .038). Our findings show that delayed presentation to hospital is more likely in stroke patients living in an elderly couple household, especially those with evening onset in an aging society. [Copyright &y& Elsevier]

Background: This study aimed to investigate whether left atrial appendage (LAA) dysfunction evaluated by transesophageal echocardiography (TEE) during sinus rhythm is predictable of paroxysmal atrial fibrillation (PAF) as an embolic source in the acute stage of stroke. Methods and Results: We measured and analyzed LAA flow velocity (LAA-FV) and LAA ejection fraction (LAA-EF) in 300 acute ischemic stroke patients by TEE. We divided the acute ischemic stroke patients into 3 groups. The atrial fibrillation (AF) group (n = 58) comprised patients whose TEE was performed during AF rhythm. The PAF group (n = 42) comprised patients with a history of AF but with normal sinus rhythm when TEE was performed. The normal sinus (sinus) group (n = 200) did not have any history of AF. We found that mean LAA-FV and LAA-EF values in the PAF group were significantly lower than those in the sinus group (P < .001). The diagnostic accuracy of LAA-FV for the diagnosis of PAF calculated as the area under receiver operating characteristic curves was low (.582, 95% confidence interval [CI] = .498-.665) but that of LAA-EF was modest (.721, 95% CI = .653-.789), with an optimal cutoff point of 49.1%. Conclusions: LAA dysfunction as determined by TEE (LAA-EF < 49.1%) in the acute stage of stroke is predictive of PAF with moderate accuracy. Long-term electrocardiographic monitoring is recommended for cryptogenic stroke patients with LAA dysfunction. [Copyright &y& Elsevier]

Background: The therapeutic efficacy of low-dose intravenous alteplase (0.6 mg/kg) for basilar artery occlusion (BAO) remains unknown. Methods: BAO patients enrolled from the Japanese multicenter registry involving 600 stroke patients treated with the low-dose intravenous alteplase were studied. Results: Twenty-five patients had BAO (8 women ranging from 32-92 years of age; mean baseline National Institutes of Health Stroke Scale [NIHSS] score 16). The stroke subtype was cardioembolic in 15 patients and atherothrombotic in 4 patients. BAO was recanalized during hospitalization in 18 (78%) of 23 patients undergoing follow-up angiography. Within the initial 24 hours, 14 patients (56%) had a ≥8-point decrease in the NIHSS score, being more common than 267 patients with middle cerebral artery occlusion (MCO) from the same registry (odds ratio [OR] 2.50; 95% confidence interval [CI] 1.06-5.97) after adjustment by sex, age, and baseline NIHSS score. In addition, 4 patients (16%) had a ≥4-point increase in the score, being marginally more common than MCO patients (OR 3.13; 95% CI 0.81-10.25). Symptomatic intracranial hemorrhage within the initial 36 hours (8% v 5%), independence at 3 months (modified Rankin Scale score ≤2, 48% v 52%), and mortality at 3 months (4% v 6%) were similar when comparing BAO and MCO patients. When compared with previous studies of BAO, vital and functional outcomes at 3 months were relatively better in our study. Conclusions: The use of low-dose alteplase resulted in similar outcomes when comparing acute BAO and MCO patients. [Copyright &y& Elsevier]

Objectives: The aim was to investigate triage methods for suspected transient ischemic attacks (TIAs) with focal or nonfocal symptoms.Materials and Methods: In total, 350 patients with suspected TIAs were enrolled and followed for one year. Potential high-risk factors for TIAs, such as atrial fibrillation, carotid artery stenosis, crescendo TIA, and ABCD2 score ≥ 4, were evaluated. Patients were classified into 3 groups according to the initial neurological symptoms: focal, nonfocal, and mixed (both focal and nonfocal) groups. Stroke-free survival rates were compared via Kaplan-Meier analysis.Results: Diffusion-weighted MRI (DWI) was performed for 89.8% of the patients within 7 days, and the frequency of acute brain infarction on DWI was significantly lower in the nonfocal group (focal, 24.1%; nonfocal, 7.2%; mixed, 22.2%; P < .01). There was no significant difference in the one-year event-free survival rates across the groups. Significantly higher stroke risk was observed in patients with one or more high-risk categories or the ABCD2 score (≥ 4) in the focal group (P = .021 and .26, respectively), whereas no significant difference was observed in the other groups. Across all symptom groups, significantly higher stroke risk was observed in patients showing acute infarcts on DWI evaluated within 7 days.Conclusions: Both high-risk categorization (≥ 1 potential high-risk factors) and ABCD2 score (≥ 4) alone were useful tools for identifying higher stroke risk in patients with focal symptom but not with nonfocal symptoms in isolation. Further studies are warranted in triage methods for TIA with nonfocal in isolation in conjunction with DWI. [ABSTRACT FROM AUTHOR]

This study examined outcomes of patients with acute ischemic stroke (AIS) with major cerebral artery occlusion after the approval of intravenous recombinant tissue-type plasminogen activator (IV rt-PA) but before approval of the MERCI retriever. We retrospectively enrolled 1170 consecutive patients with AIS and major cerebral artery occlusion (496 women; mean age, 73.9 ± 12.3 years) who were admitted within 24 hours after the onset of symptoms to 12 Japanese stroke centers between October 2005 and June 2009. Cardioembolism was a leading cause of AIS in this group (68.2%). The occlusion sites of the major cerebral arteries included the common carotid artery and internal carotid artery (ICA; 29.6%), middle cerebral artery (52.2%), and basilar artery (7.6%). Recanalization therapy (RT) was performed in 32.0% of patients (IV rt-PA, 20.0%; neuroendovascular therapy, 9.4%; combined, 2.5%). Symptomatic intracerebral hemorrhage within 36 hours with a ≥1-point increase in the National Institutes of Health Stroke Scale score occurred in 5.3% of the patients. At 3 months (or at hospital discharge), 29.3% of the patients had a favorable outcome (based on a modified Rankin scale score of 0-2), 23.8% were bedridden, and 15.6% died. After multivariate adjustment, RT was positively associated with a favorable outcome and negatively associated with death, whereas age, baseline National Institutes of Health Stroke Scale score, and ICA occlusion were negatively associated with a favorable outcome and positively associated with death. One-third of the patients with AIS and major cerebral artery occlusion were treated with RT, which was independently associated with favorable outcomes and death. However, 40% of the patients became bedridden or died during the post-alteplase, pre-MERCI era in Japan. [Copyright &y& Elsevier]

There is no prehospital stratification tool specifically for predicting thrombolytic therapy after transportation. We developed a new prehospital scale named the Maria Prehospital Stroke Scale (MPSS) by modifying the Cincinnati Prehospital Stroke Scale. Our objective is to evaluate its utility in a citywide bypass transportation protocol for intravenous (IV) tissue plasminogen activator (tPA). In the MPSS, facial droop, arm drift, and speech disturbance are tested by emergency medical technicians (EMTs). Facial droop is graded as normal (0) or abnormal (1), and the other 2 items are graded in 3 levels as normal (0), not severe (1), and severe (2). Thus, the total MPSS score ranges from 0 to 5. The predictive value of MPSS for thrombolytic therapy after bypass transportation was evaluated in 1057 patients. The MPSS scored by EMTs was significantly correlated with the National Institutes of Health Stroke Scale score in the emergency room (Spearman rho = .67, P = .000). The onset-to-door time was significantly longer with a low MPSS score (analysis of variance, F5,4.21 = .001). The rate of thrombolytic therapy was increased when the MPSS score increased from 0 to 5: 0%, 4.1%, 8.8%, 13.0%, 20.3%, and 31.5%, respectively. The areas under the receiver operating characteristic curve for the correct diagnosis of stroke and prediction of IV tPA therapy were calculated as .737 (95% confidence interval [CI]: .688-.786) and .689 (95% CI: .645-.732), respectively. Multivariate logistic regression analysis showed that the MPSS score and the detection-to-door time were independent predictors of tPA use after transportation. The MPSS is a novel prehospital stratification tool for the prediction of thrombolytic therapy after transportation. [Copyright &y& Elsevier]

Stroke is often preceded by a transient ischemic attack (TIA). To properly recognize TIA and take prompt initial action, all citizens should be fully educated about TIA. Our objective is to evaluate how much knowledge of TIA has spread among Japanese citizens. As a preliminary study with this goal, we conducted an Internet-based questionnaire survey of 30,000 Japanese citizens aged 20 years or more, excluding health care professionals, from across Japan to investigate their awareness and knowledge of stroke and TIA. Valid responses were obtained from 11,121 Japanese citizens, aged 44.8 ± 13.1 (mean ± SD) years. The most frequent response pertaining to initial action at TIA onset was “visit the family doctor” (41.8%), followed by “immediately call an ambulance” (22.4%). Tokushima, Kagawa, and Kumamoto were the top 3 prefectures with the highest ambulance request rates. Factors contributing to immediately calling an ambulance were respondents'' confidence about the involvement of stroke (odds ratio [OR] 2.290, 95% confidence interval [CI] 1.250-4.318, P = .009) and knowledge of the importance of initiating treatment within 3 hours of symptom onset (OR 2.273, 95% CI 1.923-2.825, P = .000). Although television was the primary source of information about stroke for all groups of age, older respondents obtained more information from newspapers than younger respondents. The results showed that many Japanese citizens would fail to call an ambulance in response to TIA, and diagnosis by a primary care physician appears to be the main triage system for the treatment of TIA. Rather than instituting a nationally uniform strategy of education for the promotion of TIA awareness among Japanese citizens, education programs should account for age-specific and regional differences among citizens. [Copyright &y& Elsevier]

Background: Proinflammatory state has been implicated as a pathogenetic mechanism in the progression of intracranial large artery atherosclerosis (ILA). High levels of inflammatory biomarkers in healthy populations and in patients with acute stroke or acute coronary syndrome are known to be associated with subsequent stroke events. This study investigated the relationship between circulating biomarkers measured early after stroke onset and future ILA progression. Methods: In 48 patients with acute ischemic stroke, high-sensitivity C-reactive protein (hs-CRP), interleukin-6 (IL-6), IL-18, tumor necrosis factor–α, matrix metalloproteinase (MMP)-2 and MMP-9 were measured within 48 hours after onset. Baseline severity and ILA progression were assessed by serial magnetic resonance angiography (MRA). The median follow-up period for MRA was 3.1 years. Hazard ratio (HR) was calculated using the Cox proportional hazard model adjusted for traditional risk factors, and accuracy of predicted ILA progression was analyzed by receiver operating characteristic (ROC) curve analysis. Results: ILA progression was observed in 6 of 48 patients (12.5%). After adjusting for age, sex, and presence of hypertension, baseline ILA severity score (HR 2.814; 95% confidence interval [CI] 1.172-6.754) and IL-6 (HR 1.215; 95% CI 1.002-1.473) were significantly associated with ILA progression. Area under the ROC curve (AUC) for prediction of ILA progression by traditional risks, baseline ILA severity score and IL-6, was 0.647. When IL-6 was removed from this model, AUC remained at 0.631. Conclusions: In addition to traditional risk factors and baseline radiologic findings, circulating levels of IL-6 measured soon after stroke onset are associated with future ILA progression. [ABSTRACT FROM AUTHOR]

The potent free radical scavenger edavarone is widely used in Japan to treat acute ischemic stroke within 24 hours after onset. Recent experimental studies have shown that edavarone alleviates blood-brain barrier disruption in conjunction with suppression of the inflammatory reaction in acute brain ischemia. We investigated the effects of edaravone on circulating inflammatory biomarkers in patients with ischemic stroke. Patients with acute ischemic stroke admitted 12-36 hours after onset of symptoms were prospectively enrolled. Intravenous edaravone at 60 mg/day for 14 days was administered to patients admitted 12-24 hours after symptom onset (edaravone group; n = 29). Patients admitted 24-36 hours after onset served as controls (control group; n = 34). Venous blood samples were obtained on admission and at 48 hours, 7 days, and 14 days after symptom onset. Serum concentrations of high-sensitivity C-reactive protein, interleukin (IL)-6, IL-10, IL-18, tumor necrosis factor α, matrix metalloproteinase (MMP)-2, and MMP-9 were measured. General linear models were used to compare changes in concentrations of these biomarkers over time between the groups. In the control group, the mean MMP-9 concentration increased gradually from 3.857 ± 1.880 ng/mL to 4.538 ± 1.966 ng/mL over the 14-day period (P = .027, one-way repeated-measures analysis of variance [ANOVA]), but the edavarone group demonstrated no such increase (P = .564). A significant group–time interaction was demonstrated only for MMP-9 (P = .029, two-way repeated-measures ANOVA), and no significant differences in other biomarkers were seen between groups. Our data indicate that edaravone suppresses serum MMP-9 level in patients with acute ischemic stroke. Further studies with a larger sample size are needed to explore the relationship between circulating MMP-9 level and the protective effect of edaravone. [ABSTRACT FROM AUTHOR]

Community-based stroke care in Japan is currently provided in acute hospitals, convalescent rehabilitation units, general practices, sanatorium-type wards, nursing care facilities, and in-home/commuting care services. We conducted a nationwide survey to identify factors influencing cooperation among the various providers of community-based stroke care. We sent questionnaires to 11,178 facilities and assessed the independent variables of excellent and fair cooperation among the care providers. Of the providers that responded, 66% were engaged in medical practice or long-term care for stroke patients. The following independent variables were inversely associated with excellent or fair cooperation in the community: area with the higher population density among 3 groups divided by tertile threshold (odds ratio [OR], 0.53; 95% confidence interval [CI], 0.41-0.69), facilities covered by long-term care insurance (OR, 0.27; 95% CI, 0.22-0.34), and insufficient communication with local government (OR, 0.19; 95% CI, 0.14-0.24). Positive independent variables of excellent or fair cooperation were the sharing of patient information in the community (OR, 2.53; 95% CI, 1.78-3.66), use of a scale for assessing activities of daily living (OR, 1.93; 95% CI, 1.42-2.63), appropriate utilization of care support managers (OR, 1.91; 95% CI, 1.43-2.55), and adequate comprehension of the long-term care insurance system (OR, 1.54; 95% CI, 1.24-1.92). Our findings suggest that improved communication between healthcare providers and local government, along with appropriate attention to the problems facing providers covered by long-term care insurance, may improve community-based stroke care in Japan. [Copyright &y& Elsevier]

Antiplatelet effects of angiotensin II receptor blocker have been suggested, but satisfactory results in clinical settings are lacking. We investigated spontaneous platelet aggregation (SPA) and CD62P levels in patients with hypertension and chronic-stage ischemic stroke. The study comprised 35 patients assigned to losartan (50 mg/day) or telmisartan (40 mg/day) for 4 weeks randomly. SPA was evaluated using laser-scattered light aggregometry and CD62P levels using whole blood flow cytometry before and after treatment. SPA was not significantly reduced after losartan or telmisartan treatment. CD62P was significantly reduced after losartan treatment (P = .016), but no significant differences were noted with telmisartan. These findings suggest that standard doses of losartan display antiplatelet effect as measured by CD62P levels. [Copyright &y& Elsevier]

The accuracy of the acetazolamide (ACZ) challenge test using semiquantitative SPECT in detecting Stage II hemodynamic failure, i.e. cerebral misery perfusion, in patients so diagnosed with PET has yet to be determined. This study was carried out in 53 patients who had a unilateral occlusion or severe stenosis of their cerebral artery. Asymmetry index (AI) was used to determine relative CBF distribution on each SPECT image. ΔAI (regional vasodilatory capacity) values were compared with the values of several PET parameters. We also repeated SPECT and PET studies in 15 patients after a mean interval of 2.6 years from entry. The correlation between changes in ΔAI and PET data were examined. The ΔAI value closely correlated with the ipsilateral OEF value (r=−0.64, p<0.001). Sensitivity–specificity curve analysis revealed that the optimal cut-off value for detecting Stage II hemodynamic failure was −13.5% of ΔAI, at which point the diagnostic accuracy was 82%. In follow-up studies, changes in ΔAI correlated significantly with changes in OEF values (r=−0.68, p<0.01). Semiquantitative SPECT examination with ACZ challenge detects Stage II hemodynamic failure with a diagnostic accuracy of 82%. An improvement in reduced vasodilatory capacity as determined by SPECT coincides with a reduction in OEF values. [Copyright &y& Elsevier]

Background context: In recent years there have been an increasing number of reports on surgical cases involving delayed neurological deficits caused by vertebral collapse after osteoporotic vertebral fracture.Purpose: We do not yet know which patients are most susceptible to delayed vertebral collapse and subsequent neurological deficits, or whether this pathological condition can be prevented or predicted. In this study, we investigated the mechanism of progression and radiographic features characteristic of this disease, and we report here the predictive or risk factors for delayed osteoporotic vertebral collapse.Study design: Retrospectively, we investigated the pathogenesis and diagnosis of delayed vertebral collapse with neurological deficit resulting from osteoporosis.Patient sample: A total of 28 patients (7 men and 21 women) with neurological deficits resulting from vertebral collapse caused by osteoporotic vertebral fractures were the subjects for this study.Outcome measures: Comparisons and investigations about clinical features and radiographic findings between the patient group of delayed vertebral collapse with neurological deficits and the group of osteoporotic spinal fracture with no neurological deficits.Methods: The following factors were examined: the cause of injury; the length of time from injury, or the onset of pain, to the onset of neurological symptoms; radiographic findings obtained during the above period; the clinical course of vertebral fracture on plain X-ray films; time of appearance of the intravertebral cleft, and its localization and changes.Results: Six patients were hospitalized and prescribed a period of 2 weeks of bed rest followed by the fitting of a corset; seven outpatients were corseted but not prescribed bed rest; 15 patients were given medication only at an outpatient clinic. At radiography, intravertebral clefts were detected in 22 patients (79%) during the period from the appearance of pain to the onset of neurological deficit. In 14 patients (50%) who were radiographed every 1 to 2 weeks from the injury to the onset of neurological symptoms, the course of progression to collapse of the vertebral body could be observed.Conclusion: Initial correct diagnosis and immobilization are important in preventing the delayed collapse with neurological deficit. The presence of an intravertebral cleft and instability of the affected vertebra represent risk factors for vertebral collapse with neurological deficit, requiring careful observation. [Copyright &y& Elsevier]

Objective: Some cardiac abnormalities could be a substrate for potential embolic source in cryptogenic stroke (CS). We evaluated whether cardiac and echocardiographic markers were associated with CS in patients with incidental patent foramen ovale (PFO) as defined using the Risk of Paradoxical Embolism (RoPE) score.Materials and Methods: Among 677 patients enrolled in a multicenter observational CS registry, 300 patients (44%) had PFOs detected by transesophageal echocardiography. They were classified into probable PFO-related stroke (RoPE score>6, n = 32) and stroke with incidental PFO (RoPE score≤6, n = 268) groups, and clinical characteristics, laboratory findings, cardiac and echocardiographic markers (i.e. brain natriuretic peptide, left atrial [LA] diameter, ejection fraction, early transmitral flow velocity/early diastolic tissue Doppler imaging velocity [E/e'], LA appendage flow velocity, spontaneous echo contrast, atrial septal aneurysm, substantial PFO, and aortic arch plaques), stroke recurrence, and excellent outcome (modified Rankin scale score <2) at discharge were compared. Risk factors for low RoPE scores were determined using multiple logistic regression analysis.Results: Higher brain natriuretic peptide levels (p = 0.032), LA enlargement (p < 0.001), higher E/e' (p = 0.001), lower LA appendage flow velocity (p < 0.001), non-substantial PFO (p = 0.021), and aortic arch plaques (p = 0.002) were associated with the low RoPE score group. Patients with high RoPE scores had excellent outcomes (58% versus 78%, p = 0.035). LA enlargement (age- and sex-adjusted odds ratio, 1.15; 95 % confidence interval, 1.00-1.32; p = 0.039) was an independent predictor of low RoPE scores.Conclusions: Abnormal cardiac substrate could be associated with CS occurrence in a subset of patients with PFO. Patients with CS who had incidental PFO may be at risk of cardioembolism. [ABSTRACT FROM AUTHOR]

Our objective is to clarify relationship between reversible cerebral vasoconstriction syndrome and administrating etanercept during puerperium. Several lines of evidence have suggested tumor necrosis factor (TNF) as a mediator of vascular dysfunction associated with estrogen deficiency. A 32-year-old woman resumed etanercept (25 mg/week), a TNF inhibitor, which had been discontinued during pregnancy, because of the deterioration of rheumatoid arthritis. She was admitted to our hospital with upper right quadrant blindness and mild right hemiparesis accompanied by pulsating left occipital pain, which had appeared 4 hours after restarting etanercept (25 mg/week). Magnetic resonance imaging and angiography revealed acute left hippocampal infarction with multiple segmental stenoses of the main intracranial arteries. Reversible cerebral vasoconstriction syndrome was diagnosed based on improvement of the multiple stenoses on magnetic resonance angiography on hospital day 17. A causal relationship was considered to exist between TNF inhibition by etanercept and multiple cerebral vasoconstrictions with brain infarct in this puerperant. [ABSTRACT FROM AUTHOR]

Objectives: While the intravenous recombinant tissue plasminogen activator (rt-PA) therapy for acute ischemic stroke patients with cancer is recommended when survival of ≥ 6 months is expected, the risk factors for death and stroke recurrence within 6 months after stroke are not well known. Thus, we aimed to identify markers for death and recurrence risks within six months from stroke onset in patients with cancer.Materials and Methods: In a retrospective cohort study, the subjects comprised acute ischemic stroke patients with cancer hospitalized at St. Marianna University hospital from 2008 through 2019. To evaluate the associations between the clinical factors within 24 h of the initial stroke and death or stroke recurrence events within 6 months from stroke onset, Logistic analysis and Cox proportional hazards regression analysis was used respectively. Next, the optimal cutoff point of markers for different mortality groups was determined using the receiver operating characteristic curve analysis and cumulative outcome rate of each group was compared using the Kaplan-Meier method.Results: Among 194 patients with cancer who developed acute stroke, 167 were ultimately selected for analysis. 47 subjects (28.14%) passed away within 6 months following stroke onset, and 20 subjects (11.98%) had stroke recurrence. High D-dimer levels, low fibrinogen levels, high Glasgow prognostic scores (GPS), and multiple vascular territory infarctions was independently associated with death, where higher death rate was significantly confirmed in the group with D-dimer levels of ≥3.95 mg/dl, fibrinogen levels <277.5 mg/dl and GPS scores of 2. Low fibrinogen level, lack of antithrombotic therapy, and the presence of metastasis were associated with stroke recurrence.Conclusions: When patients with cancer suffer stroke, D-dimer levels, fibrinogen levels, GPS, and multiple vascular territory infarctions would be associated with the risk of death within 6 months. Low fibrinogen levels, lack of antithrombotic therapy, and the presence of metastasis correlated with high risk of stroke recurrence. [ABSTRACT FROM AUTHOR]

Objectives: In-stent intimal restenosis (ISR) caused by neointimal hyperplasia can develop <24 months after carotid artery stenting (CAS). The utility of plaque imaging by carotid ultrasonography (US) or magnetic resonance imaging (MRI) has been investigated for the prediction of ipsilateral stroke. We aimed to investigate whether these imaging techniques are useful for detecting carotid plaques prone to ISR.Materials and Methods: We examined 133 patients (mean age of 72.1 ± 8.4 years old) that received CAS at a single hospital from 2014 to 2018. A pre-CAS carotid plaque evaluation was performed by carotid angiography, duplex carotid US, and black-blood carotid artery MRI (BB-MRI). The mean stenosis rate was 71.0 ± 12.3% by the North American Symptomatic Carotid Endarterectomy Trial (NASCET) methods. Follow-up carotid angiography was performed 6 months after CAS in all patients according to a predefined protocol. ISR was defined as in-stent intimal hyperplasia more than 50% stenosed based on the NASCET criteria. The selection of the stent type was at the discretion of the treating physician. Predictors of ISR were determined by multivariate logistic regression analysis.Results: Follow-up angiography demonstrated ISR in 33 patients (24.8%). In 44 patients, more than two stents were deployed. Univariate logistic regression analyses demonstrated echolucent lesion, floating plaque, complete occlusive or pseudo-occlusive lesion, and closed-cell stent use as significantly associated with ISR (>50%). Multivariate logistic regression analysis demonstrated that echolucent lesion (OR 4.667, 95% CI 1.849-11.779) and closed-cell stent use (OR .378, 95% CI .148-.968) were significantly associated with ISR.Conclusions: Preprocedural plaque characterization by carotid US appeared to be useful to predict ISR 6 months after CAS. [ABSTRACT FROM AUTHOR]

A 65-year-old man with a history of Wallenberg syndrome caused by vertebral artery dissection at 62 years old was admitted to our hospital with nausea, vertigo, right facial dysesthesia, right hemiplegia, crossed sensory disturbance (sensory loss and numbness in the right face and left body below the neck), and right limb ataxia. Magnetic resonance imaging (MRI) performed 80 minutes after onset revealed no acute ischemic stroke lesions, but magnetic resonance angiography (MRA) demonstrated complete occlusion of the right vertebral artery. Based on these neurological and MRA findings, atypical lateral medullary infarction was suggested, and intravenous tissue plasminogen activator (IV-tPA) was started 178 minutes after onset. Right hemiplegia improved immediately after IV-tPA administration. MRI performed on hospital day 2 showed an acute ischemic lesion on the right side of the medulla oblongata, resulting in a diagnosis of Opalski syndrome. Opalski syndrome is a rare subtype of Wallenberg syndrome accompanied by hemiplegia of the side ipsilateral to the lesion, and expansion of the stroke lesion to the corticospinal tract below the pyramidal decussation is considered to cause ipsilateral hemiplegia. Based on this case and previous reports, Opalski syndrome should be considered when limb ataxia and crossed sensory deficit are observed among patients with hyperacute-onset hemiplegia, and IV t-PA therapy should be considered even in the absence of neurological findings such as dysphagia, dysarthria, and Horner's signs and radiological evidence of acute ischemic stroke. [ABSTRACT FROM AUTHOR]

• Wooden breast has a high mechanical strength even 5 days after slaughter. • Myofibrils weakening after slaughter hastens myofibrillar fragmentation in wooden breast. • Connective tissues in such breast were unchanged during postmortem aging till day 5. • The stiffness in wooden breast can be contributed to unchanged connective tissues. Wooden breast is a common problem in the poultry industry, occurring when broiler breast meat becomes rubber-like and extremely hard. Unclear points remain regarding the mechanical strength changes caused by post-mortem biochemical changes in wooden breasts. This study aimed to investigate this knowledge gap. We found endogenous protease activity to be high in wooden breasts and observed a 30 kDa fragment of troponin T (an indicator of postmortem tenderness) from day 1 postmortem. The amount of intramuscular connective tissue in wooden breasts was greater than that of normal breast meat, particularly in the perimysium. The intramuscular connective tissue structure and quantity significantly affect the mechanical strength of meat. It became clear that the wooden breasts are much more mechanically stronger than normal breasts at postmortem day 5 because the large amount of intramuscular connective tissue in the wooden breasts has hardly changed even 5 days postmortem. [ABSTRACT FROM AUTHOR]

Background and Purpose: Various pathogenesis are presumed to be involved in the etiology of embolic stroke of undetermined source (ESUS), which has a high recurrence rate, and much remains unknown about the clinical subtype of recurrent stroke. The purpose of this study was to clarify the pathogenesis of ESUS using the ASCOD classification for ESUS patients and to examine the factors involved in the recurrence of ischemic stroke.Methods: The subjects of this study were 236 of these patients who fulfilled the criteria for ESUS. The rate of stroke recurrent, subtype of recurrent ischemic stroke, and new-onset atrial fibrillation (AF) in these patients were surveyed retrospectively, and each patient was graded for the A, S, and C categories of the ASCOD classification.Results: Ischemic stroke recurred in 32 patients during the follow-up period (7 days to 12.9 years [median 54.3 months]), and new-onset AF was seen in 44 (18.6%) patients. The most subtype of recurrent ischemic stroke was ESUS again (19 patients). Multivariate analysis with a Cox proportional hazards model, the S score (hazard ratio 5.21; 95% confidence interval (CI) 2.38-11.42; P < .001) and the number of A, S, C categories (hazard ratio 1.90; 95% CI 1.14-3.10; P = .013) were factors significantly related to recurrent ischemic stroke.Conclusions: Assessment of comorbid conditions in ESUS patients based on the ASCOD classification may be useful in predicting the likelihood of recurrence of ischemic stroke. [ABSTRACT FROM AUTHOR]

Background: In patients with acute ischemic stroke, current guidelines recommend maintaining blood glucose levels in a range of 140-180 mg/dL and closely monitoring to prevent hypoglycemia (<60 mg/dL). We aimed to assess glucose variability by continuous glucose monitoring (CGM) and to demonstrate the risk of acute ischemic stroke patients with glucose levels outside of the glucose management recommendations.Methods: Patients with ischemic stroke admitted within 7 days after onset were prospectively enrolled, and their blood glucose levels were monitored every 15 minutes for 72-hour period using the FreeStyle Libre Pro. Multivariate logistic regression analyses were used to analyze potential predictors for hyperglycemic (>180 mg/dL) and hypoglycemic (<60 mg/dL) events.Results: A total of 39 acute ischemic stroke patients (mean age 75.9 ± 11.5 years) were enrolled, and CGM was started from 58.6 ± 41.9 hours after stroke onset. CGM showed hypoglycemic events in 19 patients and hyperglycemic events in 21 patients, and the frequencies of hypo- and hyperglycemic events during CGM were 10.1 ± 15.7% and 11.9 ± 22.5%, respectively. Hypoglycemic events were mainly observed in the night-time in patients with normoglycemia at admission. Logistic regression analyses demonstrated significant associations between the blood glucose level at admission and hypo- and hyperglycemic events on CGM.Conclusions: This study of CGM found that many stroke patients have blood glucose levels outside the recommended guideline range in the acute phase. Blood glucose level on admission may be used as a predictor for hypo- and hyperglycemic events after admission. [ABSTRACT FROM AUTHOR]