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Background: Cerebral microbleeds (CMBs) detected on susceptibility-weighted imaging (SWI) are associated with cerebral small vessel disease. Chronic kidney disease and microalbuminuria have been associated with the presence of CMBs in stroke patients. Urinary immunoglobulin G (IgG) is measured to document glomerular injury; however, the relationship between urinary IgG and CMBs is unknown. Methods: We retrospectively enrolled consecutive patients who had been admitted with transient ischemic attack (TIA) or ischemic stroke and identified those who had undergone SWI and a spot urine test. The location of CMBs was classified on magnetic resonance imaging as strictly lobar, deep/infratentorial (D/I), or mixed areas. We analyzed the association between urinary IgG and the presence and location of CMBs. Results: We included 298 patients (86 female, median age 70 years, median eGFR 65.8 mL/min/1.73 m2). Positive urinary IgG and CMB results were found in 58 (19%) and 160 patients (54%), respectively. Urinary IgG positivity was significantly associated with CMBs compared with non-CMBs (28% vs. 9%, p < 0.001), and with D/I or mixed CMBs compared with non-D/I or mixed CMBs (34% vs. 10%, p < 0.001). Multivariate analysis revealed that urinary IgG and hypertension positivity were strongly associated with D/I or mixed CMBs (OR 3.479, 95% CI: 1.776–6.818, p < 0.001; OR 3.415, 95% CI: 1.863–6.258, p < 0.001). Conclusions: Urinary IgG was associated with the prevalence of D/I or mixed location CMBs in TIA or ischemic stroke patients. Our findings provide new insights into the association between urinary IgG and the distribution of CMBs. [ABSTRACT FROM AUTHOR]

Introduction and Objectives: The clinical characteristics of convexity subarachnoid hemorrhage (cSAH) accompanying hyperacute ischemic stroke are unknown. We aimed to investigate the incidence and clinical characteristics of cSAH with hyperacute ischemic stroke. Methods: Participants comprised symptomatic ischemic stroke patients with ≤4.5 h from onset to door who also underwent initial MRI ≤4.5 h from onset. We reviewed initial and follow-up MRI during admission to identify cSAH. Retrospective reviews of cSAH incidence and clinical characteristics were performed. Results: We screened 1,249 consecutive symptomatic ischemic stroke patients, including 384 patients (279 males [73%]; median age, 67 years). Of the 384 patients, arterial ischemic stroke was seen in 382 patients, and venous ischemic stroke in 2 patients. Of the hyperacute arterial ischemic stroke, cSAH was identified within 4.5 h of ischemic stroke onset in 2 patients (0.5%) and around 6 days from ischemic stroke onset in 2 patients (0.5%). Of the hyperacute venous ischemic stroke, cSAH was observed in 1 patient on initial MRI. Comparing the clinical characteristics of hyperacute arterial ischemic stroke with and without cSAH, patients with cSAH were more likely to have arterial stenosis or occlusion ipsilateral to the cSAH (100 vs. 47%, p = 0.048), and the ischemic lesion only in the right hemisphere (100 vs. 33%, p = 0.013). In all cases, outcomes were favorable (modified Rankin Scale 0–1 at 3 months from onset). Conclusions: Convexity SAH was observed in 0.5% of hyperacute ischemic patients within 4.5 h of ischemic stroke onset and in 0.5% around 6 days from ischemic stroke onset. [ABSTRACT FROM AUTHOR]

Background: Although subcortical infarction patients sometimes show larger infarction size than the definition of small vessel occlusion (SVO), there are no specific predictors of larger size. The aim of this study was to identify the factors, including magnetic resonance imaging (MRI) and ultrasonographic parameters, to predict larger subcortical infarction. Methods: Consecutive patients with acute supratentorial subcortical infarction were studied. Patients were classified into 2 groups (L: larger group, ≥15 mm and ≥3 slices; S: smaller group, SVO based on the TOAST classification). Clinical information, MRI findings including the presence of microbleeds, and ultrasonography findings were evaluated and compared between the 2 groups. Results: A total of 120 patients (81 male, mean 67 years old) were enrolled. The L group included 22 patients (18%), and the S group had 98 patients (82%). On neuroimaging, microbleeds were seen less frequently in the L group than in the S group (23 vs. 53%, p = 0.017), and peak systolic velocity (PSV) by transcranial color-coded sonography was faster in the L group than in the S group (121 ± 39.8 vs. 83.4 ± 25.4 cm/s, p = 0.002). On multivariate logistic regression analysis, no evidence of microbleeds (OR 4.4, 95% CI 1.41–13.68, p = 0.011) and PSV over 92 cm/s (OR 3.1, 95% CI 1.007–9.719, p = 0.049) were found to be independently associated with larger size. Conclusion: Microbleeds is related to smaller size and middle cerebral artery PSV > 92 cm/s indicate larger size in supratentorial subcortical infarcts. [ABSTRACT FROM AUTHOR]

Background/Aims: The factors related to cerebrovascular complications in cerebral venous sinus thrombosis (CVST) are controversial. We focused on venous stasis and investigated its relationship with cerebrovascular complications in CVST. Methods: CVST patients between June 2013 and October 2016 were enrolled. Relationships between cerebrovascular complications, defined as cerebral venous infarction, intracerebral hemorrhage, or subarachnoid hemorrhage, and cerebrum venous stasis and other clinical information were retrospectively analyzed. Venous stasis was evaluated by the prominence of the veins on susceptibility-weighted imaging (SWI). The cerebrum was divided into 10 regions according to the venous drainage territories, and venous stasis was quantified by adding one point for venous prominence on SWI for each region (CVST SWI score). Results: All 5 cases in the noncomplicated group had a CVST SWI score of 0. The 3 patients with CVST SWI scores higher than 0 had cerebrovascular complications. The CVST SWI scores were higher in the complicated group than in the noncomplicated group (3.0 vs. 0, p = 0.010). Seizures were seen in all patients with complications and in none of the patients without complications (3 vs. 0, p = 0.018). Conclusion: Venous stasis evaluated by SWI can help predict cerebrovascular complications in CVST. A seizure is an important initial symptom that suggests cerebrovascular complications in CVST. [ABSTRACT FROM AUTHOR]

Background and Purpose: The purpose of the present study was to test the hypothesis that plasma brain natriuretic peptide (BNP) is associated with short-term mortality after intracerebral hemorrhage (ICH). Methods: We prospectively enrolled 271 patients (median age 72 years; 109 females) who were admitted within 24 h of ICH onset between April 2007 and July 2011 and in whom plasma BNP levels were measured upon admission. The patients were assigned to two groups according to survival within 1 month of ICH. Factors associated with mortality were determined by multivariate logistic regression analysis. Results: Within 1 month of ICH, 48 (17.7%) of the 271 enrolled patients died. The median (interquartile range) level of plasma BNP was significantly higher in the group of non-survivors than in the group of survivors [102.5 (48.7-205.0) vs. 32.4 (17.3-85.0) pg/ml; p < 0.001]. A cutoff BNP level of 60.0 pg/ml could predict death within 1 month of ICH. Multivariate logistic regression analysis showed that a plasma BNP of >60.0 pg/ml (OR 4.7; 95% CI 1.43-15.63; p = 0.011) was independently associated with mortality within 1 month after ICH. Conclusions: A high BNP level upon admission is associated with mortality within 1 month after ICH. © 2014 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

Background and Purpose: We investigated whether brain natriuretic peptide (BNP) can serve as a biological marker of long-term mortality in ischemic stroke survivors. Methods: Consecutive patients with ischemic stroke within 24 h of onset from April 2007 to December 2010 were prospectively enrolled, and admission plasma BNP levels were measured. Survivors were followed up until 1 year after stroke onset. Patients were divided into two groups: the deceased group and the surviving group. The factors associated with long-term mortality were investigated by multiple logistic regression analysis. Results: A total of 736 patients who were alive at hospital discharge were included; 130 (17.7%) patients died. On multivariate analysis, age >75 years (odds ratio, OR, 2.83; 95% CI, 1.74-4.60, p = 0.0001), dialysis-dependent chronic renal failure (OR, 5.99; 95% CI, 2.18-16.47, p = 0.0005), modified Rankin Scale score >3 at discharge (OR, 4.41; 95% CI, 2.76-7.05, p < 0.0001), and plasma BNP >100.0 pg/ml (OR, 3.94; 95% CI, 2.31-6.73, p < 0.0001) were found to be independently associated with long-term mortality. We developed a risk score from 4 variables (each variable: 1 point, total score: 0-4 points). The mortality rates were 2% with a score of 0, 9% with a score of 1, 27% with a score of 2 and 50% with a score ≥3. Conclusions: The risk score, composed of clinical parameters and BNP, may predict long-term mortality in ischemic stroke survivors. Copyright © 2013 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

Background and Purpose: Our previous retrospective study demonstrated that a brain natriuretic peptide (BNP) level of >140 pg/ml on admission was useful to distinguish cardioembolism (CE) from non-CE. The aim of the present study was to prospectively investigate the utility of this predefined threshold. Method: Two hundred and twenty-one consecutive patients were prospectively enrolled. On admission, the BNP levels of the patients were measured and classified according to low BNP (≤140.0 pg/ml) or high BNP (>140.0 pg/ml) levels. Final diagnosis of stroke subtype on discharge was made using the TOAST criteria. Measured parameters included the sensitivity, specificity, positive predictive value, and negative predictive value for CE in the high BNP group. Results: There were 81 patients in the high BNP group and 140 patients in the low BNP group. A total of 76 (34.4%) patients were diagnosed with CE, including 59 (72.8%) patients in the high BNP group and 17 (12.1%) patients in the low BNP group (p < 0.001). A BNP level >140.0 pg/ml corresponded to a sensitivity of 77.6%, specificity of 84.8%, positive predictive value of 72.8%, and negative predictive value of 87.9% for a diagnosis of CE. Conclusion: A BNP level of >140.0 pg/ml on admission in patients with acute ischemic stroke is a strong biochemical predictor for CE. Copyright © 2013 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

Background and Purpose: Vessel signs, such as the susceptibility vessel sign (SVS) on T2*-gradient echo imaging (T2*) and the hyperdense middle cerebral artery sign (HMCAS) on CT, are well-known markers of arterial occlusion. However, the relationship between the signs is not fully known. Methods: Patients suspected of having hyperacute (<3 h from symptom onset) stroke were prospectively enrolled. MRI including T2* and MR angiography, and thin-section CT were performed on admission. The consistency between SVS and HMCAS were evaluated. Results: A total of 67 patients [38 males, median age: 76 (interquartile range: 67-82) years, median NIHSS score: 12 (4-21)] were enrolled. SVS was observed in 6 patients (9%), and HMCAS was present in 8 (12%). Sixteen patients (24%) had middle cerebral artery proximal (M1) occlusion on MR angiography. The presence or absence of SVS was highly consistent with that of HMCAS when all cases were evaluated (κ = 0.841), as well as when only patients with M1 occlusion were assessed (κ = 0.750). Conclusion: SVS and HMCAS were highly consistent with each other in suspected hyperacute stroke patients. SVS and HMCAS may represent the same thrombus. Copyright © 2012 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

Purpose: The present study investigated clinical characteristics including plasma brain natriuretic peptide (BNP) among transient ischemic attack (TIA) and stroke patients with atrial fibrillation (AF). Methods: We prospectively enrolled 227 consecutive patients with AF within 24 h of onset of TIA or stroke, and plasma BNP was measured on admission. Patients were divided into 2 groups: TIA and stroke groups. The factors associated with TIA were investigated by multivariate logistic regression analysis. Results: 21 patients (9.3%) were diagnosed with TIA, and 206 patients (90.7%) with stroke. The plasma BNP level of the TIA group was significantly lower than that of the stroke group [median (interquartile range) 86.5 (72.7-189.0) pg/ml vs. 269.0 (146.0-432.0) pg/ml, p = 0.0002]. The optimal cutoff level, sensitivity, and specificity of BNP levels to distinguish the TIA group from the stroke group were 120 pg/ml, 79.1 and 66.7%, respectively. Multivariate logistic regression analysis demonstrated that pre-admission warfarin use (OR 3.7; 95% CI 1.178-11.570, p = 0.0250), glucose of ≤120 mg/dl (OR 5.1; 95% CI 1.629-16.238, p = 0.0052) and a plasma BNP of ≤120 pg/ml (OR 6.1; 95% CI 1.967-18.931, p = 0.0017) were independently associated with TIA. Conclusions: In AF patients, the BNP value on admission is lower in those with TIA than in those with stroke. Thus, cardiac function may be associated with neurological severity at the onset of TIA and stroke. Copyright © 2011 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

Background/Aims: The main predictors of intracerebral hemorrhage (ICH) are clinical stroke severity and large ischemic lesions. Therefore, ICA occlusion as severe stroke is thought to frequently have ICH after tissue plasminogen activator (t-PA) therapy. The aim of this study was to investigate whether ICA occlusion more frequently had ICH after t-PA therapy compared with other occluded arteries. Subjects andMethods: We prospectively studied consecutive stroke patients treated with t-PA within 3 h of onset. We investigated the frequency of ICH after t-PA therapy for each occluded artery. Results: 165 patients were enrolled. Initial MRA demonstrated ICA occlusion in 38 patients, M1 in 48, M2 in 28, and BA and PCA in 12. At 24 h after t-PA infusion, 113 (68.5%) patients (non-HT group) did not have hemorrhagic transformation, 37 (22.4%; HI group) had hemorrhagic cerebral infarction and 15 (9.1%; ICH group) had ICH. The ICH group most frequently had M2 occlusion, NIHSS ≥15, and ≥1/3 of the MCA territory among the three groups. The frequency of ICH was 2.6% in no occlusion, 10.5% in ICA occlusion, 6.3% in M1, 21.4% in M2, and 8.3% in PCA and BA (p = 0.1016). Conclusion: Patients with ICA occlusion did not have ICH more frequently after t-PA therapy in comparison to other occluded arteries. Copyright © 2011 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

Background and Purpose: Patients with unknown onset time would be able to receive intravenous thrombolysis when showing diffusion-weighted imaging (DWI)/fluid-attenuated inversion recovery (FLAIR) mismatch. Methods: Consecutive acute stroke patients with unknown onset time were prospectively enrolled. We defined patients as having unknown onset time when the last known normal time (LNT) was not consistent with the first found abnormal time (FAT). Only patients with anterior-circulation stroke and presence of arterial lesion were enrolled. Intravenous thrombolysis was conducted within 3 h from FAT if the patient showed DWI/FLAIR mismatch. Results: From June 2009 to May 2010, 10 patients [median age, 84 years (interquartile range, IQR, 64-90); National Institutes of Health Stroke Scale (NIHSS) score, 14 (IQR, 9-19)] were enrolled. Subjects included 4 patients who developed stroke during sleep, 5 with disturbance of consciousness, and 1 with aphasia. Median interval between LNT and thrombolysis was 5.6 h (IQR, 4.5-9.8) and median interval between FAT and thrombolysis was 2.5 h (IQR, 2.1-2.8). Three patients had internal carotid artery occlusion, 5 had M1 occlusion, and 2 had M2 occlusion. Early recanalization within 24 h was seen in 7 patients (complete recanalization, n = 4; partial recanalization, n = 3). No patients experienced symptomatic cerebral hemorrhage within 48 h. At day 7, 5 patients showed dramatic recovery (defined as ≥10-point reduction in total NIHSS score or score of 0 or 1). At 3 months, favorable outcome (modified Rankin scale score, 0-2) was seen in 4 patients. Conclusion: Acute stroke patients with DWI/FLAIR mismatch may be able to safely receive intravenous thrombolysis. Copyright © 2011 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

Purpose: The present study investigated the factors related to neurological deterioration in pontine infarction. Methods: Consecutive patients with acute pontine infarction without basilar artery (BA) occlusion were enrolled. Patients were classified into two groups (D, group with neurological deterioration; ND, group without neurological deterioration). After magnetic resonance angiography was performed to identify the diameters of internal carotid artery (ICA) and BA, the BA diameter/ICA diameter (BA/ICA) ratio was calculated. When the ischemic lesion on diffusion-weighted magnetic resonance imaging extended to the ventral basal pial surface, it was diagnosed as branch atheromatous disease (BAD). Results: Neurological deterioration occurred in 16 (31%) of 51 patients. BAD was found in 13 (81%) of 16 patients of the D group and 14 (40%) of 35 in the ND group (p = 0.008). The BA/ICA ratio was 0.73 (0.59–0.84) in the D group and 0.64 (0.55–0.71) in the ND group (p = 0.049). Multivariate regression analysis demonstrated that BAD (OR 15.62, 95% CI 2.37–103.13, p = 0.004) and a BA/ICA ratio of ≥0.70 (OR 7.76, 95% CI 1.55–38.88, p = 0.013) were independent factors associated with neurological deterioration. Conclusion: The BA diameter may be associated with neurological deterioration in acute pontine infarction. Copyright © 2010 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]