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Aphasia induced by an infratentorial stroke has rarely been reported, and its mechanism has not been fully identified. We evaluated two individuals who had been admitted to Saiseikai Kumamoto Hospital in Kumamoto, Japan, due to acute ischemic stroke in order to determine whether their aphasia was induced by an infratentorial stroke. The first patient, a 59-year-old man with a history of left parietal embolic stroke with very mild sequelae of anomia, developed Wernicke's aphasia, nonfluent speech, and right limb ataxia as a result of the stroke. The second patient, a 76-year-old woman with a history of chronic renal failure, experienced transcortical sensory aphasia and right one-and-a-half syndrome as a result of the stroke. Both patients' recent ischemic lesions were limited to the right cerebellar hemisphere and the right medial portion of the midbrain. However, SPECT showed low-uptake lesions in both patients' left cerebral hemisphere that did not include the recent ischemic lesions but that had spread to an extent that was difficult to be explained by the old or recent ischemic lesions and that might be responsible for their recent aphasia. We believe that the aphasia experienced by these two patients may have been caused by crossed cerebello-cerebral diaschisis.

Background: In acute ischemic stroke (AIS) patients due to intracranial atherosclerosis-related occlusions (ICAS-O), despite successful reperfusion with mechanical thrombectomy (MT), unexpected early reocclusion sometimes occurs and worsens clinical outcome. We investigated prevalence, outcomes, and predictors of early reocclusion within 48 hours of MT in AIS due to ICAS-O. Methods: In 557 consecutive AIS patients who underwent MT from January, 2016 to March, 2019 in two stroke centers, 71 patients due to ICAS-O were retrospectively evaluated. We divided them into two groups: patients with early reocclusion and those without. Clinical and angiographical findings and outcomes were compared between the 2 groups. Multivariable logistic regression analysis was used to investigate predictors of early reocclusion after MT. Results: Of 71 patients (aged 72 ± 10 years; 23 women; median NIHSS score, 15), early reocclusion was observed in 11 (15%). The first procedure for recanalization was stent retriever in 25 patients (35%), Penumbra system in 25 patients (35%), and balloon angioplasty in 21 patients (30%). Of these, 63 patients (88%) received rescue therapy (balloon angioplasty, 50; intracranial stenting, 13). In the early reocclusion group, more number of intraprocedural reocclusion (median [IQR], 3 [2-3] vs. 1 [0-1], p < 0.001), a higher rate of remaining stenosis on the final angiography (67.6 ± 5.9% vs 57.3 ± 15.9%, p = 0.044), and a higher rate of procedure-related adverse events (27% vs 5%, p = 0.043) were observed compared to the other group. On logistic regression analysis, a total number of intraprocedural reocclusion was independently associated with early reocclusion (odds ratio, 31.4; 95% confidence interval, 2.6-375.2). Early reocclusion was related to a low rate of favorable outcome at 90 days (modified Rankin Scale ≤ 2, 9% vs 54%, p = 0.007). Conclusions: In AIS patients due to ICAS-O, early reocclusion within 48 hours was not rare and associated with unfavorable outcome. Patients with repeated intraprocedural reocclusion are at high risk for early reocclusion; they might need follow-up angiographical assessment and intensive antithrombotic treatment.

Background: When considering weekend effect or off-hour effect, time period from admission to regular hospital working hours might affect stroke prognosis more strongly than the timing of admission. We investigated whether admission time until working hours affects clinical prognosis using a regional multicenter stroke registry. Methods: We recruited data from the stroke registry ‘K-PLUS,’ between 2013 and 2017. Acute stroke patients admitted within 24 hours from the last time to be well were included. Patients with premorbid modified Rankin Scale (mRS) score of 3 or more were excluded. Working hours were defined as 9:00-17:00 on weekdays. Patients were divided into those admitted during working hours (WH group) and two other groups according to the time from admission to working hours: within 24 hours (short-wait group), over 24 hours (long-wait group). In-hospital complications and the mRS score at discharge were compared among the groups. Results: Out of 4,729 participants, 2,912 (62%) were admitted outside working hours. Although in-hospital pneumonia after stroke occurred more frequently in the long-wait group (10%) than in the other groups (7%), mortality was not different among the 3 groups. The proportion of patients with mRS score 0-1 at discharge showed a decreasing trend with the time period before working hours: 37% in the WH group, 34% in the short-wait group, and 31% in the long-wait group (p< 0.001). When the WH group was used as a reference, the odds ratio for mRS score 0-1 was 0.86 (95% confidence interval, 0.73-0.93) in the short-wait group and 0.78 (0.65-0.93) in the long-wait group, respectively, after adjusting for other factors including age, stroke severity, and thrombolytic therapy. Conclusion: Our regional multicenter stroke registry demonstrated the evidence that acute stroke patients admitted before 24 hours or more until the regular hospital working hours have poor prognosis.

Background: In acute ischemic stroke patients with distal intracranial vessel occlusion, efficacy of endovascular therapy remains debatable. A combined approach of stent retriever-assisted aspiration catheter for distal intracranial vessel occlusion (Distal combined technique; DCT) has potential for better recanalization rate than traditional techniques. The aim of this study was to investigate the efficacy of DCT. Methods: We evaluated consecutive acute ischemic stroke patients with distal anterior circulation artery occlusions including M2/M3 or A2/A3 segment, who underwent endovascular therapy from January, 2016 to June, 2018 in our center. Angiographical findings (modified Thrombolysis in Cerebral Ischemic [mTICI] score, including TICI 2c category), number of procedures, the processing time from puncture to reperfusion, favorable clinical outcome at 90-day (modified Rankin Scale [mRS] ≤ 2), and any symptomatic intracranial hemorrhage were compared between the DCT group and the non-DCT group. Results: Of 49 patients (mean aged 76 ± 11 years; 25 (51%) women; median NIHSS score at baseline 15), 17 (35%) were treated with DCT. Occlusion site was M2 in 25 patients, M2-3 in 18, and A2/A3 in 6. In the DCT group, higher reperfusion rates at the first pass (mTICI ≥ 2b, 94% vs. 53%, p = 0.003; mTICI ≥ 2c, 76% vs. 15%, p < 0.001; mTICI3 52% vs. 12%, p = 0.005), less number of procedures (median 1 vs. 2, p < 0.001), and shorter time from puncture to successful reperfusion (mean 33 min. vs. 53 min., p = 0.002) were observed. After all the endovascular procedures, the final successful reperfusion rate was also higher in the DCT group than in the non-DCT group (mTICI ≥ 2b, 100% vs. 84%, p = 0.148; mTICI ≥ 2c, 88% vs. 53% p = 0.025; mTICI3, 70% vs. 43%, p = 0.131). Symptomatic intracranial hemorrhage occurred in 1 patient in each group. A higher trend was observed in the rate of mRS ≤ 2 at 90 days in the DCT group (83% vs. 52% p = 0.083) compared to the non-DCT group. Conclusions: In patients with distal intracranial vessel occlusion, combined approach of stent retriever-assisted aspiration catheter is safe and efficacious; possibly leading to favorable long-term outcome.

Introduction: Relationship between the selection of oral anticoagulants after acute stroke as secondary prevention and clinical outcome is not elucidated. Our aim is to compare clinical outcome in patients receiving direct oral anticoagulants (DOACs) versus warfarin after their stroke. Methods: In the regional stroke registry, K-PLUS, 1,019 consecutive patients with cardioembolic stroke who were prescribed anticoagulants were retrospectively enrolled from April 2011 to May 2016. Patients with premorbid modified Rankin Scale score of 3 or more and those with incomplete clinical data were excluded. The residual 323 patients were divided into 2 groups by their receiving anticoagulants after their stroke: the warfarin group and the DOACs group. Clinical characteristics, length of hospital stay, Functional Independence Measure (FIM) scores on admission and at discharge of rehabilitation hospital, and mean daily FIM gain were compared between the 2 groups. Results: In the 323 patients, median age was 79 (interquartile range: 73-85) years and 176 (54.5%) were men. A total of 146 patients (46.2%) was prescribed DOACs (dabigatran in 15, rivaroxaban in 46, apixaban in 72, and edoxaban in 13). Median age (81 vs. 79 in median, p = .03) and NIHSS score on acute hospital admission (10 in DOACs vs. 17 in warfarin, p < .01) were lower, and length of acute hospital stay was shorter (13 vs. 17 days, p < .01) in the DOACs group than the warfarin group. In rehabilitation hospitals, both FIM score on admission (86 vs. 32, p < .01) and daily FIM gain (0.22 vs. 0.10, p < .01) was significantly higher in the DOACs group. On multivariate analysis, DOACs prescription (odds ratio 1.79; 95% CI, 1.10-2.93) and NIHSS on acute hospital admission (1.04 per 1 point; 1.01-1.08) were correlated with daily FIM gain ≥ 0.15, independent of other factors including age, length of acute hospital stay, and FIM on admission of rehabilitation hospital. Conclusion: Patients receiving DOACs after their cardioembolic stroke might achieve better clinical outcome than those with warfarin.

Background: Stroke severity is mitigated by preceding anticoagulants in acute stroke patients with atrial fibrillation (AF). Such mitigative effects might be different between warfarin and direct oral anticoagulants (DOACs). We compared stroke severity and characteristics in patients who had specific antithrombotics to patients without any prophylactics. Methods: We recruited data from K-PLUS Registry, a regional multicenter stroke registry, between 2009 and 2017. Patients who had AF diagnosed before onset or during hospitalization were included. Background characteristics, stroke severity, and in-hospital death were analyzed according to preceding antithrombotic agents (warfarin, DOACs, antiplatelets aone, or none) at onset. Results: Out of 6,697 participants, 1,765 (median 82 years old) had AF; 526 (30%) were prescribed warfarin, 196 (11%) DOACs, 365 (21%) antiplatelets alone, and 526 (38%) were none. Proportion of patients with CHA 2 DS 2 -Vasc score ≥2 was the lowest in patients without anticoagulants (91.7%). Patients taking DOACs were younger (median 79 years), and more frequently resided home. Large lesions were more prevalent in patients with antiplatelets (28%) or those with no antithrombotics (28%) compared to those with DOACs (12%) or with warfarin (21%). NIHSS score was the lowest in patients with DOACs (median 5) compared to those with warfarin (10), antiplatelets (11), or none (13), and in-hospital mortality was also the lowest (4.6%, 6.0%, 9.4%, and 8.0%, respectively). When non-antithrombotics patients were used as a reference, adjusted odds ratio for moderate to severe stroke (NIHSS score ≥16) was 0.53 (95% confidence interval, 0.36-0.77) in those with DOACs, while 0.92 (0.72-1.17) in those with warfarin and 0.94 (0.71-1.23) in those with antiplatelets. Conclusion: In this regional multicenter cohort, preceding DOACs prescription might mitigate stroke severity in AF patients more strongly than other antithrombotics.

Background: In acute ischemic stroke, emergent transportation to comprehensive stroke center (CSC) is crucial for appropriate endovascular therapy (EVT). However, time delay for transfer increase the risk of subsequent intracranial hemorrhage (ICH), Ischemic change in the deep white matter on diffusion-weighted imaging (DWI-W) is one of neuroradiological predictors for subsequent ICH and poor outcome. We hypothesized that pre-transfer DWI-W and DWI-ASPECTS might predict subsequent ICH after EVT. Methods: We retrospectively collected acute stroke patients transferred for EVT to our CSC from October 2013 to July 2017. Patients who underwent MRI before transportation were analyzed. We investigated whether presence of DWI-W was associated with subsequent ICH, and compared the usefulness of ASPECTS+W with traditional scoring system in predicting subsequent ICH after EVT. Results: A total of 99 patients (aged 73.6 ± 11.4 years; initial NIHSS score, median 17 [IQR 10 - 22]; DWI-ASPECTS, 7 [6 - 8]; ASPECTS+W, 8 [6 - 9]) were included. DWI-W was detected in 49 patients (49%), and 35 (35%) developed subsequent ICH. Patients with DWI-W had significantly higher NIHSS score (18 vs. 14, p = 0.038), and developed subsequent ICH after EVT more frequently (46% vs. 24%, p = 0.021) compared to those without. In multivariate analysis, presence of DWI-W (OR 2.86; 95% CI 1.15 - 7.47; p =0.023), presence of dyslipidemia (OR 2.87; 95% CI 1.01 - 8.41; p = 0.046), and administration of IV-tPA (OR 2.74; 95% CI 1.11 - 7.12; p = 0.028) predicted ICH independently. In additional analyses with different models, lower ASPECTS+W (OR 0.79 per point increase; 95% CI 0.64 - 0.98; p = 0.031) predicted ICH better than DWI-ASPECTS (OR 0.80 per point increase; 95% CI 0.63 - 1.01; p = 0.064) did. Conclusions: Presence of DWI-W on MRI before transportation is a useful predictor of subsequent ICH after EVT.

Background: 2016 Kumamoto Earthquake in 2016 is characterized by a huge foreshock of magnitude-6.5, a magnitude-7.3 mainshock, and numerous, sustained aftershocks. Objective: To elucidate the influence of the Kumamoto Earthquake to ischemic stroke by investigating acute stroke patients who were admitted to the acute hospital located closest to the epicenter of the foreshock and mainshock during 1 month. Methods: Acute ischemic stroke patients within 7 days of onset who were admitted during April 14 and May 13, 2016, and those admitted in the same period in 2015 were investigated. Patients’ characteristics, stroke severity, subtype, onset-admission time, and laboratory data were compared between 2015 and 2016. Results: A number of acute ischemic stroke patients increased by 1.2 times from 43 (14 women) to 69 (27 women), and age was younger in 2016 (median, 72 years; interquartile range, 65-81) than in 2015 (78; 67-85; p = 0.042). No differences were observed in background characteristics, vital signs, stroke severity, or stroke subtype between the two years. Onset-to-admission time was longer in 2016 than in 2015 (951 vs. 441 minutes, p = 0.023). Among laboratory data, platelet count was higher after the earthquake, whereas other data were similar in the two years. Conclusions: Number of ischemic stroke admitted to the closest to the epicenter increased than the previous year and the time from onset to admission prolonged. These data indicate that patients were transferred from wider area after huge earthquakes. An increment of platelet was the only change observed in laboratory data after the earthquake. Multicenter, longitudinal observation would be needed to clarify the effect of the earthquake to cerebrovascular events.

Background: Distal hyperintense vessels (DHV) on fluid-attenuated inversion recovery imaging (FLAIR) is a noninvasive and useful imaging marker that reflects leptomeningeal collateral flow. We investigated relationship between DHV and collateral grade on cerebral angiography, and clinical outcome after endovascular therapy (EVT) in patients with AIS. Methods: We retrospectively analyzed the patients with AIS in two comprehensive stroke centers from October 2013 to February 2016. We selected the patients who underwent FLAIR sequence before EVT. DHV score (range 0-6) was evaluated based on the presence of DHV in each ASPECTS territory (M1-M6). Collateral grades on cerebral angiography were assessed with the American Society of Interventional and Therapeutic Neuroradiology Collateral Grading System (grade 0-4). Favorable clinical outcomes was defined as modified Rankin Scale [mRS] of 0-2 at 90 days. Results: A total of 60 patients (aged 71.2 ± 10.5 years; initial NIHSS score, 15 ± 8; median DWI-ASPECTS, 7) were included. DHV was detected in 42 patients (70%); median DHV score was 2 (IQR, 1-4). Higher DHV score was significantly related to better collateral flow grade ( p p p Conclusions: DHV score on FLAIR is a marker of collateral flow status and can predict better clinical outcome in patients with AIS after EVT.

Background and Purpose— Diffusion-weighted imaging can depict secondary signal change of the substantia nigra of patients with ipsilateral striatal infarction via a decrease in the apparent diffusion coefficient (ADC). Clinical predictors of this phenomenon remain unclear. Methods— We assessed 98 stroke patients with acute ischemic lesions in the hemilateral basal ganglia, external capsule, or internal capsule. The ADC values of the bilateral substantia nigra obtained from a follow-up MRI, various clinical factors, and patients’ outcome were analyzed. Nineteen patients who underwent a follow-up MRI within 3 days were excluded from analysis because none of them demonstrated a significant ADC change of substantia nigra. Results— Of 79 patients, 21 (26.6%) revealed a decreased ADC in the substantia nigra. Ischemic lesions in the globus pallidus (odds ratio 12.90) and the presence of emboligenic diseases (odds ratio 6.95) were independent predictors for an ADC decrease in the substantia nigra. The clinical outcome 3 months after stroke onset was not different between patients with an ADC decrease and patients without. Conclusions— A reduction of ADC in the substantia nigra after acute striatal infarction was more frequently observed when the globus pallidus was affected or when the patient had emboligenic diseases, however, did not necessarily relate to the patient’s clinical outcome.

Background: Collateral grade on cerebral angiography has great predictive significance for patient outcome, which is important to determine indication for endovascular therapy in acute ischemic stroke (AIS). Distal hyperintense vessels (DHV) on fluid-attenuated inversion recovery imaging (FLAIR) is a noninvasive and useful imaging marker that reflects leptomeningeal collateral flow. We investigated whether DHV in patients with AIS was associated with collaterals grade on cerebral angiography and clinical outcome after endovascular therapy. Methods: We retrospectively reviewed patients with AIS who had internal carotid artery or middle cerebral artery occlusion in three comprehensive stroke centers from August 2011 to July 2015. We selected those who underwent FLAIR sequence before endovascular therapy. Presence of DHV was evaluated using a previously-published method. Collateral grades on pre-treatment cerebral angiography were assessed with the American Society of Interventional and Therapeutic Neuroradiology Collateral Grading System on angiography (grade 0-4). We analyzed the relationship between DHV and patient characteristics, collateral flow grade, and good clinical outcomes (modified Rankin Scale [mRS] of 0-2 at 90 days). Results: A total of 38 patients (aged 71.7 ± 10.3 years; men, 71%; NIHSS score, 20 ± 6; median DWI-ASPECTS, 8) were included. DHV was detected in 29 patients (76%). Presence of DHV was significantly related to better collateral flow grade on angiography (2.5 vs. 1.3, p = 0.006), lower NIHSS score on day 7 (median, 7.8 vs. 16.3, p = 0.034), and higher rate of mRS 0-2 at 90 days (69% vs. 11%, p = 0.005), but was not related to DWI-ASPECTS (p = 0.819) or Thrombolysis in Cerebral Infraction (TICI) 2b/3 reperfusion rate (p = 0.128). In multivariate analysis, both presence of DHV (OR, 17.7; p = 0.013) and TICI 2b/3 reperfusion (OR, 21.3; p = 0.002) were independent predictors of mRS 0-2 at 90 days. Conclusions: DHV on FLAIR is a marker of collateral flow status and might predict better clinical outcomes in patients with AIS. Using FLAIR sequence for evaluation of collateral status might be useful to select candidates for endovascular therapy.

Background: Collateral status at baseline is an important predictor of clinical outcome in patients with acute ischemic stroke (AIS). Non-contrast time-of-flight MR angiography (TOF-MRA) might provide information of blood flow features non-invasively. TOF-MRA could become a marker of collateral status and clinical outcome in patients with AIS. Methods: We retrospectively reviewed patients with AIS who had internal carotid artery or middle cerebral artery occlusion in three comprehensive stroke centers from August 2011 to July 2015. Those who underwent TOF-MRA sequence before endovascular therapy were investigated. Collateral status on TOF-MRA was graded by the previously-published regional leptomeningeal collateral (rLMC) score on CT angiography (0-20); collateral grade on angiography was assessed with the American Society of Interventional and Therapeutic Neuroradiology Collateral Grading System (0-4). We analyzed the relationship between rLMC score on TOF-MRA and patient characteristics, collateral flow grade, and good clinical outcome (modified Rankin Scale [mRS] of 0-2 at 90 days). Results: A total of 38 patients (aged 71.7 ± 10.3 years; men, 71%; NIHSS score, 20 ± 6; median DWI-ASPECTS, 8) were included. Collateral grade on angiography was 0 to 1 in 10 (26%) patients, 2 in 6 (15%), 3 in 19 (50%), and 4 in 3 (7%), which was correlated to rLMC score on TOF-MRA (p < 0.001). Higher rLMC score on TOF-MRA was not related to baseline DWI-ASPECTS and reperfusion (Thrombolysis in Cerebral Infraction [TICI] 2b/3) after endovascular treatment, but was related to mRS 0-2 at 90 days (p = 0.021). All patients with high rLMC score (15-20) demonstrated mRS 0-2 at 90 days, whereas 69% of those with medium rLMC score (8-14) and 31% of those with low rLMC score did. In multivariate analysis, both rLMC score on TOF-MRA (OR, 1.5 per 1 point; p = 0.009) and reperfusion (TICI 2b/3 reperfusion; OR, 49.9; p < 0.001) were independent predictors of mRS 0-2 at 90 days. Conclusions: rLMC score on TOF-MRA is a noninvasive and feasible parameter of collateral flow status and related to clinical outcome in patients with AIS. TOF-MRA might be a useful non-invasive imaging method to select candidates for endovascular therapy.

Background: Cerebrovascular reactivity to acetazolamide on 123I-IMP SPECT is used to detect misery perfusion due to intracranial atherosclerosis. Noninvasive fractional flow reserve (FFR) on time-of-flight magnetic resonance angiography (TOF-MRA) can provide a feasible alternative to identify high-risk intracranial atherosclerosis. We here demonstrate the association between FFR on TOF-MRA and cerebral blood flow pattern on 123I-IMP SPECT. Methods: Patients with a unilateral middle cerebral artery (MCA) stenosis who underwent both TOF-MRA and 123I-IMP SPECT with acetazolamide administration were retrospectively recruited from our radiology database. Signal intensity (SI) was measured in the background, proximal and distal to the stenotic lesion in the MCA on TOF-MRA. Adjusted FFR was calculated: FFR = [distal SI - background SI] / [proximal SI - background SI]. Mean cerebral blood flow (CBF) at rest, CBF after acetazolamide administration, and cerebrovascular reactivity (CVR) were measured in the target MCA territory. CBF patterns of MCA were divided into three: Stage II, CBF at rest of < 80% in that of normal subject and CVR below 10%; Stage 0, CVR over 30% regardless of CBF at rest, and Stage I, any other CBF patterns. We sought the optimum cut-off point for FFR to identify MCA territories with Stage II CBF on 123I-IMP SPECT. Results: A total of 41 sets of diagnostic imaging in 23 patients (mean age 57 y; 14 men, 9 women) was assessed. Four (9.8%) MCA territories demonstrated Stage II, 21 (51.2%) stage I, and 16 (39.0%) stage 0. Mean FFR of MCA with Stage II pattern was 0.59 (IQR 0.38 - 0.69), Stage I was 0.78 (IQR 0.70- 0.92), and Stage 0 was 0.90 (IQR 0.81 - 0.93). The optimal cut-off point for FFR to predict Stage II was ≤ 0.7 (sensitivity 100%; specificity 86%). Conclusion: In patients with unilateral MCA lesions, an FFR decrease was correlated with misery perfusion on 123I-IMP SPECT with acetazolamide, which may be a more feasible predictor of high-risk intracranial stenosis.

Background and Purpose: Noninvasive fractional flow reserve (FFR) on time-of-flight magnetic resonance angiography (TOF-MRA) may be used to identify high-risk intracranial lesions. We tested whether FFR was associated with vascular territory of the qualifying lacunar stroke in participants of the Secondary Prevention of Small Subcortical Strokes (SPS3) trial and the utility of FFR for predicting recurrent stroke during the trial. Methods: SPS3 was a randomized trial investigating optimal blood pressure target and antiplatelet regimen in patients with recent, symptomatic, MRI-confirmed lacunar stroke patients TOF-MRA proximate to study entry was adequate and available for 2169 of 3020 study patients. Signal intensity (SI) was measured in the background, and proximal and distal aspects of 7 intracranial arteries (internal carotid, middle cerebral, basilar, and vertebral). Adjusted FFR was then calculated in each artery: FFR = [distal SI - background SI] / [proximal SI - background SI] and divided into quartiles by artery. Associations between the vascular territory of the qualifying infarct and the FFR quartile of the relevant artery were investigated using contingency tables and chi-square tests. Risks for recurrent stroke associated with FFR quartiles were evaluated using Cox Proportional Hazards models (model adjusted for assigned treatment groups). Results: Mean age of the 2169 patients included was 63 yr with 63% male; hypertension, diabetes, and prior lacunar stroke were present in 75%, 36%, and 10% respectively. Median FFRs varied by artery with the lowest in the basilar (0.793) and highest in the middle cerebral arteries (left 1.154; right 1.176). A recurrent stroke occurred in 195 patients during a mean follow-up of 3.5 years (annualized rate 2.5% per patient-year).No significant association was found between the FFR tertiles and the vascular territory of the qualifying infarct. Quartiles of adjusted FFR in any of the 7 arteries were not found to be predictive of recurrent stroke. Conclusion: In this large well-characterized cohort of lacunar stroke patients, FFR was not associated with the location of the qualifying subcortical infarct and did not predict the risk of recurrent stroke.

Background and Purpose: Intracranial arterial dolichoectasia (IADE) is associated with atherothrombotic strokes, but its relationship with lacunar infarcts is less certain. We investigated the prevalence of IADE and associated risk of recurrent stroke and death in the Secondary Prevention of Small Subcortical Strokes (SPS3) trial. Methods: Maximum diameter of the intracranial internal carotid artery (ICA), middle cerebral artery (MCA), vertebral artery (VA), and basilar artery (BA) were measured on 2794 MRAs with IADE defined a priori as >7.0 mm for ICA, >4.0 mm for MCA, >4.0 mm for VA, and >4.5 mm for BA. Patient characteristics and outcomes were compared between patients with and without IADE. Results: IADE was present in ≥1 artery in 210 (7.1%) patients, none in ICA, 5 MCA, 163 BA, and 116 VA. Patients with IADE were more often older (65 vs. 63 years; p = 0.01) male (81% vs. 61 %; p Conclusion: In this large well characterized cohort of lacunar stroke patients, dilatation of BA was independently associated with death but not recurrent stroke, and IADE in other arteries did not predict stroke or death. IAED in lacunar stroke patients seems to be unrelated to the mechanism and severity of small vessel disease.

Studies of four male victims who were killed in an accidental tunnel gas explosion on urban reclaimed land are described. The studies were judicial autopsy examinations to determine the precise causes of death. Two men died of carbon monoxide intoxication, one died of massive brain damage, and the fourth died of drowning. The concentrations of methane in several organs were much lower than the lethal level, whereas those in adipose tissue were relatively high. These findings indicated that a low concentration of methane was almost always present in the atmosphere at the construction site. Recently, coal mine accidents have been decreasing in Japan. However, there is still a possibility of underground explosions or gas leaks in confined spaces other than coal mines. To determine the precise cause of death in such cases, careful autopsies and other examinations should be performed using methods similar to those used in coal mine accidents.

Background and Purpose: Intracranial arterial dolichoectasia (IADE) is a common finding in atherothrombotic strokes, but its relationship with lacunar infarcts is less certain. We investigated the prevalence of IADE and its correlation with risk factors as well as with recurrent stroke within the Secondary Prevention of Small Subcortical Strokes (SPS3) study cohort. Methods: The greatest diameter of the following arteries was measured on MRA: bilateral internal carotid artery (ICA), middle cerebral artery (MCA), vertebral artery (VA), and the basilar artery (BA). IADE criteria were a diameter of over 7.0 mm for ICA, over 4.0 mm for MCA, over 4.0 mm for VA, and over 4.5 mm for BA. BA elongation was assessed according to Smoker’s criteria. Results: Of the 3020 SPS3 participants, 2562 MRAs were assessed. Diameters were: ICA, 4.4 +/- 0.6 mm; MCA, 2.6 +/- 0.4 mm; BA, 3.4 +/- 0.7 mm; and VA, 2.4 +/- 0.7 mm. Of the measured participants 8% met criteria for IADE; 65% had IADE in a single artery, 28% in two arteries, and 7% in more than two arteries. Abnormality in either height of the bifurcation (66.7% vs. 4.6%, p Conclusion: In this large and well characterized cohort of lacunar stroke patients, IADE was present in 8%, approximately half of whom demonstrated BA elongation. The relationship between IADE and incidence of recurrent stroke will be presented. Ongoing analyses from SPS3 will likely elucidate if IADE is a risk factor for stroke recurrence in lacunar stroke patients.

INTRODUCTION: In patients with hyperacute ischemic stroke, diffusion-weighted imaging (DWI) sometimes fails to detect early CT ischemic lesions showing parenchymal hypoattenuation, which is termed Reversed Discrepancy (RD). The aim of the present study was to elucidate the factors associated to the development of RD. Method: One hundred sixty four consecutive patients with hyperacute anterior circulation ischemic stroke were enrolled. All patients underwent both MRI and CT within 3 hours of onset and before treatment. Three stroke neurologists independently and retrospectively evaluated presence of early ischemic changes in each the Alberta Stroke Programme Early CT Score (ASPECTS) region. Presence of RD was defined when the early ischemic change detected on CT was not detected on DWI. Patients’ baseline characteristics, ASPECTS on CT, ASPECTS on DWI, and modified Rankin Scale (mRS) 3 months after onset were compared between patients with RD (RD group) and without RD regions (non-RD group). Results: RD was found in 40 (32%) patients (mean age 78.7 years; 50 % men); it was located in the basal ganglia (n=23), the cortex (n=27), and the basal ganglia plus the cortex (n=10). RD group was older (78.7±9.6 vs. 74.1±12.1 years, p=0.03), had a higher NIHSS score on admission (median, 22 vs. 11, p Conclusions: Atrial fibrillation was related to the presence of RD. Patients with RD had unfavorable outcome.

Background: Most of lacunar infarcts (LI) are due to penetrating small vessel disease, although other mechanisms can be responsible for LI. We sought to determine the relationship between the size and shape of LI and underlying risk factors and recurrent ischemic stroke rates. Methods: 872 images from the 3020 patients enrolled in the Secondary Prevention of Small Subcortical Strokes (SPS3) trial were included in this analysis. SPS3 is a multi-center randomized trial of MRI proven lacunar stroke patients. Participants with confirmation of their index event by DWI were reviewed. Infarct volume was measured planimetrically, and shape was classified as ovoid/spheroid, slab, stick, or multi-component based on visual analysis after 3D reconstruction of axial MRI slices using OsiriX software. Results: Infarct shape was ovoid/spheroid in 67%, slab in 10%, stick in 6%, and multi-component in 17% of patients. Median infarct volumes differed by shape with the smallest LI volumes observed in ovoid/spheroid: 0.52, 0.76, 0.62, and 0.93 respectively, p < 0.001. Patients with ovoid/spheroid LI were of similar age (means 61 vs. 62 yr, p = 0.4), sex (57 vs 60%, p=0.5), and hypertension status (81% vs. 80%, p = 0.7), but more likely to be diabetic (43% vs. 32%, p = 0.003) and have IHD (17% vs. 10%, p =0.02) vs. those with other shapes combined. Prevalence of relevant intracranial large vessel occlusion on vascular imaging was 7% in the ovoid/spheroid S3 group and 9% in others (p = 0.5). The 6-year re-current stroke rate was 16.1% with 91 strokes occurring. There was no difference in reinfarction rate based on shape or volume. Conclusion: Lacunar strokes comprise a heterogeneous group of cerebral infarction likely secondary to variable etiologies. In this preliminary analysis infarct shape was correlated with risk factors but not with stroke infarct. Final analysis will be presented and likely the ongoing SPS3 data analyses will elucidate these differences.

Background and purpose: Prediction of swallowing function in dysphagic patients with acute stroke is indispensable for discussing percutaneous endoscopic gastrostomy (PEG) placement. We performed a retrospective study using database of a large number of acute ischemic stroke patients to clarify predictors for acquisition of oral intake in chronic phase. Methods: A total 4,972 consecutive acute stroke patients were admitted to our stroke center during 8.5 years; a questionnaire was sent to all the survivors after 3 months of onset. We investigated nutritional access after 3 months of onset in 588 patients who could not eat orally 10 days after admission, and analyzed predictive factors for their acquisition of oral intake. Continuous variables were dichotomized to identify the most sensitive predictors; the cutoff values were investigated by receiver operating characteristics curve analysis. Results: Out of 588 dysphagic patients, 75 died during the 3 months, and 143 (28%) of the residual 513 achieved oral intake after 3 months. In logistic-regression models, age ≤80 years, absence of hyperlipidemia, absence of atrial fibrillation, modified Rankin Scale score 0 before onset, and low National Institutes of Health Stroke Scale (NIHSS) score independently predicted oral intake 3 months after onset. From two different model analyses, NIHSS score ≤17 on day 10 (OR 3.63, 95% CI 2.37-5.56) was found to be a stronger predictor for oral intake than NIHSS score ≤17 on admission (OR 2.34, 95% CI 1.52-3.59). At 3 months, 17/143 (12%) patients with oral intake were living at home, while only 1/370 (0.3%) patients without oral intake were. Conclusion: A quarter of dysphagic patients with acute stroke obtained oral intake 3 months after onset. Clinicians should be cautious about PEG placement for stroke patients with severe dysphagia who were independent prior to the stroke, aged ≤80 years, and show NIHSS score ≤17 on day 10, because their swallowing dysfunction may improve in a few months.

A 49-year-old woman with diabetes mellitus and hyperlipidemia experienced frequent transient monocular blindness in the right eye during a 3-week period. Examination revealed atherothrombotic occlusion of the right ophthalmic artery (OA) without embolic sources. After treatment with aspirin, attacks resolved completely. Her symptoms were attributed to microembolism from the occluded OA.