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Background and purpose A transient ischemic attack (TIA) can occur without self‐awareness of symptoms. We aimed to investigate characteristics of patients with a tissue‐based diagnosis of TIA but having no self‐awareness of their symptoms and whose symptoms were witnessed by bystanders. Methods We used data from the multicenter registry of 1414 patients with a clinical diagnosis of TIA. For patients without evidence of ischemic lesions on imaging, clinical characteristics were compared between patients with and without self‐awareness of their TIA symptoms. Results Among 896 patients (559 men, median age of 70 years), 59 (6.6%) were unaware of their TIA symptoms, but had those symptoms witnessed by bystanders. Patients without self‐awareness of symptoms were older and more frequently female, and more likely to have previous history of stroke, premorbid disability, and atrial fibrillation, but less likely to have dyslipidemia than those with self‐awareness. Patients without self‐awareness of symptoms arrive at hospitals earlier than those with self‐awareness (P, Graphical Table of Contents Among 896 patients (559 men, median age of 70 years) with diagnosis of a tissue‐based transient ischemic attack (TIA), 59 (6.6%) were unaware of their symptoms but had their symptoms witnessed by bystanders. The cumulative incidence rate of occurrence of ischemic stroke after 1 year from TIA was higher in patients without self‐awareness than those with self‐awareness (16.3% vs. 6.9%, log‐rank; P = 0.010).

A 48-year-old man with rapid onset of fever elevation developed acute myelitis over a period of a week. MRI of the spinal cord revealed a longitudinal T2-hyperintense intraspinal lesion extending from C6 to Th8 level. Clinical symptoms and findings resolved with immunotherapy. In serological analysis, no antibodies related to various collagen diseases, anti-aquaporin-4 (AQP4) antibody and anti-myelin oligodendrocyte glycoprotein (MOG) antibody were detected. Anti-lactosylceramide (LacCer) antibodies were detected in the acute phase of serum and cerebrospinal fluid, with titers showing decrements in the recovery phase. The present case supports the notion that acute myelitis can occur as an anti-neutral glycolipid antibody-related disorder. Anti-neutral glycolipid antibodies should be examined in future pertinent cases of myelitis.

Background and Purpose— Patients with transient ischemic attack (TIA) occasionally show nonfocal symptoms, such as unconsciousness, amnesia, and unsteadiness. The purpose of this study was to clarify the characteristics and prognosis of patients with TIA with nonfocal symptoms, using data from the PROMISE-TIA (Prospective Multicenter Registry to Identify Subsequent Cardiovascular Events After Transient Ischemic Attack). Methods— Patients with TIA within 7 days of onset were consecutively enrolled in the Japanese nationwide registry. Factors associated with nonfocal symptoms and 1-year risks of ischemic stroke and coronary artery diseases were assessed in multivariate-adjusted models. Results— We studied 1362 patients with TIA (879 men; mean age, 69±12 years), including 219 (16%) with nonfocal symptoms. Patients with TIA with nonfocal symptoms were more likely to show acute ischemic lesions in the posterior circulation on diffusion-weighted imaging (multivariate-adjusted odds ratio, 3.07; 95% confidence interval, 1.57–5.82) and arterial stenosis or occlusion in the posterior circulation on vascular examination (odds ratio, 1.94; 95% confidence interval, 1.19–3.09) than those without nonfocal symptoms. Although 1-year risk of ischemic stroke did not differ significantly between groups (adjusted hazard ratio, 0.79; 95% confidence interval, 0.42–1.37), risk of coronary artery disease was higher in patients with TIA with nonfocal symptoms (hazard ratio, 3.37; 95% confidence interval, 1.14–9.03). Conclusions— Both acute ischemic lesions and arterial stenosis and occlusion in the posterior circulation were more frequently observed in patients with TIA with nonfocal symptoms.

Objective The purpose of this study was to identify the predictors of subsequent ischemic stroke events in patients with transient ischemic attack (TIA) attributable to intracranial arterial occlusive lesions. Methods The study population included 82 patients (55 men; mean age, 69.3±12.1 years) with TIA caused by intracranial arterial occlusive lesions who were admitted to our stroke care unit within 48 h of the onset of a TIA between April 2008 and November 2015. TIA was diagnosed if focal neurological symptoms ascribable to a vascular etiology lasted less than 24 h, irrespective of the presence of ischemic insults on imaging. The primary endpoint was an ischemic stroke event within 90 days of the onset of a TIA. Results The 90-day risk of ischemic stroke after the onset of a TIA was 14.6% [95% confidence interval (CI): 8.6-23.9%]. Cox proportional hazards multivariate analyses revealed that diffusion-weighted imaging (DWI) positivity [hazard ratio (HR), 8.73; 95%CI, 2.20-41.59; p=0.002], prior ischemic stroke (HR, 4.03; 95%CI, 1.07-15.99; p=0.040), and a high serum level of alkaline phosphatase (ALP) on admission (HR, 1.15; 95%CI, 1.05-1.26; p=0.002, for every +10 U/L) were significant independent predictors of ischemic stroke within 90 days after the onset of a TIA. Conclusion Our results suggested that patients with a TIA attributable to intracranial artery disease who showed DWI lesions, prior ischemic stroke, or high serum levels of ALP on admission were at high risk of subsequent ischemic stroke events.

11C-Pittsburgh compound-B (11C-PIB) positron emission tomography (PET) is used to visualize and quantify amyloid deposition in the brain cortex in pathological conditions such as Alzheimer’s disease (AD). Intense 11C-PIB retention is also observed in the white matter (WM) of both healthy individuals and AD patients. However, the clinical implications of this retention in brain WM have not been clarified. We investigated the relationship between the extent of white matter lesions (WMLs) and the binding potential of 11C-PIB (BPND) in the WM in patients with hypertensive small vessel disease. We further examined the relationship between the extent of WMLs and BPND in WML and in normal-appearing white matter (NAWM). Twenty-one hypertensive vasculopathy patients, without AD and major cerebral arterial stenosis and/or occlusion, were enrolled (9 women, 68 ± 7 years). Regions of WML and NAWM were extracted using magnetization-prepared rapid gradient-echo and fluid-attenuated inversion recovery of magnetic resonance images. Volumes of interest (VOIs) were set in the cortex-subcortex, basal ganglia, and centrum semiovale (CS). BPND in the cortex-subcortex, basal ganglia, CS, WML, and NAWM were estimated on 11C-PIB PET using Logan graphical analysis with cerebellar regions as references. The relationships between WML volume and BPND in each region were examined by linear regression analysis. BPND was higher in the CS and basal ganglia than in the cortex-subcortex regions. WML volume had a significant inverse correlation with BPND in the CS (Slope = −0.0042, R 2 = 0.44, P

BACKGROUND Time and resource limitations prevent cognitive assessment in acute-to-subacute settings, even in comprehensive stroke centers. OBJECTIVE To assess cognitive function in acute stroke patients undergoing routine clinical, laboratory, and radiological investigations, with a view to improving post-stroke care and treatment. METHODS Sixty-nine patients (72.6±11.1 years; 65% male) were prospectively enrolled within 14 days of acute ischemic stroke. Patients with altered consciousness, aphasia, or dysarthria were excluded. Clinical features including modified Rankin and NIH stroke scales, and vascular risk factors were assessed, as well as neuroimaging parameters by semi-quantitative evaluation of medial temporal lobe atrophy (MTLA) using MRA source images, FLAIR images for white matter changes (Fazekas scores), and T2∗ images for cerebral microbleeds. Neuropsychological screening was conducted using the Montreal Cognitive Assessment (MoCA) test. Univariate and multivariate analyses were used to evaluate the influence of variables on MoCA total and subscale scores. RESULTS Lower MoCA scores of 22 or less were associated with MTLA [OR (95% CI), 5.3 (1.0-27.5); p = 0.045], education years [OR (95% CI), 0.71 (0.55-0.91); p = 0.007], and modified Rankin scale at discharge [OR (95% CI), 2.4 (1.3-4.5); p = 0.007]. The delayed recall MoCA score was correlated with MTLA (r = - 0.452, p

A 16-year-old healthy male experienced gastrointestinal symptoms and 9 days later developed fever, headache, numbness of the left hand, and disturbance of consciousness with rapid deterioration to a comatose state. These clinical symptoms resolved after treatment with steroid pulse, plasma exchange, and intravenous immunoglobulin. Along with the recovery, ophthalmoplegia and ataxia were observed. These symptoms and the detection of a high titer of serum anti-GQ1b immunoglobulin G autoantibodies led to the diagnosis of Bickerstaff's brainstem encephalitis (BBE). Brain 123I-IMP SPECT indicated hypoperfusion of the brainstem and bilateral cerebellar cortex during the acute phase, which increased during the recovery phase. This finding is indicative of reversible dysfunction in the cerebellar cortex and brainstem in the acute phase of BBE.

Background and Purpose- Patients with transient ischemic attack (TIA) occasionally show nonfocal symptoms, such as unconsciousness, amnesia, and unsteadiness. The purpose of this study was to clarify the characteristics and prognosis of patients with TIA with nonfocal symptoms, using data from the PROMISE-TIA (Prospective Multicenter Registry to Identify Subsequent Cardiovascular Events After Transient Ischemic Attack). Methods- Patients with TIA within 7 days of onset were consecutively enrolled in the Japanese nationwide registry. Factors associated with nonfocal symptoms and 1-year risks of ischemic stroke and coronary artery diseases were assessed in multivariate-adjusted models. Results- We studied 1362 patients with TIA (879 men; mean age, 69±12 years), including 219 (16%) with nonfocal symptoms. Patients with TIA with nonfocal symptoms were more likely to show acute ischemic lesions in the posterior circulation on diffusion-weighted imaging (multivariate-adjusted odds ratio, 3.07; 95% confidence interval, 1.57-5.82) and arterial stenosis or occlusion in the posterior circulation on vascular examination (odds ratio, 1.94; 95% confidence interval, 1.19-3.09) than those without nonfocal symptoms. Although 1-year risk of ischemic stroke did not differ significantly between groups (adjusted hazard ratio, 0.79; 95% confidence interval, 0.42-1.37), risk of coronary artery disease was higher in patients with TIA with nonfocal symptoms (hazard ratio, 3.37; 95% confidence interval, 1.14-9.03). Conclusions- Both acute ischemic lesions and arterial stenosis and occlusion in the posterior circulation were more frequently observed in patients with TIA with nonfocal symptoms.

Background/Aims: The aims of this study were to determine the differences in clinical characteristics and the risk of ischemic stroke between patients with transient ischemic attack (TIA) attributable to extracranial carotid and intracranial artery occlusive lesions. Methods: Among 445 patients admitted to our stroke care unit within 48 h of TIA onset between April 2008 and December 2013, 85 patients (63 men, mean age 69.4 years) with large artery occlusive lesions relevant to symptoms were included in this study. The primary endpoints were ischemic stroke at 2 and 90 days after TIA onset. Results: Twenty-eight patients had carotid artery occlusive lesions (extracranial group), and 57 patients had intracranial artery occlusive lesions (intracranial group). Patients in the intracranial group were significantly younger, had lower levels of fibrinogen, and were less likely to have occlusion when compared with those in the extracranial group. Eleven patients in the extracranial group and none in the intracranial group underwent revascularization procedures within 90 days of TIA onset. The 2-day risk (14.2 vs. 0%, p = 0.044) and the 90-day risk (17.1 vs. 0%, p = 0.020) of ischemic stroke after TIA onset were significantly higher in the intracranial group than in the extracranial group. Conclusions: Among our patients with TIA caused by large artery disease, patients with intracranial artery occlusive lesions were more frequent and were at higher risk of early ischemic stroke than those with extracranial carotid artery occlusive lesions. These data highlight the importance of prompt assessment of intracranial artery lesions in patients with TIA.

Introduction: Early stroke risk in patients with transient ischemic attack (TIA) due to small vessel occlusion (SVO) is underestimated. We assessed whether TIA patients due to SVO are at a higher early stroke risk, using the data of a prospective, multicenter, observational registration study in Japan (PROMISE-TIA registry). Methods: The study subjects were 1,320 TIA patients (470 women, 69±12 years, median ABCD2 score 5) within 7 days of onset. The primary outcome was recurrent stroke within 30 days after TIA. SVO-TIA was defined as having lacunar TIA syndrome without cardiac source of embolism or large artery stenosis, as the exact determination of TIA due to SVO is difficult. Lacunar TIA syndrome was defined as unilateral weakness or sensory disturbance of at least two of three body parts (face, arm, and leg) in the absence of cortical dysfunction. Predictors for 30-day recurrent stroke were estimated using a Cox proportional hazards model. Results: Recurrent stroke within 30 days after TIA was observed in 61 patients (4.6%). In multivariable analysis, SVO-TIA (hazard ratio, 1.87; 95%CI, 1.11-3.11), higher systolic blood pressure at presentation (hazard ratio, 1.18 (per 10mmHg increase); 95%CI, 1.08-1.28) and presentation within 3 hours after onset (hazard ratio, 2.25; 95%CI, 1.30-4.10) were independently associated with recurrent stroke. Furthermore, SVO-TIA with an evidence of subcortical or brainstem infarcts on diffusion weighted imaging (definite TIA due to SVO) was a stronger predictor for recurrent stroke (hazard ratio, 3.63; 95%CI, 1.59-7.23). The presence of cardiac source of embolism and symptomatic large artery steno-occlusion were not significant predictors. Conclusions: The data from a Japanese large TIA registry suggested that patients with TIA due to SVO were at a higher risk of early recurrent stroke.

A 46-year-old woman without cardiovascular risk factors who was taking oral prednisolone for Sjogren syndrome presented with repeated episodes of transient left hemiparesis and left-sided sensory disturbance over a 2-year period despite preventive therapy with antiplatelets and anticoagulants. Infarcts were always identified in the right middle cerebral artery territory on brain magnetic resonance imaging (Figure 1) without any sign of cerebrovascular stenosis or emboligenic sources. She was referred and admitted to our hospital 2 years after the initial onset. Carotid magnetic resonance angiography showed that the origin of the right internal carotid artery (ICA) bent inward (Figure 2A). However, follow-up magnetic resonance angiography the next day revealed that the origin of the right ICA bent outward, as commonly seen (Figure 2B). On carotid ultrasonography, …

We herein report two autopsy cases of severe cardioembolic stroke with oscillating thrombi in the bilateral extracranial internal carotid arteries (ICAs) demonstrated on carotid ultrasonography performed on admission. An autopsy study of case 1 conducted on the third hospital day revealed no thrombi, while that of case 2 conducted on the 42nd hospital day revealed red thrombi in the extracranial ICAs. Our postmortem studies confirm that oscillating thrombi may be seen in the region of blood stasis caused by occlusion of the distal portion of the ICA, thus reflecting a pre-state of thrombus formation.

Twenty-one hypertensive vasculopathy patients, without AD and major cerebral arterial stenosis and/or occlusion, were enrolled (9 women, 68 ± 7 years). Regions of WML and NAWM were extracted using magnetization-prepared rapid gradient-echo and fluid-attenuated inversion recovery of magnetic resonance images. Volumes of interest (VOIs) were set in the cortex-subcortex, basal ganglia, and centrum semiovale (CS). BPBP

We describe herein the case of a 71-year-old man with the cardiac variant of Fabry disease presenting with cardioembolic stroke. Stroke is one of the most well-known manifestations of Fabry disease, and lacunar stroke is a widely recognized etiology. However, little is known about stroke in patients with the cardiac variant of Fabry disease. The cardiac variant of Fabry disease should be considered as a potential cardiac source of embolic stroke.

An 89-year-old woman was admitted to our stroke care unit because of transient ischemic attack caused by cardioembolic occlusion of the right internal carotid artery. She developed recurrent ischemic stroke shortly after hospitalization. She was very quickly treated with intravenous tissue plasminogen activator, because she had been just hospitalized, and had a favorable outcome. Earlier thrombolysis to patients with ischemic stroke is associated with better outcomes. Hospitalization in a stroke care unit is useful for close observation of patients with transient ischemic attack, and allows timely administration of tissue plasminogen activator.

We had an opportunity to visit the Kerckhoff Klinik, a representative cardiovascular hospital with high-quality health care, the Kopfklinik of Heidelberg University, a representative acute stroke hospital in Germany, and the Kliniken Schmieder, a rehabilitation hospital. As a result, we obtained useful information concerning the healthcare system, acute stroke care system, inter-hospital cooperation, and evaluation system for the quality of medical care in Germany.

Since October, 2005 when intravenous thrombolysis with rt-PA (IV-rtPA) for hyperacute stroke was approved, acute stroke care system (ASCS) has been under remodeling in Japan. We conducted a nation-wide survey to reveal the status of 5,398 acute hospitals in 2006. In this study, we investigated the differences in ASCS by population density. The replies of the questionnaires in terms of ASCS were divided into three groups based on the population density; highest tertile (H), middle tertile (M) and lowest tertile (L) groups. The answers of hospitals attending stroke patients were compared among the three groups. 1,586 hospitals (29.4%) responded. The upper and lower tertile thresholds were 2,050 and 461 people/km2, respectively. 65% of H group, 75% of M group and 76% of L group attended acute stroke patients (p=0.0001). 47%, 43%, and 50% had direct telephone line with the emergency services, respectively (ns). The early admission rate, within 3 hours of onset, over 20% of all was seen in 23%, 23% and 26%, respectively (ns). Stroke expertise physicians were available on a 24/7 basis in 56%, 63% and 45%, respectively (p

背景および目的：脳卒中では緊密な連携の重要性が強調されている．脳卒中地域医療における急性期病院の実態を明らかにする． 方法：急性期病院2,185施設に対しアンケート調査を行った． 結果：有効回答46%で，うち52%が脳卒中患者を診療していた．多くが，地域医療圏は二次医療圏（45%）であるとし，その中心的役割は急性期病院（69%）と回答した．他の急性期病院，回復期リハ病棟，一般診療所，維持期施設事業所，周辺地域全体，自治体との連携が良好は75%，75%，74%，69%，73%，34%であった．医療（介護）情報を既に共有しているのは20%（14%）で，共有する予定51%（51%），共有する予定なし25%（30%）であった．医療保険と介護保険のシステムでは十分なリハビリを提供しにくいとの回答が67%に達した． 結論：脳卒中連携において中心的役割を担う急性期病院でも，地域での情報共有は未だ十分ではなかった．

脳卒中医療・介護施設の緊密な連携と情報共有の重要性が強調されている．一般診療所（診療所，3,709施設）に対して，施設の概要，脳卒中地域連携，介護保険，適当な評価尺度に関するアンケート調査を行った．有効回答21%で，うち58%が脳卒中を診療していた．1カ月に平均622人（脳卒中患者81人）診療し，うち要介護者平均81人（脳卒中患者32人）であった．脳卒中患者が必要なリハビリを「十分に受けている」と回答したのは5%であった．多くが地域医療圏を「二次医療圏」（34%）や「市町村」（29%），その中心的役割を「急性期病院」（86%）と回答した．他の医療・介護施設事業所や自治体との連携が良好との回答は必ずしも多くなかった．医療（介護）情報を「既に共有」，「共有予定」，「共有予定なし」は各々11（10）%，27（26）%，57（60）%であった．医療・介護保険のシステムの問題では「十分なリハビリを提供しにくい」（60%）が最多であった．第三者が診療所を評価するのに適当な評価尺度は「急性期病院との連携」（68%）が最多であった．本調査により，一般診療所の現状が明らかとなった．

背景及び目的：脳卒中では緊密な連携の重要性が強調されている．回復期病棟の実態を明らかにする． 方法：回復期病棟347施設に対しアンケート調査を行った． 結果：有効回答50%で，うち95%が脳卒中患者を診療していた．受け入れ制限理由として人工呼吸器と透析が多く，受け入れ待機1週間以内は47%，平均在院日数は88日，自宅退院率は61%であった．他の回復期病棟や自治体との連携は良好とはいえなかった．医療（介護）情報を「既に共有」，「共有予定」，「共有予定なし」と回答したものは13（13）%，56（55）%，25（28）%であった．医療・介護保険システムでは「十分なリハビリを提供しにくい」との回答が84%に達した．第三者による回復期病棟評価尺度として「リハビリ機能」を挙げるものが最多であった（86%）． 結論：脳卒中連携において重要な役割が期待されている回復期病棟の有する諸問題がかなり明らかとなった．

脳卒中医療・介護施設の緊密な連携と情報共有の重要性が強調されている．通所および訪問介護4,166施設・事業所に対して，施設の概要，脳卒中地域連携，介護保険，適当な評価尺度に関するアンケート調査を行った．有効回答22%で，うち80%が脳卒中患者に介護サービスを提供していた．利用者は1カ月平均112人（脳卒中患者26人）で，受け入れ制限理由は「特になし」（47%）が最多であった．81%がリハビリを提供していたが，脳卒中後遺症のある利用者がリハビリを「十分に受けている」と回答したのは10%であった．多くが地域医療圏を「市町村」（43%）と回答し，その中心的役割を「回復期病棟」（38%）に求めていた．他の医療介護施設事業所や自治体との連携が良好との回答は多くはなかった．医療（介護）情報を「既に共有」，「共有予定」，「共有予定なし」は各々9（10）%，15（17）%，62（59）%であった．医療保険と介護保険によるシステムの問題点をあげる割合が高く，なかでも「十分なリハビリを提供しにくい」（60%）が最多であった．第三者が通所および訪問介護施設事業所を評価するのに適当な評価尺度では「介護支援専門員との連携」（44%）が最多であった．本調査により，通所および訪問介護施設・事業所の現状が明らかとなった．

脳卒中医療・介護施設の緊密な連携と情報共有の重要性が強調されている．維持期入院入所771施設に対して，施設の概要，脳卒中地域連携，介護保険，適当な評価尺度に関するアンケート調査を行った．有効回答24%で，うち82%が脳卒中診療や介護に従事していた．平均106床（脳卒中患者37床）であった．22%で待機期間が半年以上であった．脳卒中患者が在宅で生活できない主な理由は「独居」73%，「高齢者のみの世帯」76%，「その他の介護力不足」77%で，自宅に戻っていたのは平均10%であった．「十分なリハビリ機能を維持」は15%で，脳卒中患者にリハビリを「十分に提供できている」のは9%であった．多くが地域医療圏は「市町村」（38%），その中心的役割は急性期病院（42%）と回答した．他の医療介護施設事業所や自治体との連携が良好との回答は多くなかった．医療（介護）情報を「既に共有」，「共有予定」，「共有予定なし」は各々8（8）%，17（19）%，64（61）%であった．医療保険と介護保険によるシステムの問題点をあげる割合が高かった．第三者が維持期入院入所施設を評価するのに適当な評価尺度は「リハビリ機能」（47%）が最多であった．本調査により，維持期入院入所施設の現状が明らかとなった．

Background: The purpose of this study was to determine the differences in clinical characteristics and the risk of ischemic stroke between patients with transient ischemic attack (TIA) attributable to extracranial carotid and intracranial artery occlusive lesions. Methods: Among 445 patients admitted to our stroke care unit within 48 hours of TIA onset between April 2008 and December 2013, 85 patients (63 men, 69.4 years) with large artery occlusive lesions relevant to symptoms were included in this study. The primary endpoints were ischemic stroke at 2 days and 90 days after TIA onset. Results: Twenty-eight patients had carotid artery occlusive lesions (extracranial group), and 57 patients had intracranial artery occlusive lesions (intracranial group). Patients in the intracranial group were significantly younger, had lower levels of fibrinogen, and were less likely to have occlusion when compared to those in the extracranial group. Eleven patients in the extracranial group and no patient in the intracranial group underwent revascularization procedures within 90 days of TIA onset. The 2-day risk (14.2% vs. 0%, p = 0.044) and 90-day risk (17.1% vs. 0%, p = 0.020) of ischemic stroke after TIA onset were significantly higher in the intracranial group than in the extracranial group. Conclusions: Patients with intracranial artery occlusive lesions were more frequent and were at higher risk of early ischemic stroke than those with extracranial carotid artery occlusive lesions among our patients with TIA caused by large artery disease. These data highlight the importance of prompt assessment of intracranial artery lesions in patients with TIA.

The significance of the stroke unit (SU) in Japan, where the medical system differs from those in Europe and the USA, remains unclear. We conducted a prospective multicenter study to clarify this issue. The study subjects consisted of 7614 consecutive patients with completed stroke, excluding subarachnoid hemorrhage, who were admitted to 117 hospitals in Japan within 72 hours of stroke onset from December 2004 to December 2005. We divided the hospitals into those with and those without an SU, and investigated whether or not the treatment in the SU could improve the patients' clinical outcome. In our preliminary analysis using data for the initial 4268 patients, logistic regression analysis demonstrated that the only significant and independent predictor of case fatality at 28 days and 3 months after onset was the NIHSS score on admission. Treatment in the SU, however, was significantly associated with a favorable outcome (mRS, 0-2) at 3 months after stroke onset as well as age, male gender, the pre-stroke mRS score, and the NIHSS score on admission. Assessments of swallowing functions and the application of an early rehabilitation program within the initial week were more frequently given in acute stroke patients at hospitals with an SU than at those without an SU. The present results indicate that the treatment in an SU may also improve the clinical outcome of patients at 3 months after stroke onset in Japan.

Background and Purpose— The aim of this study was to elucidate the factors associated with the time from symptom onset to arrival at a stroke center (onset-to-door time [ODT]) in patients with classically defined transient ischemic attack using data from a multicenter, retrospective study. Methods— The subjects were patients with transient ischemic attack admitted to 13 stroke centers in Japan within 7 days of onset between 2008 and 2009. A total of 464 patients registered (292 men, 68.5±13.2 years old), and 421 of them (268 men, 68.8±13.1 years old) were included in the analyses. ODT was classified into the following 5 categories: 24 hours. Results— There were 233 patients (55.3%) who visited a stroke center within 3 hours of symptom onset. Multiple ordinal logistic regression analysis revealed that motor weakness, speech disturbance, and duration of symptoms >10 minutes were independently associated with a short ODT. Furthermore, a history of transient ischemic attack and hypertension and a referral from another medical facility were independently associated with a long ODT. Patients with a higher ABCD 2 score were likely to arrive at a stroke center more quickly. Conclusions— We identified several factors that were positively and negatively associated with the ODT in patients with transient ischemic attack.

Background: Platelet hyper-aggregability is an important risk factor for leukoaraiosis. In this study we investigated whether aggravation of leukoaraiosis can be controlled by means of long-term correction of platelet hyper-aggregability.Methods:Twenty-one patients with leukoaraiosis and uncorrected platelet hyper-aggregability were compared with 21 controls matched for age, grade of leukoaraiosis and observation period whose platelet hyper-aggregability was corrected. Platelet aggregability was estimated by an optical analytical method with a nine-stage display using two different concentrations each of adenosine diphosphate (ADP) and collagen (the double ADP method).Results:The mean observation period between two magnetic resonance imaging (MRI) scans for both groups was 4.1 years. In the non-corrected group, moderate to severe aggravation of leukoaraiosis was observed in a large number of patients. In the corrected group, only a small number of patients showed generally mild aggravation of leukoaraiosis. The number of patients showing aggravation of periventricular hyperintensity (PVH) was 7 in 21 in the non-corrected group versus 1 in 21 (p=0.022) in the corrected group, and for aggravation of deep white-matter hyperintensity, these values were 9 in 21 versus 4 in 21, respectively. Thus, the difference was more significant if the degree of aggravation was taken into account.Conclusion:The progress of leukoaraiosis is greatly inhibited by long-term correction of platelet hyper-aggregability.

Background and Purpose: Several clinical scales, such as the ABCD2 score, were developed for predicting early stroke after transient ischemic attack (TIA). We aimed to derive a new score from our TIA registry. Methods: The PROMISE-TIA registry was a multicenter prospective study in Japan. From June 2011 to December 2013, 1353 patients within 7 days of TIA onset were enrolled. Among them, we analyzed 1277 patients (822 men, 69.5 ± 12.4 years) who completed followed-up at 90 days after TIA onset. The components of the score were determined by the multivariate Cox proportional hazards model. We included them into the analysis if the p-value was under 0.1. The accuracy of our score was compared to that of the ABCD2, ABCD3, and ABCD3-I scores by using the C-statistics. Results: Cox hazard model showed that age≧80 years (HR: 1.91; 95%CI: 0.95-3.61, p=0.069), systolic blood pressure (SBP)≧160 or diastolic blood pressure (DBP)≧90 at presentation (HR: 4.05; 95%CI: 2.01-9.05, p Conclusions: Our ABC score can be useful for predicting risk of ischemic stroke within 7 days and 90days after TIA onset.

Background and Purpose: Cerebral microbleeds (CMBs) are associated with not only higher age but also extensive white matter lesions (WMLs), indicating that CMBs could be a reflection of microangiopathy. CMBs have not yet been examined in association with cerebral blood flow (CBF) and metabolism. The purpose of this study was to clarify the relationships of CMBs with WMLs volume, and CBF and metabolism in patients with ischemic stroke. Methods: We enrolled 19 patients who had past history of non-cardioembolic stroke without severe stenosis (>50%) in major cerebral arteries (69±7 years, 9 women). We measured WMLs volume and counted the number of CMBs on a 1.5-T magnetic resonance imaging (MRI) scanner. CBF, cerebral blood volume, oxygen extraction fraction and cerebral metabolic rate of oxygen were measured with 15 O-labeled gas positron emission tomography (PET). We set 36 regions of interest (ROIs) in the cortex-subcortex regions, basal ganglia and centra semiovale in each patient on MRI. MRI was superimposed on PET images and 4 parameters of each ROI were calculated. Results: CMBs existed in 14 out of 19 patients (median 5; range 0-39). Patients were divided into 2 groups according to the number of CMBs; less than 5 as the group I (n=9) and 5 or more as the group II (n=10). WMLs volume of the group II was larger than that of the group I (median 38.4 with range of 25.1-91.5 vs. 10.0 with 4.2-73.4 ml, p=0.020). In the centra semiovale, CBF of the group II was significantly lower than that of the group I (12.5±2.5 vs. 15.7±3.5 ml/100g/min, p=0.031). In the other regions, there were no significant differences in all 4 parameters of PET between the 2 groups. Conclusions: We showed that the increases in the number of CMBs could indicate cerebral ischemia in the deep white matter of patients with non-cardioembolic stroke without major cerebral arterial stenosis.

Objectives: The purpose of this study was to elucidate the factors that correlate with unfavorable outcomes and to develop a simple validated model for assessing risk of unfavorable outcomes in patients with minor ischemic stroke. Methods: The derivation cohort included 1,313 patients hospitalized within 72 hours after onset with an initial NIH Stroke Scale score of 0 to 3 enrolled in a prospective, multicenter, observational study. Unfavorable outcome was defined as dependency (modified Rankin Scale score of 3–5) or death at 90 days. The predictive values of factors related to unfavorable outcome were evaluated. External validation was performed in 879 patients from a single-center stroke registry. Results: In the derivation cohort, a total of 203 patients (15%) had unfavorable outcomes. On multivariable analysis, women (odds ratio [OR] 1.95, 95% confidence interval [CI] 1.30–2.94), age ≥72 years (OR 2.80, 95% CI 1.83–4.36), intra/extracranial vascular occlusive lesion (OR 2.80, 95% CI 1.82–4.28), leg weakness (OR 1.72, 95% CI 1.06–2.82), and extinction/inattention (OR 5.55, 95% CI 1.30–21.71) were independently associated with unfavorable outcome. Patients having both a vascular lesion and either leg weakness or extinction/inattention showed 4.63 (95% CI 2.23–9.33) times the risk of unfavorable outcome compared with those having neither. In the validation cohort, the risk was similar, at 3.77 (95% CI 1.64–8.37). Conclusions: Intra- and extracranial vascular imaging, NIH Stroke Scale items such as leg weakness and extinction/inattention, and their combination, as well as female sex and advanced age, may be useful for predicting unfavorable outcomes in patients with minor stroke.

Background and Purpose —The purpose of this study was to clarify whether the relevant risk factors for silent cerebral infarcts (SCIs) in subcortical white matter (WM) are different from those in the basal ganglia (BG). Methods —Subjects of this study were 219 adults without a history of stroke or transient ischemic attack and without any abnormality on a neurological examination who consecutively visited the neurology service in our hospital between January 1994 and November 1997 requesting medical evaluation for possible cerebrovascular diseases. Subjects included 141 men and 78 women ranging in age from 33 to 83 years (mean±SD, 63.2±9.5 years). We performed brain MRIs and cervical/cranial MR angiographies on all subjects. In this study, SCI was defined as a focal lesion >5 mm in diameter that was prolonged on both T2-weighted and proton density images. Results —SCIs in the WM and/or BG were detected in 88 (40.2%) of the 219 subjects. No SCI >15 mm was observed in this series. Fifty of the subjects had SCIs only in the WM, 32 subjects had SCIs in both the WM and BG, and 6 subjects had SCIs only in the BG. Thus, 82 (93.2%) of 88 subjects with SCIs had lesions in the WM. Most subjects with SCIs in the BG also had SCIs in the WM. Multiple logistic regression analyses revealed that age, female sex, and hypertension were significant and independent predictors of SCIs in the WM, and that age, a history of ischemic heart disease, and carotid artery stenosis were significant and independent predictors of SCIs in the BG. Conclusions —The present study indicated that the relevant risk factors for SCIs in the WM and those for SCI in the BG were different. Our results suggest that SCIs are prone to first appear in the WM in association with aging and hypertension, and the additional appearance of SCIs in the BG predicts a progression of generalized atherosclerosis that is manifested in the carotid and coronary arteries.

Purpose: As transient ischemic attack (TIA) is a medical emergency associated with a high risk of early recurrent stoke, an immediate seeking medical attention is essential to reduce a risk of stroke after TIA. The purpose of this study was to investigate factors relating to an early visit to a stroke center in patients with TIA, using data of a multicenter retrospective study. Methods: The subjects of this study were TIA patients admitted to 13 stroke centers within 7 days after onset between 2008 and 2009. The diagnosis of TIA was made in this study if clinical symptoms lasted less than 24 hours, regardless of imaging findings. We compared baseline characteristics between patients visiting a stroke center within 3 hours of TIA onset (early visit, EV group) and those after the initial 3 hours (late visit, LV group), using Chi-square tests. Results: Four hundred sixty-four patients (292 men, mean age of 69 years) were registered. Of them, 240 patients (52%) belonged to the EV group and 220 (47%) used an ambulance. One hundred twenty-seven patients (27.4%) were referred from some other medical facility and 23 patients (5.0%) were from another department within the hospital. As compared to patients in the LV group, those in the EV group more commonly had motor symptoms (p < 0.0001) and consciousness disturbance (p = 0.0027), and were less commonly referred from some other medical facility (p < 0.0001) or from another department (p = 0.0057). Patients were less likely to have a past history of TIA in the EV group than in the LV group, but not significantly (p = 0.065). Conclusions: Almost half of TIA patients visited a stroke center within 3 hours after onset. Motor symptoms and consciousness disturbance were related to an early visit. Referrals from some other medical facility or department were associated with delay in a contact to stroke specialists.

Limited evidence exists on the relationships between severity of white-matter lesions (WMLs) and cerebral hemodynamics in patients without major cerebral artery disease. To examine changes of cerebral blood flow (CBF), oxygen metabolism, and vascular reserve capacity associated with severity of WML in patients with lacunar stroke, we used a positron emission tomography (PET). Eighteen lacunar patients were divided into two groups according to the severity of WMLs, assessed by Fazekas classification; grades 0 to 1 as mild WML group and grades 2 to 3 as severe WML group. Rapid dual autoradiography was performed with 15O-labeled gas-PET followed by 15O-labeled water-PET with acetazolamide (ACZ) challenge. Compared with the mild WML group, the severe WML group showed lower CBF (20.6 ± 4.4 versus 29.9 ± 8.2 mL/100 g per minute, P = 0.008), higher oxygen extraction fraction (OEF) (55.2 ± 7.4 versus 46.7 ± 5.3%, P = 0.013), and lower cerebral metabolic rate of oxygen (CMRO2) (1.95 ± 0.41 versus 2.44 ± 0.42 mL/100 g per minute, P = 0.025) in the centrum semiovale. There were no significant differences in the ACZ reactivity between the two groups (48.6 ± 22.6% versus 42.5 ± 17.2%, P = 0.524). Lacunar patients with severe WMLs exhibited reduced CBF and CMRO2, and increased OEF in the centrum semiovale. The ACZ reactivity was preserved in both patients with severe and mild WMLs in each site of the brain.

脳動脈と冠動脈における動脈硬化性病変の関連性を知るために, 当センターで脳血管造影検査と冠動脈造影検査の両方を施行した17症例についてretrospective studyを行った.以下の結果が得られた. (1) 全例が男性だった. (2) 危険因子として喫煙, 高脂血症および高血圧が高率に認められた. (3) 14例では冠動脈疾患が先行していた. (4) 頭蓋外脳動脈 (頸部内頸動脈および椎骨動脈) の狭窄度と冠動脈狭窄度との問に相関がみられた (Spearman rank correlation;p

Very simple N-octanoyl-L-glutamic acid oligomers (residue number, N = 1-4) have been synthesized and the vibrational spectra of these oligomer films, made by casting them from a dimethylformamide solution onto an NaCl plate, have been investigated together with their time dependence. The results have been compared with those of two β-forms (β1 and β2) and the α-helix of the longer N-octanoyl-L-glutamic acid oligomers (N = 6-14) and with those of poly(L-glutamic acid). Even the N-octanoyl monomer and the dimer as well as the trimer and the tetramer take up an α-helical-type structure, in which the hydrogen-bonding network formed by the α,γ-CO2H and the peptide groups are very similar to that in α-helical poly(L-glutamic acid). For the cast films of these simple oligomers, a transition similar to the α → β1 or α → β2 transition in poly(L-glutamic acid) is observed at 20°C. In particular, ionization of the α-CO2H groups in the cast films is promoted at a higher relative humidity. The α → β-like transition is promoted by the α-CO2- group so formed.

N-Octanoyl-L-glutamic acid oligomers (residue number, N = 3-6, 8, 10, 12, 14, 16, 18, 20 and 22) have been synthesized in order to study their molecular conformations in the solid state. The X-ray diffraction powder patterns and the vibrational spectra of these oligomers have been investigated and compared with those of two β-forms (β1 and β2) and the α-helix of poly(L-glutamic acid). The results are summarized as follows. These oligomers take up a β1- or β2-like structure, similar to that of the two β-forms of poly(L-glutamic acid). The methods used to precipitate the samples are related to the conformational preferences in the solid state. β1 ? β2 interconversion is possible by reprecipitation of the sample. Preferential stabilization of the β1- or β2-forms is strongly dependent on the residue number. Films of the oligomers, made by casting them from a dimethylformamide solution onto NaCl or KBr plates, take up an α-helical structure, and the α → β1 or α → β2 transition depends on the residue number of the cast film.

For diagnosing patients with ischemic cerebrovascular disease, non-invasive count-based method with (15)O(2) and H (2) (15) O positron-emission tomography (PET) data is widely used to measure asymmetric increases in oxygen extraction fraction (OEF). For shortening study time, we have proposed dual-tracer autoradiographic (DARG) protocol in which (15)O(2) gas and C(15)O(2) gas are sequentially administrated within short period. In this paper, we evaluated feasibility of the non-invasive count-based method with the DARG protocol.Twenty-three patients [67.8 +/- 9.9 (mean +/- SD) years] with chronic unilateral brain infarction were examined by the use of measurements of asymmetric OEF elevation. As DARG protocol, (15)O(2) and C(15)O(2) gases were inhaled with 5-min interval and dynamic PET data were acquired for 8 min. Quantitative OEF (qOEF) image was computed with PET data and arterial input function. Ratio image of (15)O(2) and C(15)O(2) phases of PET data was computed as count-based OEF (cbOEF) image. The asymmetric indices (AI) of qOEF (qOEF-AI) and cbOEF (cbOEF-AI) were obtained from regions of interest symmetric placed on left and right sides of cerebral hemisphere. To optimize the summation time of PET data for the cbOEF image, qOEF and cbOEF images with various summation times were compared.Image quality of cbOEF image was better than that of qOEF image. The best correlation coefficient of 0.94 was obtained when the cbOEF image was calculated from 0 to 180 s of (15)O(2) summed image and 340 to 440 s of C(15)O(2) summed image.Using the appropriate summation time, we obtained the cbOEF image with good correlation with qOEF image, which suggests non-invasive cbOEF image can be used for evaluating the degree of misery perfusion in patients with chronic unilateral brain infarction. The count-based method with DARG protocol has a potential to dramatically reduce the examination time of (15)O PET study.

A method is described for calculating intersections between two arbitrary surfaces. This method can be applied not only to every type of surface, but also to offset surface or envelope which is not representable in terms of a basic functional forms. In this method, all surfaces and surface data are expressed by two independent parameters. This method comprises two essential processes. The first is to detect the intersection points between two surfaces by successive unidimensional searches. The second is to trace intersection curves by solving initial value problem by using the intersection points obtained as initial points. The singular points on intersection curves can also be detected by using the same successive unidimensional searches. The algorithm presented here provides adequately accurate results.

Background and Purpose— The Ministry of Health, Labor, and Welfare of Japan approved the use of recombinant tissue-type plasminogen activator (rt-PA) for the treatment of acute ischemic stroke in October 2005. The impact of the regulatory approval of rt-PA on the processes of acute stroke management was examined. Methods— A prospective, multicenter, observational study was conducted between December 2004 and December 2005 in 84 Japanese institutes, including 24 institutes with a stroke unit. We enrolled 4620 consecutive patients who were hospitalized within 72 hours after the onset of completed ischemic stroke; 1089 of them were hospitalized after rt-PA was approved. The patients’ characteristics and the processes of stroke management were compared before and after rt-PA approval. Results— Age, gender, stroke subtype, time from onset to hospital visit, and National Institutes of Health Stroke Scale score on admission were similar between the 2 periods. With approval, the percentage of patients treated with intravenous rt-PA therapy increased from 0.7% to 2.6% ( P P P =0.587). Within 24 hours of stroke onset, conventional MRI ( P =0.003), diffusion-weighted MRI ( P P =0.001), carotid ultrasound ( P =0.004), measurement of prothrombin time or activated partial thromboplastin time ( P =0.034), and measurement of blood sugar ( P =0.015) were performed more frequently after rt-PA approval. Conclusions— The present results indicate that the approval of intravenous rt-PA therapy resulted in dramatic changes in the processes of management for acute stroke patients.

OBJECTIVES Concurrence of coronary atherosclerotic lesions and intracranial aneurysms has been pointed out in several postmortem and clinical studies. However, the relative risk for intracranial aneurysms in patients with ischaemic heart disease remains uncertain. The aim of this study is to elucidate clinically whether ischaemic heart disease is a risk factor for intracranial aneurysms. METHODS Between October 1993 and May 1995, 84 patients with ischaemic heart disease with angiographically established coronary artery stenoses who had no history of stroke (ischaemic heart disease group; men:women=58:26, mean (SD) age=61.1 (9.6) years) and 200 age matched subjects with minor neurological disorders who had no history of ischaemic heart disease (control group; men:women=117:83, mean (SD) age=62.0 (9.2) years) were screened with magnetic resonance angiography (MRA) for the presence of unruptured intracranial aneurysms. For all MRA positive patients, selective angiography was then undertaken. RESULTS In the ischaemic heart disease group, the frequency of unruptured intracranial aneurysms established angiographically was 3.4% for men and 15.4% for women, compared with 2.6% and 3.6% respectively in the control group. Multiple logistic regression analyses disclosed that ischaemic heart disease was a significant and independent predictor for intracranial aneurysms in women. CONCLUSIONS These results suggest that in women ischaemic heart disease is a risk factor for intracranial aneurysms. Coexistence of intracranial aneurysms should be suspected in women patients with ischaemic heart disease.

Background and Purpose— To evaluate the current status of care and cost of acute ischemic stroke in Japan, we performed a hospital-based analysis at a tertiary emergency hospital with a 24-hour neurology-neurosurgery team and care unit. Methods— During the 12-month period of October 2000 to September 2001, we collected data on 179 patients consecutively hospitalized with acute ischemic stroke within 7 days of onset. We examined demographic data, in-hospital care, length of hospital stay, outcome at discharge, and hospital costs. The medical cost data were collected from official hospital medical cost charts, which calculated direct medical costs for beds, staff, examinations, medications, and rehabilitation. Results— The mean age was 70 years, and 69% were male. Hospital arrival was within 3 hours of onset in 30% of the patients. A history of stroke was present in 37%. The mean initial National Institutes of Health Stroke Scale score was 8.3 points (median, 6 points). Using the Trial of Org 10172 in Acute Stroke Treatment classification, 25% were lacunar, 27% were atherothrombotic, 33% were cardioembolic, and 15% were of unknown origin. All patients underwent neuroimaging studies during hospitalization; 96% and 92% underwent CT and MRI with MR angiography, respectively. Antithrombotic medications were given in 94%, none of whom received thrombolysis. A newly licensed neuroprotective agent, edaravone, was given in 16%. More than half of the patients (55%) were initially admitted to the neurological intensive care unit. Overall, 64% received in-hospital rehabilitation. Mean length of stay was 33 days. In-hospital mortality rate was 3%. On the modified Rankin Scale (mRS), 63% were independent (mRS, 0 to 2) and 34% were dependent (mRS, 3 to 5) at discharge. Two thirds of the patients (65%) went directly back home. The mean hospital cost per patient was $6887 ($209/d), of which 69% was attributable to the costs for beds and staff, 12% for medications, 7% for rehabilitation, 6% for imaging studies, 5% for laboratory examinations, and 1% for other costs. Conclusions— Despite the single hospital-based analysis, this study provided current, precise data on short-term inpatient care and costs of acute ischemic stroke in Japan. Because stroke often carries a permanent dependence, long-term cost-effective stroke care should be established.