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OBJECTIVE Magnetic resonance imaging–guided focused ultrasound (MRgFUS) is a novel and useful treatment for essential tremor (ET); however, the factors impacting treatment outcome are unknown. The authors conducted this study to determine the factors affecting the outcome of MRgFUS. METHODS From May 2016 through August 2017, 15 patients with ET were admitted to Ohnishi Neurological Center and treated with MRgFUS. To determine the factors impacting treatment outcome, the authors retrospectively studied correlations between the Clinical Rating Scale for Tremor (CRST) improvement rate and age, disease duration, baseline CRST score, skull density ratio (SDR), skull volume, maximum delivered energy, or maximum temperature. RESULTS The mean CRST score was 18.5 ± 5.8 at baseline and 4.6 ± 5.7 at 1 year. The rate of improvement in the CRST score was 80% ± 22%. Younger age and lower baseline CRST score were correlated with a higher CRST improvement rate (p = 0.025 and 0.007, respectively). To obtain a CRST improvement rate ≥ 50%, a maximum temperature ≥ 55°C was necessary. There was no correlation between SDR and CRST improvement rate (p = 0.658). A lower SDR and higher skull volume required significantly higher maximum delivered energy (p = 0.014 and 0.016, respectively). A higher maximum temperature was associated with a significantly larger lesion volume (p = 0.026). CONCLUSIONS Younger age and lower baseline CRST score were favorable outcome factors. It is important to assess predictive factors when applying MRgFUS.

BACKGROUND Several feasibility studies and a randomized, controlled, multicenter trial have demonstrated the safety and efficacy of unilateral transcranial magnetic resonance-guided focused ultrasound (FUS) lesioning of the ventral intermediate thalamic nucleus in treating essential tremor. OBJECTIVE To evaluate the safety and efficacy of FUS thalamotomy in a Japanese patient cohort through a prospective, multicenter, single-arm confirmatory trial. METHODS A total of 35 patients with disabling refractory essential tremor underwent unilateral FUS thalamotomy and were followed up for 12 post-treatment months. Safety was measured as the incidence and severity of treatment-related adverse events. Efficacy was measured as the tremor severity and quality of life improvements using the Clinical Rating Scale for Tremor and Questionnaire for Essential Tremor. RESULTS The mean skull density ratio (SDR) was 0.47. There was a significant decrease in the mean postural tremor score of the treated hand from baseline to 12 mo by 56.4% (95% CI: 46.7%-66.1%; P

Cosmetics are used to improve physical appearance, but the benefits may be limited to people without visual impairment. The importance of attractiveness among blind persons has not been assessed. We investigated the influence of makeup on brain activity of blind persons using functional magnetic resonance imaging (fMRI). Participants were 7 blind females (BFs) who learned to fully apply makeup and 9 mostly age-matched normally sighted females (NSFs). Brain activity was measured using fMRI before and after application of makeup and during a makeup image task in each state. In the default mode network at rest, there was no difference between the BFs and NSFs. However, a lateral visual network to the opposite side was observed in the NSFs, whereas no such network was noted in the BFs. A weak network was noted in the BFs in the occipital fusiform gyrus and temporal occipital fusiform cortex, and an extensive visual area network defect was noted. Also, activity after makeup application was significantly higher in the nucleus accumbens, pallidum, and hippocampus. Activity in the right middle cingulate gyrus, right cerebral white matter, and right anterior cingulate gyrus was higher before makeup in both BFs and NSFs, and the activity was significantly higher and more extensive in the BFs. In conclusion, applying makeup is a personally rewarding activity, even for BFs, as it strongly activates the reward system and the reward/memory system network, even in the absence of a visual area network.

Background: Giant aneurysms arising from the vertebral artery (VA) are rare; they represent 4% to 6% of all intracranial giant aneurysm. The natural history of thrombosed aneurysms is extremely poor. Most such lesions progressively enlarge and result in irreversible progression of neurological deficits and fatal sequelae through resultant compression of the brainstem. We present the clinical experience of giant thrombosed vertebral artery aneurysm successfully treated via a bilateral suboccipital approach. A 62 –year-old woman presented with slight dysarthria and ataxia for one year. Neurological examination showed right lateral gaze nystagmus, bilateral absent corneal reflex, absent gag reflex, bilateral dysdiadochokinesia, poor right finger nose test, and slightly poor tandem gait. MRI showed a 27 mm giant thrombosed left VA aneurysm with brain stem compression. We performed trapping of the aneurysm and thrombectomy through a bilateral suboccipital approach. First, the distal portion was clipped from the left side. Next, the proximal portion was approached from the right side. Thrombectomy was performed and after shrinkage of the aneurysm, the clips were applied involving some part of the aneurysm just distal to PICA. Conclusion: The optimum treatment for aneurysm of this type is thought to be complete obliteration of the parent artery with trapping and thrombectomy to decompress the brainstem. Sometimes if PICA could not be preserved Occipital artery (OA)-PICA bypass should be considered.

Background and Purpose— We assessed whether lower-dose alteplase at 0.6 mg/kg is efficacious and safe for acute fluid-attenuated inversion recovery-negative stroke with unknown time of onset. Methods— This was an investigator-initiated, multicenter, randomized, open-label, blinded-end point trial. Patients met the standard indication criteria for intravenous thrombolysis other than a time last-known-well >4.5 hours (eg, wake-up stroke). Patients were randomly assigned (1:1) to receive alteplase at 0.6 mg/kg or standard medical treatment if magnetic resonance imaging showed acute ischemic lesion on diffusion-weighted imaging and no marked corresponding hyperintensity on fluid-attenuated inversion recovery. The primary outcome was a favorable outcome (90-day modified Rankin Scale score of 0–1). Results— Following the early stop and positive results of the WAKE-UP trial (Efficacy and Safety of MRI-Based Thrombolysis in Wake-Up Stroke), this trial was prematurely terminated with 131 of the anticipated 300 patients (55 women; mean age, 74.4±12.2 years). Favorable outcome was comparable between the alteplase group (32/68, 47.1%) and the control group (28/58, 48.3%; relative risk [RR], 0.97 [95% CI, 0.68–1.41]; P =0.892). Symptomatic intracranial hemorrhage within 22 to 36 hours occurred in 1/71 and 0/60 (RR, infinity [95% CI, 0.06 to infinity]; P >0.999), respectively. Death at 90 days occurred in 2/71 and 2/60 (RR, 0.85 [95% CI, 0.06–12.58]; P >0.999), respectively. Conclusions— No difference in favorable outcome was seen between alteplase and control groups among patients with ischemic stroke with unknown time of onset. The safety of alteplase at 0.6 mg/kg was comparable to that of standard treatment. Early study termination precludes any definitive conclusions. Registration— URL: https://www.clinicaltrials.gov ; Unique identifier: NCT02002325.

Acute basilar artery occlusion (BAO) is associated with major morbidities and a high mortality rate. The prevalence of acute BAO is 10.4% among patients treated with thrombectomy for acute large vessel occlusion. Vertebral artery stump syndrome (VASS) reportedly causes ischemic stroke with tandem occlusions as vertebral artery (VA) origin occlusion and BAO. The pathogenesis of ischemic stroke due to VASS can be attributed to thrombi or emboli. Acute embolic BAO due to VASS accounted for 2 of 25 cases (8.0%) of BAO treated using thrombectomy between April 2014 and May 2019 in our registry. VASS must be considered as one cause of BAO. With the initial Magnetic resonance angiography on arrival, it is difficult to distinguish between BAO due to simple cardiogenic embolus and due to embolus caused by VASS rapidly. In patients suffering from acute embolic BAO due to VASS, the presence of VA origin occlusion makes endovascular therapy (EVT) difficult to perform. Here, we report consecutive cases of thrombectomy for acute embolic BAO due to VASS, showing markedly different outcomes. VA origin occlusion severely limits the technical options for EVT. Visualization or conjecture of the origin of both or dominant VAs conceivably offers the possibility of successful EVT and may allow good outcomes.

Background: Superselective shunt occlusion (SSSO) for cavernous sinus dural arteriovenous fistula (CSDAVF) avoids the risk of cranial nerve palsy, unlike entire sinus packing, but requires paying attention to recurrence. Distinguishing between true and paradoxical worsening of postoperative ophthalmic symptoms using a less-invasive modality is often difficult. Here, we report a case of true worsening of neuro-ophthalmic symptom by recurrent CSDAVF detected by venous-arterial spin labeling (ASL) on magnetic resonance imaging. Case Description: A 55-year-old woman with neither contributory medical history nor previous head trauma presented with neuro-ophthalmic symptoms and pulsatile tinnitus. Digital subtraction angiography (DSA) revealed CSDAVF with multiple shunted pouches. She underwent successful transvenous SSSO, but neuroophthalmic symptom worsened after SSSO and venous-ASL revealed increased signal intensity in the right superior orbital vein (SOV). DSA confirmed recurrent CSDAVF and additional transvenous embolization was performed. Neuro-ophthalmic symptoms and venous-ASL hyperintensity on SOV improved postoperatively. Conclusion: Venous-ASL is noninvasive and seems useful for detecting true worsening of neuro-ophthalmic symptoms of recurrent CSDAVF.

Objective To study clinical significance of augmentation of intraoperative motor evoked potentials (MEPs) during direct open surgery for middle cerebral artery (MCA) aneurysms. Methods Between 2009 and 2017, 134 MCA aneurysm surgeries were performed with intraoperative MEP monitoring. The frequency and cause of augmentation with >50% increase of MEP amplitude from baseline were studied. Factors associated with MEP augmentation were investigated. Results MEP augmentation was demonstrated in 9 patients. All 9 events were observed just after application of the temporary clip to the parent artery. The ratio of the maximum amplitude to baseline was 2.6 ± 1.1 at an mean of 2.4 ± 1.1 minutes after parent artery occlusion. Ten patients who did not show MEP augmentation after parent artery occlusion were compared with the patients showing MEP augmentation. The distance of the temporary clip point from the midline was smaller in patients with MEP augmentation compared with patients without MEP augmentation (P = 0.033). Conclusions MEP augmentation was thought to be an early ischemic sign preceding a significant decrease in MEPs during MCA aneurysm surgery. Transient augmentation of MEPs was more frequently observed in cases with a temporary clip applied to the more proximal part of the MCA.

International audience; BACKGROUND: Patients who have had a stroke with unknown time of onset have been previously excluded from thrombolysis. We aimed to establish whether intravenous alteplase is safe and effective in such patients when salvageable tissue has been identified with imaging biomarkers. METHODS: We did a systematic review and meta-analysis of individual patient data for trials published before Sept 21, 2020. Randomised trials of intravenous alteplase versus standard of care or placebo in adults with stroke with unknown time of onset with perfusion-diffusion MRI, perfusion CT, or MRI with diffusion weighted imaging-fluid attenuated inversion recovery (DWI-FLAIR) mismatch were eligible. The primary outcome was favourable functional outcome (score of 0-1 on the modified Rankin Scale [mRS]) at 90 days indicating no disability using an unconditional mixed-effect logistic-regression model fitted to estimate the treatment effect. Secondary outcomes were mRS shift towards a better functional outcome and independent outcome (mRS 0-2) at 90 days. Safety outcomes included death, severe disability or death (mRS score 4-6), and symptomatic intracranial haemorrhage. This study is registered with PROSPERO, CRD42020166903. FINDINGS: Of 249 identified abstracts, four trials met our eligibility criteria for inclusion: WAKE-UP, EXTEND, THAWS, and ECASS-4. The four trials provided individual patient data for 843 individuals, of whom 429 (51%) were assigned to alteplase and 414 (49%) to placebo or standard care. A favourable outcome occurred in 199 (47%) of 420 patients with alteplase and in 160 (39%) of 409 patients among controls (adjusted odds ratio [OR] 1·49 [95% CI 1·10-2·03]; p=0·011), with low heterogeneity across studies (I(2)=27%). Alteplase was associated with a significant shift towards better functional outcome (adjusted common OR 1·38 [95% CI 1·05-1·80]; p=0·019), and a higher odds of independent outcome (adjusted OR 1·50 [1·06-2·12]; p=0·022). In the alteplase group, 90 (21%) patients were severely disabled or died (mRS score 4-6), compared with 102 (25%) patients in the control group (adjusted OR 0·76 [0·52-1·11]; p=0·15). 27 (6%) patients died in the alteplase group and 14 (3%) patients died among controls (adjusted OR 2·06 [1·03-4·09]; p=0·040). The prevalence of symptomatic intracranial haemorrhage was higher in the alteplase group than among controls (11 [3%] vs two [\textless1%], adjusted OR 5·58 [1·22-25·50]; p=0·024). INTERPRETATION: In patients who have had a stroke with unknown time of onset with a DWI-FLAIR or perfusion mismatch, intravenous alteplase resulted in better functional outcome at 90 days than placebo or standard care. A net benefit was observed for all functional outcomes despite an increased risk of symptomatic intracranial haemorrhage. Although there were more deaths with alteplase than placebo, there were fewer cases of severe disability or death. FUNDING: None.

Background and Purpose: High blood pressure increases bleeding risk during treatment with antithrombotic medication. The association between blood pressure levels and the risk of recurrent stroke during long-term secondary stroke prevention with thienopyridines (particularly prasugrel) has not been well studied. Methods: This was a post hoc analysis of the randomized, double-blind, multicenter PRASTRO-I trial (Comparison of Prasugrel and Clopidogrel in Japanese Patients With Ischemic Stroke-I). Patients with noncardioembolic stroke were randomly assigned (1:1) to receive prasugrel 3.75 mg/day or clopidogrel 75 mg/day for 96 to 104 weeks. Risks of any ischemic or hemorrhagic stroke, combined ischemic events, and combined bleeding events were determined based on the mean level and visit-to-visit variability, including successive variation, of systolic blood pressure (SBP) throughout the observational period. These risks were also compared between quartiles of mean SBP level and successive variation of SBP. Results: A total of 3747 patients (age 62.1±8.5 years, 797 women), with a median average SBP level during the observational period of 132.5 mm Hg, were studied. All the risks of any stroke (146 events; hazard ratio, 1.318 [95% CI, 1.094–1.583] per 10-mm Hg increase), ischemic stroke (133 events, 1.219 [1.010–1.466]), hemorrhagic stroke (13 events, 3.247 [1.660–6.296]), ischemic events (142 events, 1.219 [1.020–1.466]), and bleeding events (47 events, 1.629 [1.172–2.261]) correlated with increasing mean SBP overall. Similarly, an increased risk of these events correlated with increasing successive variation of SBP (hazard ratio, 3.078 [95% CI, 2.220–4.225] per 10-mm Hg increase; 3.051 [2.179–4.262]; 3.276 [1.172–9.092]; 2.865 [2.042–4.011]; 2.764 [1.524–5.016], respectively). Event rates did not differ between the clopidogrel and prasugrel groups within each quartile of SBP or successive variation of SBP. Conclusions: Both high mean SBP level and high visit-to-visit variability in SBP were significantly associated with the risk of recurrent stroke during long-term medication with either prasugrel or clopidogrel after stroke. Control of hypertension would be important regardless of the type of antiplatelet drugs. Registration: URL: https://www.clinicaltrials.jp ; Unique identifier: JapicCTI-111582.

Introduction: Essential tremor is the most common movement disorder in adults. Bilateral symptoms are typical; however, bilateral thalamotomy for essential tremor is associated with a high probability of adverse events. We retrospectively investigated the efficacy and safety of staged bilateral ventral intermediate nucleus thalamotomy for refractory essential tremor using magnetic resonance imaging-guided focused ultrasound. Methods: We enrolled 5 consecutive patients with refractory essential tremor between September 2016 and March 2020. Patients underwent a second operation at least 1 year after the first operation. The second lesion was created asymmetrically to the first lesion. Results: Mean patient age was 57.6 years, and the mean interval between the 2 operations was 27.8 months. The second lesion center was superior to the first lesion in all patients. The mean baseline, second preoperative, and second postoperative Clinical Rating Scale for Tremor total scores were 63.6, 49.2, and 21.8, respectively. The mean baseline, second preoperative, and second postoperative Clinical Rating Scale for Tremor part C scores were 18.4, 8.2, and 2.6, respectively. One patient had permanent adverse events of slight dysarthria and discomfort in the tongue. No patient experienced dysphagia or cognitive dysfunction after the second operation. Four of the 5 patients were satisfied with the results of the bilateral treatment, including the patient who had permanent adverse events. Conclusions: Magnetic resonance imaging-guided focused ultrasound is an effective method for bilateral thalamotomy when adhering to the following considerations: (1) asymmetrical lesions are created and (2) sufficient interval (>1 year) between operations.

Background and Purpose: We determined to identify patients with unknown onset stroke who could have favorable 90-day outcomes after low-dose thrombolysis from the THAWS (Thrombolysis for Acute Wake-Up and Unclear-Onset Strokes With Alteplase at 0.6 mg/kg) database. Methods: This was a subanalysis of an investigator-initiated, multicenter, randomized, open-label, blinded–end point trial. Patients with stroke with a time last-known-well >4.5 hours who showed a mismatch between diffusion-weighted imaging (DWI) and fluid-attenuated inversion recovery were randomly assigned (1:1) to receive alteplase at 0.6 mg/kg intravenously or standard medical treatment. The patients were dichotomized by ischemic core size or National Institutes of Health Stroke Scale score, and the effects of assigned treatments were compared in each group. The efficacy outcome was favorable outcome at 90 days, defined as a modified Rankin Scale score of 0 to 1. Results: The median DWI-Alberta Stroke Program Early CT Score (ASPECTS) was 9, and the median ischemic core volume was 2.5 mL. Both favorable outcome (47.1% versus 48.3%) and any intracranial hemorrhage (26% versus 14%) at 22 to 36 hours were comparable between the 68 thrombolyzed patients and the 58 control patients. There was a significant treatment-by-cohort interaction for favorable outcome between dichotomized patients by ASPECTS on DWI ( P =0.026) and core volume ( P =0.035). Favorable outcome was more common in the alteplase group than in the control group in patients with DWI-ASPECTS 5 to 8 (RR, 4.75 [95% CI, 1.33–30.2]), although not in patients with DWI-ASPECTS 9 to 10. Favorable outcome tended to be more common in the alteplase group than in the control group in patients with core volume >6.4 mL (RR, 6.15 [95% CI, 0.87–43.64]), although not in patients with volume ≤6.4 mL. The frequency of any intracranial hemorrhage did not differ significantly between the 2 treatment groups in any dichotomized patients. Conclusions: Patients developing unknown onset stroke with DWI-ASPECTS 5 to 8 showed favorable outcomes more commonly after low-dose thrombolysis than after standard treatment. Registration: URL: https://www.clinicaltrials.gov ; Unique Identifier: NCT02002325. URL: https://www.umin.ac.jp/ctr ; Unique Identifier: UMIN000011630.

Background Identification of stroke signs by emergency medical technicians (EMTs) is important for initiating the “stroke chain of survival.” The aim of the present study was to clarify the effect of EMT-led lessons on stroke awareness for schoolchildren in the Akashi project on the transportation time to arrive at the hospital. Methods Stroke lessons were given by EMTs to 887 elementary school children in elementary schools between September 2014 and October 2015. Data on transportation times from prehospital records and final diagnoses at discharge were collected from both pre- (period 1; January-June 2014) and posteducation (period 2; January-June 2016) periods. Transportation time or onset-to-door time was divided into two parts: the onset-to-call time and the call-to-door time. Results One hundred forty-four patients in period 1 and 143 in period 2 were transported with potential strokes identified by EMTs. Among these, 119 (83%) in period 1 and 114 (80%) in period 2 had final diagnosis of stroke or transient ischemic attack. The mean age in period 2 was older than that in period 1 (75 years old versus 72 years old); however, there were no significant differences in gender and consciousness level between the 2 periods. The median call-to-door time of 28 minutes for period-2 patients was significantly shorter than that for period-1 patients (32 minutes, P = .0057). There were no differences in median onset-to-door times and onset-to-call times between the 2 periods. Conclusions School-based education about stroke conducted by EMTs may be a promising strategy to cut the prehospital delay and to widely spread stroke awareness via school children and EMTs.

Ischemic stroke is one of the most common complications of infective endocarditis (IE). IE must be considered as one of the causes of acute ischemic stroke (AIS) with emergent large vessel occlusion (ELVO), but early diagnosis of IE is difficult. AIS with ELVO must be treated using endovascular thrombectomy (EVT), with or without intravenous thrombolysis (IVT). IVT for AIS due to IE is not well established and remains controversial because of the risk of intracranial hemorrhage. A 42-year-old man suffered from right hemiparesis and disorientation, and AIS with ELVO was diagnosed. EVT with IVT was successfully performed and recanalization was achieved, but catastrophic multiple cerebral microbleeds appeared after treatment. EVT without IVT could be chosen for AIS caused by IE to avoid hemorrhagic complications. Hypointense signal spots on T2*-weighted magnetic resonance imaging (MRI) and susceptibility-weighted MRI could facilitate early diagnosis of IE.

SUMMARY After invasion into intercellular spaces of tomato plants, the soil-borne plant pathogenic Ralstonia solanacearum strain OE1-1 forms mushroom-shaped biofilms (mushroom-type biofilms, mBFs) on tomato cells, leading to its virulence. The strain OE1-1 produces aryl-furanone secondary metabolites, ralfuranones (A, B, J, K and L), dependent on the quorum sensing (QS) system with methyl 3-hydroxymyristate (3-OH MAME) synthesized by PhcB as a QS signal. Ralfuranones are associated with the feedback loop of the QS system. A ralfuranones productivity-deficient mutant (ΔralA) exhibited significantly reduced growth in intercellular spaces than strain OE1-1, losing its virulence. To analyse function of ralfuranones in mBF formation by OE1-1 cells, we observed cell aggregates of R. solanacearum strains statically incubated in tomato apoplast fluids on filters under the scanning electron microscope. The ΔralA strain formed microcolonies and mBFs significantly less than strain OE1-1. Supplement of ralfuranones A, B, J or K but not L significantly enhanced development of mBF formation by the ΔralA. Furthermore, a phcB- and ralA-deleted mutant (ΔphcB/ralA) exhibited less formation of mBFs than OE1-1, though a QS-deficient phcB-deleted mutant formed mBFs similar to OE1-1. Supplementation with 3-OH MAME significantly reduced formation of mBFs by the ΔphcB/ralA. Application of each ralfuranone significantly increased formation of mBFs by the ΔphcB/ralA supplied with 3-OH MAME. Together, our findings indicate that ralfuranones are implicated in not only development of mBFs by strain OE1-1 but also suppression of the QS-mediated negative regulation of mBF formation. This article is protected by copyright. All rights reserved.

SUMMARY The soil-borne plant pathogenic Ralstonia solanacearum strain OE1-1 produces and secretes methyl 3-hydroxymyristate (3-OH MAME) as a quorum sensing (QS) signal, which contributes to its virulence. A global virulence regulator, PhcA, functioning through the QS system positively regulates the expression of ralA, which encodes furanone synthase, to produce aryl-furanone secondary metabolites, ralfuranones. A ralfuranone-deficient mutant (ΔralA) is weakly virulent when directly inoculated into tomato xylem vessels. To investigate the functions of ralfuranones, we analysed R. solanacearum transcriptome data generated by RNA sequencing technology. ΔralA expressed phcB, which is associated with 3-OH MAME production, and phcA at levels similar to those in strain OE1-1. Additionally, ΔralA exhibited downregulated expression of more than 90% of the QS-positively regulated genes, and upregulated expression of more than 75% of the QS-negatively regulated genes. These results suggest that ralfuranones affect the QS feedback loop. Ralfuranone supplementation restored the ability of ΔralA cells to aggregate. Additionally, ralfuranones A and B restored the swimming motility of ΔralA to wild-type levels. However, the application of exogenous ralfuranones did not affect the production of the major exopolysaccharide, EPS I, in ΔralA. Quantitative real-time PCR assays revealed that the deletion of ralA results in downregulated expression of vsrAD and vsrBC, which encode a sensor kinase and a response regulator, respectively, in the two-component regulatory systems that influence EPS I production. The application of ralfuranone B restored the expression of these two genes. Overall, our findings indicate that integrated signalling via ralfuranones influences the QS and virulence of R. solanacearum. This article is protected by copyright. All rights reserved.

The epidemiology of patients with traumatic brain injury (TBI) has changed dramatically over recent decades as a result of rapid advances in aging societies. We assessed the influence of age on outcomes of patients with TBI and sought to identify prognostic factors for in-hospital mortality of TBI among elderly patients.Using a nationwide database, we analyzed data from 5651 patients with TBI. Univariate analysis was conducted to compare patient demographics, neurologic status on admission, radiologic findings, systemic complication rates, length of hospital stay, in-hospital mortality, and home discharge rates between elderly and nonelderly groups. Multivariable analysis was conducted to determine prognostic factors for in-hospital mortality among elderly patients.Overall in-hospital mortality was significantly higher in elderly patients (12.8% vs. 19.3%; P0.001). In-hospital mortality of elderly patients with mild TBI increased significantly at7 days after admission, whereas that of elderly patients with moderate or severe TBI was significantly higher immediately after admission. Age (odds ratio [OR], 1.62; P = 0.024), male sex (OR, 1.30; P = 0.004), Japan Coma Scale score on admission (OR, 5.95, P0.001), and incidence of acute subdural hematoma (OR, 1.89; P0.001) were associated with in-hospital mortality in elderly patients with TBI.Elderly patients with TBI showed significantly higher in-hospital mortality. Delayed increases in in-hospital mortality were observed among elderly patients with mild TBI. Level of consciousness on admission was the strongest predictor of in-hospital mortality among elderly patients.

Background: Endovascular treatment for acute tandem occlusion (ATO) of the combination of an ipsilateral extracranial internal carotid artery (ICA) steno-occlusive lesion with concurrent intracranial artery occlusion is challenging. Whether extracranial lesions, especially in cases of the left common carotid artery (LCCA) origin steno-occlusive lesions, should be treated after recanalization of an occluded intracranial artery by mechanical thrombectomy simultaneously in the same session has not been established. We report two cases of successful ATO with LCCA origin steno-occlusive lesions treated by staged retrograde transcarotid LCCA stenting followed emergent mechanical thrombectomy in two sessions because of the tortuous aortic arch. Case Description: A 61-year-old man with left ICA occlusion and an 82-year-old woman with left middle cerebral artery occlusion underwent emergent mechanical thrombectomy for ATO with LCCA origin stenoocclusive lesions. We achieved recanalization of large vessels, but severe stenosis of LCCAs remained. Because of the tortuous aortic arch, we decided to treat LCCA origin steno-occlusive lesions with staged stenting in the other session followed emergent mechanical thrombectomy. Postoperative courses were uneventful, and their symptoms improved. We performed stenting using a transcarotid approach through CCA cut down for LCCA steno-occlusive lesions without any complications. Conclusion: The staged strategy leaving LCCA origin stenosis seems to offer a better strategy than the simultaneous strategy for ATO with LCCA origin steno-occlusive lesions. A retrograde transcarotid approach through CCA cut down is recommended for LCCA stenting.

The relationship between stroke etiology and clot pathology remains controversial.We performed histological analysis of clots retrieved from 52 acute ischemic stroke patients using hematoxylin and eosin staining and immunohistochemistry (CD42b and oxidative/hypoxic stress markers). The correlations between clot composition and the stroke etiological group (i.e., cardioembolic, cryptogenic, or large artery atherosclerosis) were assessed.Of the 52 clots analyzed, there were no significant differences in histopathologic composition (e.g., white blood cells, red blood cells, fibrin, and platelets) between the 3 etiological groups (P = .92). By contrast, all large artery atherosclerosis clots showed a localized pattern with the oxidative stress marker 4-hydroxyl-2-nonenal (P.01). From all 52 clots, 4-hydroxyl-2-nonenal expression patterns were localized in 28.8% of clots, diffuse in 57.7% of clots, and no signal in 13.5% of clots.A localized pattern of 4-hydroxyl-2-nonenal staining may be a novel and effective marker for large artery atherosclerosis (sensitivity 100%, specificity 82%).

Background In some cases of cervical artery dissection, vascular repair subsequently occurs at the stenotic or occluded sites. The factors responsible for this type of vascular repair remain unknown, but some reports from in vitro and animal models suggest that it is related to lipid metabolism. Aim In the present study, we investigated the relationship between vascular repair and dyslipidemia in cervical artery dissection. Methods Patients with internal carotid artery and vertebral artery dissection who were admitted between April 2012 and March 2015 were included. Vascular repair was evaluated using magnetic resonance angiography. All patients were treated conservatively using antihypertensive and antiplatelet drugs, and also with statins in the presence of dyslipidemia. In this study, we investigated the relationship between vascular repair and dyslipidemia in cervical artery dissection. Results Vascular repair was observed in 34 out of 55 patients (61.8%, repair group). Total cholesterol (203 mg/dL in repair group vs 225 mg/dL in non-repair group), low-density lipoprotein cholesterol (119 mg/dL vs 140 mg/dL), low-density lipoprotein cholesterol/high-density lipoprotein cholesterol ratio (2.09 vs 2.74) and triglycerides (117 mg/dL vs 154 mg/dL) were significantly negatively correlated with vascular repair. However, statin use was not significantly related to this type of repair. Conclusions We showed a relationship between vascular repair after cervical artery dissection and dyslipidemia. As cervical artery dissection often occurs at a relatively young age, vascular repair and the management of dyslipidemia are important issues to consider for the prevention of arteriosclerotic cerebrovascular diseases in later life.

Background: The WAKE-UP trial recently revealed the efficacy of magnetic resonance imaging (MRI)-based intravenous thrombolysis with alteplase at 0·9 mg/kg in acute ischemic stroke patients with unknown time of onset. We assessed whether lower-dose alteplase at 0·6 mg/kg is efficacious and safe in patients under the same conditions. Methods: This was an investigator-initiated, multicenter, randomized, open-label, blinded-endpoint trial. Patients met the standard indication criteria for intravenous thrombolysis other than a time last-known-well >4·5 h (e.g., wake-up stroke). Patients were randomly assigned (1:1) to receive alteplase at 0·6 mg/kg or standard medical treatment if MRI showed acute ischemic lesion on diffusion-weighted imaging and no marked corresponding hyperintensity on FLAIR. The primary outcome was a favorable outcome (90-day modified Rankin Scale score of 0-1). Findings: Following the early stop and positive results of the WAKE-UP trial, this trial was prematurely terminated with 131 of the anticipated 300 patients (55 women; mean age: 74·4±12·2 years; median National Institutes of Health Stroke Scale score: 7; interquartile range: 4-13). Favorable outcome was comparable between the alteplase group (32/68, 47·1%) and the control group (28/58, 48·3%) (relative risk (RR), 0·97; 95% confidence interval (CI), 0·68 to 1·41; p=0·892). Symptomatic intracranial hemorrhage within 22-36 h occurred in 1/71 (1·4%) and 0/60 (RR, infinity; 95%CI, 0·06 to infinity; p=1·0), respectively. Death at 90 days occurred in 2/71 (2·8%) and 2/60 (3·3%) (RR, 0·85; 95%CI, 0·06 to 12·58; p=1·0), respectively. Interpretation: No difference in favorable outcome was seen between alteplase and control groups among ischemic stroke patients with unknown time of onset. The safety of alteplase at 0·6 mg/kg was comparable to that of standard treatment. Early study termination precludes any definitive conclusions, and additional research may be warranted. Trial Registration: This trial was registered with ClinicalTrials.gov NCT02002325 and UMIN 000011630. Funding Statement: This trial was funded mainly by the Japan Agency for Medical Research and Development (AMED) (JP16ek0210025h and JP18ek0210091h), and the Ministry of Health, Labour, and Welfare, and partly by the Intramural Research Fund for Cardiovascular Diseases of National Cerebral and Cardiovascular Center (H23-4-3; maintenance of the administration infrastructure for international multicenter studies of clinical stroke; P. I., K. Toyoda), and the Mihara Cerebrovascular Disorder Research Promotion Fund. Declaration of Interests: MK reports honoraria from Bayer, BMS/Pfizer, Daiichi-Sankyo and Nippon Boehringer Ingelheim, scientific advisory board from Ono, and research supports from Takeda, Daiichi-Sankyo, Nippon Boehringer Ingelheim, Astellas, Pfizer and Shionogi, outside the submitted work. RI reports personal fees from Bayer, personal fees from Bristol-Myers Squibb, personal fees from Daiichi-Sankyo, personal fees from Boehringer Ingelheim, personal fees from Pfizer, personal fees from Stryker, personal fees from Medtronic, personal fees from Otsuka Pharmaceutical, personal fees from GE, grants from Tohoku Fukushi University, personal fees from Tanabe Mitsubishi , personal fees from Johnson and Johnson, outside the submitted work. TI reports grants from Ogaki Tokusyukai Hospital, grants from GlaxoSmithKline K.K., outside the submitted work. YN reports personal fees from Bayer, Bristol-Myers Squibb, Eisai, Daiichi Sankyo, Mochida, Ono, and Takeda, outside the submitted work. YO reports personal fees from Boehringer Ingelheim, personal fees from Bayer, personal fees from Pfizer, personal fees from Daiichi-Sankyo, personal fees from Bristol Myer Squibb, personal fees from Otsuka, outside the submitted work. NS reports personal fees from Otsuka, outside the submitted work. SY reports personal fees from Medtronic, personal fees from Stryker, personal fees from Kaneka Medics, personal fees from Otsuka Pharmaceutical, during the conduct of the study; personal fees from Boehringer-Ingelheim, personal fees from Daiichi Sankyo, personal fees from Pfizer, personal fees from Bayer, personal fees from Sanofi, personal fees from Bristol-Meyers, outside the submitted work. TU reports personal fees from Boehringer Ingelheim, personal fees from Bristol-Myers Squibb, personal fees from AstraZeneca K.K., personal fees from Bayer Pharmaceutical Co., Ltd., personal fees from Otsuka Pharmaceutical Co., Ltd., personal fees from Takeda Pharmaceutical Co., Ltd., personal fees from Mitsubishi-Tanabe Pharma Co., Ltd, personal fees from UCB Japan Co., Ltd., personal fees from Kowa Shinyaku Co., Ltd., personal fees from Sumitomo Dainippon Pharma Co., Ltd., personal fees from Astellas Pharma Inc., personal fees from AbbVie GK, personal fees from Medtronic Japan Co., Ltd., personal fees from Eisai Co., Ltd., personal fees from Daiichi Sankyo Co., Ltd., personal fees from CSL Behring, personal fees from Japanese Physical Therapy Association, outside the submitted work. MI reports grants from Shimadzu Corporation, grants and personal fees from Otsuka Pharmaceutical Company Ltd., personal fees from Daiichi Sankyo Company Ltd., personal fees from Pfizer Inc., personal fees from Eisai, outside the submitted work. TK reports personal fees from Bayer Yakuhin Ltd, grants and personal fees from Daiichi Sankyo Co Ltd, grants and personal fees from Chugai Pharmaceutical Co Ltd, grants from Takeda Pharmaceutical Co Ltd, grants from Eisai Co Ltd, grants from Astellas Pharma Inc, grants from MSD KK, grants from Mitsubishi Tanabe Pharma Co, outside the submitted work. Dr. Sasaki reports personal fees from Mitsubishi Tanabe, personal fees from Bayer, personal fees from Astellas, personal fees from Ono Pharma, personal fees from Mediphysics, personal fees from Actelion, personal fees from Ezai, personal fees from FujiFilm, personal fees from Daiichi Sankyo, personal fees from Nippon Boehlinger Ingelheim, personal fees from Otsuka, personal fees from Chugai, grants and personal fees from Hitachi, grants from Actelion, grants from GE Healthcare, outside the submitted work. KK reports personal fees（honoraria for lecture presentations） from Bayer Yakuhin. KM reports personal fees and other from Bayer Yakuhin, personal fees from Otsuka Pharmaceutical, personal fees from Boehringer-Ingelhaem, personal fees from Mitsubishi Tanabe Pharma Cooperation, outside the submitted work; and personal fees (honoraria for seminar presentation) and other (Advisory Board) from AstraZeneca; personal fees (honoraria for seminar presentation) from Pfizer, Japan Stryker, Dai-ichi Sankyo, Astellas Pharma, Nippon Chemiphar and Fuji Film RI Pharma; and other (Advisory Board) from CSL Behring, Medico's Hirata, EPS Corporation, HEALIOS K.K. and T-PEC Corporation. KT reports personal fees from Daiichi-Sankyo, personal fees from Bayer Yakuhin, personal fees from Brystol-Meyers-Squibb, personal fees from Nippon Behringer Ingerheim, outside the submitted work. None of the other authors have any conflicts of interest to declare. Ethics Approval Statement: The trial protocol was approved by the Ministry of Health, Labour, and Welfare, Japan to perform a treatment not covered by the national health insurance system. The trial was approved by the local ethics committee or institutional review board at each participating center. Patients or their relatives provided written informed consent according to ethical regulations.

Background Magnetic resonance-guided focused ultrasound thalamotomy (FUS-T) is an emerging treatment for essential tremor (ET). Objective To determine the predictors of outcomes after FUS-T. Methods Two treatment groups were analyzed: 75 ET patients enrolled in the pivotal trial, between 2013 and 2015; and 114 patients enrolled in the postpivotal trials, between 2015 and 2016. All patients had medication-refractory, disabling ET, and underwent unilateral FUS-T. The primary outcome (hand tremor score, 32-point scale with higher scores indicating worse tremor) and the secondary outcome variables (Clinical Rating Scale for Tremor Part C score: 32-point scale with higher scores indicating more disability) were assessed at baseline and 1, 3, 6, and 12 mo. The operative outcome variables (ie, peak temperature, number of sonications) were analyzed. The results between the 2 treatment groups, pivotal and postpivotal, were compared with repeated measures analysis of variance and adjusted for confounding variables. Results A total of 179 patients completed the 12-mo evaluation. The significant predictors of tremor outcomes were patient age, disease duration, peak temperature, and number of sonications. A greater improvement in hand tremor scores was observed in the postpivotal group at all time points, including 12 mo (61.9% ± 24.9% vs 52.1% ± 24.9%, P = .009). In the postpivotal group, higher energy was used, resulting in higher peak temperatures (56.7 ± 2.5 vs 55.6 ± 2.8°C, P = .004). After adjusting for age, years of disease, number of sonications, and maximum temperature, the treatment group was a significant predictor of outcomes (F = 7.9 [1,165], P = .005). Conclusion We observed an improvement in outcomes in the postpivotal group compared to the pivotal group potentially reflecting a learning curve with FUS-T. The other associations of tremor outcomes included patient age, disease duration, peak temperature, and number of sonications.

Ralstonia solanacearum, a plant pathogenic bacterium causing "bacterial wilt" on crops, uses a quorum sensing (QS) system consisting of phc regulatory elements to control its virulence. Methyl 3-hydroxypalmitate (3-OH PAME) was previously identified as the QS signal in strain AW1. However, 3-OH PAME has not been reportedly detected from any other strains, and this suggests that they produce another unknown QS signal. Here we identify (R)-methyl 3-hydroxymyristate [(R)-3-OH MAME] as a new QS signal that regulates the production of virulence factors and secondary metabolites. (R)-3-OH MAME was synthesized by the methyltransferase PhcB and sensed by the histidine kinase PhcS. The phylogenetic trees of these proteins from R. solanacearum strains were divided into two groups, according to their QS signal types--(R)-3-OH MAME or (R)-3-OH PAME. These results demonstrate that (R)-3-OH MAME is another crucial QS signal and highlight the unique evolution of QS systems in R. solanacearum.

Advancing school-based education is a promising means to spread knowledge pertaining to stroke. The aim of the current study was to clarify whether stroke lessons provided by schoolteachers could deliver stroke knowledge to children (aged 9-11 years) and their parents, at a similar level to when taught by medical staff.Schoolteachers conducted lessons on stroke for school children using the educational materials we prepared (i.e., the teacher group; 1051 children and 719 parents). This was compared with our previous data from Akashi city and Tochigi prefecture, in which the stroke lessons were conducted by medical staff (i.e., the medical group; 1031 children and 756 parents). Three campaigns were conducted between September 2014 and May 2016. Each child was given education materials to take home to discuss stroke with their parents. The children and their parents answered questionnaires on stroke knowledge, at baseline, immediately after the lesson, and at 3 months after the lesson.Compared with the time point before the lesson, both children and parents instructed by the teacher group showed significant increases in the scores about stroke symptoms and risk factors, immediately and at 3 months after the lesson (P .001). The combined analysis for the group instructed by medical personnel showed no significant differences in the stroke knowledge scores between the 2 groups at 3 months.Teacher-led lessons, using our educational material, adequately delivered knowledge of stroke to children and parents, in a manner that was similar to when medical staff delivered this information.

ObjectiveStroke lessons for youth provided by emergency medical technicians (EMTs) may be an effective strategy to facilitate early intervention for patients with stroke. The aim of this study was to examine how effective EMT-led lessons on stroke awareness for schoolchildren were at disseminating stroke information.Setting, participants and outcome measuresThe study was performed in the city of Akashi, Hyogo, Japan (Akashi project). Children (aged 9–10 years old) at 11 public elementary schools and their parents were enrolled in this study. EMTs from the firefighting headquarters provided lessons on stroke to the children using our educational materials between September 2014 and October 2015. Each child was given our educational materials to take home and discuss stroke with their parents. The children and their parents answered questionnaires on stroke knowledge before, immediately and at 3 months after the lesson.ResultsA total of 763 children and 489 parents were enrolled (ie, 64% of children). The scores of either stroke symptoms or risk factors were significantly higher immediately and at 3 months after the lesson, compared with before the lesson, both in children and the parents (pConclusionStroke education by EMTs was effective in increasing stroke awareness in elementary school children, as well as their parents.

Background The increasing number of reports of complications after sacrificing the superior petrosal veins, the largest veins in the posterior fossa, has led to a need for an increased understanding of the anatomy of these veins and the superior petrosal sinus into which they empty. Objective To examine the anatomy of the superior petrosal veins and their size, draining area, and tributaries, as well as the anatomic variations of the superior petrosal sinus. Method Injected cadaveric cerebellopontine angles and 3-dimensional multifusion angiography images were examined. Results The 4 groups of the superior petrosal veins based on their tributaries, course, and draining areas are the petrosal, posterior mesencephalic, anterior pontomesencephalic, and tentorial groups. The largest group was the petrosal group. Its largest tributary, the vein of the cerebellopontine fissure, was usually identifiable in the suprafloccular cistern located above the flocculus on the lateral surface of the middle cerebellar peduncle. The medial or lateral segment of the superior petrosal sinus was absent in 40% of cerebellopontine angles studied with venography. Conclusion The superior petrosal veins and their largest tributaries, especially the vein of the cerebellopontine fissure, should be preserved if possible. Obliteration of superior petrosal sinuses in which either the lateral or medial portion is absent may result in loss of the drainage pathway of the superior petrosal veins. Preoperative assessment of the superior petrosal sinus should be considered before transpetrosal surgery in which the superior petrosal sinus may be obliterated.

After invasion into intercellular spaces of tomato plants, the soil‐borne, plant‐pathogenic Ralstonia solanacearum strain OE1‐1 forms mushroom‐shaped biofilms (mushroom‐type biofilms, mBFs) on tomato cells, leading to its virulence. The strain OE1‐1 produces aryl‐furanone secondary metabolites, ralfuranones (A, B, J, K and L), dependent on the quorum sensing (QS) system, with methyl 3‐hydroxymyristate (3‐OH MAME) synthesized by PhcB as a QS signal. Ralfuranones are associated with the feedback loop of the QS system. A ralfuranone productivity‐deficient mutant (ΔralA) exhibited significantly reduced growth in intercellular spaces compared with strain OE1‐1, losing its virulence. To analyse the function of ralfuranones in mBF formation by OE1‐1 cells, we observed cell aggregates of R. solanacearum strains statically incubated in tomato apoplast fluids on filters under a scanning electron microscope. The ΔralA strain formed significantly fewer microcolonies and mBFs than strain OE1‐1. Supplementation of ralfuranones A, B, J and K, but not L, significantly enhanced the development of mBF formation by ΔralA. Furthermore, a phcB‐ and ralA‐deleted mutant (ΔphcB/ralA) exhibited less formation of mBFs than OE1‐1, although a QS‐deficient, phcB‐deleted mutant formed mBFs similar to OE1‐1. Supplementation with 3‐OH MAME significantly reduced the formation of mBFs by ΔphcB/ralA. The application of each ralfuranone significantly increased the formation of mBFs by ΔphcB/ralA supplied with 3‐OH MAME. Together, our findings indicate that ralfuranones are implicated not only in the development of mBFs by strain OE1‐1, but also in the suppression of QS‐mediated negative regulation of mBF formation.

In many cases of anterior choroidal artery aneurysms (IC-AChA An), anterior choroidal arteries (AChA) arise from the aneurysmal neck or dome. This is an important reason for a higher rate of surgical complications. We treated 29 cases of IC-AChA An between January 2006 and May 2010, and classified them based on the origin of AChA by retrospective investigation of preoperative 3D-DSA. Cases in which AChA mainly arose from internal carotid arteries were classified as Group 1, those from the aneurysmal neck were classified as Group 2, and those from the aneurysmal dome were classified as Group 3. Thare were 3 cases (10.3%) in Group 1, 21 cases (72.4%) in Group 2 and 5 cases (17.2%) in Group 3. The average of dome /neck ratio was 1.22. Clipping was performed with indocyanine green (ICG) videoangiography in 27 cases and motor evoked potential monitoring (MEP) in 18 cases. There were no ischemic lesions in MRI or neurological dysfunction after surgeries in any of the groups. In 3 of 18 cases with MEP—1 in Group 2 and 2 in Group 3—the amplitudes decreased. In 2 of the 3 cases, ICG videoangiography showed good blood flow. We should keep in mind that ICG videoangiography is not quantitative. ICG videoangiography is very useful, but MEP is routinely needed. Group 1 and Group 2 cases about 90% of all cases, require careful modification of the origin of AChA in clipping. Understanding the origin of AChA using 3D-DSA before surgery is very important to realize good surgical results.

Measurements of platelet reactivity and assessment of the efficacy of antiplatelet drugs are widely recognized as pre-requisite for the diagnosis and treatment of stroke patients. A recently established shear-induced platelet reactivity test using non-anticoagulated blood (the Global Thrombosis Test) has facilitated measurements of physiologically relevant platelet function and thrombolytic activity. 195 healthy volunteers, not taking antiplatelet drugs or anticoagulants, and 185 patients with acute cerebrovascular diseases were enrolled. The effect of antiplatelet drugs on platelet function and thrombolytic activity was assessed using the Global Thrombosis Test after 14 days of medication. The occlusion time (OT), an index of platelet reactivity, in healthy controls was 284.9 ± 92.2 s. The lysis time (LT), an index of thrombolytic activity, in healthy controls was 2,231 ± 1,223 s. Both times had no significant difference between males and females. The OT of all stroke patients was 210.3 ± 140.8 s and was shorter than that of the healthy controls (284.9 ± 92.2, p < 0.0001). The LT of all stroke patients was 3,159 ± 1,549 s and was longer than that of the controls (2,231 ± 1,223, p < 0.0001). Medication significantly prolonged the OT from 184.5 ± 150.6 s (before) to 295.3 ± 208.1 s (after) in all patients, indicating a reversal of the hyper-platelet reactivity. In addition, medication shortened the LT from 3,924 ± 1,718 s (before) to 3,107 ± 1,794 s (after) in all patients. A prothrombotic state exists in stroke patients due to enhanced platelet function and suppressed thrombolytic activity. Medication improved these physiological parameters of haemostasis.

Twenty-two patients with cerebrovascular occlusive disease including 6-moyamoya disease underwent superficial temporal artery-middle cerebral artery (STA-MCA) bypass surgery between February 2007 and March 2008. In atherosclerotic cases, a single bypass between the parietal branch of STA and the posterior temporal artery was performed. In cases of moyamoya disease, a double bypass between both branches of STA and MCA (M4) on both frontal and temporal lobe with indirect bypass was performed. Perfusion areas of bypass flow from STA were evaluated by intraoperative near-infrared indocyanine green (ICG) videoangiography. This allowed unprecedented direct visualization of bypass flow in detail. In most atherosclerotic cases, perfusions of bypass flow were localized on the surface within the temporal lobe. In cases of advanced moyamoya disease, local perfusion areas only around the recipient artery were observed. This is the first report of perfusion areas of bypass flow being evaluated by intraoperative direct observation. With more cases, intraoperative ICG videoangiography may help surgeons select the recipient artery or decide if supplementary indirect bypass is necessary in moyamoya disease.

Pineal parenchyma tumor of intermediate differentiation (PPTID) is a very rare intracranial tumor, and pathological investigation limited to immunohistological and ultrastructural analyses have been published to date. Although intraoperative cytology is one of the important approaches for initial diagnosis in brain tumors, no or little studies on cellular morphology of PPTID have been demonstrated due to its rarity. We report here cytological features of PPTID obtained from stereotactic surgical specimens in a case of 27-year-old female manifested by dizziness and diplopia. Brain MRI revealed an unhomogeneously enhanced, large-sized tumor (56 x 52 x 60 mm) mainly located in the pineal region expanding from the midbrain to superior portion of the cerebellum and the fourth ventricle. Squash cytology showed increased nucleocytoplasmic ratio, hyperchromatic nuclei, and small rosette-like cell cluster but cellular pleomorphism was mild to moderate and necrotic background was not observed. Histology showed high cellularity, moderate nuclear atypia, and small rosette formation but neither bizarre tumor cells nor necrosis was present. Mitotic counts were very low (less than 1 per 10 high-power fields) and the MIB-1 labeling index was relatively high (10.1%). Tumor cells were immunohistochemically positive for neural markers such as synaptophysin, neurospecific enolase but not for glial fibrillary acidic protein or S-100. In some parts, cells were strongly reactive for neurofilament protein. Taken together, we made a final diagnosis of PPTID. This is the first presentation of cytological analysis by squash preparation that gives an important clue to accurate diagnosis of pineal parenchymal tumor and to understand its malignant potential.

脳主幹動脈急性閉塞に対するt-PA静注療法（以下t-PA）および超選択的血栓溶解療法（以下PTA）の再開通の有無，症候性出血の頻度，および3カ月後のmRSを比較し，急性期治療の現状および今後の課題について検討した．対象はt-PA 45症例，PTA 96症例．t-PAとPTAを比較すると，全体の再開通率は35.6%対21.9%，部位別では，中大脳動脈遠位部50.0%対16.7%，中大脳動脈近位部52.6%対25.0%，内頚動脈6.3%対5.3%，脳底動脈25.0%対26.3%．症候性頭蓋内出血0%対5.2%．3カ月後のmRS0，1群は17.4%対12.5%，2，3群は15.3%対14.6%，4，5群は54.3%対47.9%，6群は13%対25%．以上よりt-PA静注療法は，従来の血管内治療に比べ，中大脳動脈閉塞に対する再開通率が良好で，全体の成績向上に貢献した．しかし，内頚動脈や脳底動脈閉塞では両群とも再開通率が不良であり，今後治療の改善や工夫が望まれる．