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Background: Liver fibrosis (LF) is reported to affect the development of cerebral small vessel disease (SVDs) including cerebral microbleeds (CMBs). The Fibrosis-4 (Fib4) index is a simple and non-invasive scoring method for detecting LF. Herein, we investigated the association between the severity of LF and the presence or distribution of CMBs. Methods: From October 2012 to May 2022, patients with acute ischemic stroke within 24 hours from onset were retrospectively enrolled. Exclusion criteria were those associated with malignancy or missing clinical data including MRI findings before treatment started, or functional outcome at 3 months after discharge. The distribution of CMBs were classified on MRI as strictly lobar, or not (deep/ infratentorial or mixed area). FIB-4 index is calculated as follows: FIB-4 = [age (years)*aspartate aminotransferase (U/L)] / [platelet count (10 9 /L) *√alanine aminotransferase (U/L)]. We analyzed the association between the severity of LF, according to the tertile of Fib4 index; mild-LF (Fib4 index < 1.30), moderate-LF (1.30 ≤ Fib4 index < 2.67), severe-LF (2.67 ≤ Fib4 index), and the presence and distribution of CMBs. Results: 614 subjects (median age 69 years, 435 men) were retrospectively enrolled. Fib4 index were higher in order of only lobar, deep/ infratentorial or mixed area, and none CMBs ( p < 0.001). Also, severe LF group showed the highest number of CMBs (p < 0.001). Age on admission (OR 1.040, 95% CI 1.020-1.050, p < 0.001), hypertension (OR 1.840, 95%CI 1.260-2.690, p = 0.002), and anti-thrombotic drugs using (OR 1.500, 95% CI 1.020-2.190, p = 0.038) were independently associated with the presence of CMBs. In anatomical distribution of CMBs, Fib4 index (OR 0.701, 95%CI 0.505-0.974, p = 0.034) were only independent predictive factor of the CMBs on D/I or mixed area. Conclusion: The novel association between silent LF and the distribution of CMBs as located in only lobar were established.

Background and Purpose: Delayed leukoencephalopathy (DL) following ischemic stroke with large vessel occlusion (LVO) is rarely reported and the pathophysiology is unclear. We aimed to investigate the incidence, clinical characteristics of DL following acute ischemic stroke. Methods: Consecutive ischemic stroke patients were screened. Inclusion criteria were: 1) onset to door time within 7 days; and 2) availability of initial and a second or more MRI after 14 days from onset with DWI, FLAIR, and MRA. We defined DL as newly detected diffuse hyperintensities restricted to the white matter on FLAIR mostly accompanied with partial DWI hyperintensities after 14 days from onset. First, we estimated the incidence of DL and whether a LVO would be a factor associated with DL following all the acute ischemic stroke. Second, limiting the patients with LVO, we evaluated the incidence and the factors associated with DL. Results: We screened 1,857 consecutive ischemic stroke patients. Of all, 792 with all the acute ischemic stroke (573 (72%) male, median age 67 years), and 183 with LVO (128 (70%) male, median age 67 years) were included in each analysis. DL were detected in 18 patients in all the acute ischemic stroke (2%), and 17 in patients with LVO (9%) (Figure). First, LVO was strongly associated with DL following all the acute ischemic stroke (OR 62.3, 95% CI 8.23 to 471, p p = 0.019), NIHSS score at admission (OR 1.06, 95% CI 1.01 to 1.11, p = 0.014), complete recanalization (OR unable to calculate due to 100% prevalence in DL group, p p Conclusions: DL is not an uncommon phenomenon especially after LVO. Age, neurological severity, mechanical thrombectomy, and complete recanalization might be related to DL.

Background and Purpose: To compare clinical features including carotid ultrasound findings, especially carotid plaque features, between patients with and without aortic complicated lesion (ACL) in embolic stroke of undetermined source (ESUS). Methods: Patients were selected from a comprehensive stroke center between April 2013 and April 2022. Inclusion criteria were: 1) consecutive ischemic stroke patients 2) who fulfilled ESUS criteria based on NAVIGATE-ESUS trial, and 3) who underwent transesophageal echocardiogram (TEE), and 4) admitted 7 days from onset. We compared clinical features, including carotid ultrasound findings in common carotid artery and internal carotid artery such as carotid plaque thickness on the each side, maximum carotid plaque thickness and carotid plaque laterality ratio defined as maximum left carotid plaque thickness divided by maximum right carotid plaque thickness, between ESUS patients with ACL (ACL-ESUS) and without ACL (non ACL-ESUS). Results: We screened 2,066 consecutive ischemic stroke patients, including 177 ESUS patients (136 [77%] male, median age 64 years old). Of all, 35 patients had ACL (30 [86%] male, median age 71 years old, Figure A). ACL-ESUS showed older age (ACL-ESUS vs. non ACL-ESUS; 71 vs. 64 years old, p = 0.004), higher frequency of having carotid plaque more than 1.6mm ipsilateral to the infarct (82% vs. 53%, p = 0.013), higher frequency of having cortical lesion (46% vs. 26%, p = 0.023), and higher carotid plaque laterality ratio (1.18 vs. 1.00, p = 0.042). In multivariable analysis, demonstrating cortical lesion (OR 2.86, 95%CI 1.03-7.92, p = 0.043), carotid plaque laterality ratio (OR 2.75, 95%CI 1.03-7.32, p =0.043) were independently associated with ACL (Figure B). Conclusions: In ESUS patients, higher carotid plaque laterality ratio was associated with ACL, suggesting TEE should be conducted to reveal ACL in ESUS patients with left-dominant carotid plaque.

Background and Purpose: Blood viscosity (BV) is associated with blood stagnation leading to thrombosis. Some polyunsaturated fatty acids (PUFAs) are said to have an antithrombotic effect. First, we aimed to determine the association between BV and the presence of the susceptivity vessel sign (SVS) in patients with cardioembolism (CE) due to atrial fibrillation (AF). Second, we aimed to reveal the association between BV and PUFAs levels. Methods: Consecutive patients with ischemic stroke who met the following inclusion criteria were included: 1) patients with CE, defined by TOAST classification, secondary to AF; 2) onset to door time within 24 h; 3) availability of MRI, including susceptibility-weighted images, obtained at our hospital before IV rt-PA and/or MT; and 4) availability of PUFAs measurements on the day of or the day after the hospital visit. Hematocrit-derived BV at high shear rate (300 sec -1 ) was calculated using the following formula: BV = 1.4175+ 5.878*Ht - 12.98*Ht 2 + 31.964*Ht 3 (Ht = Hematocrit/100). First, we assessed whether BV could be associated with the presence of SVS. Second, we evaluated whether some PUFAs (dihomo-γ-linolenic acid [DGLA], arachidonic acid, eicosapentaenoic acid, docosahexaenoic acid) levels could be the factors associated with BV. Results: We screened 1,720 consecutive ischemic stroke patients and included 137 patients (95 [69%] male, median age 73 years). Of 137, SVS was observed in 83 (61%) patients. In multivariable logistic regression analysis, BV was independently associated with the presence of SVS (odds ratio [OR] 0.391, 95% confidence interval [CI] 0.18-0.86, p = 0.02, Figure). Multiple linear regression analysis revealed a significant positive association between DGLA levels and BV (unstandardized coefficient 0.01, 95% confidence interval 0.01 to 0.02, p < 0.01). Conclusions: Lower BV might be related to the presence of SVS with CE due to AF and DGLA level might be positively associated with BV.

Background and Purpose: Ischemic stroke developed while bathing (ISB) occasionally causes fatal accident. Factors associated with ISB remain unclear. We aimed to estimate the clinical characteristics of ISB, especially the subtype of stroke and the association between cerebral small vessel disease (CSVD) markers. Methods: Consecutive patients with ischemic stroke ≤48 h from onset who underwent MRI during the hospitalization were included. We divided patients into ISB and non-ISB group to analyze differences in clinical characteristics, especially the stroke subtype based on TOAST classification and the association between CSVD markers. The CSVD markers were evaluated by MRI and defined as old lacunes, white matter hyperintensities scale (separately scored by periventricular hyperintensity [PVH] and deep and subcortical white matter hyperintensity), the number of cerebral microbleeds (CMBs) categorized as lobar, deep, and infratentorial lesions, and the scale of enlarged perivascular space in the basal ganglia and centrum semiovale. Results: We screened 2,112 consecutive patients with ischemic stroke including 1,517 patients (1,070 [71%] male, median age 69 years). Of these patients, 52 (3%) were included in ISB group. In univariable analysis, ISB group showed higher frequency of large-artery atherosclerosis ( p = 0.004), lower frequency of cardioembolism ( p = 0.008), smaller number of cerebral microbleeds in deep lesions ( p = 0.025) and lower grade of PVH ( p = 0.023). ISB group showed a lower NIHSS score on admission ( p = 0.002). However, there was no difference in mRS score at 3 months from the onset. In the multivariable analysis (Figure), large-artery atherosclerosis (OR 2.46, 95% CI 1.21-5.01, p = 0.013) and CMBs in deep lesions (OR 0.75, 95% CI 0.58-0.98, p = 0.038) showed independently associated with ISB. Conclusions: ISB showed higher frequency of large-artery atherosclerosis, however, had a less association with the presence of CMBs in deep lesions.

Although high-frequency repetitive transcranial magnetic stimulation (HF-rTMS) in chronic intracerebral hemorrhage (ICH) is beneficial, it has been poorly investigated in rTMS for acute ICH. Our aim is to investigate the effects and safety of rTMS in acute spontaneous ICH.We prospectively performed HF-rTMS on consecutive patients with ICH within 24 h from onset between April 2019 and August 2021. The inclusion criterion was (1) persistent paralysis, with an NIHSS scale of 1 or higher for at least 3 days after onset. The exclusion criteria were (1) cortical, subcortical, and cerebellar ICH, (2) disturbance of consciousness, and (3) over 80 years of age. For the purpose of comparison, we used a conventional rehabilitation group whose patients met the same criteria between April 2016 and March 2019. We evaluated incidence of epilepsy and exacerbation of the NIHSS score in the rTMS group. We also compared the two groups regarding clinical background and outcome.Enrolled in the study were a total of 44 patients. Of the patients, 22 (50%) were in the rTMS group. The median (IQR) time from onset to the start of rTMS was 9 (6-12) days. There were no cases of epilepsy or exacerbation of NIHSS after the start of rTMS. Favorable outcome (modified Rankin Scale score of between 0 and 2) at 3 months was frequently observed in the rTMS group (73% vs 27%, p = 0.006). HF-rTMS was independently associated with favorable outcome at 3 months (OR = 11.5, 95% CI = 2.194-60.447, p = 0.004).HF-rTMS may be safe and effective in acute ICH patients.

Since smartphone applications are revolutionizing telemedicine, a new application specifically for stroke care (JOIN) was designed. Addition of the JOIN smartphone application to the stroke treatment workflow in our hospital was assessed. JOIN has key functions that may improve the care of stroke patients, including the ability to (1) exchange information such as patient data and medical images in real-time throughout the entire process of patient management; (2) track each step of the protocol from door to discharge; and (3) facilitate real-time interaction of all team members via text, audio, and a video chat system. Two periods, 2.7 years before the implementation of JOIN (Pre-JOIN) with 37 patients and 2.2 years after (Post-JOIN) with 54 patients, were compared, and the workflow for all 91 patients who had a cerebral infarction and were treated with tissue plasminogen activator (tPA) and/or thrombectomy between October 2012 and July 2017 was reviewed. There were noticeable reductions in overall patient management time, including times for door-to-imaging, starting tPA treatment, and endovascular intervention with JOIN. Staff members were unanimously satisfied with JOIN, due to the increased efficiency of information exchange and the ability for real-time discussions with different professionals when needed. No significant changes in patient outcomes (as assessed by modified Rankin Scale [mRS] scores) at 3 months and in the total cost for the treatment were observed. A smartphone-based application with the capability of sharing information instantaneously among healthcare professionals facilitated time-sensitive, acute care of ischemic stroke patients.

The purpose of the present study is to report the clinical characteristics of polyradiculoneuropathy induced by immune checkpoint inhibitors (ICIs). We retrospectively reviewed lists of all inpatients with neurological immune-related adverse events (irAEs) treated at the neurology departments of three hospitals in January 2017 and December 2019. We also performed a review of the previous case reports with polyradiculoneuropathy induced by ICI therapy. We had 4 patients with polyradiculoneuropathy following ICI therapy. We comprehensively reviewed our 4 patients and 32 previous case reports. There were 28 men and 8 women with a mean onset age of 61 years. ICI monotherapy was performed in 27 patients, whereas the combination of ICIs was administered in 9 patients. All patients except 2 showed limb weakness, which was observed symmetrically and predominantly in the legs rather than the arms. Bulbar involvement was observed in 7 patients. The laboratory findings were demyelination in electrophysiological studies and elevated protein with lymphocytes in the cerebrospinal fluid. Disease severity was ranked on the Hughes functional scale; 17 patients were grade 4 or greater. The treatment responses to corticosteroid and intravenous methylprednisolone were favorable. Intravenous immunoglobulin was also used in combination with steroids. Seven patients died, including 4 who on mechanical ventilation. Polyradiculoneuropathy induced by ICIs has a distinct subset of neurological irAEs and requires early recognition.

Objective Risk control of thromboembolic complications (TECs) during stent-assisted coil embolization (SACE) for unruptured intracranial aneurysms (UIAs) is crucial for satisfactory treatment outcomes. We retrospectively evaluated the data from our cohort of SACE for UIAs to analyze the role of anatomical, clinical, and stent type-related factors to determine the optimal preoperative values of light transmission aggregometry (LTA) for TEC prevention. Methods From July 2015 to May 2018, we retrospectively analyzed the data from 132 patients with SACE-treated UIAs at our hospital. Data regarding the aneurysm location, maximum diameter, stent type used, preoperative LTA value, and ischemic and hemorrhagic complications were collected. Aspirin 100 mg and clopidogrel 75 mg were started 7 days before surgery, with a “boost” dose (an additional 75 mg of clopidogrel for an LTA value >60%) added after August 2016 to address clopidogrel resistance. After multivariate analysis, we developed our original combined parameter termed the thromboembolic predictor (TEP). Receiver operating characteristic (ROC) analysis for TEP and each significant variable was performed. Results TECs were confirmed in 5 of the 132 patients (3.8%) and hemorrhagic complications in 9 of the 132 patients (6.8%). From the multivariate analysis results, the LTA value and maximum diameter were chosen as significant variables and included in the TEP. ROC analysis of the LTA value revealed a sensitivity and specificity of 0.866 and 0.600, respectively (area under the curve, 0.747), with a cutoff of 62%. TEP permitted the establishment of an optimal LTA value according to the aneurysm maximum diameter to predict for TECs. The complication rate for the Neuroform EZ, Enterprise, Neuroform Atlas, and LVIS stents was 2.9%, 10.5%, 1.4%, and 14.3%, respectively. Conclusions The preoperative LTA value contributes to the prediction of TECs after SACE for UIAs. The TEP (relating the LTA cutoff to aneurysm size) allows for improved antiplatelet therapy adjustment before SACE to reduce TECs.

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

Background: Lacunar infarct (LI) is a heterogeneous disorder of cerebral small vessel. Hierarchical clustering (HC) is useful for exploring potential underlying clinical phenotype in heterogeneous disease. Our aim is to identify the predictive factors of poor functional outcome in LI to classify the subjects into distinct subgroups using HC and compare the clinical variables including clinical outcome among groups. Methods: From October 2012 to April 2020, LI patients within 24 hours from the onset were enrolled. We used a HC k-means clustering algorithm on patients’ baseline data. We also compared clinical outcome among each cluster groups. Results: Among 187 patients (144 male, median age 66 years old, median NIHSS score2), three clusters were identified. Cluster1(58%), mostly comprised of younger patients (p 2-6 was 4% of cluster1, 100% of cluster 2 and 12% of cluster 3 (p=0.001). In multivariate logistic regression analysis, the phenotype of cluster was the strongest predictor of poor functional outcome (OR 16.1, 95% CI 6.04-42.9, p Conclusion: Three clusters with different clinical outcome were identified. The phenotype of cluster was the strongest predictive factor of poor functional outcome. Further study to identify whether management of these components provide different clinical outcome was warranted.

Background and Purpose: Repetitive transcranial magnetic stimulation (rTMS) in chronic intracranial hemorrhage (ICH) is beneficial, it has been poorly investigated in rTMS for acute ICH. Our aim is to investigate safety and effects of rTMS in acute ICH. Methods: We prospectively performed high-frequency rTMS to consecutive patients with acute ICH within 24 hours from onset between April 2019 and March 2021. Exclusion criteria were: 1) subcortical ICH; 2) ventricular perforation; 3) history of symptomatic stroke; 4) surgical management for ICH; 5) disturbance of consciousness; 6) over 80 years old at admission; and 7) convulsion after onset. Inclusion criterion was 1) persistent paralysis with a NIHSS scale 1 of higher for at least 3 days after onset. The comparison was made with historical control group; patients who met the same criteria between April 2016 and March 2019. We evaluated incidence of epilepsy and exacerbation of NIHSS score in rTMS group. We also compared clinical background and outcome among groups. Results: A total of 40 patients (29 male, median age 56 years, median NIHSS score on admission 13) were enrolled. Of them, 18 patients (45%) were rTMS group. The median (IQR) time from onset to the start of rTMS is 9 (6-12) days. There were no case of epilepsy or exacerbation of NIHSS after the start of rTMS. There were no significant differences in median age (54 years vs 57 years, p=0.70), median hemorrhage volume at admission (9.3 ml vs 11.3 ml, p=0.43) or median NIHSS score on admission (13 vs 12, p=0.99) among groups. Favorable 90 days outcome (modified Rankin Scale score of 0-2) was frequently observed in rTMS group (67% vs 27%, p = 0.02). Conclusion: High-frequency rTMS may be safe and effective in acute intracranial hemorrhage patients.

Background and Purpose: Recent several studies demonstrated that percutaneous patent foramen ovale (PFO) closure reduced the risk of stroke recurrence for patients with cryptogenic stroke and PFO. Our aim of this retrospective study is to evaluate the usefulness of transcranial color flow imaging (TC-CFI) in the diagnosis of anatomically high risk PFO, in which percutaneous PFO closure is expected to be more effective in preventing embolism. Methods: Subjects were ischemic stroke patients who were investigated the presence of right-to-left shunt (RLS) using TC-CFI and transesophageal echocardiography (TEE). Anatomically high risk PFO evaluated by TEE were defined as satisfying one or more of the following findings: 1) large shunt (more than 20 microbubbles (MB) identified in the left ventricular system), 2) atrial septal aneurism, and 3) the presence of shunt without Valsalva maneuver (VM). TC-CFI was performed in the middle cerebral artery and/or intracranial vertebral artery once without VM and three times with VM, respectively. The number of microembolic signals from MB was determined using international Consensus Criteria (ICC). The accuracy of TC-CFI for high risk PFO diagnosed by TEE was calculated, and then the positive rate of TC-CFI in detecting high risk PFO was also analyzed by TC-CFI’s findings (A: ICC grade II or higher, B: positive without VM, and C: positive on multiple times or in multiple vessels). Results: We analyzed 176 patients (41 females, mean age 64 years) admitted to our facility from July 2019 to July 2021. Of them, 44 patients (25%) had PFO, and 29 patients (16%) were high risk. The diagnostic power of TC-CFI was sufficient, with sensitivity of 93%, specificity of 80%, and accuracy of 89%. The positive rate of each finding was significantly higher in C than in A and B (A: 23%, B: 39%, and C: 55%. P=0.04). Conclusions: To perform the TC-CFI procedure frequently in multiple vessels is useful for screening of high risk PFO.

Background and Purpose: The difference among anterior and posterior circulation stroke regarding vascular risk factors is commonly known. Our aim is to verify the difference of clinical backgrounds between anterior and posterior circulation in hyperacute stroke with large vessel occlusion (LVO) caused by atherosclerotic occlusion (AO). Methods: This multicenter, retrospective study included LVO patients who were performed revascularization therapy (thrombectomy, intravenous thrombolysis, or both) between October 2017 and May 2021. The definition of AO was the fixed residual stenosis/occlusion at the initially occluded lesion confirmed in the second angiographic imaging performed 7 days later from symptom onset. The patients were dichotomized by LVO location, anterior or posterior. Traditional risk factors and laboratory data were compared. Results: Among the 1770 consecutive stroke patients admitted during the study period, 162 patients (104 men, median age 76 years old) were enrolled in our study. AO was diagnosed in 41 patients (25%; 27% of anterior circulation vs. 17% of posterior, P=0.291). In total cohort, patients with anterior circulation showed higher frequency of atrial fibrillation, lower glycosylated hemoglobin level, higher D dimer level, and higher brain natriuretic peptide level (Figure 1 black bar). The cohort of AO patients had a similar tendency (Figure 1 blue bar). Conclusion: One fourth of patients with LVO are AO. In anterior circulation stroke with AO, attention should be paid to stroke recurrence due to not only atherosclerosis but embolism.

Background and Purpose: Our aim is to investigate the factors of outcome in ESUS with possible embolic source (PES) caused by non-high risk cardiac sources, malignancy, and mild atherosclerosis. Methods: Patients were selected from a comprehensive stroke center between April 2013 and April 2021. Inclusion criteria were: 1) consecutive ischemic stroke patients who fulfilled ESUS criteria based on NAVIGATE-ESUS trial, 2) who underwent TEE 3) who admitted our hospital within 7 days from stroke onset 4) pre stroke modified Rankin scale (mRS) score below 1 and 5) available mRS score at 3 months from stroke onset. PES included atrial cardiopathy (large left atrium diameter, slow out flow in left atrium appendage, and frequent premature atrium contraction), left ventricular dysfunction (history of heart failure, abnormal ventricular wall motion, and reduced ejection fraction), cardiac valve disease, right-to-left shunt, malignancy, and atherosclerosis (ipsilateral carotid plaque and aortic complicated lesion). We compared PES, between mRS score 0-1 (favorable outcome group) and mRS score 2-6 (unfavorable outcome group). Results: We screened 1,824 consecutive ischemic stroke patients, including 191 in ESUS patients. 159 (83%) patients were ESUS with PES. Of all, 33 patients had unfavorable outcomes (25 [76%] male, median age 64 years old, Figure A). Higher National Institute of Health Stroke Scale score on admission (OR 4.50, 95%CI 1.96-10.30, p p =0.028) were independently associated with unfavorable outcome (Figure B). Conclusions: Atherothrombotic emboli may contribute to outcome of ESUS with PES.

The susceptibility vessel sign (SVS) on susceptibility-weighted image, a magnetic resonance imaging technique, reveals thrombi as hypointense signals. We aimed to examine the association between polyunsaturated fatty acid (PUFA) levels and the presence of the SVS and its length in cardioembolism due to atrial fibrillation (AF).Consecutive ischemic stroke patients who met the following inclusion criteria were screened: 1) patients with cardioembolism, defined by Trial of ORG 10172 in Acute Stroke Treatment, secondary to AF; 2) onset to door time within 24 h; 3) availability of magnetic resonance images, including susceptibility-weighted images, obtained at our hospital before performing recanalizing therapy; and 4) availability of PUFA measurements on the day of or the day after the hospital visit. We evaluated whether PUFA levels might be associated with the presence of the SVS and its length.We retrospectively screened 1720 consecutive ischemic stroke patients, and included 137 patients (95 (69%) male, median age 73 years) who met the inclusion criteria in the analyses. In binomial logistic regression analysis, lower dihomo-γ-linolenic acid (DGLA) level was associated with the presence of SVS (odds ratio 0.545, 95% confidence interval 0.374 to 0.794, p = 0.002). Multiple linear regression analysis revealed a significant negative association between DGLA levels and SVS length (unstandardized coefficient -7.430, 95% confidence interval -13.256 to -1.603, p = 0.013).Low DGLA level is associated with the presence of SVS and its length in patients with cardioembolism secondary to AF.

To determine the impact of old lacunes and their sites on the prognosis of one-sided supratentorial intracerebral hemorrhage (ICH) by classifying lacunes sites in relation to anatomical structures using MRI.Consecutive patients with one-sided supratentorial ICH ≤72 h from onset to door who underwent MRI were retrospectively included. The sites of old lacunes were categorized as follows: deep subcortical white matter, caudate head, lentiform, posterior limb and genu of the internal capsule, thalamus, and brainstem. We also evaluated all other cerebral small vessel disease markers. An unfavorable outcome was defined as a modified Rankin Scale score of 3 to 6 at 3 months after onset. We investigated whether old lacunes in particular locations were related to unfavorable outcomes.We included 186 patients with one-sided supratentorial ICH (126 [68%] males, median age 62 years). Of 186 patients, 65 (35%) patients had unfavorable outcomes. Factors associated with unfavorable outcomes were age (OR 2.261, 95% CI 1.332-3.839, p = 0.003), National Institutes of Health Stroke Scale [NIHSS] score at admission (OR 1.175, 95% CI 1.090-1.267, p 0.001), and old thalamic lacunes contralateral to the hematoma (OR 3.805, 95% CI 1.009-14.340, p = 0.048). Patients with old thalamic lacunes contralateral to the hematoma tended to have arm (p = 0.006) and leg (p = 0.011) motor impairment on the paralyzed side at discharge as estimated by the NIHSS score.Old thalamic lacunes contralateral to the hematoma may be related to unfavorable outcomes in ICH.

To diagnose atherosclerotic occlusion mechanism in acute ischemic stroke patients with large vessel occlusion prior to revascularization therapy is challenging. The aim was to verify the relationship between atherosclerotic occlusion and non-culprit stenosis detected in urgent neuroimaging prior to interventional procedure.This study collected hyperacute stroke with large vessel occlusion, who underwent revascularization therapy (intravenous thrombolysis, thrombectomy, or both). An atherosclerotic occlusion was defined as an occlusion that did not recanalize or had residual stenosis at the initially occluded lesion, ensured in the second angiographic imaging performed after 1 week. The remaining patients who did not fulfill the definition of atherosclerotic occlusion was classified as embolic occlusion. A non-culprit stenosis was defined as a ≥ 50%-99% stenosis located other than the culprit occluded artery. Logistic regression analyses were performed to determine the factors independently associated with atherosclerotic occlusion.A total of 162 patients (104 men, median age 76 years old) were enrolled in our study. Forty one patients (25%) was atherosclerotic occlusion. Non-culprit stenosis was frequently observed in the atherosclerotic occlusion group than the embolic occlusion group (68% vs. 26%, P 0.001). The presence of non-culprit stenosis was independently associated with atherosclerotic occlusion (OR, 11.00; 95% CI, 3.96-30.52; P 0.001).In hyperacute stroke receiving endovascular therapy, non-culprit stenosis identification may be needed in order to perform an adequate revascularization, especially for atherosclerotic occlusion.

To determine transcranial Doppler ultrasonography (TCD) parameters related to unfavorable outcomes, and to clarify the correlations between those parameters and heart functions in acute ischemic stroke without major vessel stenoses and occlusions.Patients were selected from a comprehensive stroke center between October 2012 and June 2019. Inclusion criteria were: 1) acute ischemic stroke without major vessel stenoses and occlusions; and 2) ability to measure blood flow in the middle cerebral artery by TCD. Unfavorable outcomes were defined as a modified Rankin Scale score of 2-6 at 3 months after onset. First, we investigated TCD parameters related to unfavorable outcomes. Second, correlations between those parameters and heart functions as assessed by transthoracic echocardiography were evaluated.We screened 1,527 consecutive ischemic stroke patients, including 130 patients (109 [83%] male; median age, 60 years). Middle cerebral artery pulsatility index (M1 PI) (Odds ratio (OR) 0.057, 95%confidence interval (CI) 0.007-0.494, p = 0.009) was independently associated with unfavorable outcomes. Concerning the relation between M1 PI and heart functions, peak early filling velocity/velocity of mitral annulus early diastolic motion (E/e') (OR 1.195, 95%CI 1.011-1.413, p = 0.037) was a factor independently associated with high M1 PI.High M1 PI predicts unfavorable outcome regardless of ischemic stroke subtype without major vessel stenoses and occlusions. High M1 PI correlates with high E/e', suggesting diastolic dysfunction.

Bulbar symptoms in amyotrophic lateral sclerosis (ALS) are variable, reflecting bulbar and pseudobulbar palsy. The current study sought to characterize the pharyngeal findings in ALS using a fiberoptic laryngoscope and compare them with the findings of general neurological examination.We enrolled ALS patients with bulbar symptoms who were admitted between 2014 and 2020. All participants were evaluated on salivary status, velopharyngeal movement during speech and swallowing, pharyngeal constriction, and vocal cord movement using fiberoptic laryngoscopy. The laryngoscopic findings were compared with general neurological examination results.A total of 50 patients (31 men; median age: 69 years) were enrolled. Salivary residue in the hypopharynx was the most common abnormal finding on laryngoscopy (40 patients; 80%). Twenty-three patients (46%) exhibited velopharyngeal insufficiency, 18 of which exhibited good velopharyngeal closure in swallowing and poor velopharyngeal closure in speech. Thus, these patients presented speech-swallow dissociation (SSD) in velopharyngeal closure. Five patients (10%) exhibited unilateral weakness of the pharyngeal constrictor muscles in phonation. Compared with general neurological examinations, emotional incontinence was more frequent in patients who presented with SSD in velopharyngeal movement, compared with those who did not. None of the five patients with unilateral weakness of pharyngeal constriction showed curtain movement on examination via the mouth.The specific findings of laryngoscopy in ALS patients, such as SSD in velopharyngeal closure and laterality in pharyngeal constriction, could not be evaluated by general neurological examination via the mouth.

Background and Purpose: The association between the cerebral microbleed (CMB) count and outcomes in ischemic stroke has not been fully clarified. The aim of this study was to investigate the relationship between the CMB count and functional outcomes in patients with a minor ischemic stroke treated with antiplatelet therapy. Methods: Non-cardiogenic minor ischemic stroke (NIHSS score 4), and their clinical outcomes were compared. Deep white matter hyperintensities (DWMHs) were assessed using the Fazekas scale, and the relationship between DWMH burden and the CMB count was evaluated. A poor outcome was defined as a modified Rankin scale (mRS) score of 3-6 90 days after symptom onset. Logistic regression analysis was performed to evaluate whether the CMB count contributes to poor outcomes. Results: A total of 240 patients were enrolled, and their pre mRS scores were matched based on CMB presence. The median CMB count increased linearly with the Fazekas scale grade (P4 CMB group, P=0.002). Multivariate logistic regression analysis performed with well-known risk factors including DWMH showed that CMB burden (subgroups) was the independent factor associated with poor outcomes (odds ratio 1.75, 95% confidence interval 1.13-2.72, P=0.012), whereas the DWMH burden was not. Conclusion: The CMB count contributes independently to poor outcomes in minor ischemic stroke patients treated with antiplatelet therapy.

Background and Purpose: Recent several studies demonstrated that percutaneous patent foramen ovale (PFO) closure reduced the risk of stroke recurrence for patients with cryptogenic stroke (CS) and PFO. Our aim of this retrospective study is to survey the frequency of CS, which can be an indication of PFO closure. Methods: Subjects were consecutive stroke patients with symptomatic ischemic lesion detected by magnetic resonance imaging. Of them, CS were extracted according to exclusion of small-vessel collusion, large-artery atherosclerosis, cardioembolism, definite case of aortogenic embolism, and distinctive causeof ischemic stroke such as arterial dissection, hypercoagulable state and so on. After that, we selected patients in accordance with clinical guideline of PFO closure recommended by the Japanese Stroke Association (Figure). We analyzed the prevalence of CS with right-to-left shunt (RLS) as a good and recommended candidates for PFO closure. Results: Among 1,374 ischemic stroke patients from October 2012 to September 2019 , CS were 240 patients (83 females, mean age of 66 years, 17% of subjects). Of them, 100 patients (42%) had RLS (PFO; 65, atrial septal defect; 1, pulmonary arteriovenous fistula; 1, positive on transcranial Doppler (not performed in TEE) including 21 cases of definite of paradoxical embolism. In 65 patients of CS with PFO, 30 patients younger than 60 years (13% of CS) were good candidates for PFO closure. Moreover, 22 of 1,374 (1.6%) patients who were recommended candidates had one or more high risk factors of PFO, for example large shunt, atrial septal aneurysm, and the presence of shunt at rest (Figure). Conclusions: In our preliminary survey, 2% of acute ischemic stroke should be PFO closure candidates.

Objectives To investigate the differences in clinical backgrounds, especially weekly variations of stroke occurrence, between hyper-acute ischemic stroke patients with and without regular employment (RE), as well as the impact of RE on outcome. Materials and methods Symptomatic ischemic stroke patients with ≤4.5 h from onset to door were enrolled. First, we divided patients into the RE and non-RE group to analyze differences in clinical characteristics, especially relation between weekly variations of stroke occurrence and RE. Second, we divided the same patients into those with and without favorable outcomes (modified Rankin Scale score of 0 to 2 at 3 months from stroke onset) to analyze the impact of RE on outcomes. Results We screened 1,249 consecutive symptomatic ischemic stroke patients and included 377 patients (284 [75%] males; median age, 67 years). Of these patients, 248 (66%) were included in RE group. First, RE was independently associated with occurrence of stroke on Monday in reference to Sunday or a public holiday (OR 2.562, 95% CI 1.004-6.535, p = 0.049). Second, RE (OR 2.888 95% CI 1.378-6.050, p = 0.005) was a factor independently associated with a favorable outcome. Conclusions Patients with RE were more likely to have a hyper-acute ischemic stroke on Monday in reference to Sunday or a public holiday. However, RE before stroke onset appears to have a positive impact on outcome.

Background Cases of exacerbation of pre-existing neuromuscular diseases induced by immune checkpoint inhibitors (ICIs) have rarely been reported because patients with autoimmune diseases have generally been excluded from ICI therapy due to the increased risk of exacerbation. We describe the first case of an elderly patient who experienced exacerbation of a previously undiagnosed sporadic inclusion body myositis (sIBM), the most common myopathy in the geriatric population, which was triggered by anti-programmed cell death-1 therapy. Case presentation A 75-year-old man who was receiving pembrolizumab presented with limb weakness. Three years prior, he had noticed slowly progressive limb weakness, but he received no diagnosis. After the first infusion of pembrolizumab, his creatine kinase (CK) levels had increased. The neurological examination and muscle biopsy findings confirmed the diagnosis of sIBM and suggested exacerbation of sIBM induced by pembrolizumab. After the patient’s CK levels decreased, pembrolizumab was restarted. The tumor progressed after its treatment with pembrolizumab. The patient died after 15 months of follow-up. Conclusions In patients with slowly progressive limb weakness, sIBM should be explored before ICI therapy. In addition, if patients show high CK levels after ICI introduction, it is necessary to confirm whether they have sIBM in order to avoid unnecessary immunosuppressive therapies and assess whether they can tolerate ICI reintroduction.

This is the rare case report that bilateral vagus nerve paralysis was emerged as the initial symptom of acute myelogenous leukemia (AML). An 83-year-old man admitted to our hospital because of dysphagia. His dysphagia progressed two months prior to admission. Although physical examination revealed no abnormality, videoendoscopy and videofluorography examination clearly revealed bilateral vagus nerve palsy. Brain MRI showed hypointense signals at the bilateral clivus on T1 weighted images, suggesting tumor infiltration to bilateral petroclivus. He was diagnosed as AML by blood samples and bone marrow biopsy. After initiation of the treatment including radiation therapy, dysphagia shows mild improvement. Although bilateral cranial nerve palsy due to malignant tumor involving at the clivus is very uncommon, we should pay attention to the symptom.

Background and Purpose: The relationship between cerebral microbleeds (CMBs) and prognosis in patients with ischemic stroke is still unclear. Our aim here was to verify the relationship between CMBs and functional outcomes in patients with minor ischemic stroke treated with antiplatelet therapy. Methods: We retrospectively reviewed consecutive patients with a non-cardiogenic minor ischemic stroke (NIHSS

Early hematoma expansion (HE) is seen in approximately 30% of patients with intracerebral hemorrhage (ICH), but detecting patients with a high HE risk is challenging.The NAG scale is a simple predictive scale for HE in acute ICH patients. Multi-institutional validation of the usefulness of this scale was the aim of this study.We retrospectively reviewed 142 consecutive primary ICH patients admitted to our hospital between September 2016 and December 2018. The NAG scale consists of three factors: National Institutes of Health Stroke Scale (NIHSS) score ≥ 10, anticoagulant use, and glucose ≥133 mg/dl (1 point each). Patients underwent non-contrast computed tomography (CT) within 24 h of symptom onset and follow-up CT 6 h, 24 h, and 7 days after admission. We defined HE as increased hemorrhage volume 33% or an absolute increase of6 mL on follow-up CT. Poor prognosis was defined as a modified Rankin scale score of 4-6 at discharge. We performed logistic regression analysis and created receiver operating characteristic curves to determine the discrimination ability of the NAG score.Patients constituted 96 men and 46 women (median age: 64 years; median NIHSS: 11), and HE was observed in 38/142 patients (27%). Higher NAG sores were associated with HE (P .001), poor prognosis (P .001), and in-hospital death (P .001). The C statistic was 0.72 (95% confidence interval [CI]: 0.63-0.82) for HE, 0.67 (95% CI: 0.58-0.76) for poor prognosis, and 0.85 (95% CI: 0.74-0.95) for in-hospital death. Multivariate logistic regression analysis with known risk factors showed that NAG scale score was an independent risk factor for HE (odds ratio: 2.95; 95% CI: 1.57-5.52; P = .001).The NAG scale showed good discrimination in our multi-institutional validation.

Background and Purpose: We aimed to investigate the differences in weekly variations of stroke occurrence between hyper-acute ischemic stroke patients with and without regular employments (RE), and the impact of RE on outcome. Methods: Consecutive symptomatic ischemic stroke patients with < 4.5 h from onset to door between October 2012 and May 2018 were enrolled. All the situations of employment on admission were obtained from interviews with the participant or substitute guardians. First, we divided the patients into with and without RE to evaluate the differences in weekly variations of stroke occurrence. Second, we divided the same patients into with and without favorable outcome (mRS score of 0 to 2 at 3 months from the onset) to evaluate the impact of RE on outcome. Results: We screened 1,249 consecutive symptomatic ischemic stroke patients, including 385 patients (292 (76%) male, median age 67 years) with hyper-acute ischemic stroke. Of all, 251 patients (65%) were included in RE group. In the multivariate analysis, patients with RE were more likely to develop strokes on Monday compared to that on Sunday and public holiday (OR 2.841, 95% CI 1.145-7,049, p = 0.024, Figure A). In the multivariate analysis, the factors associated with favorable outcome were low NIHSS score on admission (OR 0.909, 95% CI 0.857-0.964, p = 0.001), not receiving endovascular therapy (OR 0.175 95% CI 0.069-0.444, p p = 0.039, Figure B). Conclusions: There were dramatic differences in weekly variations of hyper-acute ischemic stroke occurrence between patients with and without RE. Monday seems to be “a black day” for ischemic stroke patients with RE. RE had a positive impact on outcome in hyper-acute ischemic stroke.

Background and Purpose: Hyperintense vessel sign on FLAIR (HVS) has been described in hyperacute stroke patients with arterial occlusion. It’s a surrogate marker for stroke severity in patients with acute ischemic stroke of the anterior circulation. We aimed to reveal the clinical significance of HVS in patients with acute posterior circulation infarction. Methods: This observational study is based on a single-center prospective registry study. Inclusion criteria were: symptomatic ischemic stroke patients who have lesions only in posterior circulation; and taken initial MRI within 14 days from onset.An unfavorable outcome was defined as mRS score of 2 to 6 at 3 months from the onset. First investigation is to estimate whether HVS could be related to the subtype of acute ischemic stroke (cohort A). Second, the correlation between HVS and mRS at 3 months was evaluated (cohort B). Results: From October 2012 to May 2019, consecutive 1,079 ischemic stroke subjects were screened, including 277 in cohort A (191 male, median age 64 years) and 240 in cohort B (165 male, median age 66 years, Figure A). In cohort A, HVS was independently associated with intracranial artery dissection (OR 5.228; 95% CI 2.270-12.039; p = 0.001) and large-artery atherosclerosis (OR 3.582; 95% CI 1.244-10.317; p = 0.018, Figure B). In cohort B, HVS was not a factor independently associated with unfavorable outcome (OR 2.925; 95% CI 0.881-9.714; p = 0.080). Conclusions: HVS in patients with posterior circulation infarct suggests intracranial artery dissection or large-artery atherosclerosis, but does not have impact on their clinical courses.

Background and Purpose: Early hematoma expansion (HE) is seen in about 30% of intracerebral hemorrhage (ICH) patients, but detecting those patients with high risk of HE is challenging. The NAG scale was previously published as the simple predictive scale for HE in acute ICH patients. Multi-institutional validation for utility of the scale was the aim of this study. Methods: We retrospectively reviewed consecutive primary ICH patients, who were admitted between September 2016 and December 2018 to Jikei University Hospital or Kashiwa Hospital, Japan. NAG scale is consist of 3 factors based on examination on admission; NIHSS ≥10, Anticoagulant agents use, Glucose ≥133 mg/dl, with 1 point assigned for each parameter. Patients received an initial non-contrast computed tomography (CT) scan within 24 hours from symptom onset, and underwent follow-up CT scans at 6 hours, 24 hours, and 7 days after admission. The HE was defined as an increment in hemorrhage volume >33% or an absolute increase >6 mL on follow-up CT scans. Poor prognosis was defined as modified Rankin Scale 4-6 at discharge. We performed logistic regression analysis and receiver operating characteristic curves to determine discrimination ability of the score. Results: A total of 142 patients (96 men; median age 64 years; median NIHSS 11) were included in our study, and HE was observed in 38 patients (27%). Higher NAG sores were related to HE (P The C statistic was 0.72 (95% confidence interval [CI], 0.63-0.82) for HE, 0.67 (95% CI, 0.58-0.76) for poor prognosis, and 0.85 (95% CI, 0.74-0.95) for in-hospital death. Multivariate logistic regression analysis with known risk factors showed the NAG scale was the independent factor for HE (Odds ratio, 2.95; 95% CI, 1.57-5.52; P = 0.001). Conclusion: Multi-institutional validation of the NAG scale showed good discrimination.

Background and Purpose: To determine the parameters of transcranial color-coded duplex sonography (TCCS) related to unfavorable outcomes, and further to clarify the correlation between those parameters and heart functions in acute ischemic stroke without vessel stenosis. Methods: Patients were selected from a comprehensive stroke center between October 2012 and June 2019. Inclusion criteria were: acute ischemic stroke or TIA; able to measure blood flow of either the left or right middle cerebral artery (M1) by TCCS with ≤7 days from onset; and have no vessel stenoses or occlusions assessed by MRA and carotid artery ultrasonography. An unfavorable outcome was defined as mRS score of 2 to 6 at 3 months from the onset. First, we investigated the parameters of TCCS related to unfavorable outcomes (cohort A). Second, the correlation between those parameters and heart functions assessed by transthoracic echocardiography was evaluated (cohort B). Results: We screened 1,529 consecutive ischemic stroke patients, including 173 in cohort A (146 (84%) male, median age 59 years) and 192 in cohort B (162 (84%) male, median age 60 years) (Figure A). In cohort A, high M1 pulsatility index (PI) (OR 0.043; 95% CI 0.005-0.407; p = 0.006) was independently associated with an unfavorable outcome (Figure B). In cohort B, higher age (OR 1.532; 95% CI 1.118-2.009; p = 0.008), higher E/e' (OR 1.143; 95% CI 1.011-1.292; p = 0.033), and aortic valve regurgitation (AR > mild) (OR 4.780; 95% CI 1.261-18.114; p = 0.021) were factors independently associated with high M1 PI (Figure C). Conclusions: High M1 PI predicts an unfavorable outcome and correlates with high E/e' suggesting diastolic heart dysfunction and aortic valve regurgitation in acute ischemic stroke without vessel lesion.

Background: Control of risks of thromboembolic complications (TEC) during stent assisted coil embolization (SACE) for unruptured intracranial aneurysm (UIA) is crucial for outcome. We evaluated retrospectively our cohort of SACE for UIA, analyzing the role of anatomical, clinical and stent type related factors to determine optimal presurgical values of light transmission aggregometry (LTA) for TEC prevention. Methods: From July 2015 to May 2018 we retrospectively analyzed 132 SACE treated UIA patients at our hospital. Aneurysm location and maximum diameter, preoperative LTA-value, ischemic and hemorrhagic complications, preoperative and discharge Modified Rankin scale (mRS) were collected. Aspirin 100 mg and clopidogrel 75 mg were started 7 days before operation, with “boost” therapy (additional 75mg clopidogrel in LTA-value >60) added after August 2016, addressing clopidogrel resistance. After multivariate analysis we developed our original combined parameter called TEC predictor (TEP). Receiver operating characteristic (ROC) analysis for TEP and each significant variable were performed. Results: TEC were confirmed in five (3.8%, 5/132) and hemorrhagic - in nine patients (6.8%, 9/132), with mRS deterioration post-operatively in five patients (5/132, 3.8%). By multivariate analysis, LTA-value and maximum diameter were chosen as significant variables, and included in TEP. ROC analysis of LTA-value showed sensitivity and specificity of 0.866 and 0.600 respectively (AUC=0.747) with cut-off point of 62. TEP permitted establishing optimal LTA-value according to the aneurysm maximum diameter to predict TEC. Neuroform-EZ, Enterprise, Neuroform-Atlas, and LVIS stents complications were 2.9%, 10.5%, 1.4%, and 14.3%, respectively. Conclusions: Preoperative LTA-value contributes to predicting TEC after SACE of UIA. TEP (relating LTA cutoff value to aneurysm size) provides improved antiplatelet therapy adjustment prior to SACE for TEC reduction.

Background and Purpose Early hematoma expansion (HE) is not rare in intracerebral hemorrhage (ICH) patients, but detecting those patients with high risk of HE is challenging. The aim of this retrospective study was to investigate the factors associated with HE in acute ICH patients, and to develop a simple predictive scale for HE. Methods We retrospectively reviewed consecutive patients with primary ICH, who received an initial non-contrast computed tomography (CT) scan within 24 hours from symptom onset. Patients underwent follow-up CT scans at 6 hours, 24 hours, and 7 days after admission. We compared the clinical characteristics of patients with and without HE (defined as an increase in intracerebral hemorrhage volume >33% or an absolute increase >6 mL on follow-up CT scans), and performed a logistic regression analysis to determine the predictors of HE. Results A total of 118 patients (78 men; median age 63 years; interquartile range 54–73) were included in our study. HE was observed in 30 patients (25%). HE patients showed higher rates of anticoagulant use (20% vs. 2%, respectively; P=0.003), high National Institutes of Health Stroke Scale on admission (13 vs. 7, respectively; P=0.001), and high plasma glucose (141 mg/dl vs. 113 mg/dl, respectively; P=0.001) compared with patients without HE. After multivariate logistic regression analysis, we selected three factors for defining the NAG scale (1 point as baseline National Institutes of Health Stroke Scale ≥10, 1 point as anticoagulant use, and 1 point as plasma glucose ≥133 mg/dL). The frequencies of HE associated with the NAG scale scores were as follows: score 0, 4%; score 1, 25%; score 2, 60%; score 3, 100%. Conclusion Stroke severity, hyperglycemia, and anticoagulation use were factors independently associated with HE. The NAG scale consists of readily available factors and can predict HE.

Background and Purpose— This study’s objective is to determine if nonstenotic carotid plaque of Methods— This was a cross-sectional observational study. We identified consecutive patients with anterior circulation embolic stroke of undetermined source (ESUS), excluding stroke in multiple vascular territories. Using ultrasonography, we measured the internal carotid plaque size and stenosis for each patient. We dichotomized the plaque size at several predefined thresholds and calculated the frequency of the plaque size and morphology above each threshold ipsilateral versus contralateral to the stroke site. Results— We included 53 patients with unilateral anterior circulation ESUS. Initially, we found that plaque with a thickness ≥1.5 mm was present ipsilateral to the stroke site in 59% of the patients, and present contralateral to the stroke site in 42% of the patients (31/53 versus 22/53 patients; P =0.049). Plaque with low echo likewise had a similar prevalence when present ipsilateral (9%) and contralateral (4%) to the stroke site (5/53 versus 2/53; P =0.25). Conclusions— Internal carotid artery plaque with a thickness ≥1.5 mm but that is nonstenotic (

The association between the cerebral microbleed (CMB) count and outcomes in ischemic stroke has not been fully clarified. The aim of this study was to investigate the relationship between the CMBs count and functional outcomes in patients with a minor ischemic stroke treated with antiplatelet therapy METHODS: Non-cardiogenic minor ischemic stroke (NIHSS score 4 on admission) patients who were treated with antiplatelet therapy were enrolled. The patients were divided into four groups based on the number of CMBs (absent, 1, 2-4, and 4), and their clinical outcomes were compared. A poor outcome was defined as a modified Rankin scale (mRS) score of 3-6 90 days after symptom onset. Logistic regression analysis was performed to evaluate whether the CMBs count contributes to poor outcomes with well-known risk factors such as age, NIHSS score on admission, ischemic stroke recurrence, large artery atherosclerosis stroke subtype, and DWMHs.A total of 240 patients were enrolled, and their pre mRS scores were matched based on CMB presence. A higher burden of CMBs was linearly correlated with the incidence of poor outcomes (4% in the absent group, 8% in the 1 CMB group, 13% in the 2-4 CMB group, and 20% in the 4 CMB group, P = 0.002). Multivariate logistic regression analysis showed that CMBs count was one of the independent factor associated with poor outcomes (odds ratio 1.07, 95% confidence interval 1.02-1.12, P = 0.003).The CMBs count contributes independently to poor outcomes in minor ischemic stroke patients treated with antiplatelet therapy.