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Blood-brain barrier (BBB) breakdown is considered a key step in the pathophysiology of reversible cerebral vasoconstriction syndrome (RCVS); however, its temporal course remains unclear. Based on the characteristics and dynamics ofBetween 2011 and 2019, we enrolled seven patients (one male and six female patients) with RCVS without ischemic or hemorrhagic stroke or posterior reversible encephalopathy syndrome.Thunderclap headache was the initial symptom in all the patients and was most commonly triggered by bathing (three patients). All the patients exhibited vasoconstriction and reduced cerebral uptake ofReduced cerebral uptake of

Highlights • We report the first case of cerebral amyloid angiopathy-related inflammation (CAA-RI) presenting palinopsia initially. • Palinopsia is generally caused by intracranial diseases involving the parietal and occipital areas. • CAA dominantly affects parietal and occipital lobes, therefore palinopsia could be an important phenomenon of the disease.

Background: Emergency medical services are an important part of acute stroke management. We devised a prehospital stroke scale, the TOYOTA prehospital stroke scale for tissue plasminogen activator (t-PA) intravenous therapy (TOPSPIN) for triaging patients with ischemic stroke and especial indications for intravenous t-PA therapy in December 2006; this scale comprises 5 items including consciousness, atrial fibrillation, language disorder, disturbance of the upper extremities, and disturbance of the lower extremities. The aim of this study was to analyze the results of 10 years of TOPSPIN implementation and to distinguish ischemic stroke from hemorrhagic stroke in the real world. Methods: We prospectively enrolled consecutive patients who were transferred to our hospital and evaluated by Toyota city ambulance services using the TOPSPIN from December 2006 to January 2017. We examined definite diagnosis at the time of hospital discharge (ischemic stroke, hemorrhagic stroke, or stroke mimic), positive-predictive value of the stroke, the rate of the recanalization therapy, and clinical differentiation among patients with hemorrhagic stroke, ischemic stroke, and stroke mimics. Results: A total of 1,482 consecutive patients were enrolled; 1,134 (76.5%) were patients with stroke (628 ischemic-type, 34 transient ischemic attack-type, and 472 hemorrhagic-type) and 348 (23.5%) without stroke (80 with seizure, 42 with syncope, 27 with hypoglycemia, and 199 other). Among 628 patients with ischemic stroke, 130 (20.7%) received intravenous recombinant t-PA treatment, endovascular therapy, or both. The presence of atrial fibrillation, older age, lower blood pressure, and lower total TOPSPIN score was more commonly associated with ischemic stroke than with hemorrhagic stroke. In multivariable logistic regression analysis, the presence of atrial fibrillation was independently associated with ischemic stroke (OR 2.33; 95% CI 1.61–3.40). Conclusions: The TOPSPIN is a simple prehospital stroke scale that includes an assessment of atrial fibrillation. Detection of atrial fibrillation in the prehospital stage may point to a higher probability of ischemic stroke.

Introduction: Hyperperfusion syndrome ( HPS ) probably occurs after carotid artery stenting ( CAS ) of an extremely high-grade carotid artery stenosis (ex-CS). However, it has not been established how to prevent HPS. Hypothesis: Intentional residual stenosis (iRS ) after CAS not followed by balloon dilatation (bD) can prevent HPS in patients with an ex-CS and spontaneously dilates thereafter. Methods: We included in our study patients with an ex-CS who underwent elective CAS not followed by bD for iRS from 2015 to 2018. We defined an ex-CS as a stenosis of more than NASCET 70% which caused delayed filling of contrast material in an internal carotid angiogram and reduced signal intensity (ratio of less than 0.9) of the ipsilateral middle cerebral artery (MCA) compared to the contralateral MCA on magnetic resonance angiograms (MRA), and defined a residual stenosis (rS) as angiographic stenosis of more than NASCET 30% or peak systolic velocity (PSV) of more than 80 cm/s by Doppler ultrasonography. We defined hyperperfusion phenomenon (HPP) as increase of cerebral blood flow in single photon emission computed tomography scans or cerebral metabolic rate of oxygen by measuring blood oxygen content. We evaluated patients’ baseline characteristics, rS just after CAS, incidence of HPS and HPP. Three months after CAS, they underwent conventional angiographic investigation. Results: During the study period, 26 CAS met our inclusive criteria. Their median carotid stenosis was NASCET 81.8%. Signal intensity ratio of MRA was 0.75. Median PSV before and just after CAS was 311.5 and 76.1 cm/s (p Conclusion: Intentional residual stenosis after CAS of an ex-CS probably prevented hyperperfusion syndrome and spontaneously dilated at 3 months after CAS.

Introduction: Most of patients with mild neurological symptoms despite the carotid or middle cerebral artery occlusion (CO or MCAO) are treated without thrombectomy because of no its evidence.However, among them, some patients’ neurological symptoms deteriorate during hospitalization. Methods: We included in our retrospective study acute ischemic stroke patients 1) who were admitted to our institution between April 2011 and January 2018, 2) who could walk before stroke, 3) who underwent MR angiography(MRA), displaying occlusion of the internal carotid artery(ICA) or the M1 segment of the middle cerebral artery(MCA), 4) who presented low NIHSS scores of 4 or less and didn’t undergo thrombectomy.We evaluated patients’ baseline features, NIHSS scores on arrival and at discharge, and time-intensity curve (TIC)-cerebral blood flow (CBF) grade. TICs were generated on region of interests set at symmetrical positions of the bilateral MCA territories. According to the time to peak (TP) and the peak signal (PS) comparing the affected side(a) with the contralateral side(c), we defined (TPa/TPa) divided by (TPc/TPc) as CBF% and grade 1 as CBF% of less than 0.2, grade 2 as CBF% of 0.2 or more and CBF% less than 0.7 and grade 3 as CBF% of 0.7 or more. We defined patients with NIHSS at discharge higher than NIHSS on admission as Group Worse and defined others as Group Non-Worse. Result: Thirty-six patients met our inclusion criteria and were analyzed. The median age was 76.5 years, and 24 patients were men. Median NIHSS score on arrival and at discharge was 2 and 1. There were no patients with CBF grade 1, 8 patients with CBF grade 2 and 28 with CBF grade 3. There were 7 patients in Group Worse and 29 in Group Non-Worse.In Group Worse and Non-Worse, median age was 64 and 78 (ns), median NIHSS score at admission was 2 and 2 (ns), 4 patients and 4 patients in CBF grade 2 and 3 patients and 25 patients in CBF grade 3 (p Conclusion: CBF grade based on dMRi is the significant predictor of neurological deterioration. In cases of CBF grade 2 due to the ICA or MCA occlusion, neurological symptoms probably deteriorate in 50% of patients during hospitalization without thrombectomy.

Severe hyperglycemia often occurs when acute stroke patients receive enteral tube feeding. Hyperglycemia should be managed because it adversely affects stroke outcome. However, it remains unclear how blood glucose level (BGL) changes with enteral nutrition in acute stroke patients. Our purpose was to investigate features of the blood glucose curve in acute stroke patients receiving enteral feeding. We retrospectively evaluated acute stroke patients who developed hyperglycemia during enteral tube feeding and underwent CGM in our institution. We evaluated characteristics of blood glucose curves, fasting and peak BGL, and time to peak of BGL. Six patients were analyzed. The median fasting BGL was 125.5 mg/dL and the median peak BGL was 351.5 mg/dL. The blood glucose curve showed the following characteristics following: 1) BGL elevated slowly reach the peak in 180 to 240 minutes; 2) BGL decreased slowly or very little after its peak; 3) there was a large gap between fasting and peak BGL regardless of presence of diabetes mellitus. We grouped the curves into four types by time to peak and how BGL decreased after peak. (Received August 17, 2017; Accepted February 1, 2018; Published July 1, 2018).

Introduction: Hyperglycemia found at arrival or after admission must be treated as soon as possible in acute stroke patients, because hyperglycemia impairs their clinical outcome. However, it hasn’t been established how to treat it. Hypothesis: Sodium-glucose cotransporter-2 (SGLT2) inhibitors can lower blood glucose level soon and safely in an acute stroke stage. Patients and Methods: We included acute stroke patients 1) who were admitted between September 2015 and June 2017, 2) who could orally take food after admission, 3) who presented fasting blood glucose level of higher than 150 mg/dl on the 3rd day, and 4) who received the SGLT2 inhibitor of luseogliflozin 2.5mg on the 3rd day to lower blood glucose level. We excluded patients undergoing enteral feeding or insulin therapy. We didn’t use sulfonylureas nor glinides. We provided food with appropriate calorie, determined according to Harris-Benedict equation, including carbohydrates (carbo) adjusted to 40% of the target calorie. We evaluated blood glucose level, urine glucose and urine ketones at arrival and on the 6th day. Results: Fifty-six patients matched our criteria. On admission, their average age was 71 years, average body mass index was 24.1 kg/m2, their average HbA1c was 7.6 %, blood glucose level was 192 mg/dl and creatinine clearance was 64.6 ml/min. Patients take food with average 1400 kcal including carbo of 140 g/day. Average three days after starting luseogliflozin treatment, their average fasting blood glucose level was improved to 117 mg/dl, 54 patients (96%) presented positive urine glucose and 29 patients (52%) positive urine ketones. No symptoms of hypoglycemia or ketoacidosis occurred. Conclusion: Luseogliflozin coupled with food including carbo of average 140 g/day could lower blood glucose level soon and safely in acute stroke patients with appropriate conditions.

A 78-year-old man was admitted to our hospital because of sudden right hemiparesis and dysarthria. His cranial MRI showed an area of hyperintensity in left pons on DWI and MRA revealed dilated, elongated and tortuous intracranial artery. We diagnosed as acute phase ischemic stroke and intracranial arterial dolichoectasia (IADE). Intravenous infusion of rt-PA was performed 157 minutes after the onset of symptoms, and his hemiparesis improved. However, he subsequently suffered from cerebral infarction 4 times in 6 months, and we treated him twice with thrombolytic therapy. Although thrombolytic therapy was effective in the short term and antithrombotic therapy was continued, he had bilateral hemiplegia and severe dysphagia because of repeated cerebral infarctions. Hence basilar artery was dilated with intramural hemorrhage over 6 months, and we discontinued antithrombolytic therapy. It is possible that antithrombolytic therapy affects enlargement of IADE. Antithrombolytic therapy for IADE should be done carefully.

A 53-year-old male with a past medical history of hypertension and bipolar disorder gradually developed gait disturbance and cognitive dysfunction over half a year. His cranial MRI showed an area of hyperintensity in the right occipital lobe on T2 weighted images and the surface of the lesion was enhanced along the sulci. We diagnosed his condition as amyloid-β-related angiitis (ABRA) based on brain biopsy. Repeated, frequent seizures resistant to several antiepileptic drugs (AEDs) occurred after the operation. Steroid therapy was effective and the symptoms, including the intractable seizures and MRI abnormalities dramatically improved. In contrast to the common wild type e3/e3 ApoE genotype, a majority of ABRA patients have e4/e4. However, in this case the rare e4/e2 type was detected. The e4 allele is considered to promote Aβ deposition on the vessel wall, and e2 is speculated to trigger vessel ruptures or vascular inflammation. Although seizure is not a common complication of brain biopsy, it occurred repeatedly and responded poorly to AEDs in this case. Surgical stress in this patient with e2 probably induced the uncontrolled seizures. ApoE genotype may be an effective and low-invasive marker in case of suspected ABRA and in predicting the risks of the complication from brain biopsy.

Although D2/3 agonists have been used as a first-line medication for idiopathic restless legs syndrome (iRLS), findings on D2/3 receptors have been inconsistent. Here, we aimed to clarify the contribution of D2/3 receptor function to the clinical symptoms of iRLS by comparing the binding potential (BPND) of [11C]raclopride with clinical improvements after D2/3 stimulation by pramipexole. Eight drug-naïve, iRLS patients and eight age-matched healthy subjects were scanned with positron emission tomography (PET). After PET scans, all patients received pramipexole (0.125 mg) orally for 2 weeks. Patients were evaluated every day with several standardized clinical tests. The BPND values were compared using regions of interest and voxel-based methods. Results showed that the mean magnitude of [11C]raclopride BPND in the mesolimbic dopamine region (nucleus accumbens (NA) and caudate) was significantly lower in the iRLS group. No significant differences between groups were observed in the putamen. The NA [11C]raclopride BPND levels correlated negatively with clinical severity scores and positively with the degree of posttreatment improvement in iRLS. The present results suggest that alterations in mesolimbic D2/3 receptor function reflect the pathophysiology of iRLS, and the baseline availability of D2/3 receptors may predict the clinical outcome after D2/3 agonist treatment.