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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.

OBJECTIVEShunt-dependent hydrocephalus (SDHC) may arise after aneurysmal subarachnoid hemorrhage (aSAH) as CSF resorptive mechanisms are disrupted. Using propensity score analysis, the authors aimed to investigate which treatment modality, surgical clipping or endovascular treatment, is superior in reducing rates of SDHC after aSAH.METHODSThe authors’ multicenter SAH database, comprising 3 stroke centers affiliated with Kyoto University, Japan, was used to identify patients treated between January 2009 and July 2016. Univariate and multivariate analyses were performed to characterize risk factors for SDHC after aSAH. A propensity score model was generated for both treatment groups, incorporating relevant patient covariates to detect any superiority for prevention of SDHC after aSAH.RESULTSA total of 566 patients were enrolled in this study. SDHC developed in 127 patients (22%). On multivariate analysis, age older than 53 years, the presence of intraventricular hematoma, and surgical clipping as opposed to endovascular coiling were independently associated with SDHC after aSAH. After propensity score matching, 136 patients treated with surgical clipping and 136 with endovascular treatment were matched. Propensity score–matched cohorts exhibited a significantly lower incidence of SDHC after endovascular treatment than after surgical clipping (16% vs 30%, p = 0.009; OR 2.2, 95% CI 1.2–4.2). SDHC was independently associated with poor neurological outcomes (modified Rankin Scale score 3–6) at discharge (OR 4.3, 95% CI 2.6–7.3; p < 0.001).CONCLUSIONSSDHC after aSAH occurred significantly more frequently in patients who underwent surgical clipping. Strategies for treatment of ruptured aneurysms should be used to mitigate SDHC and minimize poor outcomes.

Background and Purpose: Recent studies have demonstrated that endovascular reperfusion therapy improves clinical outcomes at 90 days after ischemic stroke. However, the effects on long-term outcomes are not well known. We hypothesized that successful reperfusion might be associated with long-term improvement beyond 90 days after endovascular therapy. To assess the long-term effects beyond 90 days, we analyzed the association of successful reperfusion with a temporal change in modified Rankin Scale (mRS) score from 90 days to 1 year after endovascular therapy. Methods: We retrospectively analyzed a database of consecutive patients with acute ischemic stroke who received endovascular therapy between April 2006 and March 2016 at 4 centers. We compared the incidences of improvement and deterioration in patients with successful reperfusion (i.e., modified thrombolysis in cerebral infarction score of 2b or 3) with those in patients with unsuccessful reperfusion. We defined improvement and deterioration as decrease and increase on the mRS score by 1 point or more from 90 days to 1 year after endovascular therapy respectively. Results: A total of 268 patients were included in the current study. The rate of patients with improvement tended to be higher in patients with successful reperfusion than in patients with unsuccessful reperfusion (20% [34/167 patients] vs. 12% [12/101], p = 0.07). The rate of patients with deterioration was lower in patients with successful reperfusion than in patients with unsuccessful reperfusion (25% [42/167] vs. 42% [42/101], p < 0.01). After adjustment for confounders, successful reperfusion was associated with improvement (adjusted OR 2.65; 95% CI 1.23–5.73; p < 0.05) and deterioration (adjusted OR 0.33; 95% CI 0.18–0.62; p < 0.01), independent of the 90-day mRS score. Conclusions: Successful reperfusion has further beneficial legacy effects on long-term outcomes beyond 90 days after stroke.

Objective Although carotid artery stenting (CAS) has been gaining popularity as an alternative to carotid endarterectomy (CEA), perioperative stroke rate following contemporary CAS remains significantly higher than stroke rate after CEA. The purpose of this study was to assess perioperative (within 30 days) therapeutic results in patients with carotid stenosis (CS) after introduction of preoperative carotid magnetic resonance imaging plaque evaluation in a single center performing both CEA and CAS. Methods Based on prospectively collected data for patients with CS who were scheduled for carotid revascularization, retrospective analysis was conducted of 295 consecutive patients with CS. An intervention was selected after consideration of periprocedural risks for both CEA and CAS. Concerning risk factors for CAS, results of magnetic resonance imaging plaque evaluation were emphasized with a view toward reducing embolic complications. Results CAS was performed in 114 patients, and CEA was performed in 181 patients. Comparing baseline characteristics of the 295 patients, age, T1 signal intensity of plaque, symptomatic CS, urgent intervention, and diabetes mellitus differed significantly between CAS and CEA groups. Among patients who underwent CAS, new hyperintense lesions on diffusion-weighted imaging were confirmed in 47 patients. New hyperintense lesions on diffusion-weighted imaging were recognized in 21.4% of patients who underwent CEA ( n = 39), significantly less frequent than in patients who underwent CAS. Conclusions The overall short-term outcome of CEA and CAS is acceptable. Preoperative carotid magnetic resonance imaging evaluation of plaque might contribute to low rates of ischemic complications in CAS.

Severe hypoglycemia is known to cause acute focal neurological symptoms. In cases with a medical history of diabetes mellitus (DM), the diagnosis and treatment of hypoglycemia-induced neurological symptoms are simple. However, severe hypoglycemia can occur in patients who are not taking hypoglycemic agents such as insulin or long-acting sulfonylurea drugs. We describe a 95-year-old man with sudden onset of right hemiparesis who showed high signal intensity on diffusion-weighted imaging involving the left internal capsule with corresponding reduced apparent diffusion coefficient hypointensity. Laboratory findings revealed severe hypoglycemia (27 mg/dl). However, he was not taking insulin or long-acting sulfonylurea drugs but disopyramide and clarithromycin had been administered. In addition, he had kidney dysfunction with an estimated glomerular filtration rate (GFR) of 42.9 ml/min/1.73 m2. After the blood glucose level was normalized, the left hemiparesis completely recovered and abnormal findings of magnetic resonance imaging (MRI) study also became normal. A combination of disopyramide and clarithromycin may cause severe hypoglycemia-induced neurological symptoms particularly in patients with kidney dysfunction. Even in a patient with sudden-onset hemiparesis and no history of DM, the possibility of hypoglycemia-induced neurological deficit should be considered.

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 Primary intracranial leiomyosarcoma is a very rare occurrence, and primary leiomyosarcoma with intratumoral hemorrhage has not been described previously. We present a case of a rapidly enlarging primary intracranial leiomyosarcoma with intratumoral hemorrhage. Case Description A 41-year-old female presented with right hemiparesis and gait disturbance. She had a brain tumor on the frontal lobe that was growing rapidly. An intratumoral hemorrhage had occurred suddenly. We removed the tumor after hemorrhage. After the operation, postoperative chemotherapy and radiotherapy were not performed, but the tumor did not recur. Conclusions To the best our knowledge, this is the first report of primary intracranial leiomyosarcoma with intratumoral hemorrhage.

Background We describe the “triple balloon protection technique” (TBPT) using the Mo.Ma Ultra in combination with the Carotid GuardWire during carotid artery stenting (CAS). This technique is expected to prevent distal embolism to the internal and external carotid arteries, and is suitable for East Asians in whom the origin of the superior thyroid artery is lower than that in Caucasians. Methods From December 2012 to May 2013, 11 patients underwent CAS using TBPT in our center. Results Procedural success was achieved in all patients. Complete flow blockade by angiography could not be obtained in 8 patients (72.7%) by proximal occlusion using the Mo.Ma Ultra only. Complete angiographic flow blockade was obtained in all patients by TBPT. No major adverse cardiovascular events, including stroke, myocardial infarction, or death because of any cause, occurred within 30 days. Conclusions The use of TBPT for CAS may be effective for preventing distal embolisms, especially for East Asians.

Delayed ischemic neurological deficit (DIND) due to symptomatic vasospasm is a major cause of morbidity and mortality after aneurysmal subarachnoid hemorrhage (aSAH). The aim of this study was to elucidate the safety and feasibility of intrathecal milrinone infusion via lumber subarachnoid catheter for prevention of DIND after aSAH. We diagnosed 425 consecutive patients with aSAH who received clipping or coil embolization within 48 h after arrival. Patients with the evidence of vasospasm on CT angiography (CTA) received the milrinone therapy via lumbar subarachnoid catheter. DIND, delayed cerebral infarction (DCI), and modified Rankin scale at 3 months after SAH were used for the assessment of outcome. Of 425 patients, 170 patients (40.0 %) with CTA-proven vasospasm received the milrinone therapy. DIND was observed in 68 patients (16.0 %), DCI in 30 patients (7.1 %), and the overall mortality was 7.2 %. In patients with WFNS grade IV and V aSAH, 26 out of 145 patients (17.9 %) were presented with DIND, 12 (8.3 %) with DCI, and the mortality was 16.0 %. No major complication related to the milrinone injection was observed. Intrathecal milrinone injection via lumbar catheter was safe and feasible, and further randomized prospective studies are needed to confirm the effectiveness of this regimen in the patients with SAH.

[BACKGROUND]: Carotid plaque characteristics influence future risk of stroke considerably. However, the severity of stenosis does not accurately reflect plaque burden in patients with expansive arterial remodeling. [OBJECTIVE]: To determine the therapeutic outcome of symptomatic carotid low-grade stenosis with vulnerable plaque based on magnetic resonance imaging (MRI) characterization. [METHODS]: We studied 25 (male, n = 23; age, 74.2 ± 5.6 years) of 29 consecutive patients with symptomatic carotid low-grade stenosis (

A 62-year-old man presented with dissection of the right middle cerebral artery (MCA) manifesting as mild headache, right hemiparesis, and slurred speech. Magnetic resonance (MR) imaging and MR angiography revealed fresh infarction in the right basal ganglia, and severe stenosis and dilatation of the right MCA. Digital subtraction angiography approximately 24 hours after admission revealed a linear contrast defect indicating an intimal flap of the M(1) segment. The diagnosis was dissection of the MCA. His neurological deficits improved gradually. Although he was neurologically stable, diffusion-weighted MR imaging revealed enlarging infarct size over the right MCA territory, and the right M(1) segment had progressive stenosis. Superficial temporal artery (STA)-MCA anastomosis was performed on the 26th day. Follow-up angiography showed good patency of the STA-MCA anastomosis, repair of the dissection of the M(1) segment, and improvement of the flow in the MCA. The patient was discharged from our hospital with no neurological deficits. Although the dissection in this case was spontaneously repaired, STA-MCA anastomosis was useful to get through a critical time. If the stenosis shows further progression or the infarction size enlarges, STA-MCA anastomosis may be effective.

This retrospective study investigated the correlations between red blood cell (RBC) count, hemoglobin, and hematocrit on admission, and mortality in 140 patients with subarachnoid hemorrhage (SAH). Correlations between the hematological parameters RBC count, hematocrit, hemoglobin, white blood cell (WBC) count, and platelet count on admission and mortality were investigated. Association of each variable with mortality was tested by univariate and multivariate logistic regression analysis. Univariate analysis showed that mortality was associated with RBC count, hematocrit, hemoglobin, and platelet count. Multivariate logistic regression analysis revealed hematocrit, WBC count, and platelet count were significant independent predictors for mortality after SAH. Hematocrit was a new significant predictor related to mortality in patients with SAH.

The relationship between subarachnoid hemorrhage (SAH) and chronic renal failure (CRF) remains unknown. We retrospectively reviewed 302 cases of SAH. Of these, 6 cases were diagnosed as CRF who needed hemodialysis. In the cases with hemodialysis, SAH of unknown origin was more frequent than in ordinary SAH cases (80.0% vs. 5.5%, P＜0.0001). No SAH occurred during hemodialysis. The frequency of SAH in the patients with hemodialysis seemed to have no relationship with the duration of hemodialysis. These results suggest that further investigation is needed to clarify the effect of hemodialysis on cerebral vessels, which may frequently lead to SAH of unknown origin.

We analyzed the outcome of patients over 80 years old with subarachnoid hemorrhage (SAH). We conducted a retrospectively evaluated the medical records and imaging studies of 49 patients treated with clipping, coiling or conservative therapy between January 2005 and December 2008. The patients were graded on admission, according to the World Federation of Neurological Surgeons (WFNS) grade, and modified Rankin Scale (mRS) at discharge. Forty-nine patients ranged from 80 to 94 (average 85.8). Seven patients were men. The WFNS grade on admission revealed that 14 patients were Grade 1, 8 Grade II, 4 Grade III, 6 Grade IV and 17 Grade V. Fourteen patients underwent surgical clipping, and 10 patients underwent coil embolization. Twenty-five patients recrived conservative therapy. The overall results evaluated as mRS at discharge were: 3 patients (6.1%) were mRS 0, 4 (8.2%) mRS 1, 4 (8.2%) mRS 2, 4 (8.2%) mRS 3, 10 (20.4%) mRS 4, 13 (26.5%) mRS 5, 12 (24.5%) mRS 6. While only 1 patient (4.2%) in the conservative group had a favorable outcome (mRS 0-3), 13 patients in the operative group (54.2%) had favorable outcomes: 8 patients (80.0%) who underwent coil embolization and 5 patients (35.7%) who underwent surgical clipping. Unfavorable outcomes were caused mainly by primary brain damage and symptomatic vasospasm. In elderly SAH patients, radical treatment of ruptured aneurysm is important to achieve a favorable outcome.

2005年10月，本邦でもrecombinant tissue plasminogen activater(rt-PA)の使用が認可され，急性期脳梗塞治療に効果を上げてきた．rt-PA投与後に脳出血を合併し重篤な予後を引き起こすことがあり，脳出血予測因子の特定が望まれている．今回，当施設において2006年3月から2009年11月までにrt-PAを投与した脳梗塞58症例を用い，脳出血合併の予測因子について検討した．NIHSS 4以上の増悪を伴った症候性脳出血は3例(5.2%)のみであった．無症候性を含め，投与後24時間以内にCTおよびMRI T2*で梗塞範囲に一致した出血性変化を伴った21症例(36.2%)を出血群として，残りの非出血群と後向きに比較した．出血群は非出血群に比べて投与前NIHSSが高く，DWI ASPECTSが低い傾向を認めた．また，MRAでの主幹動脈閉塞，部分的再開通を含めた再開通を認めた症例に脳出血合併を多く認めた．結果，rt-PA投与に際して新規梗塞の範囲が大きい程，出血の危険性が上がり，NIHSSやDWI ASPECTSは出血性変化の予測因子としても有用であることが示された．

OBJECTIVE: Chronic subdural hematoma (CSDH) is a common form of intracranial hemorrhage with a substantial recurrence rate. We focused on determining independent predictors associated with the recurrence of CSDH. METHODS: We retrospectively reviewed 343 consecutive surgical cases of CSDH. Univariate and multivariate analyses were performed to describe the relationships between recurrence of CSDH and factors such as sex, age, hypertension, diabetes mellitus, heart disease, cerebrovascular disease, atrial fibrillation, antiplatelet or anticoagulant therapy, and bilateral CSDH. RESULTS: Sixty-one patients experienced a recurrence of CSDH. Univariate and multivariate analyses found that bilateral CSDH was an independent risk factor for the recurrence of CSDH. Although antiplatelet and anticoagulant therapy had no significant effect on recurrence of CSDH, the time interval between the injury and the first operation for patients with antiplatelet and/or anticoagulant therapy was shorter than that for patients without it (29.9 versus 44.2 days). CONCLUSION: Bilateral CSDH was an independent predictor for the recurrence of CSDH. Antiplatelet or anticoagulant drugs might facilitate the growth of CSDH. These results may help to identify patients at high risk for the recurrence of CSDH.

Object The goal of this study was to evaluate the usefulness of long-axis black-blood MR (BB–MR) imaging for assessing plaque morphology and distribution in patients with atherosclerotic carotid artery (CA) stenosis. Methods Sixty-eight carotid arteries in 67 patients who were scheduled to undergo CA endarterectomy or CA stent placement due to atherosclerotic stenosis were included in this study. The patients had undergone CA BB–MR imaging and digital subtraction (DS) angiography within 3 weeks of revascularization. The DS angiography studies were performed using the transfemoral artery approach with selective common CA catheterization. The BB–MR images were acquired using a 1.5-T whole-body MR imaging unit, and T1-weighted images parallel to the long axis of the artery at 1-mm intervals were obtained. Plaque distribution was evaluated by measuring the distance between the CA bifurcation and the point that appeared to be the distal extent of the plaque on BB–MR imaging (D–MR imaging) and DS angiography images (D–DS angiography). Results Plaque distribution was clearly shown in 88.2% of the cases using long-axis BB–MR images, except for 8 arteries with poor image quality. In 4 arteries, D–DS angiography could not be obtained because the distal plaque end could not be confirmed. In 56 vessels, both the D–DS angiography and D–MR imaging could be measured; the mean D–MR imaging (19.75 ± 6.85 mm [standard deviation]) was significantly longer than the average D–DS angiography (16.32 ± 7.07 mm). Conclusions Long-axis BB–MR imaging can provide a noninvasive and accurate way to show CA plaque distribution; it is of great use not only for stroke risk assessment in patients with CA atherosclerosis but also for preoperative evaluation in patients requiring CA endarterectomy or CA stent placement.

Two patients presented with sudden onset of occlusive thrombosis of the atherosclerotic carotid artery. The patients underwent carotid endarterectomy. Histological examination of the specimens clearly showed the presence of pre-existing atherosclerotic plaque with moderate stenosis and occlusive organized thrombus. Blood flow was maintained through a honeycomb pattern of multiple neovascularization within the organized thrombus. These cases suggest that both the degree of stenosis and the plaque characteristics should be considered when evaluating the risk of stroke in patients with carotid artery stenosis.

We retrospectively evaluated computed tomographic angiography (CTA) as the first choice of imaging for diagnosing ruptured cerebral aneurysms among 219 consecutive patients with non-traumatic subarachnoid hemorrhage (SAH) at our hospital between January 2001 and December 2004. We found ruptured cerebral aneurysms in 203 patients, and the first diagnostic method was Digital Subtraction Angiography (DSA) in 34 patients and CTA in 169. Complementary DSA was indicated in 27 of the latter group (CTA+DSA group), and the remaining 142 patients (CTA group) were treated based solely on CTA findings. We found that 22% of the CTA+DSA group (n=6) and 4.9% of the CTA group (n=7) (P These findings indicated that the probability of misdiagnosing multiple aneurysms is higher when they are barely visible on CTA images, and thus physicians should strive to acquaint themselves with progress in diagnostic modalities and select the most appropriate strategy for individual patients with aneurysmal SAH.

Physostigmineの皮下投与は不妊治療における人工射精法の一つで，これまで比較的安全とされ広く普及している．今回われわれは31歳の頸椎損傷後の男性が不妊治療のためにphysostigmineを皮下投与された後に血圧が上昇し，脳出血を発症した1例を経験した．MRIや脳血管撮影等の精査で明らかな器質的出血源は認めず，physostigmine投与とその後の人工射精中に血圧上昇があったことが関与し脳出血を来したと考えた．Physostigmineはコリンエステラーゼ阻害剤で血圧変動を来す可能性があり，また，頸椎損傷後はさまざまな刺激で自律神経過反射を来しうるため特に注意が必要である．Physostigmine投与後の人工射精中には血圧管理を厳重に行い，高血圧を認めた場合には迅速な降圧を行い，頭痛や神経脱落症状を認めた場合には頭部CTによる出血除外が望ましいと考えられた．

A perfusion study should be performed during the balloon occlusion test (BOT) to prevent ischemic events after therapeutic carotid occlusion. We evaluated the efficacy of X-ray angiography perfusion analysis during the BOT.Twenty-one consecutive patients who underwent the BOT of the internal carotid artery were included. Patients who had a venous phase delay of less than .5 seconds and a mean stump pressure of more than 50 mm Hg without any neurologic symptoms were considered tolerant, and other patients were considered intolerant. A time-density curve was constructed for each hemisphere using X-ray angiography perfusion software (2D-Perfusion). The mean transit time and area under the curve, which correspond to cerebral blood volume, were calculated from the curve. Differences in these parameters between the occluded and nonoccluded hemispheres and the perfusion index were compared between the tolerant and intolerant groups.In the intolerant group, the mean transit time was significantly longer (1.31 ± .72 seconds versus .44 ± .21 seconds, P = .001) and the perfusion index was significantly lower (.72 ± .16 versus .94 ± .08, P = .001) compared with those in the tolerant group. The area under the curve was not different between the groups.Parameters obtained by X-ray angiography perfusion analysis were significantly different between the tolerant and intolerant groups. The X-ray angiography perfusion analysis could be a safe and effective method for assessing ischemic tolerance before therapeutic carotid occlusion.

BackgroundReduced cerebrovascular reserve (CVR) is associated with increased risk of ischemic events in carotid steno-occlusive diseases.ObjectiveTo determine whether pretreatment CVR can predict postoperative ischemic lesions after carotid artery stenting (CAS) by retrospective analysis.MethodsWe retrospectively reviewed the medical records of 46 patients (42 men; mean age 74.2±8.3 years) who underwent CAS and preprocedural cerebral blood flow measurement by quantitative single-photon emission CT. Ischemic lesions were evaluated by diffusion-weighted image (DWI) within 72 h after the intervention. We also evaluated plaque characteristics using black-blood MR plaque imaging.ResultsNew ipsilateral DWI-positive lesions were found in 11 cases (23.9%). Patients were classified into two groups based on the presence or absence of new DWI-positive lesions, and no significant differences in characteristics were found between the DWI-positive and DWI-negative groups, except for age and CVR of the ipsilateral middle cerebral artery (MCA) territory. The DWI-positive group was significantly older than the DWI-negative group (79.7±4.1 vs 72.5±8.6 years; p=0.0085) and had lower average regional CVR (1.4±18.2% vs 22.4±25.8%; p=0.016). MR plaque imaging showed no significant difference in relative overall plaque MR signal intensity between the two groups (1.53±0.37 vs 1.34±0.26; p=0.113). In multivariate logistic regression analysis, lower CVR of the ipsilateral MCA territory (ConclusionsImpaired pretreatment CVR was associated with increased incidence of new infarction after CAS.

Perimesencephalic nonaneurysmal subarachnoid hemorrhage (PNSAH) is a benign form of subarachnoid hemorrhage and is usually not associated with any focal deficit. We describe two rare cases of PNSAH with unilateral third cranial nerve palsy. Both patients were treated conservatively. The outcomes of our two cases were excellent. The third cranial nerve palsy resolved gradually in both patients, suggesting that the prognosis for third cranial nerve palsy concomitant with PNSAH is favorable. Unilateral third cranial nerve palsy may occur as the first clinical manifestation of PNSAH.

There is a lack of evidence to compare in-hospital mortality with different types of stroke. The purpose of this study was to elucidate the in-hospital mortality after acute ischemic/hemorrhagic stroke and compare the factors associated with the mortality among stroke subtypes. All patients admitted to Kurashiki Central Hospital in Japan between January 2009 and December 2009, and diagnosed with acute ischemic/hemorrhagic stroke were included in this study. Demographics and clinical data pertaining to the patients were obtained from their medical records. Out of 738 patients who had an acute stroke, 53 (7.2%) died in the hospital. The in-hospital mortality was significantly lower in the cerebral infarction group than in the intracerebral hemorrhage and subarachnoid hemorrhage group (3.5%, 15.1%, and 17.9%, respectively; P0.0001). Age was significantly lower in the subarachnoid hemorrhage group than in the other 2 groups. With regard to past history, diabetes mellitus was significantly found to be a complication in mortality cases of intracranial hemorrhage. Further investigation is needed to clarify the effect of diabetes on mortality after intracranial hemorrhage.

Variant deep cerebral venous drainage, primarily involving the basal vein of Rosenthal (BVR), may be a cause of idiopathic subarachnoid hemorrhage (SAH). In this study, deep venous drainage was compared between 13 patients with idiopathic SAH and 35 control patients with aneurysmal SAH diagnosed by digital subtraction angiography (DSA). Venous return was evaluated by DSA on 25 sides in patients with idiopathic SAH and 67 sides in patients with aneurysmal SAH, and the relationship between the BVR and the vein of Galen was classified into 3 categories: types A (normal continuous), B (normal discontinuous), and C (primitive variant). The occurrence rates of the three categories were: idiopathic SAH, type A 24%, type C 40%; and aneurysmal SAH, type A 49.3%, type C 10.4% (p = 0.003). Combined bilateral venous drainage was classified as normal combination (AA), discontinuous combination (AB, BB), and primitive combination (AC, BC, CC), with rates: idiopathic SAH, normal 0%, primitive 58.3%; and aneurysmal SAH, normal 42.4%, primitive 21.2%. Venous drainage on either the left or right side was more commonly type C (primitive) in idiopathic SAH (p = 0.006). Three patients with left-right differences in hematoma distribution on brain computed tomography had types A, B, and C on the SAH dominant side in one patient each. No clear trend was observed between hematoma distribution and primitive variant side. Some patients with idiopathic SAH had thick hematoma in the basal cistern. Further, 3 patients with idiopathic SAH had an aneurysmal pattern, rather than a perimesencephalic pattern. All these patients had type C either on the left or right side. Therefore, although the mechanism of involvement of venous drainage in idiopathic SAH is unknown, hemorrhage is not limited to a perimesencephalic pattern. The present findings support a previous hypothesis that variant venous drainage is involved in the occurrence of idiopathic SAH. The absence of a normal combination of venous drainage is an important factor to diagnose idiopathic SAH.

The genomic organization of Tcf23, the gene coding for mouse OUT, a basic helix-loop-helix transcription factor, was determined and its chromosome location was assigned to the A3 region of chromosome 5. By in silico searching, we further found the human counterpart of the mouse OUT gene (TCF23) in the draft human genome sequence and assigned it to 2p24→p23.

We retrospectively reviewed the mortality rate of the patients with subarachnoid hemorrhage (SAH) who received initial treatment in Kurashiki Central Hospital, for the 10-year period from 1999 through 2008. The overall mortality was 18.1% (120/662). The average fatality rate in such cases has shown a decreasing trend, from 24.2% in 1999-2002 to 15.9% in 2005-2008 (p=0.016). Transition in initial diagnostic modality from the time-consuming digital subtraction angiography to the less-invasive computed tomographic angiography, appropriate indication for the operation, and improvement in postoperative management might affect this decline in fatality cases.

The optimal therapeutic approach for chronic carotid occlusion with contralateral carotid stenosis (ICO-ICS) remains uncertain. The aim of this study was to elucidate the safety and efficacy of initial vascular reconstruction for ICS in patients with ICO-ICS.Eleven patients with ICO-ICS who demonstrated severe cerebral hypoperfusion in the hemisphere ipsilateral to ICO were treated in our institution between February 2003 and November 2007. Revascularization for ICS after measuring cerebral blood flow (CBF) by single photon emission computed tomography (SPECT) was performed either by carotid endarterectomy or carotid stenting. External carotid artery-internal carotid artery (EC-IC) bypass for ICO was also performed when SPECT after revascularization for ICS still demonstrated marked hypoperfusion.In 6 patients with collateral flow via the anterior communicating artery and/or who had high-grade ICS (70%), sufficient improvement of CBF solely by revascularization for ICS was confirmed. With regard to perioperative complications, 2 patients suffered bradycardia and hypotension and another 2 showed asymptomatic cerebral infarction on diffusion-weighted magnetic resonance imaging.Overall results for revascularization of ICS prior to that for ICO in patients with ICO-ICS were acceptable. CBF of bilateral hemispheres was sufficiently improved in more than half of the patients solely by revascularization for ICS. This strategy might be both efficient and effective for ICO-ICS.

The evaluation of plaque characteritics as well as the degree of luminal narrowing is important in the management of carotid stenosis. Several reports have shown that intraplaque hemorrhage (IPH), which plays a pivotal role in plaque vulnerability, emits high signal intensity on T1-weighted images of high-resolution black-blood (BB) MRIs. When an MRI is used to screen for vulnerable plaque, a short scanning duration and a simple MRI protocol are required. This study assessed the utility of screening BB-MRI to detect IPH. Ninety-three consecutive cases with atherosclerotic carotid stenosis scheduled for carotid endarterectomy (CEA) or carotid artery stenting between January 2005 and December 2007 were included. High-resolution BB-MRI scans were obtained with 2D double-inversion recovery fast spin-echo sequences with cardiac gating. Screening BB-MRIs were performed with 3D gradient-echo sequences suppressing blood flow signals by radiofrequency wave spatial saturation over the scanning field of 3D time-of-flight MRA. The relative overall plaque signal intensities with reference to the sternocleidomastoid muscle were calculated, and the correlation of intensities on T1-weighted images between high-resolution BB-MRI and screening BB-MRI was investigated. We excluded 50 cases because of restenosis following CEA, use of a pacemaker, a long interval (10 days) between high-resolution and screening BB-MRI examinations, or poor-quality images. Among the 43 cases included, the relative overall plaque signal intensity of high-resolution BB-MRI and screening BB-MRI were closely correlated (r = 0.568, p0.001). Screening BB-MRI can be an alternative to high-resolution BB-MRI in the assessment of IPH and may be a useful tool for detection of vulnerable plaque.

Recent diffusion-weighted imaging (DWI) studies describe a relevant ischemic lesion in almost half of all patients with transient ischemic attack (TIA). We report 3 cases of TIA in which the ischemic lesions were recognized on DWI at a later date ("late-imaged TIA"). Three men (average age, 72.7 years) were admitted to our hospital on complains of monoparesis or sensory disturbance in their right arms. On admission, no apparent ischemic lesion was detected by DWI; however, spotty lesions were apparent in the left precentral or postcentral gyrus on hospital days 2-5. The neurological symptoms resolved within 24 hours, and all the cases were clinically diagnosed as TIA. Carotid MRI revealed low-grade stenosis of the left internal carotid artery with atherosclerotic plaque, characterized as so-called "vulnerable plaque". These findings suggest that the carotid atherosclerotic plaque lead to artery-to-artery embolism. Carotid MRI is considered useful as an adjunct to other imaging modalities in the diagnosis of late-imaged TIA.

Background: A dural arteriovenous fistula in the falx cerebri is a relatively rare lesion, with only two cases reported till date. One was treated with direct surgery, and the other was followed-up conservatively. Advances in catheter design and embolic materials have made safe and curative transarterial embolization of dural arteriovenous fistulas possible in the current era. Case Description: We describe a 67-year-old man with left putaminal hemorrhage who was diagnosed with an arteriovenous fistula in the anterior part of the falx cerebri that was treated with curative transarterial glue embolization through the middle meningeal artery by using n-butyl cyanoacrylate. Conclusion: Although the procedure was safely performed, understanding the potential risks of the migration of embolic materials into the ophthalmic and anterior cerebral artery system is mandatory.

Management of atherosclerotic carotid arteries requires both plaque characterization and determination of the degree of stenosis, especially when carotid stenting (CAS) is being considered for severe carotid stenosis. Recent studies have demonstrated that high-resolution MRI can identify plaque components, such as the lipid-rich necrotic core, intraplaque hemorrhage, fibrous tissue, and the calcification present in human carotid atherosclerosis. The purpose of this study was to assess the feasibility of black blood MRI (BB-MRI) for accurately identifying the plaque components in vivo. Twenty-six consecutive patients scheduled for carotid endarterectomy (CEA) underwent a BB-MRI examination within 2 weeks before the surgical procedure using a 1.5-T Philips scanner with a protocol that generated 2 contrast weightings (T1 and T2). The MR images were acquired using cardiac gating to minimize motion artifact and fat suppression to reduce MR signals from subcutaneous fatty tissue. The plaque evaluations obtained by BB-MRI were compared with the intra-operative video recordings, the excised specimens, and the histological sections. With BB-MRI, the combination of the signal intensities in the T1- and T2-weighted images for each component (lipid deposits, intra-plaque hemorrhage, fibrous plaque, and calcification) showed findings that corresponded with the excised specimens. Complex morphological features could also be assessed by BB-MRI. BB-MRI is a useful method for noninvasively imaging and characterizing atherosclerotic carotid arteries. This MRI technique can provide valuable information that can be used to decide whether to perform a CEA or a CAS in patients with severe carotid stenosis. Furthermore, BB-MRI appears to be a useful tool for the investigation of the pathogenesis and natural history of carotid atherosclerosis.

Cell differentiation is an essential process for the development of various cell types that constitute multicellular organisms. During development, the large family of factors bearing a helix-loop-helix (HLH) motif participates profoundly in this process and these factors serve as good experimental tools for investigating mechanisms underlying tissue-specific differentiation. The HLH family includes both positive and negative regulators of cell differentiation: basic HLH (bHLH)-type transcription factors and Id proteins, respectively. Following an exciting decade focusing on bHLH factors, advances achieved in studies of the inhibitory factors in the last couple of years have placed them in the front line of the research on differentiation and proliferation control. Here, we present and discuss recent results obtained using Id2-deficient mice, which manifest intriguing phenotypes in various systems.

Transcription factors belonging to the basic helix-loop-helix (bHLH) family are involved in various cell differentiation processes. We report the isolation and functional characterization of a novel bHLH factor, termed OUT. OUT, structurally related to capsulin/epicardin/Pod-1 and ABF-1/musculin/MyoR, is expressed mainly in the adult mouse reproductive organs, such as the ovary, uterus, and testis, and is barely detectable in tissues of developing embryos. Physical association of OUT with the E protein was predicted from the primary structure of OUT and confirmed by co-immunoprecipitation. However, unlike other bHLH factors, this novel protein failed to bind E-box or N-box DNA sequences and inhibited DNA binding of homo- and heterodimers consisting of E12 and MyoD in gel mobility shift assays. In luciferase assays, OUT inhibited the induction of E-box-dependent transactivation by MyoD-E12 heterodimers. Deletion studies identified the domain responsible for the inhibitory action of OUT in its bHLH and C-terminal regions. Moreover, terminal differentiation of C2C12 myoblasts was inhibited by exogenous introduction of OUT. These inhibitory functions of OUT closely resemble those of the helix-loop-helix inhibitor Id proteins. Based on these findings, we propose that this novel protein functions as a negative regulator of bHLH factors through the formation of a functionally inactive heterodimeric complex.

tal-1 (T-cell acute leukemia-1; also known as SCL) and tal-2 genes belong to a family of basic helix–loop–helix transcription factors and were originally isolated from the breakpoints of chromosomal translocations in human T-cell leukemia cell lines. tal-1 is expressed not only in hematopoietic cells but also in several endothelial structures and the central nervous system during development. On the other hand, the detailed function and the sites of expression of tal-2 have remained obscure. We cloned the tal-2 cDNA from a mouse embryonic cDNA library and examined its expression pattern in the mouse, comparing with that of tal-1. In situ analyses revealed that tal-2 transcripts are detected at embryonic day 12.5 in the following regions; 1) the diencephalon—the zona limitans intrathalamica and the pretectum, 2) the mesencephalon—the tectum, and the anterior and posterior tegmentum, 3) the metencephalon—the isthmus and the anterior pons. In the diencephalon and the mesencephalon, the expression sites of tal-2 gene were similar to those of tal-1, and its expression was stronger than that of tal-1. In the metencephalon, tal-2 expression was observed in the anterior pons, whereas tal-1 transcripts were detected in the entire pons, and showed stronger expression than tal-2. The tal-2 messages were barely detectable in the brain at birth. These results suggest that tal-1 and tal-2 are involved in the development of specific areas of the central nervous system.