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Decreased cell-mediated immunity can reactivate Varicella zoster virus (VZV), which can lead to various neurological complications, including vasculopathy. We herein report the case of a patient with acute stroke with progressive internal carotid artery stenosis due to VZV vasculopathy after chemotherapy for malignant lymphoma. Treatment for VZV vasculopathy improved the stenosis and prevented recurrent stroke. VZV vasculopathy is an important treatable cause of stroke in immunosuppressed patients.

Background Limited data are available regarding the predictors, clinical relevance, and bleeding rate by surgical devices of intracranial hemorrhage after endovascular thrombectomy. This is partially explained by the difference in the classification and definition of hemorrhage among studies. The purpose of this study was to identify the predictors of hemorrhagic transformation and isolated subarachnoid hemorrhage after endovascular thrombectomy. Methods This was a retrospective, multicenter observational cohort study of consecutive patients who underwent endovascular thrombectomy between January 2015 and December 2018. Univariate and logistic regression analyses were performed to determine the predictors, the impact on clinical outcomes, and the bleeding rate by surgical devices of hemorrhagic transformation and isolated subarachnoid hemorrhage. Results Among 610 eligible patients, hemorrhagic transformations occurred in 93 (15.2%). Fourteen patients (2.3%) were classified as having symptomatic intracranial hemorrhage. Isolated subarachnoid hemorrhage was found in 60 (9.8%) patients. In the logistic regression analyses, diabetes mellitus (odds ratio: 1.92; 95% confidence interval: 1.06–3.49) was associated with hemorrhagic transformation, and the number of device passes (odds ratio: 1.33; 95% confidence interval: 1.11–1.59) was associated with isolated subarachnoid hemorrhage. Both hemorrhagic transformation and isolated subarachnoid hemorrhage were associated with poor 90-day functional outcomes. There was a significant correlation between treatment with stent retrievers and isolated subarachnoid hemorrhage. Conclusions Patients with diabetes mellitus were vulnerable to hemorrhagic transformation, whereas those who underwent several attempts of thrombectomy were susceptible to isolated subarachnoid hemorrhage. Both hemorrhage types worsened the functional outcome. Treatment with the stent retriever was significantly associated with postprocedural isolated subarachnoid hemorrhage.

We herein reported a patient with acute ischemic stroke in the bilateral medial medullary and the left tegmentum of the pons who presented with various neurological symptoms. Fusing digital subtraction angiography (DSA) and MRI (DSA-MR fusion imaging) could reveal the infarct-relevant arteries. A 41-year-old male presented with headache, bilateral arm's dysesthesia, quadriplegia, left Horner's syndrome, upbeat nystagmus, internuclear ophthalmoplegia and left peripheral facial paralysis. Diffusion weighted MRI (DWI) revealed the high intensity lesion in the bilateral medial medullary and the left tegmentum of the pons. MRA showed right vertebral artery (VA) occlusion. A high intensity on T1 weighted imaging was shown on the right VA vessel wall. DSA-MR fusion imaging revealed the anterior spinal artery (ASA) occlusion proximal to the infarction. The stenosis was located at the origin of the right VA perforating branch distributing into the infarct lesion. The steno-occlusive lesion of ASA and VA perforating branch due to VA dissection resulted in infarction in the pontomedullary junction and caused various neurological symptoms. DSA-MR fusion imaging would prove the radiological anatomy of infarct-relevant arteries and clarify the etiology of ischemic stroke.

The Tama-REgistry of Acute endovascular Thrombectomy (TREAT) is a multicenter registry of endovascular thrombectomy in the Tama area of Tokyo. The objective of this study was to confirm the real-world status of 2 paradigms of transportation.This was a retrospective analysis of data from TREAT. Patients were divided into 2 groups and 2 periods: directly admitted to an endovascular thrombectomy-capable center (ECC; group D)/secondary transfer from a non-ECC (group S), and the first period/the second period. Transfer distance, workflow metrics, and clinical outcomes were analyzed.A total of 326 patients, including 264 in group D and 62 in group S, were analyzed. The median distance from the onset-to-ECC was 3.62km for group D and 7.87km for group S (P.001). The median onset-to-needle (OTN) time was longer for group S (168 minutes) than group D (138 minutes; P = .006). The median onset-to-reperfusion (OTR) time was significantly shorter for group D (247 minutes) than for group S (304 minutes; P = .029). With respect to the 2 periods, there was no significant difference in onset-to-puncture time between the 2 groups in the first period (207 minutes versus 243.5 minutes, respectively, P = .50), while there was one in the second period (164 minutes versus 246.5 minutes, respectively, P = .02).This region-wide registry study showed longer OTN and OTR times, with no improvement of the time course over time in patients transported via non-ECCs. These results should be used to create a regional medical policy for the management of acute ischemic stroke.

Background Although, thrombectomy for stroke more than 6 hours after onset supported by automated perfusion computed tomography (CT) software (RAPID, iSchemaView) is effective, this software is not available in Japan. This study aimed to elucidate the efficacy of thrombectomy 6-24 hours after onset in our patient cohort using conventional imaging mismatch. Methods Of 586 ischemic stroke patients who underwent thrombectomy registered from January 2015 to December 2017, patients with occlusion of the intracranial internal carotid artery or middle cerebral artery, who had last been known to be well 6-24 hours earlier and who had a prestroke modified Rankin scale (mRS) score 0 or 1 were enrolled. Clinical outcomes were the scores of the utility-weighted (UW) mRS, which ranges from 0 (death) to 10 (no symptom or disability), and the rate of functional independence (mRS score of 0-2) at 90 days. Results This study sample included 31 patients. The median baseline National Institutes of Health Stroke Scale score was 17 (interquartile range [IQR], 13-20), and the median Diffusion-Weighted Imaging-Alberta Stroke Program Early CT Score was 7 (IQR, 5-8). The median interval between the time that the patient was last known well and revascularization was 741 (IQR, 641-818) minutes. The mean UW mRS score at 90 days was 5.3, the rate of functional independence was 32%, and the 90-day mortality rate was 13%. Conclusions Thrombectomy 6-24 hours after onset which can be performed with conventional imaging mismatch might be secured for improving functional independence in stroke patients.

Background Anticoagulation therapy, particularly subcutaneous heparin therapy, is recommended for cancer-associated thrombosis. However, not starting or discontinuing anticoagulation was not rare. The aim of the present study was to examine the practical issues related to anticoagulation therapy and effects of subcutaneous heparin therapy for cancer-associated stroke. Methods Patients with cancer-associated stroke in our stroke center between October 2014 and August 2017 who were diagnosed as having acute ischemic stroke based on diffusion-weighted imaging were retrospectively enrolled. Baseline clinical characteristics, heparin injection, reasons for no subcutaneous heparin therapy, and clinical outcomes were collected. Results A total of 59 patients with cancer-associated stroke (75 ± 10 years old, male 42%) were enrolled. Lung cancer was the most frequently observed cancer (n = 17, 29%), followed by gastric cancer (n = 8, 14%) and pancreatic cancer (n = 8, 14%). Of the 19 patients (32%) who underwent subcutaneous heparin therapy, it was discontinued in 9 (47%), mainly because of patients’ medical conditions (deterioration of cancer or hemorrhagic complication). Ten patients with long-term subcutaneous heparin therapy did not have stroke recurrence. In contrast, among nine patients who discontinued subcutaneous heparin therapy, three (33%) had recurrence of ischemic stroke. Of the 40 patients without subcutaneous heparin therapy, the main reasons for no subcutaneous heparin therapy were the patients’ medical conditions (n = 22, 55%). Conclusions Although subcutaneous heparin therapy was given to only one third of cancer-associated stroke patients, long-term subcutaneous heparin therapy might prevent recurrence of cancer-associated stroke.

Thrombectomy has demonstrated clinical efficacy against acute ischemic stroke caused by intracranial occlusion of the internal carotid artery (ICA), even if performed 6–24 h after onset. This study investigated the outcomes of thrombectomy performed 6–24 h after stroke onset caused by extracranial ICA occlusion. Of 586 stroke patients receiving thrombectomy during the past 3 years and registered in the Tama Registry of Acute Endovascular Thrombectomy database, 24 were identified with ICA occlusion (14 extracranial and 10 intracranial), known to be well 6–24 h before presentation, and with pre-stroke modified Rankin Scale (mRS) score of 0 or 1. Clinical outcomes measured were the rate of functional independence at 90 days according to mRS score of 0–2 and 90 day mortality rate. Of patients with extracranial ICA occlusion, two received additional carotid stenting with thrombectomy. The median interval between the last time the patient was known to be well and hospital arrival was 601 (interquartile range, 476–729 min). Both the rate of functional independence at 90 days and 90 day mortality were comparable between patients with extracranial or intracranial ICA occlusion (36% vs. 40% and 7% vs. 10%, respectively). No symptomatic intracranial hemorrhages occurred within 24 h following treatment of extracranial ICA occlusion. Thrombectomy performed 6–24 h after extracranial ICA results in acceptable functional outcome. Further clinical study is warranted to better define the temporal window of thrombectomy for acceptable functional outcome in patients with extracranial ICA occlusion.

BackgroundDuring the COVID-19 pandemic, decreased volumes of stroke admissions and mechanical thrombectomy were reported. The study’s objective was to examine whether subarachnoid haemorrhage (SAH) hospitalisations and ruptured aneurysm coiling interventions demonstrated similar declines.MethodsWe conducted a cross-sectional, retrospective, observational study across 6 continents, 37 countries and 140 comprehensive stroke centres. Patients with the diagnosis of SAH, aneurysmal SAH, ruptured aneurysm coiling interventions and COVID-19 were identified by prospective aneurysm databases or by International Classification of Diseases, 10th Revision, codes. The 3-month cumulative volume, monthly volumes for SAH hospitalisations and ruptured aneurysm coiling procedures were compared for the period before (1 year and immediately before) and during the pandemic, defined as 1 March–31 May 2020. The prior 1-year control period (1 March–31 May 2019) was obtained to account for seasonal variation.FindingsThere was a significant decline in SAH hospitalisations, with 2044 admissions in the 3 months immediately before and 1585 admissions during the pandemic, representing a relative decline of 22.5% (95% CI −24.3% to −20.7%, pInterpretationThere was a relative decrease in the volume of SAH hospitalisations, aneurysmal SAH hospitalisations and ruptured aneurysm embolisations during the COVID-19 pandemic. These findings in SAH are consistent with a decrease in other emergencies, such as stroke and myocardial infarction.

Introduction: Stroke is a relatively common in hospitalized patients. However, previous studies have shown delays in recognition and initial assessment of in-hospital stroke. We aimed to elucidate that reorganization of in-hospital stroke code protocol can improve process of acute stroke care and save the treatment time. Methods: Our reorganization of in-hospital stroke code comprises the development of in-hospital stroke code protocol and workshop for hospital medical staff. Before the intervention, if the medical staff identified patients with suspected stroke, they first contacted the attending physician, then the physician consulted the stroke neurologists immediately or after imaging. After the intervention, to quickly identify stroke patients, the medical staff can directly consult stroke neurologists when they identified patients with at least one of acute-onset symptoms, including face droop, arm drift, speech disturbance, eye deviation, aphasia, or neglect, within 6-hour from last seen well or stroke recognition. As an educational intervention, we held workshop for nurses and residents with an understanding of how to evaluate stroke symptoms, use the protocol, and manage stroke. Data were compared between 24-month period before and 12-month period after the intervention. Outcome measure included the time from stroke recognition to initial imaging, and evaluation by stroke neurologist, and from initial imaging to groin puncture. Results: One hundred four patients were included (before, 42; after, 62). Significant time savings were seen in the median time from stroke recognition to evaluation by stroke neurologist (91 vs. 56 minutes, p=0.015), and time from initial imaging to groin puncture (113 vs. 68, p=0.040). The rate of consultation to stroke neurologists before initial imaging was significantly increased (21% vs. 47%, p=0.012). The time from stroke recognition (234 vs. 103, p=0.126), and evaluation by stroke neurologist (135 vs. 81, p=0.056) to groin puncture tended to decrease. Conclusion: Reorganization of in-hospital stroke code protocol can improve the time for initial management of in-hospital stroke.

Background: Mechanical thrombectomy (MT) has become the standard of care for acute ischemic stroke with large vessel occlusion; however, evidence remains insufficient for MT for elderly patients, especially with respect to factors affecting their outcomes. Methods: This study was a retrospective analysis of a multicenter registry of MT, called Tama Registry of Acute Endovascular Thrombectomy. Patients were divided by their age into 2 groups: Nonelderly (NE; < 80) and elderly (E; ≥80). Factors related to a good outcome (modified Rankin scale score ≤2) were examined in each group. Onset to reperfusion time (OTR) was stratified into 4 categories: category 1, 0 – ≤180 min; category 2, > 180 – ≤360 min; category 3, > 360 min or onset time not identified; and category 4, effective recanalization not achievable. Results: 143 NE patients and 78 E patients were included in this study. The E group had less chance of achieving a good outcome (NE group 51%, E group 35%; p = 0.024). In the NE group, lower OTR category was an independent prognostic factor for good outcome (p = 0.037, OR = 1.09). However, in the E group, OTR category was not a significant predictor on multivariate analysis. Instead, effective recanalization (p = 0.0081, OR 1.40) and lower National Institute of Health Stroke Scale score at presentation (p = 0.0032, OR 1.02) were the independent predictors. Conclusions: In MT for elderly patients, effective recanalization improved the patients’ outcome but OTR affected less. Further studies are warranted to establish the appropriate patient selection and treatment strategies.

Objective: Due to the recent increase in the availability of cone-beam CT (CBCT), delineation of blood vessels and intracranial stents using CBCT has been well-reported, but reports using 3D-rotational angiography (3D-RA) have been few. We evaluated delineation of carotid artery stents using 3D-RA with diluted contrast medium. Methods: We prepared simulated blood vessel phantoms covered by carotid artery stents different in material and shape. The phantoms were encapsulated with different concentration of contrast medium, and scanned using 3D-RA. The appropriate concentration of contrast medium was evaluated. Results: The appropriate concentrations of diluted contrast medium were 50–17% for the Carotid Wall Stent (Boston Scientific, Natick, MA, USA) and 20%–10% for PRECISE (Johnson & Johnson, Miami, FL, USA) and PROTÉGÉ (Covidien, Irvine, CA, USA). Conclusion: The appropriate concentration of contrast medium varied with carotid artery stent. By selecting an appropriate degree of dilution, the stent shape, plaque, intimal thickening, and vascular lumen in the stent can be visualized. Therefore, it is possible to evaluate vascular lumen after carotid artery stenting.

Characterization of vessels distal from occluded site is important when considering endovascular revascularization therapy (EVT) for acute ischemic stroke. The goal of this study was to assess the clinical value of intra-arterial contrasted high-resolution cone-beam computed tomography from the ascending aorta (Ao-CBCT) for visualization of the vessels distal from occluded site. Acute ischemic stroke patients with large vessel occlusion who were to undergo EVT were evaluated. In EVT, digital subtraction angiography (DSA) and Ao-CBCT were performed with local anesthesia. Ao-CBCT images were acquired in a 20-second rotational scan. Contrast medium was injected (1 mL/s for a total of 30 seconds using a 4-Fr catheter and an imaging delay of 10 seconds) from the ascending aorta. We assessed the image quality of Ao-CBCT and compared the visualization of the vessels distal from occluded site among magnetic resonance angiography (MRA), DSA and Ao-CBCT. We analyzed 14 patients (mean age, 66 years; three female patients). Stroke subtypes were cardiogenic (n = 6), atherothrombotic (n = 5) and others/unknown (n = 3). Occluded sites were middle cerebral artery (MCA) M1 (n = 8), MCA M2 (n = 2), internal carotid artery (ICA) (n = 2), MCA M4 (n = 1) and basilar artery (BA) (n = 1). All obtained Ao-CBCT images successfully characterized the vessels distal from occluded site, and 11 images (79%) were excellent. In all cases, Ao-CBCT images could depict distal vessels with more detail when compared with MRA and DSA. Ao-CBCT is an efficient method to obtain detailed information regarding vessels distal from occluded site when compared with conventional examination methods.

Background The functional prognosis of patients with carotid T occlusion is poor, but few comprehensive studies have investigated carotid non-T occlusion, in which the terminal internal carotid artery portion is unobstructed. We aimed to elucidate the clinical features of carotid non-T occlusion by comparing patients with acute carotid T occlusion and carotid non-T occlusion. Methods Among 362 patients who underwent thrombectomy between January 2015 and June 2018, 20 and 61 were diagnosed with carotid non-T occlusion and carotid T occlusion, respectively. We compared preoperative clinical findings, treatment strategies, treatment complications and functional outcomes between the two groups. Results Age, sex, preoperative National Institutes of Health stroke scale, cerebral infarction subtypes and medical history did not significantly differ. In contrast, preoperative diffusion-weighted imaging–Alberta Stroke Program early computed tomography scores were 9 (1–11) and 6.5 (0–11) for the carotid non-T occlusion and carotid T occlusion groups, respectively ( P = 0.015). The duration of treatment or the median number of passes (2.5 vs. 2.0), the numbers of patients with thrombolysis in cerebral infarction 2b/3, bleeding complications and modified Rankin scale scores of 0–2 on postoperative day 90 did not significantly differ between the two groups. Manual aspiration before, internal carotid artery arrest while crossing a lesion and injection into the contralateral side were significantly more frequent in patients with carotid non-T occlusion. Intracranial internal carotid artery stenosis was significantly more frequent in patients with carotid non-T occlusion ( n = 4, 20%) than carotid T occlusion ( n = 0), and 10% of patients with carotid non-T occlusion had arterial dissection. Conclusion Patients with carotid non-T occlusion more frequently had a background of intracranial internal carotid artery stenosis or arterial dissection than patients with carotid T occlusion. Specific treatment strategies should be developed to improve the clinical outcomes of patients with carotid non-T occlusion.

The efficacy of mechanical thrombectomy in the treatment of occlusions of the second segment of the middle cerebral artery (M2) has not been firmly established. This study analyzed data from patients who had undergone mechanical thrombectomy for the first segment of the middle cerebral artery (M1) and M2 occlusion from the Tama-REgistry of Acute endovascular Thrombectomy (TREAT) between January 2015 and March 2017, which is a multicenter database in the Tama area of Tokyo, Japan. The M1 and M2 occlusions were compared in order to evaluate the safety and efficacy of M2 thrombectomy. A total of 515 patients were registered, whereby 160 patients with M1 occlusion and 51 patients with M2 occlusion were included. While the puncture-to-reperfusion time was longer in the M2 occlusions (median 43 min, range 30–61 min vs. median 60 min, range 38–79 min, p = 0.01), no significant differences were seen in the proportion of patients with successful reperfusion, postoperative hemorrhagic complications and good outcome (modified Rankin scale ≤2 at 90 days). Younger age was the only independent factor associated with good outcome in patients with M2 occlusions as determined by the multivariate analysis (p = 0.033, odds ratio 0.91, 95% confidence interval 0.83–0.99). The outcome and the safety profile of mechanical thrombectomy for M2 occlusions are favorable and comparable to those of the M1 occlusion thrombectomy.

Objective The effectiveness of mechanical thrombectomy (MT) for acute basilar artery occlusion (ABAO) remains unknown. We evaluated the feasibility, safety, and efficacy of endovascular treatment for ABAO. Methods We retrospectively investigated patients with ABAO who underwent MT, using modern stent retrievers and an aspiration device, between January 2015 and December 2017 at 12 comprehensive stroke centers. Functional outcomes and 90-day mortality were analyzed as primary outcomes. Results Forty-eight patients were included. Good outcome (modified Rankin Scale mRS 0–2) was achieved in 20/48 patients and the all-cause 90-day mortality rate was 25%. Successful recanalization (modified Thrombolysis In Cerebral Infarction [mTICI] grade 2b and 3) was achieved in 47/48 patients. National Institutes of Health Stroke Scale, posterior circulation Alberta Stroke Program Early CT Score (pc-ASPECTS), DWI Brain Stem Score, mTICI (3 > 2b), and intracranial hemorrhage were significantly different between good and poor functional outcome groups. The occlusion site of BA was significantly different between patients with moderate outcome (mRS 0–3) versus others. We found that age, pc-ASPECTS and mTICI were significantly associated with functional outcomes in the logistic regression model. Conclusion MT with stent retrievers and an aspiration device for ABAO results in high successful recanalization and good outcomes. Further studies are required to confirm our results.

Background: The functional independence measure (FIM) is a standard tool to provide a detailed evaluation of ADL of patients with disabilities. This study aimed to show the differences in FIM scores as an outcome predictor between patients with anterior circulation (AC) and posterior circulation (PC) strokes. Methods: Consecutive patients with acute ischemic stroke hospitalized within 7 days after onset were investigated. Baseline NIHSS scores, 1st-FIM (< 72 h after ­admission to stroke unit), 2nd-FIM (< 72 h before discharge), and modified Rankin Scale (mRS) scores were collected. Logistic regression analyses were used to identify predictors of a favorable outcome (mRS 0–2) at 3-month after stroke. Results: Three hundred eighty-five patients (median age, 78 years; male, 59%; median length of stroke unit stay, 20 days) were included. The median baseline NIHSS, 1st- and 2nd-FIM scores were 4 (interquartile range 2–9), 65 (33–91), and 98 (54–122) respectively. Baseline NIHSS (3 vs. 4, p = 0.01) and mRS score at 3-month (1 vs. 2, p = 0.01) were lower, and 1st-FIM (75 vs. 64, p < 0.01) and 2nd-FIM (113 vs. 95, p = 0.01) were higher in 82 patients with PC than 303 patients with AC strokes. On multivariate logistic regression analysis, 2nd-FIM score was an independent predictor of favorable outcomes in both PC (OR 1.18, 95% CI 1.04–1.48, p < 0.01) and AC (OR 1.12, 95% CI 1.06–1.20, p < 0.01) strokes. The optimal cutoff scores of 2nd-FIM for predicting favorable outcome were 104 for PC (sensitivity 0.82, specificity 0.88) and 93 for AC (0.88–0.90) strokes. Conclusions: The differences in outcome predictability by FIM score between AC and PC strokes should be considered, although FIM scores at discharge from stroke unit were useful to predict a favorable outcome.

OBJECTIVE The importance of a framing coil (FC)—the first coil inserted into an aneurysm during endovascular coiling, also called a lead coil or a first coil—is recognized, but its impact on long-term outcomes, including recanalization and retreatment, is not well established. The purposes of this study were to test the hypothesis that the FC is a significant factor for aneurysmal recurrence and to provide some insights on appropriate FC selection. METHODS The authors retrospectively reviewed endovascular coiling for 280 unruptured intracranial aneurysms and gathered data on age, sex, aneurysm location, aneurysm morphology, maximal size, neck width, adjunctive techniques, recanalization, retreatment, follow-up periods, total volume packing density (VPD), volume packing density of the FC, and framing coil percentage (FCP; the percentage of FC volume in total coil volume) to clarify the associated factors for aneurysmal recurrence. RESULTS Of 236 aneurysms included in this study, 33 (14.0%) had recanalization, and 18 (7.6%) needed retreatment during a mean follow-up period of 37.7 ± 16.1 months. In multivariate analysis, aneurysm size (odds ratio [OR] = 1.29, p < 0.001), FCP < 32% (OR 3.54, p = 0.009), and VPD < 25% (OR 2.96, p = 0.015) were significantly associated with recanalization, while aneurysm size (OR 1.25, p < 0.001) and FCP < 32% (OR 6.91, p = 0.017) were significant predictors of retreatment. VPD as a continuous value or VPD with any cutoff value could not predict retreatment with statistical significance in multivariate analysis. CONCLUSIONS FCP, which is equal to the FC volume as a percentage of the total coil volume and is unaffected by the morphology of the aneurysm or the measurement error in aneurysm length, width, or height, is a novel predictor of recanalization and retreatment and is more significantly predictive of retreatment than VPD. To select FCs large enough to meet the condition of FCP ≥ 32% is a potential relevant factor for better long-term outcomes. These findings support our hypothesis that the FC is a significant factor for aneurysmal recurrence.

Two cases with ruptured vertebral artery (VA) dissection involving the origin of the posterior inferior cerebellar artery (PICA) are presented. Endovascular proximal occlusion of the dissected segment proximal to the PICA origin was performed, leaving the PICA patent in the acute stage. Stent placement from the PICA to the VA through the contralateral VA and coil embolization were added to the residual dissection in the chronic stage. Rebleedings were not observed. This is the first report of a staged, combined strategy for the treatment of a ruptured PICA involving VA dissection, which enabled preservation of the PICA without bypass surgery.

The adoption of stent retrievers has significantly improved outcomes of intravenous treatment for acute stroke due to major artery occlusion, and reducing the time to recanalization may achieve further improvements. We reviewed reductions in “door-to-needle time” (DNT) and “picture-to-puncture time” (P2P), as the results of measures to consolidate stroke response capabilities in our hospital, and compared treatment outcomes in acute recanalization patients. We investigated DNT by the route of admission for 96 consecutive patients who received intravenous tissue plasminogen activator between July 2012 and June 2015. We then retrospectively studied 52 patients with acute stroke who underwent endovascular recanalization within 8 h after stroke onset, grouped according to recanalization before (Group I; n = 23) or after (Group II; n = 29) introduction of stent retrievers. Between 2012 and 2015, mean DNT decreased. Significant differences between Groups I and II were only seen in times required, with significantly shorter DNT, picture-to-puncture time, admission to puncture time, and puncture to guiding catheter placement time in Group II. A considerable difference in DNT was seen according to the route of patient admission, and consolidation of hospital stroke response capability successfully reduced the time from admission to recanalization.

Objective It is not clear how patients with large vessel occlusion (LVO) who have undergone mechanical thrombectomy (MT) were transported to hospitals by emergency medical services. Here, we describe the current status of the stroke delivery system in a large city. Methods We investigated data from 328 patients (male, n = 199; average age, 74.8 ± 12.9 years) who underwent MT at 12 facilities in the Tama area of Tokyo, between January 2015 and December 2017. The patients were classified according to the destination institution as Stroke A eligible (group A, n = 266 [8.2%]), Tertiary critical care center (group T; n = 35 [10.7%]), and other destinations such as emergency rooms (group O; n = 27 [8.2%]), and then reasons for using Emergency Medical Service (EMS) services and outcomes were compared among the groups. Results Rates of milder stroke, and middle cerebral artery occlusion were significantly higher in group A than T, whereas that of vertebral-basilar artery occlusion was significantly lower in group A than in groups T and O. The amount of elapsed time from door to picture (DTP) was significantly lower in group A. The time from onset to recanalization, as well as rates of successful recanalization and favorable outcomes (90-day modified Rankin scale 0-2) did not significantly differ regardless of destination. Conclusions Most patients with LVO in the Tama area were categorized into group A. DTP was significantly lower in group A.

OBJECTIVE Maximal safe resection is a standard of care (SOC) for treatment of malignant glioma in light of quality of life (QOL) maintenance and better outcomes. This strategy is especially important when vital perforating arteries such as lateral striate arteries (LSA) and anterior choroidal arteries,are involved in tumor and its periphery,as their damage causes serious deterioration in the activities of daily life. Here we report a utility of preoperative cerebral angiography in glioma surgery. METHODS Six cases of perforator-involving malignant gliomas, consisting of five glioblastomas and one anaplastic ganglioma, operated from December 2018 to July 2019 were evaluated with preoperative imaging using sophisticated cerebral angiographic techniques and fusion imaging with MRI. RESULTS In all six cases, perforating arteries passed through or around the tumors. The cerebral angiography revealed the origin of LSA in all patients; one at M1,two at M1-M1 junction, and three at the superior trunk of M2. Anterior choroidal arteries and Heubner’s recurrent arteries were also identified preoperatively. By knowing the precise locations of these perforators,intraoperative resection of vascular-rich malignant gliomas could be performed with precaution of avoiding their unnecessary injury. No symptomatic complications occurred after angiography. Postoperative MRI disclosed a potential embolic infarction in the perforator territory in one patient,which resolved in a few days. CONCLUSIONS Visualization of perforators by angiography was helpful in detailed evaluation of surgical strategy and facilitated safe resection also leading to shortening of operating time. Compared to another modalities,angiography provided the best special resolution for visualization of vital perforating arteries involved in malignant gliomas.

Background and Purpose To improve results of acute thrombectomy, the time from stroke onset to efficient recanalization must be minimized. Studies have confirmed the importance of rapid treatment, workflow, and efficient team-based care for acute thrombectomy in large vessel occlusion. This study examined the challenges facing mechanical thrombectomy in the Tama area (population, 4.3 million), a densely populated urban area of Tokyo, Japan, and analyzed retrospective data from the Tama-REgistry of Acute endovascular Thrombectomy. Methods This study was a retrospective observational study using data from Tama-REgistry of Acute endovascular Thrombectomy, a multicenter registry of mechanical thrombectomy for acute ischemic stroke in the Tama area of Tokyo. The survey covered 396 patients with large vessel occlusion who underwent acute thrombectomy between January 2015 and March 2017. Participating facilities are 12 of the 13 recanalization therapy-capable stroke centers. Results We analyzed 326 cases for which modified Rankin Scale score at 90days was available, of which 264 cases were directly admitted, and 62 cases were transferred from other stroke centers. Median time from stroke onset to hospital arrival was 111 minutes, and from arrival to efficient recanalization was 135 minutes. Efficient recanalization was achieved in 257 cases (78.8%), symptomatic hemorrhage developed in 19 cases (5.8%), and modified Rankin Scale 0-2 at 90days was seen in 129 cases (39.6%). The vast majority of patients (n = 299, 94.3%) were transferred within 10km to the enrolling hospital. Conclusions These results provide useful information about the emergent transfer system for patients with large vessel occlusion in a densely populated urban area.

Background and Purpose: In patients with emergent large vessel occlusion (ELVO), fluid-attenuated inversion recovery (FLAIR) hyperintense vessel (FHV) has been linked to cerebral hypoperfusion. However, the association between FHV and infarction lesion after successful recanalization by endovascular thrombectomy (ET) remains unknown. In this study, we investigated the relationship baseline FHV and baseline or post-ET diffusion weighted imaging (DWI) positive lesions. Methods: From April 2012 to August 2016, fifty-nine patients were received ET for ELVO of the anterior circulation. We included twenty-five patients of them who obtained successful (Thrombolysis In Cerebral Infarction score 2b/3) recanalization of ICA or M1 occlusion. All patients had DWI before and after ET and FLAIR before ET. Infarct lesions and FHV were evaluated in seven cortical lesions which divided according to cortical area of Alberta Stroke Program Early CT (ASPECT) scoring (I, M1-M6). The association between baseline or post-ET DWI positive and baseline FHV was analyzed in each one hundred seventy-five lesions. Results: DWI positive lesions were present in 65/171 (37%) and 108/175 (62%) lesions on baseline and post-ET DWI, respectively. FHV was present in 89/175 (51%) lesions on baseline FLAIR. Baseline DWI positive lesion was significantly higher at FHV positive lesion than FHV negative lesion (FHV (+) vs. FHV (-): 56% vs. 17%, p Conclusion: Baseline FHV positive lesions have already been infarcted before ET and likely to become infarction after successful recanalization compared to FHV negative lesion. Because FHV positive lesion became infarct despite early successful recanalization, FHV seemed to suggest severe hypoperfusion.

Background and Purpose: Modified Rankin scale (mRS) score at 3-month after onset is widely used as clinical outcomes in stroke patients. Functional Independence Measure (FIM) is a valid tool to estimate the level of ADL. However, there were few studies whether FIM score in acute stroke patients can predict clinical outcomes at 3-month. Our aim is to reveal that FIM scores of acute stroke patients can predict favorable outcome (mRS 0-1 at 3-month). Method: We used data from a prospectively collected observational registry in single stroke center between January 2016 and March 2017. Baseline NIHSS score, acute FIM score (=within 3 days from admission to the stroke unit), discharge FIM score (=at discharge from the stroke unit), and mRS score (before stroke, at 3-month) were collected. The relationship between discharge FIM score and mRS score at 3-month were examined using Spearman’s rank correlation test. Logistic regression analyses were used to reveal the predictors of favorable outcome. Results: Of 678 patients were admitted to our stroke center due to acute stroke, 410 patients whose clinical data could be obtained (60%; mean age, 74±13 years; male, 57%; the median of length of hospital stay, 21 days; 75% with ischemic stroke) were enrolled. The median of the baseline NIHSS score, acute and discharge FIM scores were 5 (interquartile range [IQR], 2-16), 53 (IQR 22-83), and 86 (IQR 32-119), respectively. Discharge FIM score strongly correlated with mRS score at 3 month (ρ=-0.86; p Conclusions: FIM score at discharge from the stroke unit can predict favorable clinical outcome at three months. Our results can help stroke physicians to expect stroke patients’ status in the chronic phase.

Background and purpose: Functional Independence Measure (FIM) is a valid tool to estimate the level of ADL. However, there were few studies whether FIM score in acute stroke patients is associated with the short-term outcome. Our aim is to reveal whether FIM scores within 3 days from admission to a stroke unit can predict the short-term good outcome (discharge directly to home). Method: We used data from a prospectively collected observational registry in a single stroke center between January 2016 and March 2017. Baseline NIHSS score, acute FIM score (= within 3 days from admission to the stroke unit), discharge FIM score (= at discharge from the stroke unit) were collected. FIM efficiency was calculated from (discharge FIM - acute FIM)/ the length of hospital stay. Logistic regression analysis was used to determine the independent predictors of discharge directly to home. Results: Of 678 patients were admitted to our stroke center due to acute stroke, 410 patients whose clinical data could be obtained (60%; mean age, 74±13 years; male, 57%; the median of length of hospital stay, 21 days; 75% with ischemic stroke) were enrolled. The median of the baseline NIHSS score, acute FIM score, and FIM efficiency were 5 (interquartile range [IQR], 2-16), 53 (IQR 22-83), and 0.88 (IQR 0.10-1.73), respectively. In univariate logistic regression analysis, male sex, acute ischemic stroke, baseline NIHSS score, acute FIM score, discharge FIM score, the length of hospital stay, and FIM efficiency were associated with discharge directly to home. In multivariate logistic regression analysis, acute FIM score (odds ratio [OR] 1.04; 95% confidence interval [CI] 1.03-1.06; p71, with a sensitivity of 72%, specificity of 88%, and an area under the curve of 0.86 (p Conclusions: FIM scores within 3 days from admission to a stroke unit can predict discharge directly to home, which can help stroke physicians to expect the short-term outcomes.

A 80-years-old woman suddenly presented with aphasia, right hemiparesis, and dysesthesia. MRA showed the left middle cerebral artery occlusion. She was diagnosed as hyperacute ischemic stroke. She was treated with intravenous recombinant tissue plasminogen activator and underwent endovascular thrombectomy. On admission, she had a fever and high C reactive protein, and was treated with antibiotic therapy. The pathological diagnosis of the retrieved thrombus revealed the cluster of the gram positive cocci. The blood culture was negative and thransthoracic echocardiogram did not detect the vegetation. She was finally diagnosed as cardioembolic stroke due to infective endocarditis based on the pathological diagnosis of the retrieved thrombus. The pathological diagnosis of the retrieved thrombus was quite important to clarify the cause of ischemic stroke.

Intraorbital arteriovenous fistula (AVF) is a very rare disease; therefore an optimal treatment strategy has not yet been established. Here we describe the use of high-resolution cone-beam computed tomography (CBCT) and selective angiography to visualize the detailed anatomy of orbital vessels. The information provided by the intraoperative imaging led to a change in treatment strategy and eventually to successful transvenous coil embolization. A 55-year-old man presented with a 4 months history of right exophthalmos, chemosis and diplopia. Magnetic resonance (MR) imaging demonstrated a dilated superior orbital vein. Cerebral angiography showed an intraorbital AVF fed by the branch of the ophthalmic artery and drainage to the superior orbital vein (SOV) and inferior orbital vein (IOV). Superselective angiography and high-resolution CBCT with diluted contrast medium clarified that feeders of the AVF came from the first segment of the ophthalmic artery, and the shunt located surrounding an optic nerve sheath. Transvenous embolization via IOV with coils occluded the AVF. Detailed analysis of intraorbital vessels using high-resolution CBCT and selective angiography led to successful treatment by transvenous coil embolization.

Background We investigated whether junior high school students could be educated regarding stroke with an animated cartoon and a Manga that we produced for the purpose of dissemination of this knowledge. Methods We produced a 10-minute animated cartoon and a Manga that provided information regarding stroke risk factors, stroke signs and symptoms, and awareness to immediately contact emergent medical service (EMS) on identification of stroke signs and symptoms. From December 2011 to March 2012, 493 students in 15 classes of the first grade (age 12-13 years) of 3 junior high schools were enrolled in the study. Each subject watched the animated cartoon and read the Manga; this was referred to as “training.” Lessons about stroke were not given. Questionnaires on stroke knowledge were evaluated at baseline, immediately after the training, and 3 months after the training. Results The proportion of correct answers given immediately after the training was higher for all questions, except those related to arrhythmia, compared with baseline. Percentage of correct answers given at 3 months was higher than that at baseline in questions related to facial palsy (75% versus 33%), speech disturbance (91% versus 60%), hemiplegia (79% versus 52%), numbness of 1 side (58% versus 51%), calling for EMS (90% versus 85%), alcohol intake (96% versus 72%), and smoking (69% versus 54%). At 3 months after the training, 56% of students answered the FAST (facial droop, arm weakness, speech disturbance, time to call for EMS) mnemonic correctly. Conclusions Stroke education using these teaching aids of the animated cartoon and the Manga improved stroke knowledge in junior high school students.

Background The purpose of this study was to determine whether our stroke education system can help junior high school students acquire stroke knowledge when performed by a schoolteacher. Methods A stroke neurologist gave a stroke lesson to 25 students (S group) and a schoolteacher through our stroke education system. After instruction, the schoolteacher performed the same lesson using the same education system to another 75 students (T group). Questionnaires on stroke knowledge were examined at baseline, immediately after the lesson (IL), and at 3 months after the lesson (3M). We analyzed the results of stroke knowledge assessment by linear mixed effects models adjusted for gender and class difference using the student number. Results We assessed 24 students in the S group and 72 students in the T group. There were no significant differences in the changes of predicted scores of symptoms and risk factors adjusted for gender, class difference, and each student knowledge level until 3M between the 2 groups. Correct answer rates for the meaning of the FAST (facial droop, arm weakness, speech disturbance, time to call 119) at IL were 92% in the S group and 72% in the T group, respectively. At 3M, they were 83% in the S group and 84% in the T group. The correct answer rates of FAST at 3M were not significantly different adjusted for group, gender, class difference, and correct answer rate at IL. Conclusions A schoolteacher can conduct the FAST message lesson to junior high school students with a similar outcome as a stroke neurologist using our stroke education system.

Background We produced a stroke education program using the FAST (facial droop, arm weakness, speech disturbance, time to call an ambulance) mnemonic. Aims The aim of this study is to examine efficacy of our education program for junior high school students and their parents. Methods One hundred ninety students of 3 junior high schools (aged 12-13 years) and their parents were enrolled. Students received a 45-minute lesson of stroke enlightenment using the FAST mnemonic. Enlightenment items, such as a magnet poster, were distributed. Parents were educated indirectly from their child. Surveys of stroke knowledge were examined at baseline, immediately after the lesson, and at 3 months after the lesson. Results For the students, correct answers at 3 months were significantly higher than those at baseline in questions of facial palsy (98% versus 33%), speech disturbance (98% versus 54%), numbness on one side (64% versus 42%), weakness on one side (80% versus 51%), calling an ambulance (88% versus 60%), alcohol drinking (85% versus 65%), smoking (70% versus 43%), dyslipidemia (58% versus 46%), hyperglycemia (59% versus 48%), and obesity (47% versus 23%). At 3 months, the parents answered more correctly questions of facial palsy (93% versus 66%), calling an ambulance (95% versus 88%), and alcohol drinking (65% versus 51%) than at baseline. At 3 months, 96% of students and 78% of parents answered the FAST mnemonic correctly. Conclusions Our stroke education program improved stroke knowledge, especially the FAST message, for junior high school students and their parents.

The oxidation process by molybdenum-containing enzyme, xanthine oxidase, is theoretically studied with a model complex representing the reaction center and a typical benchmark substrate, formamide. Comparisons were systematically made among reaction mechanisms proposed previously. In the concerted and stepwise mechanisms that were theoretically discussed previously, the oxidation reaction takes place with a moderate activation barrier. However, the product is less stable than the reactant complex, which indicates that these mechanisms are unlikely. Moreover, the product of the concerted mechanism is not consistent with the isotope experimental result. In addition to those mechanisms, another mechanism initiated by the deprotonation of the active site was newly investigated here. In the transition state of this reaction, the carbon atom of formamide interacts with the oxo ligand of the Mo center and the hydrogen atom is moving from the carbon atom to the thioxo ligand. This reaction takes place with a moderate activation barrier and considerably large exothermicity. Furthermore, the product by this mechanism is consistent with the isotope experimental result. Also, our computations clearly show that the deprotonation of the active site occurs with considerable exothermicity in the presence of glutamic acid and substrate. The intermediate of the stepwise mechanism could not be optimized in the case of the deprotonated active site. From all these results, it should be concluded that the one-step mechanism with the deprotonated active site is the most plausible.

Background and Purpose: Stroke centers which can provide endovascular therapy (EVT) for acute ischemic stroke patients are limited. Patients who considered eligible for EVT need to be transferred to hospitals where EVT available. However, delays for interhospital transfers may reduce the opportunity for good outcomes. Besides we accepted patients from outside hospitals, we formed a neurointerventional team which called “Mobile EVT Team (MET)” to offer EVT at outside hospitals. In this study, we compare elapsed time until the beginning of EVT between patients who performed EVT at outside hospitals and who received EVT in our hospital after they were transferred. Methods: From July 2012 to June 2014, acute ischemic stroke patients who performed EVT by MET (MET group) and received EVT after they were transferred to our hospital (transfer group) were enrolled. We defined the beginning of EVT as the time of injection from guiding catheter for EVT. In MET group, if guiding catheter was indwelled before MET arrival, the beginning of EVT was defined the time of MET arrival. We compared the time from initial imaging to the beginning of EVT (“picture to treatment” time) among two groups. Results: Thirty Patients from one site (distance between hospitals: 16 miles) in MET group and 7 patients from three sites (distance between hospitals: 0.5, 1 and 3 miles) in transfer group were analyzed. There was no difference the frequency of intravenous thrombolysis therapy among two groups. In MET group, time from notification to MET arrival was 72 minutes (interquartile range [IQR], 60-81). In transfer group, time from notification to patient arrival and from patient arrival to groin puncture were 55 minutes (IQR, 50-72) and 36 minutes (25-39). Picture to groin puncture time (MET group vs. transfer group: 68minutes [54-81] vs. 139 minutes [127-217], p=0.0004), picture to treatment time (122 minutes [106-165] vs. 168 minutes [154-241], p=0.0105) and notification to treatment time (90 minutes [78-116] vs. 125 minutes [109-140], p=0.0099) were significantly shorter in MET group than in transfer group. Conclusions: MET can provide EVT at outside hospitals without time delay and can be alternative system to patient transfer.

Stroke education for the youth is expected to reduce prehospital delay by informing the bystander of appropriate action to take and providing knowledge to prevent onset of stroke in future. Previously, we developed effective teaching materials consisting of an animated cartoon and a Manga for junior high school students. The aim of this study was to evaluate the feasibility and effectiveness of our educational materials for stroke education taught by schoolteachers to elementary school children.Using our teaching materials, a 30-minute lesson was given by trained general schoolteachers. Questionnaires on stroke knowledge (symptoms and risk factors) and action to take on identification of suspected stroke symptoms were filled out by school children before, immediately after, and at 3 months after completion of the lesson.A total of 219 children (aged 10 or 11 years) received the stroke lesson. Stroke knowledge significantly increased immediately after the lesson compared with before (symptoms, P .001; risk factors, P .001); however, correct answer rates decreased at 3 months immediately after completion of the lesson (symptoms, P = .002; risk factors, P = .045). The proportion of the number of children calling emergency medical service on identifying stroke symptoms was higher immediately after the lesson than baseline (P = .007) but returned to the baseline at 3 months after the lesson.Stroke lesson by schoolteachers using our teaching materials consisting of an animated cartoon and a Manga that was previously used for junior high school students was feasible for elementary school children. However, revision of the materials is required for better retention of stroke knowledge for children.

Background and Purpose: Identifying the information of occluded distal vessels is quite important for making a suitable selection of treatment strategy and devices in endovascular revascularization therapy (EVT) for acute ischemic stroke patients. It has been demonstrated that intra-venous cone-beam CT (IV-CBCT) is able to visualize distally of the occluded vessels. In this study, intra-arterial contrasted high-resolution cone-beam CT from ascending aorta (Ao-CBCT) was newly introduced for the visualization of occluded distal vessels and its clinical values were assessed Methods: Acute ischemic stroke patients with major vessel occlusion planed EVT were evaluated. Adaption of EVT was decided by using MRI/MRA assessment in advance. In endovascular procedure, digital subtraction angiography (DSA) and Ao-CBCT were performed to evaluate occluded site, collaterals and occluded distal vessels with local anesthesia. Ao-CBCT images were acquired in 20 seconds rotational scan. Contrast medium was injected from ascending aorta with 1mL/s for a total of 30 seconds by use of a 4F or 6F catheter and an imaging delay of 10 seconds. We assessed the image quality of Ao-CBCT and compared in the visualization of occluded distal vessels among MRA, DSA and Ao-CBCT. Results: We analyzed 14 patients (mean age, 66 years. 3 female patients), respectively. Stroke subtypes were cardiogenic (n=6), atherothrombotic (n=5) and others/unknown (n=3). Occluded site were MCA M1 (n=8), MCA M2 (n=2), ICA (n=2), MCA M4 (n=1) and BA (n=1). All obtained Ao-CBCT images could evaluate occlusion distal vessels successfully and 11 images (79%) were excellent. In all cases, Ao-CBCT images could depict occluded distal vessels more detailed than MRA and DSA. Conclusions: Ao-CBCT is an efficient method to obtain the detailed information of occluded vessels compared with conventional examination methods. It requires less contrast agent compared to IV-CBCT, while maintaining enough information to determine treatment strategy.

Background and Purpose: We have reported that stroke lesson by stroke neurologists for junior high school students improved their stroke knowledge. For the next step, we investigated whether junior high school students could get the knowledge only by stroke education with a comic book and animated cartoon, which we produced to spread the stroke knowledge widely. Methods: We produce a comic book and a 10-minutes animated cartoon instructing stroke risk factors, stroke sign and symptoms, and encouraging immediate calling for emergent medical service (EMS) on identification of stroke signs and symptoms (the FAST message). Three stories were involved in this comic book and animated cartoon. The first one was a case of acute ischemic stroke treated successfully with hyperacute thrombolytic therapy. The remaining 2 stories were cases of transient ischemic attack; a case of preventing stroke successfully with an appropriate action of his family, but the other case of suffering from a completed stroke with delay of the hospital visit due to the lack of stroke symptom knowledge. From December 2011 to March 2012, 493 students in 15 classes of the 1 st grade (12 - 13 years old) of 3 junior high schools were enrolled. Each subject was distributed the comic book and watched the animated cartoon. Stroke lessons were not performed. Questionnaires on stroke knowledge were examined before, immediately after, and 3 months after the intervention. Results: Proportions of correct answer in all questions except arrhythmia were significantly higher immediately after the intervention than at baseline. At 3 month, higher proportions of correct answer for facial palsy, speech disturbance, hemiplegia, numbness of one side, calling 119 for stroke, alcohol drinking, smoking, and obesity were preserved as compared with those at baseline;75% vs. 33%, 91% vs. 60%, 79% vs. 52%, 58% vs. 51%, 79% vs. 52%, 90% vs. 85%, 96% vs.72%, 69% vs.54%, 35% vs.22%, respectively (p Conclusions: Stroke education by using our homemade comic book and animated cartoon improved knowledge about stroke among junior high school students.

Background and purpose: Efforts to increase the knowledge of stroke risk factors and warning signs for youth are expected to reduce the time from stroke onset to hospital and to be effective in stroke prevention. Although there were a few studies about stroke enlightenments for younger individuals, the effective means of stroke enlightenments for elementary school children have not been clarified. The aim of this study is to evaluate the effectiveness of stroke lesson which we developed for elementary school children using a comic book and animated cartoon. Methods: We developed a comic book and a 10-minutes animated cartoon introducing stroke risk factors, stroke sign and symptoms, and encouraging immediate calling for emergent medical service (EMS) on identification of stroke signs and symptoms. Using these materials, a 30-minutes lesson was performed by the school teacher for school children. Questionnaires on stroke knowledge (including a total of 7 correct items for risk factors and 6 for stroke signs and symptoms), consisted of multiple-choice and closed type questions, were filled out by school children before, immediately after, and 3 months after the lesson. The score was calculated as total numbers of correct answers in assessing stroke knowledge. Results: A total of 219 school children (10 or 11 years old) in 2 public elementary schools were received the stroke lesson. The knowledge about stroke risk factors at the point of immediately after the lesson increased significantly compared with that of before the lesson (mean ± standard deviation, 4.75±1.40 vs. 4.25±1.51, p Conclusion: Stroke lesson by a school teacher using a comic book and animated cartoon which we developed was effective on the stroke enlightenments for elementary school children.

A 66-year-old right-handed man suddenly developed left hemiplegia after an opponent thrust at his neck with a bamboo sword during a practice game of Kendo (Japanese swordsmanship; Figure 1). Fifty minutes later, he visited our emergency service. His blood pressure was 77/55 mm Hg in the left arm but could not be measured in the right arm; his right radial artery was initially pulseless but became palpable 1 hour later. He was somnolent and had left unilateral spatial neglect, left complete hemiplegia, and left-sided sensory disturbance. Enhanced computed tomography (CT) showed an occlusion 15 mm distal to the origin of the right common carotid artery (CCA) without any abnormal findings at the aorta and innominate and right subclavian arteries. On emergent carotid ultrasonography, an intraluminal filling defect occupied the right CCA and swung back and forth with pulsation. He was …

Background and Purpose: School-based programs of stroke enlightenment would be promising means to improve prevention of stroke as well as to spread the knowledge of stroke. Junior high school education is compulsory in Japan. We developed an educational system of stroke for junior high school students and teachers. Our purpose is to verify the effectiveness of this educational system to acquire knowledge of stroke for junior high school educations. Methods: Subjects were 100 students in the 3 rd grade of a public junior high school (40 girls, 14-15 years old). A stroke neurologist gave 45 minutes’ lesson in stroke to 25 students (S group) and 1 schoolteacher of health education by use of our educational system. A stroke neurologist also performed instructions to the schoolteacher how to use our stroke educational system to the students. The system includes stroke signs, symptoms, the FAST massage (Facial droop, Arm weakness, Speech disturbance, Time to call 119) and risk factors. After instructions by the stroke neurologist, the schoolteacher performed the lesson using the same educational system to the other 75 students (T group). Questionnaires on stroke knowledge (total 12 items for stroke signs and 10 items for risk factors) were examined for all students at the baseline and immediately after the lesson. Results: The total scores were not significantly different between the 2 groups either at the baseline or immediately after the lesson. In the S group, the items of correct answers on stroke signs[median 11(IQR 8-11) vs. 6(6-8.5) , P Conclusions: The stroke education program using our educational system would be promising means for junior high school educations.

Background and purpose: Early recognition of stroke signs and symptoms is essential for emergent treatment and improvement of clinical outcomes. We examined efficacy of a stroke education program for junior high school students and their parents. Methods: From February 2010 to May 2011, 349 students in 11 classes of the 1 st grade of 3 junior high schools (12 - 13 years old) and their parents were enrolled. The subjects were divided into 2 groups; an intervention group (6 classes, 190 students) and a control group (5 classes, 159 students). Students in the intervention group received a 45-minutes lesson on stroke signs and symptoms, the FAST message (Facial droop, Arm weakness, Speech disturbance, Time to call 119), and stroke risk factors. School items consisting of a pen, file, magnet, sticky note with the FAST message, and stroke pamphlets were also distributed to students in the intervention group. Parents of the intervention group were educated indirectly through the stroke pamphlets and items. For all subjects, questionnaires on stroke knowledge were examined at the baseline, immediate post-lesson time and 3-month after the stroke lesson. Results: Percentages of correct answers were not significantly different between the 2 students groups at the baseline. Three-months after the stroke lesson, students in the intervention group answered more correctly than the control group in the questions of facial palsy (97% in the intervention group vs. 54% in the control group; P Conclusions: The stroke education program for junior high school students and their parents improved their stroke knowledge, especially of the FAST message.