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There are a few reports of the prevalence of extracranial internal carotid artery stenosis (ICAS) in Asian patients with coronary artery disease (CAD). This was a prospective registry study of 157 consecutive Japanese patients undergoing coronary angiography that aimed to determine the prevalence of extracranial ICAS in recent Japanese patients. The associations between ICAS and the extent or the maximal stenosis of CAD were also investigated. The 131 eligible patients with suspected CAD were prospectively analyzed. Their mean age was 69.0 ± 8.2 years, and 75.6% were males. A total of 111 patients (84.7%) were angiographically diagnosed with CAD. ICAS (area stenosis ≥50% on ultrasonography) was present in 9 patients, and the prevalence in patients with CAD was 8.1%. All patients in the ICAS group had CAD, and this group was significantly more likely to have a history of stroke (p = 0.03). Although no significant relationships were found between the severity of ICAS and the maximal stenosis of CAD, the severity of ICAS increased gradually with the extent of CAD. The prevalence of ICAS in patients with CAD treated with current medical treatment was relatively low (8.1%) compared to previous reports, and the severity of ICAS was significantly associated with the extent of CAD.

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.

Background and Purpose— The incidence and cause of strokes associated with pregnancy and the puerperium are still not fully understood. The aim of this study was to characterize pregnancy-related strokes in Japan using a large-scale survey with current imaging techniques. Methods— A retrospective analysis was conducted based on clinical chart reviews in 736 stroke teaching hospitals certified by the Japan Stroke Society between 2012 and 2013, using a web-based questionnaire requesting the detailed clinical course without any personally identifying information. The collection rate of this questionnaire was 70.5%, with 151 pregnancy-associated strokes extracted. Results— Hemorrhagic strokes were observed in 111 cases (73.5%), ischemic strokes in 37 (24.5%), and mixed type in 3 cases (2.0%). The estimated incidence of pregnancy-associated stroke was 10.2 per 100 000 deliveries. Major causes of hemorrhage were aneurysm (19.8%), arteriovenous malformation (17.1%), pregnancy-induced hypertension (11.7%), and HELLP syndrome (hemolysis, elevated liver enzymes, and low platelet count) (8.1%). Preexisting cerebrovascular diseases responsible for hemorrhage were detected in 59 cases (53.1%). Among the ischemic strokes, 28 (75.7%) were arterial and 9 (24.3%) were venous infarctions. The most frequent cause of arterial infarctions was reversible cerebral vasoconstriction syndrome. Hemorrhagic stroke showed much poorer prognosis than ischemic stroke. Conclusions— The incidence of pregnancy-associated stroke in Japan did not seem higher than that in other Asian and Western countries. The proportion of hemorrhagic stroke among Japanese women was much higher than that in white women. Preexisting cerebrovascular diseases and reversible cerebral vasoconstriction syndrome play a key role in hemorrhagic and ischemic stroke, respectively.

Segmental arterial mediolysis(SAM)is a rare non-inflammatory and non-atherosclerotic arteriopathy associated with the occurrence of multiple aneurysms such as intracranial and intraperitoneal aneurysms. We report a case of intraperitoneal hemorrhage that occurred during the acute stage of subarachnoid hemorrhage(SAH). An 82-year-old woman presented with a sudden onset of loss of consciousness with a diagnosis of SAH. Digital subtraction angiography demonstrated two consecutive vertebral artery-posterior inferior cerebellar artery aneurysms. The larger aneurysm, which seemed to be ruptured, was successfully treated by coil embolization. On the 9th day after the onset of SAH, she developed aphasia secondary to the cerebral vasospasm. After selective intra-arterial infusion of fasudil hydrochloride, she was observed to maintain elevated systolic blood pressure. Her aphasia improved; however, on the 14th day, she suddenly developed hemorrhagic shock. An abdominal computed tomography scan demonstrated intraperitoneal hemorrhage secondary to a ruptured fusiform aneurysm of the right gastroepiploic artery. The lesion was successfully treated by coil embolization, although she became bedridden. Although a histopathological examination was not performed, her clinical, radiological, and serological presentation met the criteria of the clinical diagnosis of SAM. Elevated systolic blood pressure and excessive release of catecholamines in the acute stage of SAH might have caused the intraperitoneal hemorrhage. Non-saccular ruptured intracranial aneurysms should be considered among the differential diagnoses of SAM. In such cases, identifying and monitoring intraperitoneal aneurysms might be useful for earlier diagnosis and treatment of SAM, especially in the acute stage after SAH.

Background and Purpose: Evaluation of cerebral blood flow (CBF) after carotid and cerebral revascularization is essential for early detection of hyperperfusion phenomenon. Single photon emission computed tomography (SPECT) is considered to be a standard modality for evaluation of CBF. It has, however, difficulty in real-time and repetitive evaluation. Recently, arterial spin labeling MRI (ASL-MRI) has evolved with advantages of its immediacy and repetitivity. The purpose of this study is to elucidate the usefulness of ASL-MRI for evaluation of CBF after carotid and cerebral revascularization. Methods: We screened the adult patients who underwent ASL-MRI and SPECT within 24 hours of interval after carotid endarterectomy (CEA), carotid stenting (CAS), or extracranial-intracranial bypass (EC-IC bypass). After excluding the cases of poor image quality, 63 cases (23 CEA, 22 CAS, 18 EC-IC bypass) were enrolled into the study. ASL-MRI (Siemens 3.0T Magnetom Prisma; 2D-PICORE, Voxel size 1.5x1.5x4mm, TR/TE/TI=4000/15.66/1800-2500) were obtained within 24 hours after surgery. SPECT were obtained using N-isopropyl-p-[123I]iodoamphetamine with autoradiography technique. If abnormal CBF increase (≧20%) were detected, patients were treated with anti-hypertensive therapy, and underwent repeated ASL-MRI and SPECT for therapeutic evaluation. Results: Abnormal CBF increase were observed in 6 cases (2 CEA, 2 CAS, and 2 EC-IC bypass) in SPECT, and 4 (2 CEA, 2 EC-IC bypass) in ASL-MRI. In CEA, 2 cases of CBF increase detected in SPECT were also detected in ASL-MRI. In CAS, ASL-MRI did not visualize CBF increase as clearly as in SPECT. In EC-IC bypass, 2 cases of CBF increase detected in SPECT were also detected in ASL-MRI. The patient with increased CBF after revascularization surgery were treated with anti-hypertensive drugs and remained asymptomatic. Conclusion: ASL-MRI was useful for evaluation and early detection of abnormal CBF in CEA and EC-IC bypass, although not in CAS. Decay of radiofrequency pulse due to metallic material is supposed to be the reason. In cases of CEA and EC-IC bypass, ASL-MRI is expected to be an alternative to SPECT with its advantage of immediacy and repetitivity.

Background and Purpose: Small vessel infarction after cranial irradiation is rare manifestation, whereas large vessel disease is well-known as a late complication. The purpose of this study is to investigate the clinical features of the small vessel infarction associated with the previous cranial irradiation. Patients and Methods: This is a retrospective chart review study of the patients presenting with small vessel infarction after cranial irradiation, retrieved from the single center database between 1998 and 2015. We reviewed the clinical characteristics, types and doses of irradiation, interval between first irradiation and first stroke, radiographic findings of the infarctions, and clinical courses. Results: Thirteen cases were identified, 12 men, 54 +/- 14 years of age at stroke onset. Underlying diseases for irradiation were 8 primary brain tumor, 4 metastatic brain tumor, 1 Leukemia, and 1 histologically undetermined brain tumor. Irradiation methods were 9 whole brain irradiation, 2 intensity modulated radiation therapy, and 2 local irradiation. Mean dose of irradiation was 51 +/- 10 Gy. Infarcted lesions were 8 corona radiata, 5 posterior limb of internal capsule, 1 thalamus. Mean time from first irradiation to first stroke was 14 +/- 14 years. Median NIHSS score at onset was 4 (min-max: 1-11), and median modified Rankin Scale at discharge was 3 (min-max: 1-4). One case had recurrence of infarction in the different territory of perforating artery, and one case had exacerbation due to infarction growth. Conclusions: Vasculopathy after irradiation also occurs in perforating arteries as well as in large vessels. Irradiation induced small vessel vasculopathy should be recognized as an important cause of stroke among brain tumor survivor.

It is now accepted that carotid artery stenosis should be treated as a part of systemic atherothrombosis. However, little is known about the association in atherosclerosis between the carotid and coronary arteries. We retrospectively investigated the association between carotid plaque vulnerability diagnosed on carotid magnetic resonance imaging (MRI) and coexisting coronary artery stenosis in patients scheduled for carotid endarterectomy (CEA) or carotid artery stenting (CAS). Eighty-nine consecutive cases that underwent carotid reconstruction for carotid artery stenosis at Kyoto University Hospital between 2010 and 2015 were enrolled in this study. Ten cases that received neither coronary angiography (CAG) nor coronary computed tomography angiography (CCTA) as preoperative examinations, 6 cases with restenosis after CEA or CAS, and 2 cases that did not undergo carotid MRI were excluded. We evaluated relative overall signal intensity (roSI) of the carotid plaque on T1-weighted imaging and coronary artery stenosis detected on CAG or CCTA in the remaining 71 cases. Carotid plaques with roSI >1.5 were defined as MRI-detected vulnerable plaques. Thirty-one cases had a history of previous coronary intervention (stenting or bypass surgery), of which 26 (84%) showed carotid vulnerable plaques. In the cases with no history of coronary intervention, coronary artery stenosis was newly detected in 21 cases, and was not demonstrated in the other 19 cases. Fifteen of the 21 cases with coronary artery stenosis (71%) also showed carotid vulnerable plaques. On the other hand, only 4 of the 19 cases without coronary artery stenosis (21%) had carotid vulnerable plaques, representing a significant difference (P Among the cases with no history of coronary intervention, prevalence of coronary artery stenosis in cases with carotid vulnerable plaques was 79%, significantly higher than that in cases without carotid vulnerable plaques (29%). In conclusion, this study demonstrated that patients with carotid vulnerable plaques are more likely to have advanced coronary artery stenosis. Plaque characterization by carotid MRI is useful not only for treatment of carotid artery stenosis, but also for predicting coronary artery stenosis.

To improve the activities of daily living of patients with injury to the central nervous system, physical therapy starting from the acute phase of the injury is important. Recently, the efficacy of physical therapy using a hybrid assistive limb (HAL) robot suit was reported. However, individual differences exist in the effects of HAL. We investigated factors predicting the effects of HAL in 15 patients at our institution with central nervous system injury, primarily due to stroke, who underwent training using HAL during the acute phase. Patients were classified as either “with HAL suitability” or “without HAL suitability” based on scores from 10-m walking speed, gait, satisfaction, and pain. In both groups, Brunnstrom stage before HAL intervention, Fugl-Meyer assessment (FMA), stroke impairment assessment set (SIAS), and functional independence measure (FIM) were evaluated. Although motor function items did not differ significantly, FIM cognitive function items (P = 0.036), visuospatial perception items on SIAS (P = 0.0277), and pain items on SIAS (P = 0.0122) differed significantly between groups. These results indicated that training using HAL does not involve pain in patients with central nervous system injury during the acute phase, and exhibits positive effects in patients without pain and with high communication ability and visuospatial perception function. When conducting HAL intervention, incorporating functional assessment scores (FIM and SIAS), including peripheral items, may be useful to predict the suitability of HAL.

[Background and Purpose] Neuro-interventional radiology (NIVR) is increasingly recognized as an essential option for acute stroke treatment. However, the access to NIVR physician or NIVR-capable hospital is still limited. Patient transfer system between primary stroke centers (PSCs) and comprehensive stroke centers has a problem about deterioration during transfer, insufficient information transmission, small area coverage, and loss of time. We organized a mobile NIVR team consisting of 6-7 board certified NIVR physicians, and concluded a NIVR alliance program with affiliating PSCs. The team performed procedures at the local sites on request of PSCs. [Methods] Between 2008 and 2012, we concluded a NIVR alliance program with 7 affiliated PSCs. The team dispatched NIVR physicians to the PSCs immediately after receiving "rescue call." Clinical information including medical images was updated in real-time and interactive manner during travel. [Results] We received 23 calls and reacted to all cases. We treated 8 cases of acute ischemic stroke (6 mechanical thrombectomy, 3 carotid stenting, 5 for non-responder to intravenous rt-PA), and 15 for subarachnoid hemorrhage (14 aneurysm embolization, one parent artery occlusion). The mean travel distance was 39.0 km (min - max: 6.3 - 90.3). For acute ischemic stroke, the mean "door-to-puncture time" was 154 minutes (min - max: 130 - 168). For subarachnoid hemorrhage, procedure was performed on the onset or the next day. All the procedure were successfully performed and no deterioration related to procedure were observed. [Conclusions] The new application of NIVR delivery system can safely enable to avoid deterioration during transfer, cover larger area without delay, and enlarge the opportunity to access NIVR therapy for acute stroke patients.

Suicide after stroke is a grievous occurrence. Since the majority of cases under study had shown signs of recovery from stroke, persons surrounding these patients were severely shocked by these suicides. Six patients who attempted suicide within six months after stroke were investigated to determine factors following stroke that relate to suicide in order to prevent future post-stroke suicides. Clinical findings in these six cases were retrospectively analyzed in collaboration with stroke neurologists and coworkers caring for these patients. Four of six patients had sustained a recent infarction extending from the temporal cortex to the parietal cortex. Four of six patients showed depression, and five of six patients showed moderate disability after stroke. Physicians should carefully observe patients with infarction extending from the temporal cortex to the parietal cortex, depression and moderate disability, in order to prevent suicidal behavior.

The mechanism of motor recovery after stroke may involve reorganization of the surviving networks. However, details of adaptive changes in structural connectivity are not well understood. Here, we show long-term changes in white matter microstructure that relate to motor recovery in stroke patients. We studied ten subcortical ischemic stroke patients who showed motor hemiparesis at the initial clinical examination and an infarcted lesion centered in the posterior limb of internal capsule of the unilateral hemisphere at the initial diffusion-weighted magnetic resonance imaging scan. The participants underwent serial diffusion tensor imaging and motor function assessments at three consecutive time points; within 2 weeks, and at 1 and 3 months after the onset. Fractional anisotropy (FA) was analyzed for regional differences between hemispheres and time points, as well as for correlation with motor recovery using a tract-based spatial statistics analysis. The results showed significantly increased FA in the red nucleus and dorsal pons in the ipsi-lesional side at 3 months, and significantly decreased FA in the ipsi-lesional internal capsule at all time points, and in the cerebral peduncle, corona radiata, and corpus callosum at 3 months. In the correlation analysis, FA values of clusters in the red nucleus, dorsal pons, midbody of corpus callosum, and cingulum were positively correlated with recovery of motor function. Our study suggests that changes in white matter microstructure in alternative descending motor tracts including the rubro-spinal pathway, and interhemispheric callosal connections may play a key role in compensating for motor impairment after subcortical stroke., Highlights • Subcortical stroke patients showed motor hemiparesis followed by gradual recovery. • Lesion overlap was located with its center in the posterior limb of internal capsule. • Fractional anisotropy (FA) gradually increased in the red nucleus in three months. • FA in the red nucleus was positively correlated with recovery of motor paresis. • FA in the middle part of corpus callosum was also correlated with motor recovery.