Hiroyasu Sano

Clinical Outcomes of Persistent and Paroxysmal Atrial Fibrillation in Patients with Stroke

BACKGROUND We compared the clinical outcomes of persistent atrial fibrillation (PeAF) and paroxysmal atrial fibrillation (PAF) in patients with cardioembolic stroke caused by nonvalvular atrial fibrillation (NVAF) because the nature of the fibrillation can cause persistent cerebral infarction. METHODS We classified 619 of 964 patients hospitalized with cardioembolic stroke between April 2007 and December 2013 within 24 hours of onset as having PeAF (n = 447) and PAF (n = 172) according to a retrospective analysis of their clinical records, including National Institutes of Health Stroke Scale (NIHSS) scores on admission, clinical outcomes (modified Rankin Scale [mRS] scores) at 90 days after admission, and major cerebral artery occlusion. RESULTS The PeAF group was significantly older (P < .001) and had a higher prevalence of hypertension (P = .007), diabetes (P = .039), heart failure (P = .004), previous coronary artery disease (P = .002) and cerebral infarction (P < .001), medication with anticoagulants (P < .001), and elevated blood glucose on admission (P = .002). Neurologic severity assessed by NIHSS scores on admission was significantly worse in the PeAF than in the PAF group (P < .001). Significantly more patients in the PAF group had favorable outcomes (mRS, 0-2) after 90 days (P < .001). The incidence of major cerebral artery occlusion was significantly higher in the PeAF group (P < .001). CONCLUSIONS Patients with PeAF and cardioembolic stroke due to NVAF had more severe neurologic deficits on admission, more frequent major arterial occlusion, and poorer outcomes than those with PAF.

Research Article: Clinical Characteristics of Isolated Anterior Cerebral Artery Territory Infarction Due to Arterial Dissection

BACKGROUND Isolated brain infarction in the anterior cerebral artery (ACA) territory is rare, and its etiology has not yet been fully elucidated. Thus, we aimed to determine the etiologic and clinical characteristics of patients with isolated ACA territory infarction due to arterial dissection. METHODS Of 2315 patients with acute cerebral infarction admitted to our hospital between April 2007 and September 2013, 34 patients (1.5%; 28 men, 6 women; mean age, 65 ± 15 years) suffered isolated ACA territory infarction. We performed cranial magnetic resonance (MR) imaging and MR angiography for all the patients. Whenever possible, we also performed 3-dimensional computed tomography angiography, digital subtraction angiography, and MR cisternography to diagnose the stroke subtype. RESULTS The stroke subtypes of the 34 patients with isolated ACA territory infarction were atherothrombotic infarction, cardioembolic infarction, arterial dissection, and unclassified in 11 patients (32%), 11 patients (32%), 11 patients (32%), and 1 patient (3%), respectively. The mean ages at onset were 48 ± 9 and 72 ± 11 years in the dissection and nondissection groups, respectively (P < .001). Headaches were present at onset in 4 patients (36%) and 1 patient (4%) with and without dissection, respectively (P = .026). Blood pressure at onset was significantly higher among patients with dissection (systolic, 179 ± 34 mm Hg; diastolic, 102 ± 17 mm Hg) than among patients without dissection (systolic, 155 ± 30 mm Hg; diastolic, 86 ± 21 mm Hg; P < .05), and d-dimer values were significantly lower among patients with dissection (P = .034). Favorable clinical outcome (modified Rankin Scale score, 0-2) at discharge was achieved in 9 patients (82%) and 10 patients (43%) with and without dissection, respectively (P = .035). CONCLUSIONS Patients with isolated ACA territory infarction demonstrated a relatively high frequency of dissection (32%). Patients with dissection were younger, had a higher frequency of headaches, and demonstrated more favorable prognoses than patients without dissection.

CHADS2 score/CHA2DS2-VASc score and major artery occlusion in cardioembolic stroke patients with nonvalvular atrial fibrillation

Objective The associations between the CHADS2 score/ CHA2DS2-VASc score, and the presence of cerebral vessel occlusion on admission were examined in cardioembolic stroke patients with nonvalvular atrial fibrillation. Methods The subjects were 546 consecutive patients hospitalized between April 2007 and December 2012 with onset of cardioembolic stroke associated with nonvalvular atrial fibrillation within 24 h. The associations between the CHADS2 score/CHA2DS2-VASc score and the presence of occluded cerebral vessels on magnetic resonance angiography were evaluated retrospectively. Occluded cerebral vessels were classified into the internal carotid artery, middle cerebral artery (M1, M2), basilar artery, and other (anterior cerebral artery [A1], posterior cerebral artery [P1], vertebral artery). Results Major artery occlusion was seen in 52% of patients with CHADS2 score 0, 52% of patients with score 1, 57% with score 2, 75% with score 3, and 75% with score ≥4. As for the CHA2DS2-VASc score, major artery occlusion was seen in 62% of patients with score 0, 49% with score 1, 53% with score 2, 53% with score 3, 65% with score 4, 71% with score 5, and 82% with score ≥6. The incidence of concurrent major arterial occlusion increased as both scores rose. When classified by occluded blood vessel, the incidence of concurrent internal carotid artery occlusion increased as both the CHADS2 and CHA2DS2-VASc scores increased. Conclusion As the CHADS2 and CHA2DS2-VASs scores increased, the incidence of concurrent major arterial occlusion, particularly internal carotid artery occlusion, increased in patients with cardioembolic stroke associated with nonvalvular atrial fibrillation.

Clinical Features of Ischemic Stroke during Treatment with Dabigatran: An Association between Decreased Severity and a Favorable Prognosis.

OBJECTIVE Anticoagulation therapy with warfarin is associated with a favorable prognosis in ischemic stroke. Dabigatran, a new oral anticoagulant, is widely used to prevent ischemic stroke in non-valvular atrial fibrillation (NVAF) patients. However, its association with decreased severity and a favorable prognosis once ischemic stroke has occurred remains unknown. METHODS We retrospectively reviewed all the patients with NVAF-associated ischemic stroke admitted to our hospital from April 2011 to December 2014 and included those who received dabigatran therapy. We assessed whether the patients were under regular use of the drug or discontinuance and classified them into 2 groups, the treatment and discontinuation groups. Clinical data, including the age, sex, ASCOD stroke phenotype, NVAF type, prescribed drug dose, comorbidities, CHADS2 score, renal function, National Institute of Health Stroke Scale (NIHSS) score on admission, modified Rankin scale (mRS) score at discharge, D-dimer, and brain natriuretic peptide, were investigated and compared between the groups. RESULTS Nine patients were under regular dabigatran therapy, and 6 were under discontinuance of the drug. The age, sex, ASCOD stroke phenotype, NVAF type, comorbidities, renal function, and CHADS2 scores did not differ between the 2 groups; however, the NIHSS scores were significantly lower in the treatment group. The mRS scores at discharge were additionally decreased in the treatment group. Moreover, the D-dimer scores were lower in the treatment group, thus suggesting a possible role in the decreased stroke severity. CONCLUSION Dabigatran may therefore decrease the severity of ischemic stroke, even if ischemic stroke occurs.

Effects of Rosuvastatin on Serum Lipids and Arteriosclerosis in Dyslipidemic Patients with Cerebral Infarction

BACKGROUND We investigated the effect of rosuvastatin, 3-hydroxy-3-methylglutaryl-coenzyme A reductase inhibitor, on serum lipids and arteriosclerosis in dyslipidemic patients with cerebral infarction. METHODS The subjects were 24 patients with noncardiogenic cerebral infarction complicated by dyslipidemia (low-density lipoprotein cholesterol [LDL-C] ≥ 140 mg/dL). Serum lipids and highly sensitive C-reactive protein (hs-CRP) were measured at the start of the study and at 3 and 12 months after the initiation of oral rosuvastatin (5 mg/day). Cardio-ankle vascular index (CAVI), intima-media thickness (IMT), and plaque score (PS) were also determined at the start of the study and at 12 months. RESULTS Of the 24 patients admitted, 17 were eligible for statistical analysis. Total cholesterol (TC), LDL-C, and non-high-density lipoprotein cholesterol (non-HDL-C) (mean [standard deviation {SD}], mg/dL) were significantly decreased at 3 months (TC, 149.4 [20.4]; LDL-C, 78.7 [18.6]; non-HDL-C, 94.6 [21.7]) and at 12 months (TC, 154.9 [27.2]; LDL-C, 82.5 [23.3]; non-HDL-C, 100.2 [28.8]) compared with the baseline data (TC, 232.8 [29.7]; LDL-C, 162.2 [21.2]; non-HDL-C, 183.0 [27.7]). The serum hs-CRP level (mean [SD], ng/mL) was 1053.1 [818.8] at baseline, 575.2 [481.8] at 3 months, and 488.1 [357.7] at 12 months. The decrease in this parameter at 12 months was statistically significant. There was a decrease, although not statistically significant, in CAVI (mean [SD]) at 12 months (right [Rt.] 8.7 [.9]; left [Lt.] 8.6 [1.0]), compared with baseline (Rt. 9.1 [1.1]; Lt. 9.0 [1.1]). The max-IMT (mean [SD], mm) was (Rt. 2.11 [.97]; Lt. 2.01 [.75]) at baseline and (Rt. 2.18 [.82]; Lt. 2.06 [.79]) at 12 months of study treatment. The PS (mean [SD], mm) was 8.93 [4.33] at baseline and 9.61 [4.79] at 12 months; neither parameter showed a significant change. CONCLUSIONS Rosuvastatin at 5 mg/day significantly reduced serum levels of TC, LDL-C, non-HDL-C, and hs-CRP in dyslipidemic patients with cerebral infarction. No significant change in CAVI, max-IMT, or PS was noted after the study treatment.

Clinical Characteristics of Cardioembolic Transient Ischemic Attack: Comparison with Noncardioembolic Transient Ischemic Attack

BACKGROUND Previous studies show that 6%-31% of transient ischemic attacks (TIA) were caused by cardiogenic cerebral embolism (cardioembolic TIA). As prompt initiation of therapy is essential in TIA to prevent subsequent strokes, determining their cause is important. In this study, we aim to determine the features of cardioembolic TIA and to compare them with those of noncardioembolic etiology. METHODS We retrospectively reviewed patients with a tissue-defined TIA who were admitted to our hospital from April 2007 to August 2013. The etiology was categorized according to Trial of Org 10172 in Acute Stroke Treatment, and TIA of cardioembolic origin and cervicocerebrovascular etiology (noncardioembolic TIA) were included in this study. Those with 2 or more possible causes or undetermined etiologies were excluded. Age, sex, comorbidities, ABCD2 score, and CHADS2 score were assessed and compared between the 2 groups. RESULTS There were no significant differences in the neurologic symptoms and their duration, morbidities of hypertension, diabetes, and dyslipidemia between the 2 groups. Coronary and peripheral artery diseases were more common in the cardioembolic TIA group (18.4% vs. 6.9%). Incidences of prior stroke and cerebral infarction determined by MRI were similar between the 2 groups. The ABCD2 score showed a similar distribution, but the CHADS2 score was significantly different; the cardioembolic TIA group showed a higher score (P = .005). CONCLUSIONS Clinical features are similar in tissue-defined TIA of cardioembolic and noncardioembolic etiologies. The CHADS2 score can be useful in assessing the probability of cardioembolic TIA.

Intractable Neurosarcoidosis Effectively Treated with Infliximab

We herein describe the case of an 18-year-old girl who presented with dizziness and headache in 2012. In 2013, brain magnetic resonance imaging revealed multiple intracerebral small lesions and intracerebral hydrocephalus. She was diagnosed with neurosarcoidosis following a brain biopsy. Although prednisolone, methotrexate, and azathioprine were administered, her hydrocephalus worsened and her granulomatous lesions were observed to increase in number on MRI. The patients hydrocephalus showed no improvement despite her undergoing one ventriculoperitoneal shunt procedure, one septum pellucidum fenestration, and three ventriculoatrial shunt procedures. Infliximab therapy was then initiated, which resulted in a reduction in the size of the granulomatous lesions and the improvement of the patients clinical symptoms. Infliximab may be a viable therapeutic option for treating intractable neurosarcoidosis.

Cerebral Sinovenous Thrombosis in a Patient with Transient Eosinophilia

A 67-year-old man with a history of prostatic hypertrophy developed behavioral anomalies and a fever. At admission, diffusion-weighted brain magnetic resonance imaging (MRI) indicated a high-intensity signal lesion on both sides of the cerebral hemisphere. Immediately after hospitalization, he developed paralysis of the left side of the body. Diffusion-weighted MRI indicated hemorrhagic changes in the right and left parietal lobes and right occipital lobe. Magnetic resonance venography indicated superior sagittal sinus occlusion. The blood test results indicated transient eosinophilia. Cases of thrombosis with idiopathic eosinophilia have been reported, but this is the first known case of cerebral sinus thrombosis with transient eosinophilic leukocytosis.

Functional Outcomes of Decompressive Craniectomy in Patients with Malignant Middle Cerebral Artery Infarction and Their Association with Preoperative Thalamus Deformation: An Analysis of 12 Patients.

Objective Decompressive craniectomy (DC) in patients with malignant middle cerebral artery (MCA) infarction is known to decrease the mortality rate. However, the functional outcomes (communication and oral intake) of this procedure remain unclear. Most patients with malignant MCA infarction exhibit a loss of consciousness, which may be principally governed by the thalamus. We herein investigated the functional outcomes of DC at 90 days after the onset of malignant MCA infarction and their association with preoperative thalamus deformation, which can occur due to pressure and edema. Methods Twelve of 2,692 patients with acute cerebral infarction were diagnosed with malignant MCA infarction and underwent DC. We evaluated preoperative thalamus damage using brain computed tomography and its association with communication and oral intake abilities and the modified Rankin Scale (mRS) and Barthel index scores at 90 days after stroke onset. Results The mRS score at 90 days was 0-4 in five patients. Seven patients could communicate immediately after surgery, while five could do so by 90 days. Five patients were able to resume the oral intake of food at 90 days. All patients with preoperative thalamus deformation showed a poor recovery, while those with absent or slight preoperative thalamus deformation showed a good recovery. Conclusion Patients with preoperative thalamus deformation caused by pressure and edema show a poor oral intake and communication abilities after DC, suggesting that preoperative thalamus deformation is a predictor of poor functional outcomes after DC in patients with malignant MCA infarction.

Cough Headache Presenting with Reversible Cerebral Vasoconstriction Syndrome: A Case Report

Cough headache can be a primary benign condition or secondary to underlying etiologies. We herein describe a case of a 52-year-old woman with cough headache that presented as reversible cerebral vasoconstriction syndrome (RCVS). Some cases of RCVS are caused by an aberrant sympathetic response to activities that cause an intracranial pressure surge. Therefore, cough headache should be recognized as a possible presentation of RCVS, even without thunderclap headache or neurological deficits.