Kazuo Shigematsu

The eye response test alone is sufficient to predict stroke outcome—reintroduction of Japan Coma Scale: a cohort study

Objectives Prompt assessment of consciousness levels is vitally important during the emergency care of stroke patients. The Japan Coma Scale (JCS) is a one-axis coma scale published in 1974 with outstanding simplicity. The hypothesis is that JCS is sufficient to predict stroke outcome. The aim of the study was to verify the predictability of JCS, which should help JCS attain international recognition. Design A cohort study. Setting A prefectural stroke registry. Participants We analysed 13 788 stroke patients identified from January 1999 to December 2009 inclusive in the entire Kyoto prefecture and registered in the Kyoto Stroke Registry (KSR). Main outcome measures We investigated the relationship between consciousness levels, based on JCS at stroke onset and activities of daily living (ADL) at 30 days or deaths within 30 days in a large population-based stroke registry. We calculated Spearmans coefficient for the correlation between JCS and the ADL scale, generated estimated survival curves by the Kaplan-Meier method and finally compared HRs for death within 30 days after onset, comparing patients with different conscious levels based on JCS. Results A total of 13 406 (97.2%) patients were graded based on JCS. JCS correlated to the ADL scale with Spearmans correlation coefficient of 0.61. HRs for death within 30 days were 1 (reference) (95% CIs), 5.55 (4.19 to 7.37), 9.54 (7.16 to 12.71) and 35.21 (26.10 to 44.83) in those scored as JCS0, JCS1, JCS2 and JCS3, respectively. Conclusions Using a single test of eye response, JCS has outstanding merits as a coma scale, that is, simplicity and applicability. The present study adds predictability for early outcome in stroke patients. JCS is valuable, especially in an emergency setting, when a prompt assessment of consciousness levels is needed.

Neovascularization in kainic acid-induced lesions of rat striatum. An immunohistochemical study with laminin

Vascular changes occurring after stereotaxic injection of the excitatory neurotoxin kainic acid (KA) into the rat striatum were studied at various time intervals after the lesion using laminin immunohistochemistry. Laminin immunohistochemistry revealed marked vascular changes, including presumed neovascularization, in the lesioned striatum. Vessels with increased laminin immunoreactivity were demonstrated from 2 days up to at least 5 months following the injection. The majority was capillary vasculature, which was distributed throughout the lesioned striatum, sometimes being arranged densely along the needle tract. Fine spike-like sprouts called streamers were also loaded with laminin immunoreactivity. In contrast, laminin immunoreactivity in vessels in the control striatum was negligible. Vascular changes detected by laminin immunohistochemistry preceded but then almost paralleled gliosis demonstrated by glial fibrillary acidic protein immunohistochemistry. These results indicate that striatal injection of KA causes marked vascular changes including neovascularizations which are demonstrable by laminin immunohistochemistry.

Characteristics, risk factors and mortality of stroke patients in Kyoto, Japan

Objectives The aim of the study was to evaluate the characteristics, risk factors and outcome of recent stroke patients in Kyoto, Japan. Design We analysed stroke patients in the registry with regard to their characteristics, risk factors and mortality. Cox proportional hazards regressions were used to calculate adjusted HRs for death. Settings The Kyoto prefecture of Japan has established a registry to enrol new stroke patients in cooperation with the Kyoto Medical Association and its affiliated hospitals Participants The registry now has data on 14 268 patients enrolled from 1 January 1999 to 31 December 2009. Of these, 12 774(89.5%) underwent CT, 9232 (64.7%) MRI, 2504 (17.5%) angiography and 342 (2.4%) scintigraphy. Excluding 480 (3.3%) unclassified patients, 13 788 (96.6%) patients formed the basis of further analyses which were divided into three subtypes: cerebral infarction (CI), cerebral haemorrhage (CH) and subarachnoid haemorrhage (SAH). Results A total of 13 788 confirmed stroke patients in the study cohort comprised 9011 (86.3%) CI, 3549 (25.7%) CH and 1197 (8.7%) SAH cases. The mean age ±SD was 73.3±11.8, 69.1±13.6 and 62.7±13.5 in the CI, CH and SAH cases, respectively. Men were predominant in the CI and CH cases, whereas women were predominant in the SAH cases. The frequencies of risk factors were different among the subtypes. Mortality was worst in SAH, followed by CH, and least in CI. HRs for death adjusted for age, sex, histories of hypertension, arrhythmia, diabetes mellitus and hyperlipaemia and use of tobacco and/or alcohol showed a significant (p<0.001) difference among CI (as reference), CH (3.71; 3.11 to 4.43) and SAH (8.94; 7.21 to 11.11). Conclusions The characteristics, risk factors and mortality were evaluated in a quantitative manner in a large Japanese study cohort to shed light on the present status of stroke medicine.

Vomiting should be a prompt predictor of stroke outcome

Background To predict the outcome of stroke at an acute stage is important but still difficult. Vomiting is one of the commonest symptoms in stroke patients. The aim of this study is threefold: first, to examine the percentage of vomiting in each of the three major categories of strokes; second, to investigate the association between vomiting and other characteristics and third, to determine the correlation between vomiting and mortality. Methods We investigated the existence or absence of vomiting in stroke patients in the Kyoto prefecture cohort. We compared the characteristics of patients with and without vomiting. We calculated the HR for death in both types of patients, adjusted for age, sex, blood pressure, arrhythmia, tobacco and alcohol use and paresis. Results Of the 1968 confirmed stroke patients, 1349 (68.5%) had cerebral infarction (CI), 459 (23.3%) had cerebral haemorrhage (CH) and 152 (7.7%) had subarachnoid haemorrhage (SAH). Vomiting was seen in 14.5% of all stroke patients. When subdivided according to stroke type, vomiting was observed in 8.7% of CI, 23.7% of CH and 36.8% of SAH cases. HR for death and 95% CI were 5.06 and 3.26 to 7.84 (p<0.001) when all stroke patients were considered, 5.27 and 2.56 to 10.83 (p<0.001) in CI, 2.82 and 1.33 to 5.99 (p=0.007) in CH and 5.07 and 1.87 to 13.76 (p=0.001) in SAH. Conclusions Compared with patients without vomiting, the risk of death was significantly higher in patients with vomiting at the onset of stroke. Vomiting should be an early predictor of the outcome.

Monoamine oxidase-containing nerve fibers in the major cerebral arteries of rats

The localization of monoamine oxidase (MAO) in nerve fibers associated with the major cerebral arteries in rats was studied using a new coupled peroxidation method modified by adding nickel ammonium sulfate at the electron microscopic level. MAO was, localized in some unmyelinated axons, both in the adventitia and in the periadventitial nerve bundles. Schwann cell cytoplasm encircling myelinated axons in the periadventitial nerve bundles also contained a MAO-reactive substance. The incidences of MAO-containing axons in the adventitial layer of the anterior cerebral, middle cerebral, internal carotid and basilar arteries were 32.3%, 29.5%, 29.6% and 21.1%, respectively. In the periadventitial nerve bundles, MAO activity was also demonstrated in 10.8% among unmyelinated axons. Preincubation with clorgyline, a specific inhibitor of MAOA, suppressed staining in the axons, both in adventitia and in periadventitial nerve bundles, but not in the Schwann cell cytoplasm. Conversely, preincubation with deprenyl, a specific inhibitor of MAOB, suppressed staining in the Schwann cell cytoplasm, but not in the axons. Therefore, MAO in the axons is regarded as MAOA and MAO in the Schwann cell cytoplasm as MAOB. In immunosympathectomized rats (anti-NGF-treated rats), MAO reactivity was suppressed in axons associated with cerebral arteries, but was retained in some Schwann cell cytoplasm. The results indicate that the MAO-containing unmyelinated axons coincide with the postganglionic noradrenergic ones. Thus, histochemical MAO staining may be utilized to study postganglionic sympathetic nerve fibers presumably innervating the major cerebral arteries at the electron microscopic level.

Speech disturbance at stroke onset is correlated with stroke early mortality

BackgroundSpeech disturbance is a common symptom of stroke and is important as a prompt identifier of the event. The frequency of the symptom among each stroke subtype, differences between patients with and without speech disturbance and its correlation to early mortality remain unclear.MethodsThe Kyoto prefecture of Japan has established a registry to enroll new stroke patients in cooperation with the Kyoto Medical Association and its affiliated hospitals. It is named the Kyoto Stroke Registry (KSR). We confirmed the existence or absence of speech disturbance in 1693 stroke patients registered to the KSR and investigated associations between speech disturbance and other characteristics.ResultsSpeech disturbance was observed in 52.6% of cerebral infarction (CI), 47.5% of cerebral hemorrhage (CH), and 8.0% of subarachnoid hemorrhage (SAH) cases. Characteristics showing statistically significant differences between patients with and without speech disturbance and patients were age, blood pressure, history of hypertension, arrhythmia and diabetes mellitus, habit of tobacco and alcohol, and paresis. Mortality rates of patients with/without speech disturbance were 5.2%/1.2% for CI, 12.5% /4.1% for CH, and 62.5%/ 9.0% for SAH. Adjusted hazard ratios were 2.63 (1.14-6.13, p = 0.024) in CI, 4.15 (1.41-12.23, p = 0.010) in CH, and 20.46 (4.40-95.07, p < 0.001) in SAH).ConclusionSpeech disturbance was frequently observed in stroke patients at the onset and therefore could be useful to identify the problem at the earliest stage. Hazard ratio for death was higher in stroke patients with speech disturbance than patients without. Speech disturbance is a prompt predictor of stroke early mortality.Hiromi Nakano, Yoshiyuki Watanabe, Tatsuyuki Sekimoto, Kouichiro Shimizu, Akihiko Nishizawa, Atsushi Okumura and Masahiro Makino contributed equally to this work.

Weekly variations of stroke occurrence: an observational cohort study based on the Kyoto Stroke Registry, Japan

Objectives Understanding the temporal pattern of stroke onset and exploring the possible triggers are important strategies to reducing the incidence of stroke. If stroke occurs frequently on a specific day of the week, it is assumed that other factors, that is, ‘triggering factors’, induce stroke. The aim of the study is to investigate differences in the incidences of stroke among days of the week. Design Hospital-based registry stroke over an 11-year period. Setting Kyoto Prefecture, Japan. Participants A total of 13 788 patients with stroke identified from January 1999 to December 2009 inclusive in the entire Kyoto Prefecture and registered in the Kyoto Stroke Registry (KSR). Main outcome measures Patients with stroke were classified into seven groups based on the day of the week on which stroke developed. We confirmed the differences in the incidence among days using the χ2 test and then performed multinomial logistic analysis referring to the stroke incidence on Sunday to calculate the OR and 95% CI of the stroke occurrence on each day of the week. Results The OR (95% CI) for stroke occurring on Monday, Tuesday, Wednesday, Thursday, Friday and Saturday was 1.157 (1.030 to 1.293), 1.101 (0.981 to 1.236), 1.059 (0.943 to 1.188), 1.091 (0.972 to 1.225), 1.053 (0.938 to 1.205) and 1.074 (0.956 to 1.205), respectively. After stratification by stroke subtypes, cerebral infarction occurred more frequently on Monday than on Sunday (OR and 95% CI were 1.189 and 1.034 to 1.366, p=0.014) independent of age and gender. There was no significant day of the week variation in cerebral haemorrhage or subarachnoid haemorrhage. Conclusions Some factors that arise periodically appear to affect the incidence of cerebral infarction, which gradually develops over years, and this suggests an aetiological mechanism different from the conventional cumulative effect of risk factors due to long-term exposure. We propose a hypothesis that there is a ‘triggering factor’ for the development of cerebral infarction.

Different profiles of onion bulb in CIDP and CMT1A in relation to extracellular matrix.

Hypertrophic neuropathy is usually intractable, and chronic inflammatory demyelinating polyneuropathy (CIDP) and Charcot-Marie-Tooth disease Type 1A (CMT1A) are the representative disorders. The two disorders are sometimes confused both clinically and pathologically. The aim of this study was to clarify the differences in the pathology of large onion bulbs, focusing on the extracellular matrix (ECM) proteins. Nine patients with CIDP and 14 with CMT1A were included. The opened interspaces in OB were frequently shown in CMT1A patients. In CIDP, interspaces of OB packed with collagen fibers were prominent. The mean ratio of opened OB was significantly increased in CMT1A (37.9%) compared to CIDP patients (10.6%) (p = 0.003). Among the ECM examined, tenascin-C (TNC) showed a distinct difference in the pattern of immunoreactivity of OB. The mean ratio of OB showing TNC immunoreactivity was significantly larger in CIDP (29.7%, p = 0.005) than in CMT1A (5.0%). TNC immunoreactivity was confined to the area around myelin sheaths in CMT1A. The increased deposition of collagen fibers in CIDP suggests the activity of nerve regeneration. TNC expression in Schwann cell lamellae comprising OB may also suggest the activity of regeneration. Schwann cell phenotypes in CIDP may be different from CMT1A regarding the production of ECM proteins.

NEW DEMENTIA REGISTRY FOCUSING ON CARE ENVIRONMENTS AND ON CAREGIVERS WAS LAUNCHED IN JAPAN: NATIONAL HOSPITAL ORGANIZATION DEMENTIA REGISTRY (NHODR)

are likely to adhere to treatment plan. An intervention using latest Information technology with a Virtual reality (VR) environment could prove useful. This study hopes to assess the feasibility of Virtual reality for the purpose of cognitive enhancement. Methods: 7 Healthy participants from the community (ages 25–52) were assigned to a 15 minutes Virtual Reality tutorial with 14 tasks to complete. The tasks include training of Virtual Reality navigation and controller usage. The accuracy of the performance of participants and completion time were analysed to evaluate the clarity of the tutorial and the ease of use of the Virtual Reality environment. The researchers obtained assessment of participants’ experience using a 14-item questionnaire, rated using a 5-point scale. Behaviour indices of distress were also recorded, as observed by the researchers and feedback from the participants. Results: All 7 participants (Mean Age: 31.85 Years Old, Mean education: 13.57 Years) have no prior experiencewith VR games and the performance of the participants range from 8 points to 14 points, with better performance and quicker completion time in the younger participants than older participants. Level of physical discomfort was not significantly different between the age groups with 1 participant feeling motion sickness. All participants agree that the tutorial and VR environment was easy to acclimatize to and all expressed interest to return for follow up sessions. Conclusions: The preliminary results suggest that VR is not difficult to learn and familiarize with and discomfort level was low as long as the sessions were limited to a short duration. Further evaluations need to be conducted to determine the cost effectiveness of running the session as the set up duration and technical troubleshoot was observed to be a major challenge.

A NEWLY DEVELOPED TOOL TO ASSESS COGNITIVE FUNCTION USING A TABLET COMPUTER, ESPECIALLY TO DETECT AND EVALUATE MCI PATIENTS AND MILD DEMENTIA PATIENTS

into 65-79 years and >80. The 65-79 years old age group were defined as Middle LOAD (MOAD) and the >80 years old group were defined as Late LOAD (LLOAD). Furthermore we aimed to investigate additional factors that may affect the rate of decline. Methods:The study used longitudinal data from the Essex Memory Clinic which included a total of 306 participants, 56 had YOAD and 249 LOAD (165 MOAD and 84 LLOAD). The rate of cognitive decline was measured using scores from theMini Mental State Examination (MMSE), and covariates included gender, years in education and vascular risk factors. The data were examined using multilevel modelling analysis. Results: At baseline, when comparing individuals with YOAD to LOAD, those with YOAD had lower MMSE scores at baseline (18.3) compared to those with LOAD (23.0; p<.001). The MOAD group had a baseline MMSE of 23.2 and the LLOADgroup 22.8 (ns). Beingmale, having better education and being diabetic were associated with higher baseline MMSE scores. The YOAD group deteriorated faster than the LOAD group (p<.001). The MOAD group declined faster than the LLOAD group despite having similar baseline MMSE scores. Conclusions: Patients with YOAD at the time of diagnosis deteriorated faster than those with LOAD. When age was split into three categories there was a gradual slowing of decline with increasing age. Of significance was that there was also a difference in the rate of decline between the MOAD and the LLOAD groups with the LLOAD group having a more benign disease course.