Masayasu Tabuchi

Intravenous recombinant tissue plasminogen activator in acute carotid artery territory stroke

To determine the effect of intravenous recombinant tissue plasminogen activator (rt-PA) on vascular and neurologic outcomes, we enrolled 31 patients with acute carotid artery-territory ischemic stroke within 6 hours from symptom onset in a randomized, double-blind, placebo-controlled study. We gave either rt-PA (duteplase at the dose of 20 or 30 mega-international units [MIU]) or placebo intravenously for 60 minutes in patients randomly assigned to the three groups. A comparison between the baseline and postinfusion angiograms showed that complete or partial reperfusion occurred in 50% (5/10) of patients treated with 30 MIU rt-PA, 44% (4/9) of those treated with 20 MIU rt-PA, and 17% (2/12) in the control group. In patients with middle cerebral artery occlusions, reperfusion occurred in 71% (5/7) of the 30-MIU group, in 67% (4/6) of the 20-MIU group, and in 13% (1/8) of the control group. Patients treated with 30 MIU rt-PA showed a significantly early and better clinical improvement, as measured by the neurologic scale, than did those treated with placebo. Parenchymal hemorrhage occurred in one patient in each group, and frequency of clinically insignificant hemorrhagic infarction was comparable among the treatment groups. No major systemic complications occurred in any group. These results support the efficacy of intravenous infusion of rt-PA soon after the onset of stroke in producing rapid thrombolysis and neurologic recovery; it may be of particular value in patients with thromboembolic occlusion in the middle cerebral artery.

Intracarotid urokinase with thromboembolic occlusion of the middle cerebral artery.

Intracarotid urokinase infusion therapy was performed on 22 patients with evolving cerebral infarction due to acute thromboembolic occlusion of the middle cerebral artery. Mean time from onset of symptoms to start of infusion and mean dosage of urokinase were 4.5 hours and 927,000 units, respectively. Immediate recanalization was achieved in 10 patients (45%) after urokinase therapy. In patients with successful recanalization, rapid amelioration of symptoms followed the restoration of blood flow. Thrombolytic recanalization was associated with reduction of neurologic deficits and of computed tomography-demonstrable infarction volume. The reduction of infarction volume and functional outcome correlated highly with the degree of reflow. Hemorrhagic transformation of infarction occurred in four patients and controllable extracranial bleeding in three patients. These results support the safety and efficacy of urokinase therapy for acute thromboembolic occlusion of the middle cerebral artery.

Risk Factors for Silent Cerebral Infarcts in Subcortical White Matter and Basal Ganglia

BACKGROUND AND PURPOSE The purpose of this study was to clarify whether the relevant risk factors for silent cerebral infarcts (SCIs) in subcortical white matter (WM) are different from those in the basal ganglia (BG). METHODS Subjects of this study were 219 adults without a history of stroke or transient ischemic attack and without any abnormality on a neurological examination who consecutively visited the neurology service in our hospital between January 1994 and November 1997 requesting medical evaluation for possible cerebrovascular diseases. Subjects included 141 men and 78 women ranging in age from 33 to 83 years (mean+/-SD, 63.2+/-9.5 years). We performed brain MRIs and cervical/cranial MR angiographies on all subjects. In this study, SCI was defined as a focal lesion >5 mm in diameter that was prolonged on both T2-weighted and proton density images. RESULTS SCIs in the WM and/or BG were detected in 88 (40.2%) of the 219 subjects. No SCI >15 mm was observed in this series. Fifty of the subjects had SCIs only in the WM, 32 subjects had SCIs in both the WM and BG, and 6 subjects had SCIs only in the BG. Thus, 82 (93.2%) of 88 subjects with SCIs had lesions in the WM. Most subjects with SCIs in the BG also had SCIs in the WM. Multiple logistic regression analyses revealed that age, female sex, and hypertension were significant and independent predictors of SCIs in the WM, and that age, a history of ischemic heart disease, and carotid artery stenosis were significant and independent predictors of SCIs in the BG. CONCLUSIONS The present study indicated that the relevant risk factors for SCIs in the WM and those for SCI in the BG were different. Our results suggest that SCIs are prone to first appear in the WM in association with aging and hypertension, and the additional appearance of SCIs in the BG predicts a progression of generalized atherosclerosis that is manifested in the carotid and coronary arteries.

Hospital-Based Study of the Care and Cost of Acute Ischemic Stroke in Japan

Background and Purpose— To evaluate the current status of care and cost of acute ischemic stroke in Japan, we performed a hospital-based analysis at a tertiary emergency hospital with a 24-hour neurology-neurosurgery team and care unit. Methods— During the 12-month period of October 2000 to September 2001, we collected data on 179 patients consecutively hospitalized with acute ischemic stroke within 7 days of onset. We examined demographic data, in-hospital care, length of hospital stay, outcome at discharge, and hospital costs. The medical cost data were collected from official hospital medical cost charts, which calculated direct medical costs for beds, staff, examinations, medications, and rehabilitation. Results— The mean age was 70 years, and 69% were male. Hospital arrival was within 3 hours of onset in 30% of the patients. A history of stroke was present in 37%. The mean initial National Institutes of Health Stroke Scale score was 8.3 points (median, 6 points). Using the Trial of Org 10172 in Acute Stroke Treatment classification, 25% were lacunar, 27% were atherothrombotic, 33% were cardioembolic, and 15% were of unknown origin. All patients underwent neuroimaging studies during hospitalization; 96% and 92% underwent CT and MRI with MR angiography, respectively. Antithrombotic medications were given in 94%, none of whom received thrombolysis. A newly licensed neuroprotective agent, edaravone, was given in 16%. More than half of the patients (55%) were initially admitted to the neurological intensive care unit. Overall, 64% received in-hospital rehabilitation. Mean length of stay was 33 days. In-hospital mortality rate was 3%. On the modified Rankin Scale (mRS), 63% were independent (mRS, 0 to 2) and 34% were dependent (mRS, 3 to 5) at discharge. Two thirds of the patients (65%) went directly back home. The mean hospital cost per patient was

Asymptomatic Occlusive Lesions of Carotid and Intracranial Arteries in Japanese Patients With Ischemic Heart Disease: Evaluation by Brain Magnetic Resonance Angiography

6887 (

Frequency and Clinical Correlates of Occlusive Lesions of Cerebral Arteries in Japanese Patients without Stroke

209/d), of which 69% was attributable to the costs for beds and staff, 12% for medications, 7% for rehabilitation, 6% for imaging studies, 5% for laboratory examinations, and 1% for other costs. Conclusions— Despite the single hospital-based analysis, this study provided current, precise data on short-term inpatient care and costs of acute ischemic stroke in Japan. Because stroke often carries a permanent dependence, long-term cost-effective stroke care should be established.

Hypergraphia: a right hemisphere syndrome.

BACKGROUND AND PURPOSE The purpose of this study was to elucidate the prevalence and degree of asymptomatic occlusive lesions in the carotid and intracranial arteries in Japanese patients with ischemic heart disease (IHD). METHODS We performed carotid and intracranial MR angiography (MRA) on 67 patients (49 men, 18 women; age range, 40 to 78 years; mean age, 60.1 years) who had received selective coronary angiography for the clinical diagnosis of IHD. On the basis of these images, degree of stenosis in the regions of the bilateral carotid artery bifurcation and five regions of the intracranial arteries, ie, bilateral intracranial portions of the internal carotid arteries and the middle cerebral arteries and the basilar artery were estimated. RESULTS Stenosis of more than 25% narrowing of the diameter of the target arteries was found in 15 patients (22.4%) in the extracranial carotid arteries and in 11 patients (16.4%) in the intracranial arteries. Most of the stenotic lesions were mild. The incidence of extracranial carotid stenosis and the severity of coronary atherosclerosis showed a significant correlation. The mean age of the patients with intracranial arterial lesions was statistically higher than those without intracranial lesions. CONCLUSIONS Our data suggest that asymptomatic occlusive lesions in the carotid and intracranial arteries are fairly common in Japanese patients with IHD, although the degree of stenosis is relatively mild. Coexistence of carotid atherosclerosis should be suspected in IHD patients with severe coronary atherosclerosis, and the possibility of atherosclerosis in the intracranial arteries should be considered in aged IHD patients.

Detection of Occlusive Lesions in Intracranial Arteries by Three-Dimensional Time-of-Flight Magnetic Resonance Angiography

To determine the frequency and clinical correlates of intra- and extracranial arterial occlusive lesions in a stroke-free population, we studied cerebral arteries in 156 subjects with no evidence of stroke who presented at a neurologic clinic with concerns about a possible stroke (104 males ranging in age from 37 to 83 years, with a mean age of 63.0) by using MR angiographies (MRAs). According to a validated rating scheme of MRAs for occlusive lesions, the degree of stenoses in the cervical portion of the carotid artery and of the intracranial arteries including the intracranial portion of the internal carotid artery, the middle cerebral artery stem, and the basilar artery were evaluated. Stenoses (>25% narrowing in diameter) were found in 18 patients (11.5%) in the cervical carotid artery, and in 23 patients (14.7%) in the intracranial arteries. Multiple logistic regression analysis showed that age and hyperlipidemia were significant and independent predictors for cervical carotid artery stenoses, and that age and hypertension were predictors for intracranial artery stenoses. Our data based on this special cohort of stroke-free patients suggested that the risk factors for extra- and intracranial artery lesions were different, and that MRA is possibly efficient in those patients in whom cerebral artery occlusive lesions may be suspected, e.g. in hyperlipidemic or hypertensive elderly. Larger population-based studies are needed to confirm these results.

MR angiographic evaluation of carotid and intracranial arteries in Japanese patients scheduled for coronary artery bypass grafting.

A new right hemisphere symptom is reported. Five stroke patients with lesions in the perisylvian cortico-subcortical or thalamic region of the right hemisphere produced linguistically correct but semantically loose writing. The behaviour was initiated by subtle prompting and continued semiautomatically. A possible mechanism underlying this hypergraphia is discussed.

Spontaneous dural carotid cavernous sinus fistula presenting isolated ophthalmoplegia, Evaluation with MR angiography

To evaluate the accuracy of 3-dimensional time-of-flight magnetic resonance angiography (3D TOF MRA) for detecting intracranial arterial occlusive disease, this technique was compared with conventiona