Naohide Kurita

Emerging Risk Factors for Recurrent Vascular Events in Patients With Embolic Stroke of Undetermined Source

Background and Purpose— Underlying embolic causes diagnosed by transesophageal echocardiography could be implicated in mechanisms of embolic stroke of undetermined source. We aimed to explore factors, including underlying embolic causes, related to recurrent vascular events in embolic stroke of undetermined source. Methods— Patients who fulfilled the diagnostic criteria for embolic stroke of undetermined source and whose potential embolic sources were examined by transesophageal echocardiography were included. Recurrent vascular events, including ischemic stroke, cardiovascular and peripheral artery diseases, and vascular death, were retrospectively analyzed. Cox proportional hazards regression analysis was used to explore factors, including clinical characteristics, embolic causes on transesophageal echocardiography, and the Calcification in the Aortic Arch, Age, Multiple Infarction score (CAM), based on the degree of aortic arch calcification on chest radiograph (0–3 points), age (≥70 years; 1 point), and multiple infarctions on magnetic resonance imaging (multiple infarcts in 1, 2, or ≥3 territories of large intracranial arteries, 1, 2, or 3 points) associated with recurrent vascular events. Results— A total of 177 patients (age, 64.1±14.2 years; 127 men) were enrolled. Thirty-one patients had recurrent vascular events (follow-up, 3.5±2.7 years; annualized rate, 5.0% per person-year). Among embolic causes on transesophageal echocardiography, incidence of recurrent vascular events was high in patients with large aortic arch plaques (7.5% per person-year). Diabetes mellitus (hazard ratio, 2.56; 95% confidence interval, 1.23–5.32; P=0.012) and CAM score grade (hazard ratio, 2.29; 95% confidence interval, 1.11–4.72; P=0.026) predicted recurrent vascular events. Conclusions— History of diabetes mellitus and the CAM score could be novel risk factors for recurrent vascular events in embolic stroke of undetermined source.

Analysis of the Usefulness of the WORSEN Score for Predicting the Deterioration of Acute Ischemic Stroke

BACKGROUND Early neurological worsening is associated with increased mortality and long-term functional disability. We developed the WORSEN score for predicting whether patients with stroke will deteriorate during the week after stroke onset and investigated its usefulness. PATIENTS AND METHODS We retrospectively investigated the cases of 478 patients who were admitted to Juntendo University Hospital between April 2007 and March 2009. Neurological deterioration was defined as a worsening of 4 points or higher on the National Institute of Health Stroke Scale score within 1 week of admission. Based on a previous study, we developed the WORSEN score, which was derived from the following factors: wrong (poor) blood sugar control (W), old myocardial infarction (O), radiological findings (R), infarct size (S), elevated low-density lipoprotein cholesterol (E), and neurological findings (N). Next, we investigated the utility of this scoring system in 456 other patients who were admitted to Juntendo University Hospital and Juntendo Urayasu Hospital between October 2013 and December 2014. RESULTS First, we checked the utility of the WORSEN score for detecting worsening in cases of stroke. In the first patient group, deterioration was noted in 32.5% of the patients with scores higher than 3 points (sensitivity: .704 and specificity: .744). For checking reproductivity on using the second group, deterioration was detected in 36.1% of the patients with WORSEN scores higher than 3 points (sensitivity: .740 and specificity: .835). CONCLUSIONS Careful attention should be paid to patients with acute stroke with high WORSEN scores. The WORSEN score might become a valuable tool for detecting the neurological deterioration of ischemic stroke.

Teaching Video NeuroImages: Re-emergent jaw tremor in Parkinson disease

A 77-year-old woman who was diagnosed with Parkinson disease at 51 years of age presented with a 4-year history of intermittent jaw tremor. This was present at rest and declined in amplitude during voluntary movements. Tremor reappeared after the patient bit a tongue depressor continuously for 10 seconds (video on the Neurology® Web site at Neurology.org). “Re-emergent tremor” is a postural hand tremor that appears after some delay while maintaining a posture and is similar to the classic resting tremor of Parkinson disease.1 Re-emergent jaw tremor may represent an additional type of tremor characteristic of Parkinson disease.

Three Cases of Cervicocephalic Artery Dissection in an Amusement Park

About 20 cases of cerebrovascular accidents in amusement parks have been documented. However, only a few cases of amusement park stroke (APS) after roller coaster rides have been reported. Here, we present triggers of stroke, clinical characteristics, and the angiographic appearance of 3 consecutive patients of APS. Their clinical characteristics included young age, absence of atherosclerotic risk factors, and severe injuries. Serial changes in angiographic appearance led to the diagnosis of cervicocephalic artery dissection (CAD). Patients A and B were diagnosed with isolated middle cerebral artery (MCA) dissection, and patient C was diagnosed with internal carotid artery dissection involving MCA dissection. Running excitedly toward an attraction in patient A, a go-kart ride in patient B, and riding in an enhanced motion vehicle in patient C were considered as the likely triggers for APS. We had specific cases with APS associated with CAD, which can occur under diverse contexts other than roller coaster rides at amusement parks. Our findings suggest that the variable directions of the high gravitational forces induced by vehicle riding or running excitedly might injure the MCA or internal carotid artery, and thereby cause CAD in the amusement park.

The Importance of Combined Antithrombotic Treatment for Capsular Warning Syndrome

INTRODUCTION Capsular warning syndrome (CWS) is characterized by recurrent conventional episodes of motor and/or sensory deficits without cortical symptoms. The purpose of this case series study was to evaluate the safety and appropriate treatment for CWS to prevent the development of complete stroke. METHODS We reviewed our hospital records and previous reports to find patients with neurologically fluctuating profiles, and excluded those with unknown details of initial treatment/final treatment of antiplatelet therapy or radiological findings. RESULTS We retrieved two cases of CWS from our hospital, which presented motor and/or sensory symptoms followed by complete resolution without complete ischemia. The recurring episodes in both were unable to be stabilized by single antiplatelet therapy but were successfully managed using two or more antiplatelet drugs. In 11 previously reported cases of CWS, the recurring episode was frequency stabilized with plural antiplatelet therapy. CONCLUSION Multiplicate antiplatelet therapy is important for treatment of CWS, and caution is needed regarding hemorrhagic complications.

Adequate Adherence to Direct Oral Anticoagulant is Associated with Reduced Ischemic Stroke Severity in Patients with Atrial Fibrillation

BACKGROUND The impact of adherence to direct oral anticoagulants (DOACs) is unknown. We aimed to assess the effects of preceding anticoagulation treatment on neurologic severity at admission and functional outcomes at discharge in patients with atrial fibrillation (AF) who developed acute ischemic stroke. METHODS We retrospectively assessed consecutive patients with acute ischemic stroke and AF. Adherence to DOACs was assessed using the 4-item Morisky Medication Adherence Scale. Associations between preceding DOAC treatment and stroke severity at admission and functional outcomes at hospital discharge were examined. RESULTS Of 387 patients with AF and acute ischemic stroke, 248 (64.1%) were not administered an anticoagulant before stroke onset, 95 (24.5%) had subtherapeutic warfarin with an international normalized ratio less than 2 at the time of stroke, 16 (4.1%) had therapeutic warfarin, 6 (1.6%) had DOACs with nonadherence, and 22 (5.7%) had DOACs with adequate adherence. Multivariate analysis showed that DOAC treatment with adequate adherence was associated with lower odds of severe stroke (National Institute of Health Stroke Scale ≥10 at admission) (odds ratio, .24; 95% confidence interval, .03-.98; P = .04) and higher odds of excellent recovery (modified Rankin Scale score, 0-1 at discharge) (odds ratio, 4.89; 95% confidence interval, 1.51-20.6; P < .01) compared with no anticoagulation therapy. CONCLUSIONS Preceding DOAC treatment with adequate adherence has beneficial effects on stroke severity at admission and functional outcome at discharge in patients with AF. Hence, our results encourage an increased effort to bolster adherence to DOACs in patients with AF.

Analysis for usefulness of worsen score; The predicting score for the deterioration of acute ischemic stroke

・Careful attention should be paid to acute stroke patients with high WORSEN scores. Actually, patients with high WORSEN scores with low initial NIHSS scores need to be closely monitored in intensive care or acute stroke units. >For example, patients with high WORSEN scores can be managed with high volume infusion therapy, multiple types of anti-platelet therapy from the begging, and the bed rest level.

Age Stratification and Impact of Eicosapentaenoic Acid and Docosahexaenoic Acid to Arachidonic Acid Ratios in Ischemic Stroke Patients

Aim: We focused on the ratios of eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) to arachidonic acid (AA) and explored the significance of these ratios relative to clinical characteristics by age in ischemic stroke patients. Methods: We enrolled patients with acute ischemic stroke who underwent radiological investigations and laboratory examinations, including measurement of serum EPA, DHA, and AA levels, and controls. Patients were classified according to age (< 65, 65–74, and ≥ 75 years) and the tertile of EPA/AA and DHA/AA ratios, and clinical aspects were compared with these factors. Results: We analyzed 373 patients (age 70.2 ± 13.4 years; 245 males) and 105 controls. Among stroke patients, patients aged < 65 years had the lowest EPA/AA (0.35 ± 0.23, p = 0.006) and DHA/AA (0.73 ± 0.27, p < 0.001) ratios. Compared with controls, patients aged < 65 years showed lower EPA/AA (vs. 0.49 ± 0.25, p < 0.001) and DHA/AA (vs. 0.82 ± 0.26, p = 0.009) ratios. From logistic regression analysis, the EPA/AA (odds ratio 0.18, 95% confidence interval 0.04–0.81, p = 0.026) and DHA/AA (odds ratio 0.09, 95% confidence interval 0.02–0.33, p < 0.001) ratios were inversely related to patients aged < 65 years. According to age-stratified analyses, we found an association of aortic arch calcification with a lower EPA/AA ratio for patients aged ≥ 75 years and an association of multiple infarctions and cerebral white matter lesions with a lower EPA/AA ratio for patients aged 65–74 years (p < 0.05). Conclusions: The ratios of EPA/AA and DHA/AA could be specific markers for younger stroke patients. The EPA/AA ratio may be related to aortic arch calcification for elderly stroke patients and to multiple infarctions and cerebral white matter disease for middle-aged stroke patients.

Temporal Changes of Ulcerative Plaques in the Aortic Arch in Recurrent Stroke Patients

BACKGROUND Ulcerative aortic plaques (UAPs) are considered a major source of brain embolism. However, whether UAPs contribute to a specific stroke mechanism remains unknown. METHODS Three consecutive patients with recurrent embolic stroke underwent repeated transesophageal echocardiography (TEE) examinations after their initial and recurrent strokes. RESULTS All 3 patients had UAPs. Between TEEs, different morphologies of UAPs were found in cases 1 and 2, and case 3 maintained advanced UAPs with no significant morphological alteration. Case 3 underwent repeated contrast-enhanced computed tomographic examinations after each stroke event, which showed newly developed, uneven, ulcerative plaques in the aortic arch after recurrent stroke. CONCLUSIONS Repeated TEE showed dynamic changes of UAPs in recurrent stroke patients and supported the diagnosis of aortogenic brain embolism.