Ryo Itabashi

Effect of Prothrombin Complex Concentrate on Hematoma Enlargement and Clinical Outcome in Patients with Anticoagulant-Associated Intracerebral Hemorrhage

Background: The present study was carried out to determine the effect of prothrombin complex concentrate (PCC) on hematoma enlargement (HE) and the early clinical outcome of intracerebral hemorrhage (ICH) patients on long-term warfarin treatment. Methods: Themedical records and computed tomography (CT) images of 50 consecutive ICH patients on long-term warfarin treatment (35 men, 15 women; 69 ± 12 years old) were reviewed. International normalized ratio (INR) values, frequency of HE and clinical outcome were compared between patients treated with and without PCC. Results: INR values on admission were above 2.0 in 37 patients, of whom 19 were given PCC (PCC group) and 18 were not given PCC (control group). In these 37 patients, the frequency of HE (p = 0.017), the number of patients with a poor clinical outcome (modified Rankin Scale score ≧3 at 30 days or at discharge; p = 0.045) and in-hospital mortality (p = 0.042) were significantly higher in the control than in the PCC group. On multivariate logistic regression analysis with adjustment, PCC administration was independently associated (odds ratio 0.03, 95% confidence interval 0.00–0.63; p = 0.023) with a reduction in poor clinical outcome in ICH patients whose INR values were >2.0 on admission. Conclusions: Immediate INR reversal with PCC may prevent HE and subsequent poor outcome.

Pre-admission CHADS2 score is related to severity and outcome of stroke

BACKGROUND The CHADS(2) score is a stroke risk stratification system for patients with atrial fibrillation (AF). The relationship between the pre-admission CHADS(2) score and stroke severity or outcome was examined in AF-related cardioembolic stroke patients. METHODS 423 consecutive AF-related cardioembolic stroke patients (250 men, 173 women; aged 76±10 years) were reviewed. RESULTS Pre-admission CHADS(2) scores of 0, 1, 2, 3, 4, 5, and 6 were present in 4.3%, 21.0%, 34.3%, 23.6%, 11.8%, 4.5%, and 0.5% of patients, respectively. There were significant correlations (P<0.001) between CHADS(2) and National Institutes of Health Stroke Scale (NIHSS) scores on admission, and CHADS(2) and modified Rankin scale (mRS) scores at discharge. The optimal cutoff CHADS(2) score for an mRS score ≥3 was ≥2 (sensitivity 84%, specificity 38%). For death, the optimal cutoff CHADS(2) score was ≥3 (sensitivity 59%, specificity 62%). On multivariate analysis, a CHADS(2) score ≥2 was independently associated with an mRS score ≥3 (OR 1.93, 95% CI 1.39-2.72, P<0.001), and a CHADS(2) score ≥3 was independently associated with death (OR 1.46, 95% CI 1.02-2.11, P=0.038). CONCLUSIONS The CHADS(2) score is related to severity and outcomes of stroke in patients with AF.

Enlargement of Acute Intracerebral Hematomas in Patients on Long-Term Warfarin Treatment

Background: The relationship between warfarin administration and the frequent development of enlarged hematomas in patients with acute intracerebral hemorrhage (ICH) is controversial. The present study was carried out to examine this issue. Methods: This study reviewed 41 patients with nontraumatic ICH within 24 h after stroke onset from 1999 to 2003 who received long-term warfarin treatment (29 men and 12 women, 70 ± 12 years old) and 323 patients who had not been on warfarin (177 men and 146 women, 66 ± 13 years old). The hematoma volume (HV) on admission, final HV, frequency of hematoma enlargement (HE) and other background characteristics were investigated. Results: Both the HV on admission (p = 0.031) and final HV (p = 0.001) were larger in patients on warfarin than in those not receiving warfarin. HE occurred more frequently (p < 0.001), and mortality at 30 days or at discharge was higher (p = 0.003) in the warfarin group than in the control group. A multivariate adjusted logistic regression analysis showed that warfarin treatment (OR = 5.75, 95% CI = 2.41–13.8, p < 0.001), liver disease (OR = 2.59, 95% CI = 1.12–5.99, p = 0.026), and the National Institutes of Health Stroke Scale score (OR = 1.10, 95% CI = 1.04–1.15, p < 0.001, per 1-score increase) on admission were independently related to HE. Conclusions: Acute ICH in patients on long-term warfarin treatment appears to be associated with HE.

Damage to the Left Precentral Gyrus Is Associated With Apraxia of Speech in Acute Stroke

Background and Purpose— Apraxia of speech (AOS) is a motor speech disorder, which is clinically characterized by the combination of phonemic segmental changes and articulatory distortions. AOS has been believed to arise from impairment in motor speech planning/programming and differentiated from both aphasia and dysarthria. The brain regions associated with AOS are still a matter of debate. The aim of this study was to address this issue in a large number of consecutive acute ischemic stroke patients. Methods— We retrospectively studied 136 patients with isolated nonlacunar infarcts in the left middle cerebral artery territory (70.5±12.9 years old, 79 males). In accordance with speech and language assessments, the patients were classified into the following groups: pure form of AOS (pure AOS), AOS with aphasia (AOS-aphasia), and without AOS (non-AOS). Voxel-based lesion–symptom mapping analysis was performed on T2-weighted images or fluid-attenuated inversion recovery images. Using the Liebermeister method, group-wise comparisons were made between the all AOS (pure AOS plus AOS-aphasia) and non-AOS, pure AOS and non-AOS, AOS-aphasia and non-AOS, and pure AOS and AOS-aphasia groups. Results— Of the 136 patients, 22 patients were diagnosed with AOS (7 patients with pure AOS and 15 patients with AOS-aphasia). The voxel-based lesion–symptom mapping analysis demonstrated that the brain regions associated with AOS were centered on the left precentral gyrus. Conclusions— Damage to the left precentral gyrus is associated with AOS in acute to subacute stroke patients, suggesting a role of this brain region in motor speech production.

Incidence of Cardioembolic Stroke Including Paradoxical Brain Embolism in Patients with Acute Ischemic Stroke before and after the Great East Japan Earthquake

Background: The incidence of heart disease or deep vein thrombosis (DVT) reportedly increased after the Great East Japan Earthquake. We hypothesized that the incidence of cardioembolic stroke (CES) including paradoxical brain embolism (PBE) among patients with acute stroke would increase after the earthquake due to cessation of antithrombotic therapy or the increase in heart disease and DVT associated with the evacuation. The aim of this study is to evaluate the changes in the prevalence of DVT and the incidence of CES including PBE in acute ischemic stroke before and after the earthquake. Methods: We retrospectively studied 1,044 consecutive ischemic stroke patients (73.1 ± 12.5 years old, male 61.5%) who were admitted to a comprehensive stroke center (from January 2010 through March 2012) located in the earthquake disaster area within 7 days after stroke onset. The prevalence of DVT and the incidence of CES including PBE were compared before and after the earthquake of 11 March 2011. Results: The median of the initial National Institutes of Health Stroke Scale (NIHSS) scores was 4 (interquartile range: 1-8). Two hundred and eighty-two patients (27.0% of those surveyed) were diagnosed with CES. After adjustment for sex, age, NIHSS score, and patients residential address, the proportion of CES patients was significantly increased after the earthquake (odds ratio, OR 1.61, 95% confidence interval, 95% CI: 1.20-2.17). Eighty-nine patients (8.5% of those surveyed) had DVT. Compared with 2010 findings, the prevalence of DVT was significantly increased in the fourth quarter of 2011 and the first quarter of 2012 (OR 1.85, 95% CI: 1.05-3.24). Nineteen (1.8% of those surveyed) were diagnosed with PBE. The proportion of PBE patients was also significantly increased in the second half of 2011 (OR 3.69, 95% CI: 1.28-12.1). Conclusions: The incidence of CES was significantly increased after the earthquake, compared with the period before the earthquake. We encountered more PBE in the period from 3 to 9 months after the earthquake and found more DVT in the acute ischemic stroke patients in the period from 6 through 12 months after the earthquake. In these types of disasters, we have to ensure the distribution of drugs, including antithrombotics, and support the prevention of DVT in the refugees.

Effect of Cilostazol in the Treatment of Acute Ischemic Stroke in the Lenticulostriate Artery Territory

Background: Cilostazol, an inhibitor of phosphodiesterase 3, has various pleiotropic effects besides its antiplatelet activity. This study examined the efficacy of cilostazol for the treatment of acute perforating artery infarction. Methods: In this prospective, randomized, open-label, blinded-end point trial, 100 patients with cerebral infarction in the territory of the lenticulostriate arteries were enrolled within 48 h of onset. Patients were randomly treated with both cilostazol and ozagrel for 14 days (n = 50, cilostazol group) or ozagrel alone for 14 days (n = 50, control group). The primary end point was the proportion of favorable outcomes 30 days after randomization as defined by a modified Rankin Scale (mRS) score of 0–2. Secondary end points included the incidence of neurological deterioration (an increase of ≥2 on the National Institutes of Health Stroke Scale within 7 days). Results: Favorable outcomes (mRS scores 0–2) were similar in both groups (81.3 and 82.0% in the cilostazol and control groups, respectively). The incidence of neurological deterioration was lower in the cilostazol group than the control group (12.5 and 16.0%, respectively) with a 21.9% relative risk reduction, although the difference was not statistically significant. Conclusions: Cilostazol did not prevent the neurological deterioration of perforating artery infarction.

Combination oral antiplatelet therapy may increase the risk of hemorrhagic complications in patients with acute ischemic stroke caused by large artery disease

INTRODUCTION The association between the frequency or severity of bleeding complications and combination antiplatelet therapy for acute stroke treatment is not understood in detail. This retrospective study investigated whether combination oral antiplatelet therapy for cases with acute ischemic stroke due to large artery disease increased the incidence of hemorrhagic complications. MATERIALS AND METHODS We reviewed 1335 consecutive patients who were admitted to our department within 7 days of the onset of an ischemic stroke or transient ischemic attack between April 2005 and November 2009. We enrolled 167 patients with >50% stenosis or occlusion in culprit major vessels and who were administered oral antiplatelet agents within 48 hours of admission. Hemorrhagic complications were classified according to the bleeding severity index. We studied the association between the incidence and severity of hemorrhagic complications during hospitalization and the clinical characteristics, including antiplatelet therapy. RESULTS Fifty-nine and 108 patients were treated with only 1 antiplatelet agent and combination antiplatelet agents, respectively. Fourteen patients developed bleeds (3 major and 11 minor), and all of the major bleeds occurred in those given combination agents. The proportion of patients receiving combination agents was significantly higher in those with significant bleeds. Multivariate logistic regression analysis revealed that being older and receiving combination agents were independent predictors for significant bleeds during hospitalization. CONCLUSIONS Despite the retrospective nature of this study, our findings suggest that the incidence of hemorrhagic complications increases in patients with acute ischemic stroke treated with combination antiplatelet agents.

頸動脈過敏症を合併した頸動脈痛（carotidynia）の1例

A 71-year-old man presented with acute, right-sided neck pain and marked falls in blood pressure in response to cervical extension/rotation. Enhanced CT of the right carotid artery showed wall thickening and soft tissue enhancement surrounding the vessel. Ultrasonography demonstrated wall thickening and marked acceleration of the blood flow velocity. [18F] fluorodeoxyglucose (18F-FDG) positron-emission tomography (PET)-CT revealed increased FDG activity in the area of the right carotid bulb. The patients symptoms resolved in 2 weeks with nonsteroidal anti-inflammatory drug; regression of wall thickening and decreased velocity were observed on follow-up ultrasonography. A carotid inflammatory process due to carotidynia in addition to atherosclerosis may increase carotid sinus baroreceptor stimulation, resulting in the onset of carotid sinus hypersensitivity.

Bilateral thalamoperforating arteries arising from the unilateral posterior cerebral artery revealed on 3.0-tesla MR imaging

The thalamoperforating artery (TPA), also referred as the paraedian thalamic artery or thalamic-subthalamic artery, arises from he proximal P1 peduncular segment of the posterior cerebral rtery (PCA) and supplies the posteromedial thalami. The thalaoperforating arteries of both sides may often arise from the P1 on ne side, either as a single trunk or as two separate closely related essels, thus supplying the thalamus bilaterally [1]. Here, a patient s described in whom 3.0-tesla magnetic resonance imaging (MRI) learly showed bilateral TPA arising from the unilateral posterior erebral artery. In this patient, we could sensibly account for the ssociation between the neurological symptoms and the vascular natomy of the perforating arteries.

Mobile intimal flap in the brachiocephalic artery diagnosed by ultrasonography.

An 82-year-old woman was admitted to our department with transient left hemiparesis. She had neither back nor chest pains. B-mode duplex ultrasonography revealed both a mobile thrombus in the right common carotid artery (CCA) (online suppl. movie 1, www.karger.com/doi/10.1159/000322496) and a mobile intimal flap in the brachiocephalic artery (online suppl. movie 2). Computed tomography showed thoracic aortic dissection. Received: October 1, 2010 Accepted: November 2, 2010 Published online: December 23, 2010