Tadashi Terasaki

Presence of Deep White Matter Lesions on Diffusion-Weighted Imaging Is a Negative Predictor of Early Dramatic Improvement after Intravenous Tissue Plasminogen Activator Thrombolysis

Background: The impact of deep white matter lesions observed at the corona radiata on diffusion-weighted MRI (DWI-W lesions) on the clinical recovery of patients after tissue plasminogen activator (tPA) therapy is unclear. Our goal was to elucidate whether DWI findings before tPA could predict clinical recovery. Methods: A total of 83 consecutive patients with hyperacute anterior circulation ischemic stroke were enrolled. All patients underwent MRI within 3 h and received intravenous tPA. The relationships among the Alberta Stroke Program Early CT Score (ASPECTS) on DWI (DWI-ASPECTS), DWI-W lesions, early dramatic improvement (≧10-point reduction in the total National Institutes of Health Stroke Scale, NIHSS, score or a total NIHSS score of 0–2 after 24 h), early improvement (≧4-point reduction in the total NIHSS score after 24 h) and worsening (≧4-point increase in the total NIHSS score after 24 h) were assessed. Results: The median of the baseline DWI-ASPECTS value was 9 (range: 5–10), and DWI-W lesions were found in 36 patients (43%). Patients with early dramatic improvement had a shorter time from onset to tPA (116.1 ± 34.9 vs. 133.2 ± 33.1 min; p = 0.0281) and higher DWI-ASPECTS (medians: 9 vs. 9; p = 0.0568). DWI-W lesions were seen less frequently in patients with than without early dramatic improvement (26 vs. 54%; p = 0.0213). Multivariate logistic regression analysis demonstrated that absence of DWI-W lesions (OR: 1.80; 95% CI: 1.08–3.13; p = 0.0279), higher ASPECTS (OR: 1.56; 95% CI: 1.06–2.46; p = 0.0346) and shorter time from onset to tPA (OR: 0.98; 95% CI: 0.97–0.99; p = 0.0429) were independent predictors of early dramatic improvement. Conclusions: DWI-ASPECTS and DWI-W lesions appear to be useful tools for predicting early dramatic improvement.

Hyperacute-Phase Computed Tomography–Diffusion-Weighted Imaging Discrepancy and Response to Thrombolysis

This study investigated the incidence and clinical features of reversed discrepancy (RD) in patients with hyperacute ischemic stroke. Sixty-two patients with anterior circulation ischemic stroke were enrolled. All patients underwent computed tomography (CT) and magnetic resonance imaging within 3 hours and received therapy with intravenous tissue plasminogen activator. The relationships between the Alberta Stroke Programme Early CT Score on CT and diffusion-weighted imaging (DWI); deep white matter lesion on DWI (DWI-W), CT, or magnetic resonance imaging after 24 hours; dramatic improvement (defined as a change in National Institutes of Health Stroke Scale score of ≥ 10 points or a total National Institutes of Health Stroke Scale score of 0 or 1 after 24 hours); and thrombolysis-related hemorrhage were assessed. Two investigators identified RD when the early ischemic change was detected on CT but no obvious hyperintensity was noted on DWI. RD was found in 10 patients (16.1%), located in the basal ganglia in 5 patients (50%), in the basal ganglia plus the cortical area in 3 patients (30%), and in the cortical area in 2 patients (20%). Four of these 10 patients had an infarction of the basal ganglia and a DWI-W lesion. All 4 patients with both RD in the basal ganglia (bRD) and DWI-W (the bRD+W+ group) had an infarction of the basal ganglia within 24 hours. In contrast, all 4 patients with bRD but without DWI-W (the bRD+W- group) had no basal ganglia infarction. Dramatic improvement after intravenous tissue plasminogen activator therapy was significantly less common in the bRD+W+ group (0 of 4 patients) than in the bRD+W- group (3 of 4 patients; P = .0285). Our findings suggest that the presence of both bRD and a DWI-W lesion can be used to predict whether dramatic improvement will occur and whether the basal ganglia will progress to infarction.

Cerebral infarction related to varicella zoster virus vasculopathy

A 14-year-old girl developed transient disturbance of consciousness, dysarthria, and clumsiness of the right upper limb 4 months after herpes zoster ophthalmicus. Brain MRI showed acute cerebral infarction in the left middle cerebral artery (MCA) territory. CT angiography demonstrated mild stenosis in the top of the left internal carotid artery and the proximal side of the MCA. Cerebrospinal fluid (CSF) examination showed slightly mononuclear pleocytosis (6/μl). Titer of the anti-varicella zoster virus (VZV) IgG antibodies in CSF was increased, and gadolinium-enhanced brain MRI (T1-weighted imaging) revealed enhancement of the vessel walls at the stenotic lesions. Based on the diagnosis of VZV vasculopathy, methylprednisolone and valacicrovir were administered, followed by acyclovir, in addition to antithrombotic therapy using aspirin and warfarin. After these treatment, her right upper clumsiness was resolved and gadolinium-enhancement of the vessel walls was disappeared on MRI. VZV vasculopathy may cause ischemic stroke in young patients, especially in children. A careful history-taking about herpes is necessary to detect the disease as a potential cause in young stroke patients.

Calcified Cerebral Embolism Due to a Calcified Amorphous Tumor

A 59-year-old man developed brain embolism in the frontal and parietal cortex. Brain CT showed a high-density spot in the upper branch of the left middle cerebral artery, indicating calcified cerebral embolism. Calcified amorphous tumor attached to the mitral valve was identified as the cause of embolism. After surgical resection, anticoagulation was started and recurrent stroke did not occur.

Two-Year Outcomes of Anticoagulation for Acute Ischemic Stroke With Nonvalvular Atrial Fibrillation ― SAMURAI-NVAF Study ―

BACKGROUND We determined the 2-year long-term risk-benefit profile in patients with stroke or transient ischemic attack (TIA) receiving warfarin or direct oral anticoagulants (DOACs) for nonvalvular atrial fibrillation (NVAF) using a prospective, multicenter, observational registry in Japan.Methods and Results:NVAF patients within 7 days after onset of ischemic stroke/TIA were enrolled in 18 stroke centers. Outcome measures included ischemic and bleeding events and death in the 2-year follow-up period. We enrolled 1,116 patients taking either warfarin (650 patients) or DOACs (466 patients) at acute hospital discharge. DOAC users were younger and had lower National Institutes of Health Stroke Scale, CHADS2and discharge modified Rankin Scale scores than warfarin users (P<0.0001 each). Incidences of stroke/systemic embolism (adjusted hazard ratio, 1.07; 95% CI, 0.66-1.72), all ischemic events (1.13; 0.72-1.75), and ischemic stroke/TIA (1.58; 0.95-2.62) were similar between groups. Risks of intracranial hemorrhage (0.32; 0.09-0.97) and death (0.41; 0.26-0.63) were significantly lower for DOAC users. Infection was the leading cause of death, accounting for 40% of deaths among warfarin users. CONCLUSIONS Stroke/TIA patients receiving DOACs for secondary prevention were younger and had lower stroke severity and risk indices than those receiving warfarin. Estimated cumulative incidences of stroke and systemic embolism within 2 years were similar between warfarin and DOACs users, but those of death and intracranial hemorrhage were significantly lower among DOAC users.

Associations between Pre-Admission Risk Scores and Two-Year Clinical Outcomes in Ischemic Stroke or Transient Ischemic Attack Patients with Non-Valvular Atrial Fibrillation

Background: We aimed to clarify associations between pre-admission risk scores (CHADS2, CHA2DS2-VASc, and HAS-BLED) and 2-year clinical outcomes in ischemic stroke or transient ischemic attack (TIA) patients with non-valvular atrial fibrillation (NVAF) using a prospective, multicenter, observational registry. Methods: From 18 Japanese stroke centers, ischemic stroke or TIA patients with NVAF hospitalized within 7 days after onset were enrolled. Outcome measures were defined as death/disability (modified Rankin Scale score ≥3) at 2 years, 2-year mortality, and ischemic or hemorrhagic events within 2 years. Results: A total of 1,192 patients with NVAF (527 women; mean age, 78 ± 10 years), including 1,141 ischemic stroke and 51 TIA, were analyzed. Rates of death/disability, mortality, and ischemic or hemorrhagic events increased significantly with increasing pre-admission CHADS2 (p for trend <0.001 for death/disability and mortality, p for trend = 0.024 for events), CHA2DS2-VASc (p for trend <0.001 for all), and HAS-BLED (p for trend = 0.004 for death/disability, p for trend <0.001 for mortality, p for trend = 0.024 for events) scores. Pre-admission CHADS2 (OR per 1 point, 1.52; 95% CI 1.35–1.71; p <0.001 for death/disability; hazard ratio (HR) per 1 point, 1.23; 95% CI 1.12–1.35; p <0.001 for mortality; HR per 1 point, 1.14; 95% CI 1.02–1.26; p = 0.016 for events), CHA2DS2-VASc (1.55, 1.41–1.72, p < 0.001; 1.21, 1.12–1.30, p < 0.001; 1.17, 1.07–1.27, p < 0.001; respectively), and HAS-BLED (1.33, 1.17–1.52, p < 0.001; 1.23, 1.10–1.38, p < 0.001; 1.18, 1.05–1.34, p = 0.008; respectively) scores were independently associated with all outcome measures. Conclusions: In ischemic stroke or TIA patients with NVAF, all pre-admission risk scores were independently associated with death/disability at 2 years and 2-year mortality, as well as ischemic or hemorrhagic events within 2 years.

Beauty parlor stroke syndrome while drying hair at home-Stroke after taking up a hanging head-hyperextended position during activities of daily living-

症例は30歳男性.3年前よりソファーに寝そべり肘掛けから頭部を垂らし頸部を後屈させて,ドライヤーで髪を乾かす習慣があった.2002年12月2日,この姿勢で頸部を左に回旋させたところ,急に回転性のめまいが出現したため,当院を受診した.来院時,右注視方向性眼振,構音障害,顔面を含む右半身の温痛覚低下を認め,左延髄外側症候群を呈していた.MRIT2強調画像で左延髄外側に高信号域を認めた.左椎骨動脈V3部にMRIでinitimal flap,intramural hematomaを認め,脳血管造影では,string signを認めたため,椎骨動脈解離と診断した.近年,美容院での洗髪の際に頸部を後屈させた姿勢で発症する美容院卒中症候群(beauty parlor stroke syndrome)が注目されているが,本症例も同様の機序で発症したと考えられた.

A case of brainstem infarction following herpes zoster in the distribution of the thoracic root

49歳の女性が胸髄レベル(Th5)の帯状疱疹罹患1週間後,脳幹梗塞を発症した.近医でアシクロビルにて治療されたが頭痛や吐き気なども出現し増悪した.帯状疱疹発症7日後,症状はさらに増悪し左顔面の感覚低下,Horner徴候,対側の頸部以下の温痛覚低下を呈し,延髄外側症候群に進展した.脳血管造影,頭部MRIなどから本症例は帯状疱疹後の脳幹梗塞と判断した.一般的には帯状疱疹後の脳梗塞は頸動脈系に多く椎骨脳底動脈系には少ないとされている.本症例は帯状疱疹の部位と脳梗塞の部位が,離れている珍しい1例であった.

A case of atherothrombotic brain infarction with artery-to-artery embolism and recanalization of the horizontal segment of the left middle cerebral artery by antithrombotic therapy.

症例は69歳右利き男性で,感覚性失語を呈し,第1病日の脳血管造影で左中大脳動脈水平部閉塞が認められた.アテローム血栓性脳梗塞と診断し,アルガトロバンを開始した.第2病日から運動性失語へと変化し,顔面を含む右片麻痺が顕著となった、第8病日のMR angiographyで左中大脳動脈の末梢に血流が認められたことから,第21病日に再度脳血管造影を行ったところ,左中大脳動脈水平部の約90%狭窄と再開通を認め,皮質梗塞は溶解した血栓により生じた動脈原性塞栓症と考えられた.アテローム血栓性脳梗塞の中には本例のように抗血栓療法により閉塞血管が再開通し,塞栓症を生じる例が存在するものと考えられた.

A case of cerebral infarction associated with protein-losing gastroenteropathy.

蛋白漏出性胃腸症の治療中に左中大脳動脈領域の広範な脳梗塞を来した46歳男性を報告した.左眼視力低下(網膜中心動脈閉塞症)で発症し,その3時間後に意識障害,右片麻痺,失語が出現した.第2病日の脳血管造影では左内頸動脈の高度狭窄を認めた.血液生化学検査で著明な低蛋白血症と高脂血症を認め,凝固線溶系ではアンチトロンビンIIIの低下,フィブリノーゲン,FDP,D-ダイマーの上昇などの凝固線溶亢進状態がみられ,脳梗塞との関連が示唆された.抗血栓療法を施行し,経時的に施行した頸部血管エコーで,内頸動脈起始部に形成された血栓が消退し,狭窄性病変が改善していく様子が確認された.