Yoichiro Hashimoto

Aphasia during the acute phase in ischemic stroke.

Objectives: We investigated the incidence, clinical characteristics, outcome and factors associated with aphasia and early improvement in acute ischemic stroke. Methods: We consecutively studied 855 patients with acute ischemic stroke who were admitted to our hospital within 48 h after onset and who were not comatose on admission. Assessment of aphasia was performed on admission (day 0) and day 10. We examined the incidence, severity, and subtypes of aphasia, and compared the clinical background of patients with and without aphasia on admission, and also those with and without early improvement by day 10. In addition, we investigated the independent factors associated with the presence of aphasia on admission and with early improvement. Results: Of the 855 patients, 130 (15.2%) had aphasia on admission. The National Institutes of Health Stroke Scale (NIHSS) on admission (OR 1.21; 95% CI 1.17–1.26) was a significant and independent factor associated with the presence of aphasia on admission. Early improvement was seen in 56 of 121 aphasic patients (46.3%) who were still alive on day 10. A history of hypercholesterolemia (OR 3.27; 95% CI 1.14–9.39) was a significant and independent factor associated with early improvement in aphasia during the acute phase and NIHSS on admission (OR 0.95; 95% CI 0.90–0.99) was marginally significant. Conclusion: It is difficult to predict the outcome of aphasia within the first few days after the onset of ischemic stroke.

Rotational vertigo associated with parietal cortical infarction

A 65-year-old woman experienced sudden positional vertigo with rightward, horizontal nystagmus that resolved within days. MRI revealed a left parietal lobe infarction involving the supramarginal gyrus. The patient experienced a transient recurrence of vertigo after 7 days but MRI failed to reveal the presence of any new lesions; furthermore, the patients EEG was normal. We suggest that this patients vertigo was due to her parietal cortical infarction.

Progressing ischemic stroke in a homozygote with variant antithrombin III.

A 31-year-old woman developed disturbance of consciousness and left hemiparesis. Cerebral computed tomograms showed a low-density area in the right temporal lobe that extended to the right parietal and left frontal lobes as her clinical symptoms worsened. The diagnosis of familial variant of antithrombin III (AT-III) was based on decreased biologic activity and a normal immunologic level of AT-III in this patient and in her family members. Transfusion of normal AT-III concentrate led to a striking clinical recovery. Blood coagulation studies revealed that nine of 13 family members had decreased biologic AT-III activity and that the patient herself was the only homozygote with variant AT-III. We conclude that variant AT-III, especially in a homozygote, seems to be one cause of ischemic stroke in young adults and that simultaneous measurement of both the biologic and immunologic activities of AT-III is necessary to detect it.

Clinical Characteristics of Subarachnoid Hemorrhage With or Without Headache

OBJECTIVE Some patients report the absence of a typical headache at the onset of subarachnoid hemorrhage (SAH). We investigated the clinical backgrounds and characteristics of patients with SAH without headache and compared the findings with those of patients with SAH and headache. METHODS We examined 224 patients retrospectively who underwent intracranial aneurysmal clipping. Patients characteristics, Fishers computed tomography grade, situation at onset, site of ruptured aneurysm, and symptoms were compared. Subjects were categorized into two groups: headache group and nonheadache group. RESULTS Eighteen patients (8.0%) did not present with headache. There were no significant differences in terms of age, sex, Fishers computed tomography grade, onset time, or site of ruptured aneurysm. CONCLUSIONS The patients without headache have no specific clinical characteristics over patients with common SAH.

Acquisition of oral intake in severely dysphagic patients with acute stroke: A single-center, observational study involving a database of 4972 consecutive stroke patients☆

OBJECTIVE A single-center, observational study was performed to identify the predictors for oral intake 3 months after onset in stroke patients with severe dysphagia. METHODS Of 4972 consecutive acute stroke patients, 723 could not eat orally on day 10. Three months after onset, a questionnaire was sent to all patients. Those who survived and replied to the questionnaire were divided into 2 groups, and the clinical factors that predicted their acquisition of oral intake were analyzed. RESULTS Of the 586 dysphagic patients who responded, 141 (24.2%) achieved oral intake after 3 months. On logistic-regression model analysis, age ≤ 80 years, hyperlipidemia, non-cardioembolic stroke, modified Rankin Scale score 0 before onset, and National Institutes of Health Stroke Scale (NIHSS) score were independently related to oral intake 3 months after onset. From two different model analyses, NIHSS score ≤ 17 on day 10 (OR 3.58, 95% CI, 2.35-5.54) was found to be a stronger predictor for oral intake than NIHSS score ≤ 17 on admission (OR 2.17, 95% CI, 1.40-3.39). CONCLUSION In severely dysphagic acute stroke patients, functional independence at baseline, younger age, absence of hyperlipidemia, non-cardioembolic stroke, and a milder NIHSS score on day 10 are useful predictors of the resumption of oral intake.

Occlusive vessel signs on MRI as only findings of hyperacute ischemic stroke

A 64-year-old woman presented with a partial seizure on the left side of her face. Although diffusion weighted images and magnetic resonance angiography 3 h after the onset did not show any signs of ischemic stroke, a susceptibility vessel sign (SVS) on T2*-weighted gradient echo imaging (GRE) and a hyperintense vessel sign (HVS) on fluid attenuated inversion recovery images at the distal branch of the right middle cerebral artery were revealed. One day later, these GRE SVS and HVS signs disappeared and a new infarct lesion in the right insular cortex was found on magnetic resonance images (MRI). It is suggested that occlusive vessel signs on MRI, including GRE SVS and HVS, are sometimes the only findings of ischemic stroke at the hyperacute phase.

tEMPoRAl tRENdS IN oRAl INtAKE ABIlIty 3 MoNtHS AftER AcutE IScHAEMIc StRoKE: ANAlySIS of A SINglE-cENtRE dAtABASE fRoM 2003 to 2011

OBJECTIVE To analyse the 9-year trend in oral intake ability 3 months after onset in acute stroke patients, with a view to indirect clarification of advances in acute stroke treatment and swallowing rehabilitation. METHODS A database of patients admitted to our hospital (Saiseikai Kumamoto Hospital, Kumamoto) with acute ischaemic stroke between 2003 and 2011 was analysed. Exclusion criteria were: patients with premorbid modified Rankin Scale score ≥ 1; those who died during hospital stay; and those whose outcomes after 3 months were not recorded. Mode of nutritional intake was investigated with a questionnaire posted to the patient 3 months after stroke onset. Patients were divided into 2 groups according to mode of nutritional intake: an oral intake group and a non-oral intake group. Whether the date or year of admission were related to the proportion of patients with oral intake, independent of other factors, was investigated using a logistic regression model. RESULTS Of a total of 2,913 patients, 2,677 (91.9%) were included in the oral intake group. The proportion of patients with oral intake 3 months after stroke increased significantly over the period of analysis (p = 0.034 by Cochran-Armitage test). On logistic regression analysis, the trend was significant after adjustment for age, sex, vascular risk factors, stroke subtype, and stroke severity on admission (odds ratio 1.098, 95% confidence interval 1.029-1.173; per 1 year). CONCLUSION The proportion of ischaemic stroke patients in the institution studied who were capable of oral intake at 3 months post-stroke increased significantly over the past decade, independent of other patient characteristics.

Methods for Improving the Predictive Accuracy Using Multiple LinearRegression Analysis to Predict the Improvement Degree of FunctionalIndependence Measure for Stroke Patients

Multiple linear regression analysis is frequently used in studies investigating the degree of Functional Independence Measure (FIM) improvement in stroke patients. However, the coefficient of determination R2 is about 0.46 to 0.73, meaning that the prediction accuracy is not necessarily high. In order to improve the prediction accuracy, the following methods are used; using appropriate explanatory variables, using FIM effectiveness which corrected the ceiling effect as the objective variable, creating multiple prediction formulas, converting numerical variable of explanatory variables into dummy variable, adding FIM improvement for one month to the explanatory variables. Even so, it is difficult to predict patients whose FIM gain is extremely large or small. It is desirable to combine these methods or develop new methods to achieve the accurate prediction.

Questionnaire survey on recruitment for Japanese Neurology Society

Many claim that they do not have enough neurologists in Japan, but supply and demand of neurologists remains to be analyzed. To investigate the recruitment for the Japanese Society of Neurology (JSN), the subcommittee of JSN for education performed a questionnaire-based survey in 80 medical universities and 271 board-certified education facilities throughout Japan. The response rate to the questionnaire was 77.5% in medical universities and 42.4% in education facilities. It was shown that each department of neurology in university recruits average 2.2 doctors, while they supposed that more than 4 doctors to be recruited every year. The questionnaire survey included what measures JSN should take in order to promote recruitment for JSN.

Intratumoral Hemorrhage in a Patient with Malignant Meningioma under Anticoagulant Therapy

We report the case of an elderly woman with malignant meningioma and atrial fibrillation who started taking anticoagulants after an ischemic stroke and subsequently developed intratumoral hemorrhage. Further studies are required to confirm whether a particular anticoagulant agent is suitable for patients with brain tumor and atrial fibrillation.