Publications by authors named "Junpei Koge"

26 Publications

  • Page 1 of 1

Left Ventricular Abnormality and Covert Atrial Fibrillation in Embolic Stroke of Undetermined Source.

J Atheroscler Thromb 2021 Jul 22. Epub 2021 Jul 22.

Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center.

Aims: The relationship between left ventricular (LV) function and AF detection in embolic stroke of undetermined source (ESUS) patients with insertable cardiac monitors (ICMs) remains unclear. We investigated the association between LV function and AF detection in patients with ESUS after ICMs implantation.

Methods: We enrolled patients with ESUS who underwent ICMs implantation from September 2016 to September 2020 using a single-center, prospective registry. LV systolic and diastolic functions were assessed on precordial echocardiography by LV fractional shortening (LVFS) and average E/e', respectively. Associations between characteristics of LV function and detection of AF by ICMs were analyzed.

Results: Participants comprised 101 patients (median age, 74 years; male, 62%). During a median follow-up period of 442 days (interquartile range (IQR), 202-770 days), AF was detected in 24 patients (24%). Median duration from ICMs implantation to AF detection was 71 days (IQR, 13-150 days). When LVFS and E/e' were dichotomized by cutoff value, each of low LVFS (<35.5%; adjusted hazard ratio (HR), 4.77; 95% confidence interval (CI), 1.77-12.9) and high E/e' (≥ 8.65; adjusted HR, 4.56; 95%CI, 1.17-17.7) were independently associated with AF detection after adjusting for age and sex. When patients were divided into four groups according to dichotomized LVFS and E/e', the combination of low LVFS and high E/e' was independently associated with AF.

Conclusions: In patients with ESUS after ICMs implantation, the LV characteristics of low LVFS and high E/e' were associated with AF detection.
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http://dx.doi.org/10.5551/jat.62994DOI Listing
July 2021

Mechanical thrombectomy for stroke patients anticoagulated with direct oral anticoagulants versus warfarin.

J Neurol Sci 2021 Aug 17;427:117545. Epub 2021 Jun 17.

Department of Neurosurgery, Hyogo College of Medicine, Nishinomiya, Japan.

Background Outcomes after mechanical thrombectomy (MT) for large vessel occlusion (LVO) were compared between stroke patients anticoagulated with direct oral anticoagulants (DOACs) and those anticoagulated with warfarin.

Materials And Methods: From data for 2399 LVO stroke patients in a prospective, multicenter registry, patients with prior oral anticoagulation who underwent MT were analyzed. Angiographic outcomes included successful recanalization (modified Thrombolysis in Cerebral Infarction 2b/3). Clinical outcomes included modified Rankin Scale (mRS) score 0-2 at 3 months and symptomatic intracranial hemorrhage.

Results: A total of 235 patients (95 women, median age 78 [interquartile range, 72-84] years) were included. Prescribed anticoagulants were DOACs in 61 patients and warfarin in 174 patients. Of patients on warfarin, 135 (77.6%) had a non-therapeutic therapy (international normalized ration [INR] ≤1.7). Patients on therapeutic warfarin (INR >1.7) had younger age and shorter onset to hospital arrival time than those on non-therapeutic warfarin and DOACs. The achievement of successful recanalization in warfarin groups was similar to the DOACs group, with an adjusted odds ratio (aOR) for therapeutic warfarin versus DOACs of 1.14 (95% confidence interval [CI], 0.27-4.89) and non-therapeutic warfarin versus DOACs of 0.92 (95% CI, 0.39-2.20), respectively. The frequency of mRS score 0-2 at 3 months in the therapeutic (aOR, 2.63; 95% CI, 0.86-7.98) and non-therapeutic warfarin (aOR, 1.77; 95% CI, 0.76-4.09) groups were similar to those in the DOACs group. There was no significant difference in symptomatic intracranial hemorrhage between groups.

Conclusions: Angiographic and clinical outcomes after MT were similar between patients anticoagulated with DOACs and warfarin.
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http://dx.doi.org/10.1016/j.jns.2021.117545DOI Listing
August 2021

Atherosclerotic Components in Thrombi Retrieved by Thrombectomy for Internal Carotid Artery Occlusion Due to Large Artery Atherosclerosis: A Case Report.

Front Neurol 2021 28;12:670610. Epub 2021 May 28.

Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan.

The correlation between the composition of thrombi retrieved by mechanical thrombectomy (MT) and stroke etiology is inconclusive. We describe a case with atherosclerotic components in thrombi retrieved by MT for acute internal carotid artery (ICA) occlusion. A 69-year-old man with acute onset of global aphasia and right hemiplegia was transferred to our institute. His baseline National Institutes of Health Stroke Scale score was 24. Magnetic resonance imaging demonstrated acute ischemic stroke in the left parietal lobe. Magnetic resonance angiography revealed occlusion of the left ICA. MT was attempted for acute left ICA occlusion. The initial angiography showed occlusion of the proximal ICA, while intraprocedural angiography revealed a large thrombus that extended from the cervical ICA to the intracranial ICA. Successful reperfusion was achieved by five passes using stent retrievers and an aspiration catheter. A large volume of red thrombus was retrieved by each pass. The final angiogram showed successful reperfusion with modified Thrombolysis in Cerebral Ischemia grade 2b and severe stenosis in the proximal ICA. Neck magnetic resonance imaging showed severe left ICA stenosis with a vulnerable plaque. Hence, his stroke etiology was determined as large artery atherosclerosis. Histopathological examination of the retrieved thrombi revealed atheromatous components, including cholesterol clefts, foam cells, and a necrotic core. Atherosclerotic components in retrieved thrombi might provide useful clues for diagnosing stroke pathogenesis. Further studies are warranted to clarify the utility of assessing atheromatous components in retrieved thrombi in diagnosing stroke etiology.
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http://dx.doi.org/10.3389/fneur.2021.670610DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8194065PMC
May 2021

Blind Exchange With Mini-Pinning Technique Using the Tron Stent Retriever for Middle Cerebral Artery M2 Occlusion Thrombectomy in Acute Ischemic Stroke.

Front Neurol 2021 19;12:667835. Epub 2021 May 19.

Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan.

The usefulness of the blind exchange with mini-pinning (BEMP) technique has recently been reported for mechanical thrombectomy in patients with stroke owing to medium vessel occlusion (MeVO). The Tron stent retriever can be delivered and deployed through a 0.0165-inch microcatheter. This retriever has potential as an effective and safe treatment for acute ischemic stroke (AIS) due to occlusion of the M2 segment of the middle cerebral artery (MCA). Here, we report the outcomes of the BEMP technique using Tron stent retrievers for M2 occlusion thrombectomy. Consecutive patients with AIS owing to M2 occlusion who underwent the BEMP technique using 2 × 15-mm or 4 × 20-mm Tron stent retrievers were included. The technique involves deploying a Tron stent retriever through a 0.0165-inch microcatheter, followed by microcatheter removal and blind navigation of a 3MAX or 4MAX aspiration catheter over the bare Tron delivery wire until the aspiration catheter reaches the clot. A Tron stent retriever is inserted into the aspiration catheter like a cork and subsequently pulled as a unit. We assessed procedural outcomes [first-pass expanded thrombolysis in cerebral infarction (eTICI) score 2c/3 and 2b/2c/3], safety outcomes [symptomatic intracranial hemorrhage (sICH)], and clinical outcomes (good outcome rate defined as modified Rankin Scale score 0-2 at 90 days and mortality at 90 days). Eighteen M2 vessels were treated in 15 patients (six female, median age: 80 years, and median National Institutes of Health Stroke Scale score: 18). The BEMP technique was performed successfully in all cases. Whether to use a 3MAX or 4MAX catheter was determined by considering one of the following target vessels: dominant, non-dominant, or co-dominant M2 (3MAX, = 9; 4MAX, = 9). The first-pass eTICI 2c/3 and 2b/2c/3 rates were 47 (7/15) and 60% (9/15), respectively; sICH was not observed. Seven patients (47%) achieved good outcomes, and one patient (7%) died within 90 days. The Tron stent retriever was safely and effectively used in the BEMP technique for acute MCA M2 occlusion and can be combined with a 0.0165-inch microcatheter, which may be useful for treating MeVO, in general.
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http://dx.doi.org/10.3389/fneur.2021.667835DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8172139PMC
May 2021

Clopidogrel response predicts thromboembolic events associated with coil embolization of unruptured intracranial aneurysms: A prospective cohort study.

PLoS One 2021 8;16(4):e0249766. Epub 2021 Apr 8.

Department of Neurology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.

Objective: Periprocedural thromboembolic events are a serious complication associated with coil embolization of unruptured intracranial aneurysms. However, no established clinical rule for predicting thromboembolic events exists. This study aimed to clarify the significance of adding preoperative clopidogrel response value to clinical factors when predicting the occurrence of thromboembolic events during/after coil embolization and to develop a nomogram for thromboembolic event prediction.

Methods: In this prospective, single-center, cohort study, we included 345 patients undergoing elective coil embolization for unruptured intracranial aneurysm. Thromboembolic event was defined as the occurrence of intra-procedural thrombus formation and postprocedural symptomatic cerebral infarction within 7 days. We evaluated preoperative clopidogrel response and patients' clinical information. We developed a patient-clinical-information model for thromboembolic event using multivariate analysis and compared its efficiency with that of patient-clinical-information plus preoperative clopidogrel response model. The predictive performances of the two models were assessed using area under the receiver-operating characteristic curve (AUC-ROC) with bootstrap method and compared using net reclassification improvement (NRI) and integrated discrimination improvement (IDI).

Results: Twenty-eight patients experienced thromboembolic events. The clinical model included age, aneurysm location, aneurysm dome and neck size, and treatment technique. AUC-ROC for the clinical model improved from 0.707 to 0.779 after adding the clopidogrel response value. Significant intergroup differences were noted in NRI (0.617, 95% CI: 0.247-0.987, p < .001) and IDI (0.068, 95% CI: 0.021-0.116, p = .005).

Conclusions: Evaluation of preoperative clopidogrel response in addition to clinical variables improves the prediction accuracy of thromboembolic event occurrence during/after coil embolization of unruptured intracranial aneurysm.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0249766PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8031457PMC
April 2021

Early recurrent ischemic events after mechanical thrombectomy: effect of post-treatment intracranial hemorrhage.

J Neurol 2021 Aug 16;268(8):2810-2820. Epub 2021 Feb 16.

Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, 6-1 Kishibe-Shimmachi, Suita, Osaka, 564-8565, Japan.

Objective: Patients with intracranial hemorrhages (ICH) after mechanical thrombectomy (MT) may have a higher risk of early recurrent embolism (ERE) because of delayed initiation of anticoagulants. We assessed the rate of ischemic events in the early period after MT and the association with post-MT ICH.

Methods: Patients who underwent MT in our institute were retrospectively reviewed. ERE was defined as recurrent ischemic stroke and systemic embolism within 14 days after MT. The association between ERE and parenchymal hematoma (PH) was assessed. Multivariable regression analysis and inverse probability of treatment weighting was used to adjust for differences in baseline characteristics between patients with and without PH.

Results: A total of 307 patients (median age, 78 years; female, 47%; median baseline National Institutes of Health Stroke Scale score, 19) were included. ERE was observed in 12 of 307 patients (8 strokes, 4 systemic embolisms; 3.9%). Median time from MT to ERE was 6.5 days (IQR, 3-8 days). PH occurred in 21 patients (6.8%). Median time from MT to initiating oral anticoagulants was longer in patients with PH (8 days) than in those without (3 days) (p < 0.01). In both unweighted and weighted multivariable analysis, PH was significantly associated with an increased risk of ERE (unweighted odds ratio, 10.60; 95% CI, 2.66-42.23; weighted odds ratio, 12.34; 95% CI, 2.49-61.07).

Conclusions: ERE occurred in about 4% of patients after MT. PH after MT was associated with delayed initiation of oral anticoagulants and an increased risk of recurrent ischemic events.

Clinical Trial Registration: URL: https://www.clinicaltrials.gov . Unique identifier: NCT02251665.
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http://dx.doi.org/10.1007/s00415-021-10449-1DOI Listing
August 2021

Acute Stroke Care in the With-COVID-19 Era: Experience at a Comprehensive Stroke Center in Japan.

Front Neurol 2020 18;11:611504. Epub 2021 Jan 18.

Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan.

The pandemic of coronavirus disease 2019 (COVID-19) has had a significant impact on stroke healthcare, including the prehospital care system and in-hospital workflow. Japan experienced the outbreak of COVID-19, and the State of Emergency was declared during April 2020 and May 2020. The aim of the present study was to clarify the effect of the COVID-19 pandemic on a comprehensive stroke center in Japan. We retrospectively reviewed consecutive patients with acute ischemic stroke admitted in our institute between December 2019 and July 2020. The patients who underwent reperfusion therapy (intravenous thrombolysis and/or mechanical thrombectomy) were divided into the pre-COVID-19 period (December 2019 to March 2020) and the With-COVID-19 period (April 2020 to July 2020). Study outcomes were the number of stroke admissions in our institute, workflow time metrics, the frequency of modified Rankin Scale score 0-2 at discharge, and brain imaging modalities before reperfusion therapy in patients who underwent reperfusion therapy. In our institute, the number of stroke admissions decreased during the State of Emergency and then increased after the lifting of the State of Emergency. Among patients who underwent reperfusion therapy (median age, 77 years; female 27%; median baseline National Institutes of Health Stroke Scale score, 10), times from hospital arrival to imaging [25 (21-33) min vs. 30 (25-38) min, = 0.03] and to thrombolysis [38 (31-52) min vs. 51 (37-64) min, = 0.03] were prolonged compared with the pre-COVID-19 period. There was no significant difference in the frequency of modified Rankin Scale score 0-2 at discharge between the two periods (32 vs. 45%, = 0.21). The proportion of computed tomography vs. magnetic resonance imaging as an emergency brain imaging tool before reperfusion therapy changed, with computed tomography having become predominant in the With-COVID-19 period. In our institute, the number of stroke admissions, workflow time metrics, and imaging modalities for reperfusion therapy were affected by the COVID-19 pandemic.
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http://dx.doi.org/10.3389/fneur.2020.611504DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7847991PMC
January 2021

Identifying large ischemic core volume ranges in acute stroke that can benefit from mechanical thrombectomy.

J Neurointerv Surg 2020 Dec 15. Epub 2020 Dec 15.

Neurology, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan.

Background: We aimed to identify the large ischemic core (LIC) volume ranges in acute ischemic stroke patients that can benefit from mechanical thrombectomy (MT).

Methods: Consecutive patients within 24 hours of onset of anterior circulation ischemic stroke with large vessel occlusion and ischemic core volumes of 70-300 mL were included from our single-center prospective database from March 2014 to December 2019. Subjects were divided into three groups by baseline ischemic core volume (A: 70-100 mL; B: 101-130 mL; C: >130 mL). We compared modified Rankin Scale (mRS) score 0-2 at 3 months and parenchymal hematoma between patients receiving MT and standard medical treatment (SMT), and determined clinically treatable core volume ranges for MT.

Results: Of 157 patients (86 women; median age, 81 years; median ischemic core volume, 123 mL), 49 patients underwent MT. In Group A (n=52), MT patients (n=31) showed a higher proportion of mRS 0-2 at 3 months (52% vs 5%, P<0.05) versus SMT, respectively. Group B (n=36) MT patients (n=14) also had a higher proportion of mRS 0-2 at 3 months (29% vs 9%, P=0.13) versus SMT, respectively. In Group C (n=69), only four patients received MT. The 95% confidence intervals for the probability of mRS 0-2 at 3 months in patients with MT (n=49) versus SMT (n=108) intersected at 120-130 mL.

Conclusions: Ischemic core volumes between 70 and 100 mL may benefit from MT. The treatable upper core limit is approximately 120 mL in selected patients with LIC of 70-300 mL.
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http://dx.doi.org/10.1136/neurintsurg-2020-016934DOI Listing
December 2020

Paroxysmal Atrial Fibrillation in Cryptogenic Stroke Patients With Major-Vessel Occlusion.

Front Neurol 2020 12;11:580572. Epub 2020 Nov 12.

Department of Neurology, Osaka University, Suita, Japan.

To determine whether acute major-vessel occlusion (MVO) predicts atrial fibrillation (AF) in cryptogenic stroke (CS) patients, we analyzed the association between acute MVO and AF detected by insertable cardiac monitoring (ICM). We conducted a retrospective, multicenter, observational study of patients with CS who underwent ICM implantation between October 2016 and March 2018. In this analysis, we included follow-up data until June 2018. We analyzed the association of MVO with AF detected by ICM. We included 84 consecutive patients with CS who underwent ICM implantation. The proportion of patients with newly detected AF by ICM was higher in patients with MVO than in those without (41% [12/29] vs. 13% [7/55], < 0.01) within 90 days of ICM implantation. The MVO was associated with AF after adjustment for each clinically relevant factor. MVO was independently associated with AF detection in patients with CS, which suggests that MVO may be a useful predictor of latent AF. It is therefore essential to actively assess latent AF in patients with CS presenting with MVO.
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http://dx.doi.org/10.3389/fneur.2020.580572DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7689035PMC
November 2020

Treatment Outcomes by Initial Neurological Deficits in Acute Stroke Patients with Basilar Artery Occlusion: The RESCUE Japan Registry 2.

J Stroke Cerebrovasc Dis 2020 Nov 4;29(11):105256. Epub 2020 Sep 4.

Department of Neurosurgery, Hyogo College of Medicine, Nishinomiya, Japan.

Background And Purpose: We hypothesized that the relationships between treatments and outcomes in acute basilar artery occlusion (BAO) are different, depending on the severity of initial neurological deficits.

Methods: Of 2420 ischemic stroke patients with large vessel occlusion in a prospective, multicenter registry in Japan, patients with acute BAO were enrolled. Subjects were divided into two severity groups according to the baseline NIH Stroke Scale score: severe (≥10) and mild (<10) groups. The primary effectiveness outcome was favorable outcome, defined as modified Rankin Scale score 0-3 at 3 months. Safety outcomes included any intracranial hemorrhage (ICH) within 72 h. Outcomes in each group were compared between patients who received endovascular therapy (EVT) and those with standard medical treatment (SMT).

Results: In this study, 167 patients (52 female; median age 75 years) were analyzed. The favorable outcome was seen in 93 patients (56%) overall. In the severe group (n = 128), the proportion of favorable outcome was higher in patients who received EVT (60/111, 54%) than those with SMT (2/17, 12%, P < 0.01). In the mild group (n = 39), the rates of favorable outcome were comparable between the EVT (13/18, 72%) and SMT patients (18/21, 86%, P = 0.43). No significant differences in the rates of any ICH were seen among any groups.

Conclusions: In acute BAO stroke with severe neurological deficit, independent ambulation was more frequently seen in patients who received EVT than those with SMT. Patients with mild neurological deficits showed similar rates of independent ambulation between the two treatment selections.
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http://dx.doi.org/10.1016/j.jstrokecerebrovasdis.2020.105256DOI Listing
November 2020

Atrial Fibrillation After Ischemic Stroke Detected by Chest Strap-Style 7-Day Holter Monitoring and the Risk Predictors: EDUCATE-ESUS.

J Atheroscler Thromb 2021 May 15;28(5):544-554. Epub 2020 Aug 15.

Department of Cerebrovascular Medicine and Neurology, National Hospital Organization Kyushu Medical Center.

Aim: This study aimed to investigate the diagnostic yield of 7-day Holter monitoring for detecting covert atrial fibrillation (AF) in patients with recent embolic stroke of undetermined source (ESUS) and to identify the pre-entry screening biomarkers that had significant associations with later detection of AF (clinicaltrials.gov. NCT02801708).

Methods: A total of 206 patients who have recent ESUS without previously documented AF underwent Holter electrocardiography using a chest strap-style monitor. External validation of biomarkers predictive of AF was performed using 83 patients with ESUS who were implanted with insertable cardiac monitors.

Results: The 7-day Holter monitoring started at a median of 13 days after the onset of stroke. AF was detected in 14 patients, and three of these showed a single AF episode lasting <2 min. The median time delay to the first documented AF was 50 h. Each of serum brain natriuretic peptide ≥ 66.0 pg/mL (adjusted odds ratio 5.23), atrial premature contractions (APCs) ≥ 345 beats (3.80), and APC short runs ≥ 13 (5.74) on 24-h Holter prior to the 7-day Holter showed a significant association with detection of AF, independent of age and physiological findings in this derivation cohort, and all of these showed a significant association in the validation cohort (adjusted odds ratio 6.59, 7.87, and 6.16, respectively).

Conclusions: In recent ESUS patients, the detection rate of AF using the 7-day Holter monitoring was 6.8% (95% CI 4.1%-11.1%). Brain natriuretic peptide, APC count, and APC short runs in the standard clinical workup seemed to be predictors of covert AF.
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http://dx.doi.org/10.5551/jat.58420DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8193782PMC
May 2021

Bilateral carotid artery dissection due to Eagle syndrome in a patient with vascular Ehlers-Danlos syndrome: a case report.

BMC Neurol 2020 Jul 21;20(1):285. Epub 2020 Jul 21.

Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, 6-1 Kishibe-shimmachi, Suita, Osaka, 564-8565, Japan.

Background: Patients with vascular Ehlers-Danlos syndrome (EDS) occasionally suffer from arterial dissection. Eagle syndrome, which is caused by an elongated styloid process and also causes arterial dissection, is difficult to diagnose and could sometimes be overlooked. Little is known of the coexistence of these two diseases, and treatment strategy is not established. Here, we present a case of bilateral internal carotid artery (ICA) dissection due to Eagle syndrome in a patient with vascular EDS.

Case Presentation: A 30-year-old man was admitted to our hospital because of sudden onset of mild sensory disturbance in his left limbs. He had a history of Ehlers-Danlos syndrome (EDS) and also had left cervical internal carotid artery (ICA) dissection 3 years before. Diffusion-weighted imaging showed acute cerebral infarcts in the right hemisphere. Cervical computed tomography angiography (CTA) revealed the right ICA narrowing at the cervical portion in addition to the previous left cervical ICA dissection. Cervical magnetic resonance imaging (MRI) revealed double-lumen and intramural hematoma at the narrowing portion of the right cervical ICA, which indicates arterial dissection. CT also revealed bilateral elongated styloid processes which are close to each side of cervical ICA. We diagnosed him as bilateral ICA dissection due to bilateral Eagle syndrome. Considering vascular complications due to vascular EDS, we performed closer follow-up with transoral carotid ultrasonography (TOCU). In 4 months, his right ICA dissection gradually improved without stroke recurrence or deterioration of dissection.

Conclusions: Since patients with vascular EDS easily develop arterial dissection, Eagle syndrome may be overlooked. Clinicians should consider Eagle syndrome in the case of vascular EDS with extracranial ICA dissection and close follow-up should be prioritized in cases of Eagle syndrome with vascular EDS.
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http://dx.doi.org/10.1186/s12883-020-01866-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7372806PMC
July 2020

Immunotherapy-refractory vacuolar myopathy with mucin deposition in scleromyxedema: A possible role of fibroblast growth factor 2.

Neuropathology 2020 Oct 19;40(5):492-495. Epub 2020 May 19.

Department of Neurology, Neurological Institute, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.

Scleromyxedema (SME) is characterized by widespread waxy papules on the skin, with mucin deposits in the upper dermis. Twenty-one SME cases of myopathy have been reported; of the cases, six showed vacuolar formation, and two showed mucin deposition. We report the first case of SME with mucin-associated vacuolated fibers. A 45-year-old woman with SME developed progressive proximal muscle weakness. Muscle biopsy revealed myopathic changes with numerous vacuoles linked to mucin in the affected muscle fibers, which were heavily immunostained for fibroblast growth factor 2 (FGF2). Despite repeated high dose oral prednisolone and intravenous immunoglobulin administrations, muscle weakness recurred continuingly, culminating in death due to congestive heart failure. Immunotherapy was partly effective in our case, although it was refractory. Treatment responsiveness in patients with SME myopathy varied; however, due to its rarity, the mechanism remains to be elucidated. To address this issue, we investigated muscle specimens immunohistochemically and detected marked upregulation of FGF2 in the affected muscle fibers of our patient. FGF2, a strong myogenesis inhibitor, may exert a suppressive effect on muscle fiber regeneration, which may have conferred refractoriness to our patient's SME myopathy.
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http://dx.doi.org/10.1111/neup.12659DOI Listing
October 2020

Impact of thrombus migration on clinical outcomes in patients with internal carotid artery occlusions and patent middle cerebral artery.

J Neurol Sci 2020 May 15;412:116737. Epub 2020 Feb 15.

Department of Neurosurgery, Kokura Memorial Hospital, Fukuoka, Japan.

Background: Patency of the middle cerebral artery (MCA) in acute ischemic stroke with internal carotid artery (ICA) occlusions is associated with less severe stroke and favorable outcomes. However, thrombus migration to distal intracranial vessels may lead to unfavorable outcomes. We investigated the influence of thrombus migration on clinical outcomes in patients with ICA occlusions and patent MCA.

Materials And Methods: We retrospectively analyzed patients with acute ischemic stroke compromising ICA occlusions and patent MCA who were consecutively admitted to our hospital between January 2006 and March 2016. Thrombus migration was assessed (1) by analyzing the discrepancies in arterial occlusion sites between initial imaging and follow-up imaging and (2) by analyzing how occlusion sites changed during endovascular therapy.

Results: Thirty-eight patients (mean age: 74.9 years; 23 men, 15 women, median National Institutes of Health Stroke Scale score = 7.5) with ICA occlusions and patent MCA were ultimately included. We identified 10 patients (26%) with thrombus migration (spontaneous: 3; during endovascular therapy: 7). Patients with thrombus migration had higher rates of unfavorable functional outcomes (modified Rankin Scale scores 3-6 at 90 days) than those without thrombus migration (90% vs. 39%, p < .01). Multivariate analysis showed that thrombus migration was independently related to unfavorable functional outcomes (odds ratio, 42.9; 95% confidence interval, 1.5-1211.0; p = .03).

Conclusion: Thrombus migration in cases of ICA occlusion with patent MCA is associated with poor prognosis. Careful monitoring is required under these conditions even if the initial clinical presentation is mild.
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http://dx.doi.org/10.1016/j.jns.2020.116737DOI Listing
May 2020

Frequent Premature Atrial Contractions in Cryptogenic Stroke Predict Atrial Fibrillation Detection with Insertable Cardiac Monitoring.

Cerebrovasc Dis 2020 5;49(2):144-150. Epub 2020 Feb 5.

Department of Neurology, Osaka University Graduate School of Medicine, Osaka, Japan.

Objective: To determine whether frequent premature atrial contractions (PAC) predict atrial fibrillation (AF) in cryptogenic stroke patients, we analyzed the association between frequent PACs in 24-h Holter electrocardiogram recording and AF detected by insertable cardiac monitoring (ICM).

Methods: We retrospectively analyzed a database of 66 consecutive patients with cryptogenic stroke who received ICM implantation between October 2016 and March 2018 at 5 stroke centers. We included the follow-up data until June 2018 in this analysis. We defined frequent PACs as the upper quartile of the 66 patients. We analyzed the association of frequent PACs with AF detected by ICM.

Results: Frequent PACs were defined as >222 PACs per a 24-h period. The proportion of patients with newly detected AF by ICM was higher in patients with frequent PACs than those without (50% [8/16] vs. 22% [11/50], p < 0.05). Frequent PACs were associated with AF detection and time to the first AF after adjustment for CHADS2 score after index stroke, high plasma -B-type natriuretic peptide (BNP; >100 pg/mL) or serum -N-terminal pro-BNP levels (>300 pg/mL), and large left atrial diameter (≥45 mm).

Conclusion: High frequency of PACs in cryptogenic stroke may be a strong predictor of AF detected by ICM.
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http://dx.doi.org/10.1159/000505958DOI Listing
September 2020

A Visual Task Management Application for Acute Ischemic Stroke Care.

Front Neurol 2019 30;10:1118. Epub 2019 Oct 30.

Department of Neurology, Graduate School of Medical Sciences, Neurological Institute, Kyushu University, Fukuoka, Japan.

To maximize the effect of intravenous (IV) thrombolysis and/or endovascular therapy (EVT) for acute ischemic stroke (AIS), stroke centers need to establish a parallel workflow on the basis of a code stroke (CS) protocol. At Kokura Memorial Hospital (KMH), we implemented a CS system in January 2014; however, the process of information sharing within the team has occasionally been burdensome. To solve this problem using information communication technology (ICT), we developed a novel application for smart devices, named "Task Calc. Stroke" (TCS), and aimed to investigate the impact of TCS on AIS care. TCS can visualize the real-time progress of crucial tasks for AIS on a dashboard by changing color indicators. From August 2015 to March 2017, we installed TCS at KMH and recommended its use during normal business hours (NBH). We compared the door-to-computed tomography time, the door-to-complete blood count (door-to-CBC) time, the door-to-needle for IV thrombolysis time, and the door-to-puncture for EVT time among three treatment groups, one using TCS ("TCS-based CS"), one not using TCS ("phone-based CS"), and one not based on CS ("non-CS"). A questionnaire survey regarding communication problems was conducted among the CS teams at 3 months after the implementation of TCS. During the study period, 74 patients with AIS were transported to KMH within 4.5 h from onset during NBH, and 53 were treated using a CS approach (phone-based CS: 26, TSC-based CS: 27). The door-to-CBC time was significantly reduced in the TCS-based CS group compared to the phone-based CS group, from 31 to 19 min ( = 0.043). Other processing times were also reduced, albeit not significantly. The rate of IV thrombosis was higher in the TCS-based CS group (78% vs. 46%, = 0.037). The questionnaire was correctly filled in by 34/38 (89%) respondents, and 82% of the respondents felt a reduction in communication burden by using the TCS application. TCS is a novel approach that uses ICT to support information sharing in a parallel CS workflow in AIS care. It shortens the processing times of critical tasks and lessens the communication burden among team members.
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http://dx.doi.org/10.3389/fneur.2019.01118DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6831722PMC
October 2019

Recurrent rhombencephalomyelitis associated with allergen immunotherapy by mite antigen sublingual tablets.

eNeurologicalSci 2019 Jun 4;15:100190. Epub 2019 Apr 4.

Department of Neurology, Neurological Institute, Graduate School of Medical Sciences, Kyushu University, Japan.

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http://dx.doi.org/10.1016/j.ensci.2019.100190DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6460294PMC
June 2019

[Reperfusion therapy in patients with minor or mild ischemic stroke].

Authors:
Junpei Koge

Rinsho Shinkeigaku 2019 Feb 31;59(2):84-92. Epub 2019 Jan 31.

Division of Neurology, Saiseikai Fukuoka General Hospital.

A significant number of patients with minor or mild stroke symptoms on initial presentation subsequently develop neurological deterioration and poor clinical outcomes at hospital discharge. The presence of an underlying large vessel occlusion is a strong predictor of both clinical worsening and poor outcome. Although patients with a low baseline National Institutes of Health Stroke Scale (NIHSS) could have been included in some randomized controlled trials, the benefits of the mechanical thrombectomy for patients with a low NIHSS score are unknown. The causes of neurological deterioration in patients with underlying large vessel occlusion are heterogeneous, but include collateral failure, and no straightforward mechanisms are found in the majority of cases. Patients with internal carotid artery occlusion, but with a patent middle cerebral artery (MCA), can occasionally have good collateral circulation and develop only minor or mild stroke. These patients exhibit collateral MCA flow via the circle of Willis despite ipsilateral internal carotid artery occlusion. However, thrombus migration may cause occlusion of collateral MCA flow, leading to dramatic neurological deterioration. Careful observation and detailed assessment are required for the management of these patients. Recent studies have examined the efficacy and optimal timing of thrombolysis or mechanical thrombectomy for patients with minor or mild stroke. Herein, we review the mechanisms of neurological deterioration, and the efficacy of reperfusion therapy, for patients with minor or mild stroke.
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http://dx.doi.org/10.5692/clinicalneurol.cn-001255DOI Listing
February 2019

Vessel Wall Injury After Stent Retriever Thrombectomy for Internal Carotid Artery Occlusion with Duplicated Middle Cerebral Artery.

World Neurosurg 2019 Mar 7;123:54-58. Epub 2018 Dec 7.

Division of Neurology, Saiseikai Fukuoka General Hospital, Fukuoka City, Fukuoka, Japan.

Background: Experimental evidence that stent retriever thrombectomy (SRT) may cause arterial wall damage is increasing, although histopathologic findings focused on vessel wall injury after SRT have not fully been reported in humans.

Case Description: We describe an autopsy case of an 82-year-old woman who presented with acute left intracranial internal carotid artery occlusion and received SRT. When we attempted to catheterize the M1 segment of the normal middle cerebral artery (MCA), we were not aware of a duplicated MCA and advanced the microcatheter into the main MCA trunk with a smaller caliber than that of the normal M1 segment. A 6-mm Trevo thrombectomy device was deployed from the main MCA trunk but was insufficiently expanded in the MCA segment. Two passes with a Trevo resulted in failed recanalization. The patient died on postoperative day 4 because of extensive infarction. Autopsy revealed a duplicated MCA and subintimal arterial dissection in the proximal segment of the main MCA trunk. The supraclinoid internal carotid artery also revealed endothelial denudation and mural thrombus.

Conclusions: We provide a histopathologic report of vessel wall injury after SRT that caused failed recanalization. Anatomic variations of the MCA should be considered when selecting suitable thrombectomy devices in order to avoid vessel wall injury.
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http://dx.doi.org/10.1016/j.wneu.2018.11.223DOI Listing
March 2019

Carotid artery stenting with proximal embolic protection via the transbrachial approach: sheathless navigation of a 9-F balloon-guiding catheter.

Neuroradiology 2018 Oct 22;60(10):1097-1101. Epub 2018 Aug 22.

Department of Neurology, Saiseikai Fukuoka General Hospital, 1-3-46, Tenjin, Chuo-ku, Fukuoka City, Fukuoka, 810-0001, Japan.

Purpose: Transbrachial carotid artery stenting (TB-CAS) is performed as an alternative procedure for patients with hostile vascular anatomy of the aortic arch and aortic or peripheral artery disease. Proximal protection during TB-CAS is not generally feasible because a small size of the brachial artery may preclude using a large-diameter sheath introducer. We, herein present a novel method that enables proximal protection during TB-CAS by sheathless navigation of a 9-F balloon-guiding catheter equivalent to a 7-F sheath.

Methods: We analyzed eight consecutive patients who underwent TB-CAS with proximal protection using the sheathless method from April 2016 to June 2017. Relevant demographic, radiographic, and procedural features were retrospectively reviewed.

Results: We performed TB-CAS using our method for five patients with a bovine or type 3 aortic arch, for one patient with combined peripheral artery disease, and for two patients with a type 1 or 2 aortic arch. We successfully navigated the balloon-guiding catheter via the brachial artery and performed CAS under proximal flow control in all patients. However, we experienced kinking and exchange of the balloon-guiding catheter in one patient and a periprocedural thromboembolic event occurred. A pseudoaneurysm at the access site developed in one patient.

Conclusion: TB-CAS with proximal embolic protection using the sheathless method is feasible and may provide an alternative approach in carefully selected patients who have difficult anatomy in the transfemoral approach and plaques with a high risk of distal embolization.
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http://dx.doi.org/10.1007/s00234-018-2085-2DOI Listing
October 2018

Successful carotid artery stenting of a dissected, highly tortuous internal carotid artery after straightening with a peripheral microguidewire.

J Clin Neurosci 2018 Jul 20;53:265-268. Epub 2018 Apr 20.

Department of Neurology, Saiseikai Fukuoka General Hospital, Fukuoka City, Fukuoka, Japan.

Endovascular reconstruction for carotid artery dissection (CAD) involving a highly tortuous segment of the cervical internal carotid artery (ICA) is challenging because the tortuous ICA may preclude navigation of large-profile carotid stents. Successful recanalization using low-profile neurostents has been reported in small case series only. We herein describe two patients with CAD of a tortuous segment who were successfully treated with large-profile carotid stents after straightening the ICA with a stiff peripheral microguidewire. In Case 1, a 33-year-old man presented with steno-occlusive left CAD involving coiling of the cervical ICA and left M2 occlusion. We could not navigate a carotid stent through the tortuous segment of the ICA using a standard neuro-guidewire. A carotid stent was successfully deployed after straightening the tortuous ICA with a peripheral guidewire, and subsequent thrombectomy using a large-bore aspiration catheter for the occluded M2 branch resulted in recanalization. In Case 2, a 64-year-old man presented with right steno-occlusive CAD involving kinking of the cervical ICA. We successfully deployed two carotid stents after straightening the tortuous ICA with a peripheral guidewire. Stenting after straightening with a peripheral microguidewire is feasible and may provide a therapeutic option for CAD in patients with a highly tortuous ICA.
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http://dx.doi.org/10.1016/j.jocn.2018.04.009DOI Listing
July 2018

Improving treatment times for patients with in-hospital stroke using a standardized protocol.

J Neurol Sci 2017 Oct 18;381:68-73. Epub 2017 Aug 18.

Department of Neurosurgery, Kokura Memorial Hospital, Fukuoka, Japan.

Background: Previous reports have shown significant delays in treatment of in-hospital stroke (IHS). We developed and implemented our IHS alert protocol in April 2014. We aimed to determine the influence of implementation of our IHS alert protocol.

Methods: Our implementation processes comprise the following four main steps: IHS protocol development, workshops for hospital staff to learn about the protocol, preparation of standardized IHS treatment kits, and obtaining feedback in a monthly hospital staff conference. We retrospectively compared protocol metrics and clinical outcomes of patients with IHS treated with intravenous thrombolysis and/or endovascular therapy between before (January 2008-March 2014) and after implementation (April 2014-December 2016).

Results: Fifty-five patients were included (pre, 25; post, 30). After the implementation, significant reductions occurred in the median time from stroke recognition to evaluation by a neurologist (30 vs. 13.5min, p<0.01) and to first neuroimaging (50 vs. 26.5min, p<0.01) and in the median time from first neuroimaging to intravenous thrombolysis (45 vs. 16min, p=0.02). The median time from first neuroimaging to endovascular therapy had a tendency to decrease (75 vs. 53min, p=0.08). There were no differences in the favorable outcomes (modified Rankin scale score of 0-2) at discharge or the incidence of symptomatic intracranial hemorrhage between the two periods.

Conclusion: Our IHS alert protocol implementation saved time in treating patients with IHS without compromising safety.
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http://dx.doi.org/10.1016/j.jns.2017.08.023DOI Listing
October 2017

Iatrogenic Ascending Pharyngeal Artery Injury by Predilation Balloon Inflation During Carotid Artery Stenting with Flow Reversal.

World Neurosurg 2017 Oct 13;106:1053.e7-1053.e10. Epub 2017 Jul 13.

Department of Neurology, Saiseikai Fukuoka General Hospital, Fukuoka City, Fukuoka, Japan.

Background: The ascending pharyngeal artery (APA) may rarely arise from the common carotid artery bifurcation. We report an injury to the APA as an unusual complication of predilation balloon inflation during carotid artery stenting (CAS) with flow reversal.

Case Description: A 73-year-old man presented with symptomatic severe left cervical internal carotid artery stenosis. The left APA arose from the common carotid artery bifurcation. We performed CAS with flow reversal to decrease the risk of distal embolization. When we attempted to catheterize the internal carotid artery under roadmap guidance for predilation, we did not notice that the balloon catheters had advanced into the APA owing to the absence of an anterograde angiogram, and the APA was injured when the balloon catheters were inflated.

Conclusions: Our case emphasizes the importance of performing a detailed anatomic assessment before CAS and ensuring adequate angiographic visualization during the procedure under flow reversal when the origin of the APA is in the vicinity of the origin of the internal carotid artery.
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http://dx.doi.org/10.1016/j.wneu.2017.07.028DOI Listing
October 2017

A case of cerebrotendinous xanthomatosis mimicking the clinical phenotype of mitochondrial disease with a novel frame-shift mutation (c. 43_44 delGG) in CYP27A1 gene exon 1.

Rinsho Shinkeigaku 2016 10 28;56(10):667-671. Epub 2016 Oct 28.

Department of Neurology, Neurological Institute, Graduate School of Medical Sciences, Kyushu University.

A 37-old-male with a history of early childhood mental retardation was admitted to our hospital. He experienced recurrent syncopes at 23 years old, and at age 35 gait disturbance and hearing impairment developed gradually and worsened over time. His grandparents were in a consanguineous marriage. He was of short stature and absent of tendon xanthomas. Neurological examinations revealed scanning speech, dysphagia, right sensorineural hearing loss, spasticity in both upper and lower extremities, and spastic gait. Tendon reflexes were brisk throughout, and Babinski and Chaddock reflexes were both positive bilaterally. Laboratory tests revealed elevated lactate and pyruvate concentrations in both serum and cerebrospinal fluid. Fluid attenuated inversion recovery magnetic resonance imaging showed high intensity lesions in the bilateral cerebellar hemispheres, pyramidal tracts in the brainstem, and internal capsules symmetrically. Brain magnetic resonance spectroscopy measurements revealed an elevated lactate/creatine plus phosphocreatine ratio and a decreased N-acetyl-aspartate/creatine plus phosphocreatine ratio in the cerebellum. At this point, mitochondrial diseases, particularly myoclonic epilepsy with ragged-red fibers (MERRF), to be the most likely cause. We performed a biopsy of his left biceps brachii muscle, showing variations in fiber size with occasional central nuclei and very few ragged-red fibers. Blood mitochondrial respiratory enzyme assays showed normal values with elevated citrate synthase activity, and mitochondrial DNA analyses for MERRF revealed no pathogenic mutations. We then explored other possibilities and detected an elevated serum cholestanol concentration of 20.4 μg/ml (reference value <4.0) and genetic analysis by direct sequencing method disclosed a novel frame-shift mutation (c. 43_44delGG) in CYP27A1 gene exon1, leading to a diagnosis of cerebrotendinous xanthomatosis (CTX). This case emphasizes importance of awareness of CTX as a possibility when patients present with clinical phenotypes mimicking mitochondrial diseases, but with negative results for muscle pathology or genetic analyses. The measurements of serum cholestanol concentrations might be useful in diagnosing such atypical cases.
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http://dx.doi.org/10.5692/clinicalneurol.cn-000823DOI Listing
October 2016

Morvan's syndrome and myasthenia gravis related to familial Mediterranean fever gene mutations.

J Neuroinflammation 2016 Mar 29;13(1):68. Epub 2016 Mar 29.

Department of Neurology, Neurological Institute, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan.

Background: We present the first case of Morvan's syndrome (MoS) and myasthenia gravis (MG) related to familial Mediterranean fever (FMF) gene mutations.

Case Presentation: A 40-year-old woman with a 1-year history of bilateral ptosis and limb muscle weakness presented to our hospital. She also had memory impairment, insomnia, hyperhidrosis, and muscle twitches. Electromyography confirmed widespread myokymia, and there was evidence of temporal region dysfunction on electroencephalography. Anti-voltage-gated potassium channel complex antibodies and anti-acetylcholine receptor antibodies were both positive. Edrophonium administration was effective for bilateral ptosis and muscle weakness. She and her family experienced self-limiting febrile attacks with arthralgia, which led us to suspect FMF. Genetic analyses revealed compound heterozygous mutations in exon 2 of the MEFV gene (L110P/E148Q). From these findings, a diagnosis of MoS and MG complicated with MEFV gene mutations was made. Intravenous high-dose corticosteroids, plasma exchange, and intravenous immunoglobulin resulted in only transient, limited improvement, and frequent relapses, especially in the myasthenic symptoms. Interleukin (IL)-6, IL-1β, and tumor necrosis factor-α were markedly elevated in the serum, which was considered to be derived from the MEFV mutations and responsible for the resistance to immunotherapy.

Conclusion: The present case illustrates a possible link between auto-inflammation and auto-antibody-mediated neurological diseases.
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http://dx.doi.org/10.1186/s12974-016-0533-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4812638PMC
March 2016
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