Publications by authors named "Takeshi Yoshimoto"

40 Publications

p.R4810K (c.14429G > A) Variant Determines Anatomical Variations of the Circle of Willis in Cerebrovascular Disease.

Front Aging Neurosci 2021 15;13:681743. Epub 2021 Jul 15.

Department of Neurology, National Cerebral and Cardiovascular Center, Suita, Japan.

Introduction: Dysregulation of the RING finger protein 213 gene impairs vascular formation in experimental animal models. In addition, vascular abnormalities in the circle of Willis are associated with cerebrovascular disease. Here, we evaluated the relationship between the East Asian founder variant p.R4810K and consequent anatomical variations in the circle of Willis in cerebrovascular disease.

Patients And Methods: The present study is an observational cross-sectional study. It included patients with acute anterior circulation non-cardioembolic stroke admitted to our institution within 7 days of symptom onset or last-known-well from 2011 to 2019, and those who participated in the National Cerebral and Cardiovascular Center Biobank. We compared anatomical variations of the vessels constituting the circle of Willis between p.R4810K (c.14429G > A) variant carriers and non-carriers using magnetic resonance angiography and assessed the association between the variants and the presence of the vessels constituting the circle of Willis. Patients with moyamoya disease were excluded.

Results: Four hundred eighty-one patients [146 women (30%); median age 70 years; median baseline National Institutes of Health Stroke Scale score 5] were analyzed. The p.R4810K variant carriers ( = 25) were more likely to have both posterior communicating arteries (PComAs) than the variant non-carriers ( = 456) (56% vs. 13%, < 0.01). Furthermore, variant carriers were less likely to have an anterior communicating artery (AComA) than non-carriers (68% vs. 84%, = 0.04). In a multivariate logistic regression analysis, the association of p.R4810K variant carriers with the presence of both PComAs and the absence of AComA remained significant.

Conclusion: Our findings suggest that the p.R4810K variant is an important factor in determining anatomical variations in the circle of Willis.
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http://dx.doi.org/10.3389/fnagi.2021.681743DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8322682PMC
July 2021

Endovascular Therapy for Acute Ischemic Stroke in Patients With Prestroke Disability.

J Am Heart Assoc 2021 Aug 21;10(15):e020783. Epub 2021 Jul 21.

Department of Neurosurgery Hyogo College of Medicine Nishinomiya Japan.

Background Outcomes after stroke as a result of large-vessel occlusion in patients with prestroke disability were compared between endovascular therapy (EVT) and medical management. Methods and Results Of 2420 patients with acute stroke with large-vessel occlusion in a prospective, multicenter, nationwide registry in Japan, patients with prestroke modified Rankin Scale scores 2 to 4 with occlusion of the internal carotid artery, or M1 of the middle cerebral artery were analyzed. The primary effectiveness outcome was the favorable outcome, defined as return to at least the prestroke modified Rankin Scale score at 3 months. Safety outcomes included symptomatic intracranial hemorrhage. A total of 339 patients (237 women; median 85 [interquartile range (IQR), 79-89] years of age; median prestroke modified Rankin Scale score of 3 [IQR, 2-4]) were analyzed. EVT was performed in 175 patients (51.6%; mechanical thrombectomy, n=139). The EVT group was younger (<0.01) and had lower prestroke modified Rankin Scale scores (<0.01) than the medical management group. The favorable outcome was seen in 28.0% of the EVT group and in 10.9% of the medical management group (<0.01). EVT was associated with the favorable outcome (adjusted odds ratio, 3.01; 95% CI, 1.55-5.85; mixed effects multivariable model with inverse probability of treatment weighting). Symptomatic intracranial hemorrhage rates were similar between the EVT (4.0%) and medical management (4.3%) groups (=1.00). Conclusions Patients who underwent EVT showed better functional outcomes than those with medical management. Given proper patient selection, withholding EVT solely on the basis of prestroke disability might not offer the best chance of favorable outcome. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT02419794.
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http://dx.doi.org/10.1161/JAHA.121.020783DOI Listing
August 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

New diagnostic algorithm for detection of covert Bow Hunter's Syndrome.

Int J Med Sci 2021 19;18(10):2162-2165. Epub 2021 Mar 19.

Department of Neurology, National Cerebral and Cardiovascular Center, Osaka, Japan.

Bow hunter's syndrome (BHS) should not be overlooked as a cause of cerebral infarction in the posterior circulation. However, covert BHS, which does not impair blood flow with simple rotation but only at certain angles, may make the diagnosis of BHS difficult. We propose a new algorithm to detect BHS or covert BHS. We recommend that BHS and covert BHS be detected by noninvasive duplex ultrasonography, which will allow for appropriate treatment.
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http://dx.doi.org/10.7150/ijms.56442DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8040409PMC
March 2021

Study Protocol for a Randomized, Double-Blind, Placebo-Controlled, Phase-II Trial: AdrenoMedullin for Ischemic Stroke Study.

J Stroke Cerebrovasc Dis 2021 Jun 1;30(6):105761. Epub 2021 Apr 1.

Department of Neurology, National Cerebral and Cardiovascular Center, 6-1 Kishibe-Shimmachi, Suita, Osaka 564-8565, Japan. Electronic address:

Objectives: Adrenomedullin (AM), a vasoactive peptide, has strong anti-inflammatory and angiogenic properties, which have been reported to ameliorate the consequences of ischemic stroke in several animal models. After a phase I study in healthy volunteers, two phase II trials of AM for inflammatory bowel diseases have been recently completed. The current AdrenoMedullin For Ischemic Stroke (AMFIS) study aims to assess the safety and efficacy of AM in patients with acute ischemic stroke.

Materials And Methods: The AMFIS study is an investigator-initiated, randomized, double-blind, phase-II trial. AM or placebo will be administered to patients with non-cardioembolic ischemic stroke within 24 h after stroke onset. In the first cohort of the AMFIS study, patients will be randomly allocated to the investigation treatment A (30 μg/kg of AM in total for 7 days, n = 20) or placebo group (n = 10). In the second cohort, patients will be assigned to the investigation treatment B (56 μg/kg of AM in total for 7 days, n = 20) or placebo group (n = 10).

Results: Serious adverse events related to the protocol treatment will be evaluated as the primary outcome. All adverse events will be analyzed as the secondary outcome. Regarding efficacy endpoints, the change in National Institutes of Health Stroke Scale and modified Rankin Scale scores will be compared between investigation treatment and placebo groups.

Conclusions: AM is expected to be a safe and effective treatment for ischemic stroke.
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http://dx.doi.org/10.1016/j.jstrokecerebrovasdis.2021.105761DOI Listing
June 2021

Outcomes of Large Vessel Occlusion Stroke in Patients Aged ≥90 Years.

Stroke 2021 May 1;52(5):1561-1569. Epub 2021 Mar 1.

Department of Neurosurgery (K.U., S.Y.), Hyogo College of Medicine, Nishinomiya, Japan.

Background And Purpose: Outcomes in patients ≥90 years of age with stroke due to large vessel occlusion were compared between endovascular therapy (EVT) and medical management.

Methods: Of 2420 acute ischemic stroke patients with large vessel occlusion in a prospective, multicenter, nationwide registry in Japan, patients aged ≥90 years with occlusion of the internal carotid artery or M1 segment of the middle cerebral artery were included. The primary effectiveness outcome was a favorable outcome at 3 months, defined as achieving a modified Rankin Scale score of 0 to 2 or return to at least the prestroke modified Rankin Scale score at 3 months. Safety outcomes included symptomatic intracranial hemorrhage within 72 hours after onset. Intergroup biases were adjusted by multivariable adjustment with inverse probability of treatment weighting.

Results: A total of 150 patients (median age, 92 [interquartile range, 90-94] years; median prestroke modified Rankin Scale score, 2 [interquartile range, 0-4]) were analyzed. EVT was performed in 49 patients (32.7%; mechanical thrombectomy, n=43). The EVT group showed shorter time from onset to hospital arrival (=0.03), higher Alberta Stroke Program Early CT Score (<0.01), and a higher rate of treatment with intravenous thrombolysis (<0.01) than the medical management group. The favorable outcome was seen in 28.6% of the EVT group and 6.9% of the medical management group (<0.01). EVT was associated with the favorable outcome (adjusted odds ratio, 8.44 [95% CI, 1.88-37.97]). Rates of symptomatic intracranial hemorrhage were similar between the EVT group (0.0%) and the medical management group (3.9%; =0.30).

Conclusions: Patients who underwent EVT showed better functional outcomes than those with medical management without increased symptomatic intracranial hemorrhages. Given proper patient selection, withholding EVT solely on the basis of the age of patients may not offer the best chance of good outcome. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT02419794.
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http://dx.doi.org/10.1161/STROKEAHA.120.031386DOI Listing
May 2021

A nomogram to predict unfavourable outcome in patients receiving oral anticoagulants for atrial fibrillation after stroke.

Eur Stroke J 2020 Dec 26;5(4):384-393. Epub 2020 Nov 26.

Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland.

Introduction: It is unknown whether the type of treatment (direct oral anticoagulant versus vitamin K antagonist) and the time of treatment introduction (early versus late) may affect the functional outcome in stroke patients with atrial fibrillation. We aimed to develop and validate a nomogram model including direct oral anticoagulant/vitamin K antagonist and early/late oral anticoagulant introduction for predicting the probability of unfavourable outcome after stroke in atrial fibrillation-patients.

Patients And Methods: We conducted an individual patient data analysis of four prospective studies. Unfavourable functional outcome was defined as three-month modified Rankin Scale score 3 -6. To generate the nomogram, five independent predictors including age (<65 years, reference; 65--79; or 80), National Institutes of Health Stroke Scale score (0--5 points, reference; 6--15; 16--25; or >25), acute revascularisation treatments (yes, reference, or no), direct oral anticoagulant (reference) or vitamin K antagonist, and early (7 days, reference) or late (8--30) anticoagulant introduction entered into a final logistic regression model. The discriminative performance of the model was assessed by using the area under the receiver operating characteristic curve.

Results: A total of 2102 patients with complete data for generating the nomogram was randomly dichotomised into training ( = 1553) and test ( = 549) sets. The area under the receiver operating characteristic curve was 0.822 (95% confidence interval, CI: 0.800--0.844) in the training set and 0.803 (95% CI: 0.764--0.842) in the test set. The model was adequately calibrated (9.852;  = 0.276 for the Hosmer--Lemeshow test).

Discussion And Conclusion: Our nomogram is the first model including type of oral anticoagulant and time of treatment introduction to predict the probability of three-month unfavourable outcome in a large multicentre cohort of stroke patients with atrial fibrillation.
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http://dx.doi.org/10.1177/2396987320945840DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7856583PMC
December 2020

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

A Nationwide Multi-Center Questionnaire Survey on the Real-World State and Issues Regarding Post-Stroke Complications in Japan.

J Stroke Cerebrovasc Dis 2021 Apr 8;30(4):105656. Epub 2021 Feb 8.

Department of Neurology, National Cerebral and Cardiovascular Center, Osaka, Japan. Electronic address:

Objectives: Post-stroke complications affect stroke survivors across the world, although data on them are limited. We conducted a questionnaire survey to examine the real-world state and issues regarding post-stroke complications in Japan, which represents a super-aged society.

Materials And Methods: In 2018, a nationwide multi-center questionnaire survey was conducted in the top 500 Japanese hospitals regarding the number of stroke patients treated. Three questionnaires regarding post-stroke complications were mailed to the doctors responsible for stroke management.

Results: Responses were obtained from 251 hospitals (50.2%). The chief doctors responsible for stroke management answered the questionnaires. The number of stroke patients in the departments of neurology and neurosurgery was 338.3 ± 195.3 and 295.8 ± 121.8. Hospitals were classified using the categories secondary (n =142) and tertiary hospitals (n = 106); most hospitals were acute hospitals. Dementia was the most common complication (30.9%), followed by dysphagia (29.3%), and apathy (16.3%). Dementia was thought to be more common by neurologists than neurosurgeons, while apathy and bladder-rectal disorder were thought to be more common by neurosurgeons than neurologists (p = 0.001). The most difficult complication to treat was dysphagia (40.4%), followed by dementia (33.9%), epilepsy (4.1%), and fall (4.1%). Dementia was considered to lack clinical evidence regarding treatment (32.8%), followed by dysphagia (25.3%), and epilepsy (14.1%). Epilepsy was considered to lack clinical evidence among hospitals with a larger number of stroke cases (p = 0.044).

Conclusion: This study revealed the current state and issues regarding post-stroke complications in Japan. Clinicians should be aware of the importance of post-stroke complications, although data on them remain unsatisfactory.
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http://dx.doi.org/10.1016/j.jstrokecerebrovasdis.2021.105656DOI Listing
April 2021

A case of hemichorea in RNF213-related vasculopathy.

BMC Neurol 2021 Jan 22;21(1):32. Epub 2021 Jan 22.

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

Background: Internal carotid artery (ICA) stenosis has been recently reported to cause hemichorea, mainly in East Asia. The East Asian-specific p.R4810K variant of RNF213, a susceptibility gene for moyamoya disease (MMD), accounts for up to 25% of sporadic ischemic stroke with ICA stenosis cases in East Asia. However, as RNF213-related vasculopathy does not meet the diagnostic criteria for MMD, the creation of a new disease category has been suggested. Here, we report the first case of hemichorea in RNF213-related vasculopathy.

Case Presentation: An 81-year-old woman was admitted to our hospital with choreic movements in the periphery of the right extremities at rest. Though head magnetic resonance imaging showed no fresh or old cerebral infarction, I-iodoamphetamine-single photon emission computed tomography showed cerebral blood flow of < 80% in the anterior territory of the left middle cerebral artery (MCA) in a resting state and cerebrovascular reactivity of < 10% in the broader area supplied by the left MCA after acetazolamide challenge. Head magnetic resonance angiography and digital subtraction angiography revealed left ICA C1 portion stenosis with compromised collateral vessels. Involuntary movements resolved with haloperidol administration within 3 days, without apparent recurrence from continuation of the medication for a year. Genetic testing revealed the presence of the heterozygous RNF213 p.R4810K variant.

Conclusions: Chorea is thought to be caused by damage to circuitry connecting the basal ganglia with the cerebral cortex, as found in cases of MMD, which possess aberrant vessels in the basal ganglia. However, aberrant vessels and cerebral infarctions were not observed in the basal ganglia in the current case, decreasing the likelihood of a role in chorea. Alternatively, as RNF213 regulates vascular endothelial function and angiogenesis, dysregulation may impair the neurovascular unit and damage basal ganglia circuitry, contributing to the development of chorea. This case may renew interest in the concept of RNF213-related vasculopathy and the pathophysiological mechanisms behind chorea in ICA stenosis.
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http://dx.doi.org/10.1186/s12883-021-02061-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7821645PMC
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

Oral Carriage of Harboring the Gene Relates to an Increased Incidence of Cerebral Microbleeds.

Stroke 2020 12 5;51(12):3632-3639. Epub 2020 Nov 5.

Department of Neurology (S.H., S.S., S.T., H. Ishiyama, T.Y., S.I., H. Ikenouchi, Y.H., M.I.), National Cerebral and Cardiovascular Center, Suita, Japan.

Background And Purpose: Cerebral microbleeds (CMB) are associated with stroke and cognitive impairment. We previously reported a high prevalence of CMB in people with expressing Cnm, a collagen-binding protein in the oral cavity. is a major pathogen responsible for dental caries. Repeated challenge with harboring the gene encoding Cnm induced cerebral bleeding in stroke-prone spontaneously hypertensive rats. The purpose of this longitudinal study is to examine the relationship of -positive to the development of CMB.

Methods: We retrospectively investigated patients with stroke receiving oral microbiological examination and head 3T magnetic resonance imaging evaluations twice in the period 2014 to 2019, allowing >180-day interval. Patients with -positive were compared with those without. Quasi-Poisson regression models were used to explore associations between -positive and the increase in number of CMB between the 2 magnetic resonance imaging scans.

Results: A total of 111 patients were identified; 21 (19%) with -positive and 90 (81%) without. Clinical history, including blood pressure and the use of antithrombotic agents, were comparable between the 2 groups. New CMB were more commonly observed in patients with -positive (52% versus 23%; =0.008). The incidence of CMB was significantly higher in the group with -positive , especially in deep areas, (incidence rate ratios [95% CI], 5.1 [1.9-13.6] for CMB in any brain region; 15.0 [5.4-42.0] for deep CMB), which persisted after adjusting for age, sex, hypertension, and renal impairment (4.7 [1.8-11.9] for CMB in any brain region; 13.9 [4.3-44.5] for deep CMB).

Conclusions: This study demonstrates that -positive is associated with an increased incidence of CMB. Treatment for -positive infection may be a novel microbiota-based therapeutic approach for stroke and cognitive impairment.
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http://dx.doi.org/10.1161/STROKEAHA.120.029607DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7678651PMC
December 2020

Postprandial cerebral infarction resolved by extracranial-intracranial bypass surgery.

eNeurologicalSci 2020 Dec 14;21:100283. Epub 2020 Oct 14.

Department of Neurology, National Cerebral and Cardiovascular Center, Suita, Japan.

A 51-year-old man with type 2 diabetes mellitus was admitted with a 2-month history of repeated episodes of transient aphasia and right hemiparesis after food intake. His blood pressure (BP) fell when the neurological deficits developed. The fall in BP after each meal was confirmed by 24-h ambulatory blood pressure monitoring (ABPM), which established the diagnosis of postprandial hypotension (PPH). Diffusion-weighted magnetic resonance imaging of the brain showed multiple high-intensity lesions at the borderzone between the anterior and middle cerebral artery (MCA) territories in the left hemisphere. Digital subtraction angiography showed tapered occlusion at the origin of the left internal carotid artery (ICA). Despite sufficient antiplatelet therapy and medication for PPH, the transient symptoms remained. Positron emission tomography scanning using H O showed decreased cerebral blood flow with increased oxygen extraction fraction in the left MCA territory. As the symptomatic left ICA occlusion was intractable, an extracranial-intracranial (EC-IC) bypass surgery was conducted without any perioperative complications. Although PPH remained, cerebrovascular ischemic events including repeated transient ischemic attack disappeared for 2 months after surgery. The coincidence of stroke with ABPM-proved transient hypotension suggested that the brain infarcts were caused by hemodynamic changes related to PPH co-existent with the chronic left ICA occlusion. ABPM is useful in evaluating hemodynamic infarcts associated with BP fluctuation, and should be considered for patients with chronic ICA occlusion. In addition, EC-IC bypass may be a treatment option for symptomatic chronic ICA occlusion due to PPH.
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http://dx.doi.org/10.1016/j.ensci.2020.100283DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7575838PMC
December 2020

Stroke Care Trends During COVID-19 Pandemic in Zanjan Province, Iran. From the CASCADE Initiative: Statistical Analysis Plan and Preliminary Results.

J Stroke Cerebrovasc Dis 2020 Dec 16;29(12):105321. Epub 2020 Sep 16.

Westchester Medical Center Health Network, Director of Neurocritical Care and Emergency Neurological Services, Valhalla, NY, USA; Westchester Medical Center Health Network, New York Medical College, Valhalla, NY, USA.

Background: The emergence of the COVID-19 pandemic has significantly impacted global healthcare systems and this may affect stroke care and outcomes. This study examines the changes in stroke epidemiology and care during the COVID-19 pandemic in Zanjan Province, Iran.

Methods: This study is part of the CASCADE international initiative. From February 18, 2019, to July 18, 2020, we followed ischemic and hemorrhagic stroke hospitalization rates and outcomes in Valiasr Hospital, Zanjan, Iran. We used a Bayesian hierarchical model and an interrupted time series analysis (ITS) to identify changes in stroke hospitalization rate, baseline stroke severity [measured by the National Institutes of Health Stroke Scale (NIHSS)], disability [measured by the modified Rankin Scale (mRS)], presentation time (last seen normal to hospital presentation), thrombolytic therapy rate, median door-to-needle time, length of hospital stay, and in-hospital mortality. We compared in-hospital mortality between study periods using Cox-regression model.

Results: During the study period, 1,026 stroke patients were hospitalized. Stroke hospitalization rates per 100,000 population decreased from 68.09 before the pandemic to 44.50 during the pandemic, with a significant decline in both Bayesian [Beta: -1.034; Standard Error (SE): 0.22, 95% CrI: -1.48, -0.59] and ITS analysis (estimate: -1.03, SE = 0.24, p < 0.0001). Furthermore, we observed lower admission rates for patients with mild (NIHSS < 5) ischemic stroke (p < 0.0001). Although, the presentation time and door-to-needle time did not change during the pandemic, a lower proportion of patients received thrombolysis (-10.1%; p = 0.004). We did not see significant changes in admission rate to the stroke unit and in-hospital mortality rate; however, disability at discharge increased (p < 0.0001).

Conclusion: In Zanjan, Iran, the COVID-19 pandemic has significantly impacted stroke outcomes and altered the delivery of stroke care. Observed lower admission rates for milder stroke may possibly be due to fear of exposure related to COVID-19. The decrease in patients treated with thrombolysis and the increased disability at discharge may indicate changes in the delivery of stroke care and increased pressure on existing stroke acute and subacute services. The results of this research will contribute to a similar analysis of the larger CASCADE dataset in order to confirm findings at a global scale and improve measures to ensure the best quality of care for stroke patients during the COVID-19 pandemic.
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http://dx.doi.org/10.1016/j.jstrokecerebrovasdis.2020.105321DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7494258PMC
December 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

Call to Action: SARS-CoV-2 and CerebrovAscular DisordErs (CASCADE).

J Stroke Cerebrovasc Dis 2020 Sep 8;29(9):104938. Epub 2020 May 8.

Department of Medicine, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Serdang, Selangor, Malaysia.

Background And Purpose: The novel severe acute respiratory syndrome coronavirus 2 (SARS-Cov-2), now named coronavirus disease 2019 (COVID-19), may change the risk of stroke through an enhanced systemic inflammatory response, hypercoagulable state, and endothelial damage in the cerebrovascular system. Moreover, due to the current pandemic, some countries have prioritized health resources towards COVID-19 management, making it more challenging to appropriately care for other potentially disabling and fatal diseases such as stroke. The aim of this study is to identify and describe changes in stroke epidemiological trends before, during, and after the COVID-19 pandemic.

Methods: This is an international, multicenter, hospital-based study on stroke incidence and outcomes during the COVID-19 pandemic. We will describe patterns in stroke management, stroke hospitalization rate, and stroke severity, subtype (ischemic/hemorrhagic), and outcomes (including in-hospital mortality) in 2020 during COVID-19 pandemic, comparing them with the corresponding data from 2018 and 2019, and subsequently 2021. We will also use an interrupted time series (ITS) analysis to assess the change in stroke hospitalization rates before, during, and after COVID-19, in each participating center.

Conclusion: The proposed study will potentially enable us to better understand the changes in stroke care protocols, differential hospitalization rate, and severity of stroke, as it pertains to the COVID-19 pandemic. Ultimately, this will help guide clinical-based policies surrounding COVID-19 and other similar global pandemics to ensure that management of cerebrovascular comorbidity is appropriately prioritized during the global crisis. It will also guide public health guidelines for at-risk populations to reduce risks of complications from such comorbidities.
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http://dx.doi.org/10.1016/j.jstrokecerebrovasdis.2020.104938DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7205703PMC
September 2020

Various head rotations for ultrasonographic diagnosis of bilateral bow hunter's syndrome.

Acta Neurol Belg 2020 Aug 23;120(4):1003-1005. Epub 2020 May 23.

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

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http://dx.doi.org/10.1007/s13760-020-01377-4DOI Listing
August 2020

D-dimer level and outcome of minor ischemic stroke with large vessel occlusion.

J Neurol Sci 2020 06 31;413:116814. Epub 2020 Mar 31.

Department of Neurology, The Jikei University School of Medicine, Tokyo, Japan.

Objective: To determine the predictors of unfavorable outcomes in acute minor ischemic stroke patients with large vessel occlusion.

Methods: The derivation cohort included ischemic stroke patients admitted to a comprehensive stroke center within 7 days after onset with large vessel occlusion and an initial National Institutes of Health Stroke Scale score of 5 or less. An unfavorable outcome was defined as dependency (modified Rankin Scale score of 3 to 6) at 3 months from the onset. The predictive values of factors related to an unfavorable outcome were evaluated. External validation was performed from a stroke registry of a tertiary medical center.

Results: In the derivation cohort, 3839 consecutive patients were screened; a total of 130 patients were included. Twenty-four (18%) patients had unfavorable outcomes. In multivariate analysis, D-dimer ≥1900 μg/l (odds ratio (OR) 3.31, 95% confidence interval (CI) 1.14-9.61, p = .028) and age (OR 2.01, 95% CI 1.05-3.86, p = .035) were independently associated with an unfavorable outcome. No significant differences were observed regarding occluded vessel sites. In the validation cohort, 850 consecutive patients were screened; a total of 74 patients were included. D-dimer ≥1900 μg/l (OR 8.78, 95% CI 1.41-54.61, p = .020) was the only factor independently associated with an unfavorable outcome, as in the derivation cohort.

Conclusions: A high D-dimer level on admission could help predict unfavorable outcomes in patients with a minor ischemic stroke with large vessel occlusion.
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http://dx.doi.org/10.1016/j.jns.2020.116814DOI Listing
June 2020

Baseline Characteristics of Elderly Japanese Patients Aged ≥75 Years With Non-Valvular Atrial Fibrillation and a History of Stroke - ANAFIE Registry.

Circ J 2020 02 25;84(3):516-523. Epub 2020 Jan 25.

Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center.

Background: Despite the well-established benefits in patients with non-valvular atrial fibrillation (NVAF), oral anticoagulants (OAC) have been underused in elderly patients. We investigated the characteristics and status of anti-thrombotic therapy in elderly NVAF patients in Japan according to a history of stroke or of transient ischemic attack (TIA).Methods and Results:In a multicenter, prospective, observational study, 32,726 Japanese patients aged ≥75 years with NVAF were enrolled, and divided into 3 groups for the present analysis: 6,543 patients with previous ischemic stroke (IS) or TIA (2,410 women), 275 with previous hemorrhagic stroke (HS; 113 women), and the other 25,908 without previous stroke or TIA (11,470 women). Median CHADSscore was 5 in patients with IS/TIA, 2 in those with HS and 2 in those without stroke/TIA (P<0.05). Anti-thrombotic agents were used in 97.1% of patients with IS/TIA (OAC alone in 73.0%; antiplatelets alone in 3.7%; and both in 23.4%), 90.2% of those with HS (84.7%, 3.2%, and 12.1%, respectively), and 94.1% of those without stroke/TIA (83.4%, 2.7%, and 13.9%, respectively; P<0.05 for any anti-thrombotic choice). Of patients taking OAC, 72.2% received direct OAC (DOAC).

Conclusions: In this unique nationwide NVAF registry of >30,000 elderly patients, >90% of patients, even those with HS, received anti-thrombotic therapy, nearly always with OAC. DOAC were the major choice of OAC.
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http://dx.doi.org/10.1253/circj.CJ-19-0974DOI Listing
February 2020

Early Initiation of Direct Oral Anticoagulants After Onset of Stroke and Short- and Long-Term Outcomes of Patients With Nonvalvular Atrial Fibrillation.

Stroke 2020 03 22;51(3):883-891. Epub 2020 Jan 22.

From the Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan (T.M., K. Toyoda, S.Y., M.T., M.S., M. Inoue, M.K.).

Background and Purpose- We aimed to compare outcomes of ischemic stroke patients with nonvalvular atrial fibrillation between earlier and later initiation of direct oral anticoagulants (DOACs) after stroke onset. Methods- From data for 1192 nonvalvular atrial fibrillation patients with acute ischemic stroke or transient ischemic attack in a prospective, multicenter, observational study, patients who started DOACs during acute hospitalization were included and divided into 2 groups according to a median day of DOAC initiation after onset. Outcomes included stroke or systemic embolism, major bleeding, and death at 3 months, as well as those at 2 years. Results- DOACs were initiated during acute hospitalization in 499 patients in median 4 (interquartile range, 2-7) days after onset. Thus, 223 patients (median age, 74 [interquartile range, 68-81] years; 78 women) were assigned to the early group (≤3 days) and 276 patients (median age, 75 [interquartile range, 69-82] years; 101 women) to the late (≥4 days) group. The early group had lower baseline National Institutes of Health Stroke Scale score and smaller infarcts than the late group. The rate at which DOAC administration persisted at 2 years was 85.2% overall, excluding patients who died or were lost to follow-up. Multivariable Cox shared frailty models showed comparable hazards between the groups at 2 years for stroke or systemic embolism (hazard ratio, 0.86 [95% CI, 0.47-1.57]), major bleeding (hazard ratio, 1.39 [95% CI, 0.42-4.60]), and death (hazard ratio, 0.61 [95% CI, 0.28-1.33]). Outcome risks at 3 months also did not significantly differ between the groups. Conclusions- Risks for events including stroke or systemic embolism, major bleeding, and death were comparable whether DOACs were started within 3 days or from 4 days or more after the onset of nonvalvular atrial fibrillation-associated ischemic stroke or transient ischemic attack. Registration- URL: https://www.clinicaltrials.gov. Unique identifier: NCT01581502.
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http://dx.doi.org/10.1161/STROKEAHA.119.028118DOI Listing
March 2020

Use of Diffusion-Weighted Imaging-Alberta Stroke Program Early Computed Tomography Score (DWI-ASPECTS) and Ischemic Core Volume to Determine the Malignant Profile in Acute Stroke.

J Am Heart Assoc 2019 11 8;8(22):e012558. Epub 2019 Nov 8.

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

Background Malignant profiles were identified by imaging profiles and unfavorable outcomes that have poor response to reperfusion therapy. Many trials have used this profile in their inclusion criteria including large-vessel occlusion acute ischemic stroke trials. We aimed to redefine the cutoff values for malignant profile in acute ischemic stroke patients with large-vessel occlusion regardless of reperfusion therapy. Methods and Results Consecutive acute ischemic stroke patients with anterior large-vessel occlusion were prospectively extracted from the National Cerebral and Cardiovascular Center Stroke Registry between March 2014 and December 2017. Diffusion-Weighted Imaging-Alberta Stroke Program Early Computed Tomography Score (DWI-ASPECTS) and diffusion-weighted imaging lesion ischemic core volume (Vol) were measured in acute ischemic stroke patients with large-vessel occlusion with or without treatment. Unfavorable outcome was defined as a modified Rankin Scale score 5 to 6 at 3 months, and optimal DWI-ASPECTS and Vol for unfavorable outcome were assessed. In total, 198 patients (111 men, 77±13 years old) were enrolled. Median DWI-ASPECTS was 7 (5-9), and median Vol was 55 (6-134) mL. Among the patients, 72 (36%) patients underwent reperfusion therapy, and 83 (42%) had unfavorable outcomes. The threshold values for a malignant profile on receiver operating characteristic curve analysis for DWI-ASPECTS and Vol were 4 (area under the curve 0.78, <0.01; sensitivity 0.71, specificity 0.75) and 71 mL (area under the curve 0.80, <0.01; sensitivity 0.76, specificity 0.77), respectively. Conclusions The cutoff values for our redefined malignant profile were DWI-ASPECTS 4 and Vol 71 mL with no selection bias for reperfusion therapy in the real-world clinical practice. Clinical Trial Registration URL: http://www.clinicaltrials.gov Unique identifier: NCT02251665.
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http://dx.doi.org/10.1161/JAHA.119.012558DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6915267PMC
November 2019

Prevalence of RNF213 p.R4810K Variant in Early-Onset Stroke With Intracranial Arterial Stenosis.

Stroke 2019 06 7;50(6):1561-1563. Epub 2019 May 7.

From the Department of Neurology (T.K., S.O., T.Y., M.I.), National Cerebral and Cardiovascular Center, Osaka, Japan.

Background and Purpose- The ring finger protein 213 gene ( RNF213) is a susceptibility gene for moyamoya disease and large-artery ischemic stroke in East Asia. We examined the prevalence and correlates of the RNF213 p.R4810K variant in patients with early-onset ischemic stroke in a Japanese single-center cohort. Methods- We analyzed 70 early-onset stroke patients with intracranial arterial stenosis who developed a noncardioembolic stroke or transient ischemic attack from 20 to 60 years of age. Patients with moyamoya disease were excluded. Results- The RNF213 p.R4810K variant was found in 17 patients (24%), and more often in women than men (38% versus 16%, odds ratio 3.3; 95% CI, 1.1-10.2, P=0.04). The variant was identified in 35% of patients with stenosis in the M1 segment of the middle cerebral artery or the A1 segment of the anterior cerebral artery (odds ratio, 25.0; 95% CI, 1.4-438; P<0.01) but in only one patient (9%) with intracranial posterior circulation stenosis. Conventional atherosclerotic risk factors did not differ between variant carriers and noncarriers. Conclusions- The RNF213 p.R4810K variant is common in early-onset ischemic stroke with anterior circulation stenosis in Japan. Further investigation of the RNF213 gene will provide new insights into pathogenetic mechanisms of early-onset stroke.
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http://dx.doi.org/10.1161/STROKEAHA.118.024712DOI Listing
June 2019

Balloon-like Mobile Plaque in the Innominate Artery: Ultrasonographic and Pathological Perspectives of Repetitive Embolism.

J Stroke Cerebrovasc Dis 2019 Jul 1;28(7):e95-e97. Epub 2019 May 1.

Department of Neurology, National Cerebral and Cardiovascular Center, Suita, Osaka 565-8565, Japan.

Mobile plaque in the innominate artery is extremely rare and difficult to diagnose, especially in its acute stage. Its diagnosis is often delayed in many cases, resulting in delayed treatment and poor prognosis. Herein, we report the case of a 69-year-old patient with multiple cerebral infarction only in the right internal carotid artery and vertebrobasilar territories. No embolic sources were found until arterial ultrasonography detected a large balloon-like mobile plaque in the IA. Mobile plaque consisted of high-and low-echoic components and showed balloon-like plaque. Despite sufficient antiplatelet therapy, recurrence of cerebral embolism could not be prevented. IA replacement was eventually performed by cardiac surgeons. Pathological examinations showed that organized mobile plaque could have existed previously and acute thrombi, generated after the atheromatous plaque rupture caused by the mechanical burden of organized mobile plaque, could expand along with the organized mobile plaque and caused balloon-like plaque and related with repeated embolism. The IA should be explored immediately in cases of repetitive right-sided cerebral embolisms to prevent further recurrence.
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http://dx.doi.org/10.1016/j.jstrokecerebrovasdis.2019.04.015DOI Listing
July 2019

Early Achievement of Blood Pressure Lowering and Hematoma Growth in Acute Intracerebral Hemorrhage: Stroke Acute Management with Urgent Risk-Factor Assessment and Improvement-Intracerebral Hemorrhage Study.

Cerebrovasc Dis 2018 10;46(3-4):118-124. Epub 2018 Sep 10.

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

Background: Previous studies have revealed that hematoma growth mainly occurs during the first 6 h after the onset of spontaneous intracerebral hemorrhage (ICH). Early lowering of blood pressure (BP) may be beneficial for preventing hematoma growth. However, relationships between timing of BP lowering and hematoma growth in ICH remain unclear. We investigated associations between timing of BP lowering and hematoma growth for ICH.

Methods: The Stroke Acute Management with Urgent Risk-factor Assessment and Improvement (SAMURAI)-ICH Study was a multicenter, prospective, observational study investigating the safety and feasibility of early (within 3 h from onset) reduction of systolic BP (SBP) to < 160 mm Hg with intravenous nicardipine for acute hypertension in cases of spontaneous ICH. The present study was a post hoc analysis of the SAMURAI-ICH study. We examined relationships between time from onset, imaging, and initiation of treatment to target SBP achievement and hematoma growth (absolute growth ≥6 mL) in ICH patients. Target SBP achievement was defined as the time at which SBP first became < 160 mm Hg.

Results: Among 211 patients, hematoma growth was seen in 31 patients (14.7%). The time from imaging to target SBP and time from treatment to target SBP were significantly shorter in patients without hematoma growth than in those with (p = 0.043 and p = 0.032 respectively), whereas no significant difference was seen in time from onset to SBP < 160 mm Hg between groups (p = 0.177). Patients in the lower quartiles of time from imaging to target SBP and time from treatment to target SBP showed lower incidences of hematoma growth (p trend = 0.023 and 0.037 respectively). The lowest quartile of time from imaging to target SBP (< 38 min) was negatively associated with hematoma growth on multivariable logistic regression (OR 0.182; 95% CI 0.038-0.867; p = 0.032).

Conclusions: Early achievement of target SBP < 160 mm Hg is associated with a lower risk of hematoma growth in ICH.
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http://dx.doi.org/10.1159/000492728DOI Listing
June 2019

[Guillain-Barré syndrome associated with acute hepatitis A-A case report and literature review].

Rinsho Shinkeigaku 2018 Sep 31;58(9):574-577. Epub 2018 Aug 31.

Department of Neurology, Brain Attack Center, Ota Memorial Hospital.

A 44-year-old female developed acute hepatitis A (HA) 5 weeks after ingesting raw oysters. She developed ascending motor weakness, bilateral peripheral facial nerve palsy, and bulbar symptoms. A diagnosis of demyelinating Guillain-Barré syndrome (GBS) was made on the basis of her clinical manifestations and the results of a nerve conduction study. The patient showed improvement following combination treatment with intravascular immunoglobulin and high dose methylprednisolone. No antibodies against specific gangliosides, sulfated glucuronyl paragloboside (SGPG), or sulfatide were detected. HA virus (HAV) RNA was isolated from her serum and its full-length genome sequence was determined. It revealed a homology of 99.9% or more with HAV genotype IA (HAV-IA) of the 2014 outbreak. No mutant virus RNA was detected.
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http://dx.doi.org/10.5692/clinicalneurol.cn-001165DOI Listing
September 2018

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

Circ J 2018 06 1;82(7):1935-1942. Epub 2018 Jun 1.

Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center.

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, CHADSand 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.
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http://dx.doi.org/10.1253/circj.CJ-18-0067DOI Listing
June 2018

Cerebral hyperperfusion on arterial spin labeling MRI after reperfusion therapy is related to hemorrhagic transformation.

J Cereb Blood Flow Metab 2017 Sep 30;37(9):3087-3090. Epub 2017 Jun 30.

1 Department of Neurology, National Cerebral and Cardiovascular Center, Suita, Japan.

Early detection of hemorrhagic transformation after reperfusion therapy is crucial in acute stroke treatment. Here, we evaluated the relationship between hemorrhagic transformation and post-reperfusion hyperperfusion using pulsed arterial spin labeling (ASL) perfusion MRI and I-iodoamphetamine single-photon emission-computed tomography. Patients who developed hemorrhagic transformation showed significantly higher cerebral blood flow in the affected lesion after thrombolysis and/or endovascular intervention. Focal hyperperfusion (ipsilateral to contralateral ratio >1.5) was associated with hemorrhagic transformation after reperfusion (odds ratio, 9.3; 95% confidence interval, 1.4-64.0). Our findings suggest that post-reperfusion hyperperfusion on ASL could represent a reliable marker of hemorrhagic transformation.
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http://dx.doi.org/10.1177/0271678X17718099DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5584703PMC
September 2017

Ability of the Ankle Brachial Index and Brachial-Ankle Pulse Wave Velocity to Predict the 3-Month Outcome in Patients with Non-Cardioembolic Stroke.

J Atheroscler Thromb 2017 Nov 15;24(11):1167-1173. Epub 2017 May 15.

Department of Clinical Neuroscience and Therapeutics, Hiroshima University Graduate School of Biomedical and Health Sciences.

Aim: Both the ankle brachial index (ABI) and brachial-ankle pulse wave velocity (baPWV) are surrogates for atherosclerosis. In this study, we aimed to evaluate the ability of ABI and baPWV to predict stroke outcome in patients with first-ever non-cardioembolic stroke.

Methods: This study included consecutive patients with first-ever non-cardioembolic stroke admitted within 1 week after onset to Ota Memorial Hospital between January 2011 and December 2013. Baseline characteristics and National Institutes of Health stroke scale scores at admission were noted. ABI and baPWV were evaluated within 5 days of admission. The patients were categorized according to ABI (cut-off 0.9) and baPWV (cut-off 1870 cm/s) determined using the receiver operation curve for poor outcome. Clinical outcomes were defined based on the modified Rankin scale (mRS) scores 3 months after stroke onset as good (0 and 1) or poor (2-6).

Results: A total of 861 patients were available for evaluation. ABI <0.9 and baPWV >1870 cm/s were associated with poor outcome in the univariate analysis (p<0.001 and p<0.001, respectively). After adjusting for factors that showed differences between groups, ABI <0.9 was associated with poor outcome. Among patients with ABI ≥ 0.9, higher baPWV showed a slight association with poor outcome after adjustment [odds ratio 1.46 (95% CI 0.95-2.27)].

Conclusion: Our study suggests that the stroke outcome can be predicted using ABI and to an extent using baPWV when ABI ≥ 0.9 in patients with non-cardioembolic stroke.
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http://dx.doi.org/10.5551/jat.38901DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5684481PMC
November 2017
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