Publications by authors named "Yohei Tateishi"

42 Publications

Cardiac and Echocardiographic Markers in Cryptogenic Stroke with Incidental Patent Foramen Ovale.

J Stroke Cerebrovasc Dis 2021 Aug 6;30(8):105892. Epub 2021 Jun 6.

Department of Neurology, Juntendo University Urayasu Hospital, Chiba, Japan. Electronic address:

Objective: Some cardiac abnormalities could be a substrate for potential embolic source in cryptogenic stroke (CS). We evaluated whether cardiac and echocardiographic markers were associated with CS in patients with incidental patent foramen ovale (PFO) as defined using the Risk of Paradoxical Embolism (RoPE) score.

Materials And Methods: Among 677 patients enrolled in a multicenter observational CS registry, 300 patients (44%) had PFOs detected by transesophageal echocardiography. They were classified into probable PFO-related stroke (RoPE score>6, n = 32) and stroke with incidental PFO (RoPE score≤6, n = 268) groups, and clinical characteristics, laboratory findings, cardiac and echocardiographic markers (i.e. brain natriuretic peptide, left atrial [LA] diameter, ejection fraction, early transmitral flow velocity/early diastolic tissue Doppler imaging velocity [E/e'], LA appendage flow velocity, spontaneous echo contrast, atrial septal aneurysm, substantial PFO, and aortic arch plaques), stroke recurrence, and excellent outcome (modified Rankin scale score <2) at discharge were compared. Risk factors for low RoPE scores were determined using multiple logistic regression analysis.

Results: Higher brain natriuretic peptide levels (p = 0.032), LA enlargement (p < 0.001), higher E/e' (p = 0.001), lower LA appendage flow velocity (p < 0.001), non-substantial PFO (p = 0.021), and aortic arch plaques (p = 0.002) were associated with the low RoPE score group. Patients with high RoPE scores had excellent outcomes (58% versus 78%, p = 0.035). LA enlargement (age- and sex-adjusted odds ratio, 1.15; 95 % confidence interval, 1.00-1.32; p = 0.039) was an independent predictor of low RoPE scores.

Conclusions: Abnormal cardiac substrate could be associated with CS occurrence in a subset of patients with PFO. Patients with CS who had incidental PFO may be at risk of cardioembolism.
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http://dx.doi.org/10.1016/j.jstrokecerebrovasdis.2021.105892DOI Listing
August 2021

Different aspects of early and late development of atrial fibrillation during hospitalization in cryptogenic stroke.

Sci Rep 2021 Mar 29;11(1):7127. Epub 2021 Mar 29.

Department of Neurology, Juntendo University Urayasu Hospital, Chiba, Japan.

The detection of underlying atrial fibrillation (AF) has become increasingly possible by insertable cardiac monitoring (ICM). During hospitalization for cryptogenic stroke, factors related to the early and late development of AF have not been studied. CHALLENGE ESUS/CS is a multicenter registry of cryptogenic stroke patients undergoing transesophageal echocardiography. Twelve-lead electrocardiogram, continuous cardiac monitoring, and 24-h Holter electrocardiogram were all used for the detection of AF. Early and late detection of AF was determined with an allocation ratio of 1:1 among patients with AF. A total of 677 patients (68.7 ± 12.8 years; 455 men) were enrolled, and 64 patients developed AF during hospitalization. Four days after admission was identified as the approximate median day to classify early and late phases to detect AF: ≤ 4 days, 37 patients; > 4 days, 27 patients. Multiple logistic regression analysis showed that spontaneous echo contrast (SEC) (OR 5.91; 95% CI 2.19-15.97; p < 0.001) was associated with AF ≤ 4 days, whereas a large infarction > 3 cm in diameter (OR 3.28; 95% CI 1.35-7.97; p = 0.009) was associated with AF > 4 days. SEC and large infarctions were important predictors of in-hospital AF detection, particularly in the early and late stages, respectively; thus, they could serve as indications for recommending ICM.
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http://dx.doi.org/10.1038/s41598-021-86620-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8007744PMC
March 2021

Current status of a helicopter transportation system on remote islands for patients undergoing mechanical thrombectomy.

PLoS One 2021 19;16(1):e0245082. Epub 2021 Jan 19.

Department of Neurosurgery, National Hospital Organization Nagasaki Medical Center, Nagasaki, Japan.

Background: Mechanical thrombectomy (MT) is standard treatment for acute ischemic stroke (AIS) with large-vessel occlusion within 6 h of symptom onset to treatment initiation (OTP). Recent trials have extended the therapeutic time window for MT to within 24 h. However, MT treatment remains low in remote areas. Nagasaki Prefecture, Japan has many inhabited islands with no neurointerventionalists. Our hospital on the mainland is a regional hub for eight island hospitals. We evaluated clinical outcomes of MT for patients with AIS on these islands versus on the mainland.

Methods: During 2014-2019, we reviewed consecutive patients with AIS who received MT at our hospital. Patients comprised the Islands group and Mainland group. Patient characteristics and clinical outcomes were compared between groups.

Results: We included 91 patients (Islands group: 15 patients, Mainland group: 76 patients). Seven patients (46.7%) in the Islands group versus 43 (56.6%) in the Mainland group achieved favorable outcomes. Successful recanalization was obtained in 11 patients (73.3%) on the islands and 67 (88.2%) on the mainland. The median OTP time in the Islands was 365 min. In both the Islands and Mainland groups, the OTP time and successful recanalization were associated with functional outcome. The modified Rankin Scale (mRS) score at 90 days ≤2 was obtained in two patients and mRS = 3 in four patients among eight patients with OTP time >6 h.

Conclusions: Few patients with AIS on remote islands have received MT. Although patients who underwent MT on the islands had longer OTP, the clinical outcomes were acceptable. OTP time on remote islands must be shortened, as this is related to functional outcome. In some cases with successful recanalization, a favorable outcome can still be obtained even after 6 h. Even if OTP exceeds 6 h, it is desirable to appropriately select patients and actively perform MT.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0245082PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7815141PMC
May 2021

Atrial Septal Aneurysm may Cause In-Hospital Recurrence of Cryptogenic Stroke.

J Atheroscler Thromb 2021 May 17;28(5):514-523. Epub 2020 Jul 17.

Department of Neurology, Juntendo University Urayasu Hospital.

Aims: Awareness of potentially embologenic diseases is critical to determining the prognosis of cryptogenic stroke. The clinical significance of atrial septal aneurysm (ASA) in cryptogenic stroke has not been fully studied. Therefore, we explored clinical characteristics and in-hospital recurrence in patients with ASA in cryptogenic stroke.

Methods: A multicenter observational registry of cryptogenic stroke patients was conducted. We obtained baseline characteristics, radiological and laboratory findings, and echocardiographic findings, especially of embolic sources on transesophageal echocardiography. The CHALLENGE ESUS/CS (Mechanisms of Embolic Stroke Clarified by Transesophageal Echocardiography for embolic stroke of undetermined source/cryptogenic stroke) registry was recorded at http://www.umin.ac.jp/ctr/ (UMIN000032957). Patients' clinical characteristics were compared according to the presence of ASA, and factors associated with in-hospital stroke recurrence were assessed.

Results: The study included 671 patients (age, 68.7±12.7 years; 450 males; median National Institutes of Health Stroke Scale score, 2). ASA was detected in 92 patients (14%), displaying higher age (72.4±11.0 vs. 68.1 ±12.9 years, p=0.004), reduced frequency of diabetes mellitus (16% vs. 27%, p=0.030), higher frequency of right-to-left shunt (66% vs. 45%, p<0.001), and in-hospital stroke recurrence (8% vs. 3%, p=0.034). ASA was relatively associated with in-hospital recurrence (odds ratio 2.497, 95% confidence interval 0.959-6.500, p= 0.061).

Conclusions: The CHALLENGE ESUS/CS registry indicated that ASA was not rare in cryptogenic stroke, and ASA's clinical characteristics included higher age, reduced frequency of diabetes mellitus, and increased frequency of concomitant right-to-left shunt. ASA may be related to in-hospital stroke recurrence in cryptogenic stroke.
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http://dx.doi.org/10.5551/jat.56440DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8193779PMC
May 2021

Neuromyelitis Optica Spectrum Disorder Complicated by Posterior Reversible Encephalopathy Syndrome as an Initial Manifestation.

Intern Med 2020 Aug 23;59(15):1887-1890. Epub 2020 Apr 23.

Department of Neurology and Strokology, Nagasaki University Hospital, Japan.

A 25-year-old woman was admitted to our hospital due to tonic convulsion with severe headache after having experienced symptoms of nausea and vomiting for a month. Brain magnetic resonance imaging showed extensive symmetrical lesions in the cortical and subcortical areas of parieto-occipital lobes and basal ganglia, consistent with typical characteristics of posterior reversible encephalopathy syndrome (PRES). Furthermore, some residual lesions in the left side of dorsal medulla oblongata and central area of the cervical spinal cord along with the presence of serum anti-aquaporin-4 antibody yielded the diagnosis of neuromyelitis optica spectrum disorder (NMOSD). We herein discuss the mechanism by which PRES may occur together with NMOSD.
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http://dx.doi.org/10.2169/internalmedicine.4226-19DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7474992PMC
August 2020

Underlying embolic and pathologic differentiation by cerebral microbleeds in cryptogenic stroke.

J Neurol 2020 May 3;267(5):1482-1490. Epub 2020 Feb 3.

Department of Neurology, Juntendo University Urayasu Hospital, Chiba, Japan.

Background: Cryptogenic stroke encompasses diverse emboligenic mechanisms and pathogeneses. Cerebral microbleeds (CMBs) occur differently among stroke subtypes. The association of CMBs with cryptogenic stroke is essentially unknown.

Methods: CHALLENGE ESUS/CS (Mechanisms of Embolic Stroke Clarified by Transesophageal Echocardiography for ESUS/CS) is a multicenter registry with comprehensive data including gradient-echo T2*-weighted magnetic resonance imaging of cryptogenic stroke patients who underwent transesophageal echocardiography. Patients' clinical characteristics were compared according to the presence and location of CMBs.

Results: A total of 661 patients (68.7 ± 12.7 years; 445 males) were enrolled, and 209 (32%) had CMBs. Age (odds ratio [OR] 1.02, 95% confidence interval [CI] 1.00-1.04, p = 0.020), male sex (OR 1.85, 95% CI 1.18-2.91, p = 0.007), hypertension (OR 1.71, 95% CI 1.03-2.86, p = 0.039), chronic kidney disease (OR 1.64, 95% CI 1.11-2.43, p = 0.013), deep and subcortical white matter hyperintensity (OR 1.82, 95% CI 1.16-2.85, p = 0.009), and periventricular hyperintensity (OR 2.18, 95% CI 1.37-3.46, p = 0.001) were independently associated with the presence of CMBs. Aortic complicated lesions (OR 1.78, 95% CI 1.12-2.84, p = 0.015) were associated with deep and diffuse CMBs, whereas prior anticoagulant therapy (OR 7.88, 95% CI, 1.83-33.9, p = 0.006) was related to lobar CMBs.

Conclusions: CMBs were common, and age, male sex, hypertension, chronic kidney disease, and cerebral white matter diseases were related to CMBs in cryptogenic stroke. Aortic complicated lesions were associated with deep and diffuse CMBs, while prior anticoagulant therapy was related to lobar CMBs.
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http://dx.doi.org/10.1007/s00415-020-09732-4DOI Listing
May 2020

Lower serum calcium and pre-onset blood pressure elevation in cerebral hemorrhage patients undergoing hemodialysis.

Clin Exp Nephrol 2020 May 14;24(5):465-473. Epub 2020 Jan 14.

Department of Nephrology, Nagasaki University Hospital, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan.

Background: Asymptomatic blood pressure (BP) elevation may be associated with cerebral hemorrhage (CH); however, few studies have investigated this association. We aimed to evaluate BP elevation before CH in hemodialysis (HD) patients and elucidate its associated factors.

Methods: We reviewed HD patients treated for CH at our hospital between 2008 and 2019 (CH group). The control group comprised HD patients treated at Nagasaki Renal Center between 2011 and 2012. Data were obtained from medical records and three consecutive HD charts, made immediately before CH. HD1 was the session closest to onset, followed by HD2 and HD3. Systolic and mean BP were evaluated at the beginning of HD, and factors associated with BP elevation were investigated.

Results: The CH and control groups included 105 and 339 patients, respectively. Systolic and mean BP at HD1 were significantly higher than those at baseline (HD2 + HD3) in the CH group by 5 and 3 mmHg, respectively (P < 0.001). Multiple linear regression analysis showed that lower calcium levels were significantly associated with BP elevation in the CH group (P < 0.05). The CH group was sub-divided by June 2013; the latter group had lower calcium levels (9.2 mg/dL) and a marked systolic BP difference from baseline (+ 10 mmHg) compared with the former (9.5 mg/dL and - 4 mmHg).

Conclusion: Asymptomatic BP elevation was observed in HD patients before CH; this elevation was associated with lower serum calcium levels and observed more frequently in the recent era. The precise mechanism underlying this effect remains unknown.
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http://dx.doi.org/10.1007/s10157-020-01846-3DOI Listing
May 2020

Biomarkers of Cardiac Dysfunction as Risk Factors in Cryptogenic Stroke.

Cerebrovasc Dis 2019 6;48(3-6):132-139. Epub 2019 Nov 6.

Department of Neurology and Strokology, Nagasaki University Hospital, Nagasaki, Japan.

Background: It is unclear whether biomarkers of cardiac dysfunction are associated with cryptogenic stroke (CS).

Methods: We retrospectively evaluated consecutive ischemic stroke patients. Patients underwent transthoracic echocardiography to evaluate left atrial diameter and the peak transmitral filling velocity/mean mitral annular velocity during early diastole (E/e'). Patent foramen ovale (PFO) and left atrial appendage flow velocity were evaluated by transesophageal echocardiography. We compared clinical characteristics and biomarkers of cardiac dysfunction (brain natriuretic peptide [BNP], left atrial diameter, E/e', and left atrial appendage flow velocity) between CS or CS without large PFO and other causative stroke subtypes.

Results: Among 1,514 patients with ischemic stroke, 264 patients were classified as having CS. Of these, transesophageal echocardiography revealed 27/158 (17%) large PFOs. In comparison, for the noncardioembolic stroke group, which consisted of large artery and small vessel subtypes, patients with CS without large PFO had higher log10 BNP (adjusted OR 2.70; 95% CI 1.92-3.78; p < 0.001), higher log10 E/e' (3.41; 1.21-13.15; p = 0.019), and lower left atrial appendage flow velocity (0.98; 0.97-1.00; p = 0.031). Left atrial diameter was similar for noncardioembolic stroke and CS without large PFO (p = 0.380). Cutoff values of BNP, E/e', and left atrial appendage flow velocity capable of distinguishing CS without large PFO from noncardioembolic stroke were 65.0 pg/mL (sensitivity 55.3%; specificity 70.9%), 13.0 (45.5%; 68.0%), and 46.0 cm/s (37.1%; 87.5%), respectively.

Conclusion: Patients with CS without large PFO could have biomarkers of cardiac dysfunction.
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http://dx.doi.org/10.1159/000504014DOI Listing
May 2020

Arterial Spin Labeling Magnetic Resonance Imaging Can Identify the Occlusion Site and Collateral Perfusion in Patients with Acute Ischemic Stroke: Comparison with Digital Subtraction Angiography.

Cerebrovasc Dis 2019 25;48(1-2):70-76. Epub 2019 Sep 25.

Department of Neurosurgery, Nagasaki University Hospital, Nagasaki, Japan.

Background And Objectives: Determining the occlusion site and collateral blood flow is important in acute ischemic stroke. The purpose of the current study was to test whether arterial spin labeling (ASL) magnetic resonance imaging (MRI) could be used to identify the occlusion site and collateral perfusion, using digital subtraction angiography (DSA) as a gold standard.

Method: Data from 521 consecutive patients who presented with acute ischemic stroke at our institution from January 2012 to September 2014 were retrospectively reviewed. Image data were included in this study if: (1) the patient presented symptoms of acute ischemic stroke; (2) MRI was performed within 24 h of symptom onset; and (3) DSA following MRI was performed (n = 32 patients). We defined proximal intra-arterial sign (IAS) on ASL as enlarged circular or linear bright hyperintense signal within the occluded artery and distal IAS as enlarged circular or linear bright hyperintense signals within arteries inside or surrounding the affected region. The presence or absence of the proximal IAS and distal IAS were assessed, along with their inter-rater agreement and consistency with the presence of occlusion site and collateral flow on DSA images.

Results: The sensitivity and specificity for identifying occlusion site with ASL were 82.8 and 100%, respectively. Those for identifying collateral flow with ASL were 96.7 and 50%, respectively. The inter-rater reliability was excellent for proximal IAS (κ = 0.92; 95% CI 0.76-1.00) and substantial for distal IAS detection (κ = 0.78; 95% CI 0.38-1.00).

Conclusions: Proximal IAS and distal IAS on ASL imaging can provide important diagnostic clues for the detection of arterial occlusion sites and collateral perfusion in patients with acute ischemic stroke.
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http://dx.doi.org/10.1159/000503090DOI Listing
May 2020

Impact of Mechanical Thrombectomy Device on Thrombus Histology in Acute Embolic Stroke.

World Neurosurg 2019 Dec 27;132:e418-e422. Epub 2019 Aug 27.

Department of Neurosurgery, Nagasaki University School of Medicine, Nagasaki, Japan.

Background: Although many studies have evaluated the retrieved thrombus to assess the cause of stroke after mechanical thrombectomy for acute large vessel occlusion, the results remain controversial. We investigated the hypothesis that histology of the retrieved thrombus is enhanced by mechanical thrombectomy devices.

Methods: Thrombi were collected from consecutive patients who had undergone endovascular mechanical recanalization for large intracranial vessel occlusion. The mechanical thrombectomy device used was either an aspiration catheter or a stent retriever. The hematoxylin and eosin-stained specimens were quantitatively analyzed with respect to the relative fractions of the main constituents (erythrocytes and fibrin). Clinical and radiologic findings were also evaluated.

Results: Of 65 patients, an aspiration catheter was used in 27, and a stent retriever was used in 38. The presence of a preoperative susceptibility vessel sign on magnetic resonance imaging was not correlated with the percentage of erythrocytes. Thrombus cross-sectional area was larger in the aspiration group than in the stent group (P < 0.01). Conversely, the percentage of the fibrin component was higher in the stent group (P < 0.001). Preoperative intravenous administration of recombinant tissue plasminogen activator reduced thrombus cross-sectional area with a trend of increased percentage of fibrin and reduced percentage of erythrocyte in the stent group.

Conclusions: Histologic differences in retrieved thrombi are enhanced by mechanical thrombectomy devices. Stent retrievers may crush the thrombus, which may have a synergistic effect with recombinant tissue plasminogen activator. Histology of the retrieved thrombi might be different from histology of the original thrombi.
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http://dx.doi.org/10.1016/j.wneu.2019.08.130DOI Listing
December 2019

Association between serum calcium levels and prognosis, hematoma volume, and onset of cerebral hemorrhage in patients undergoing hemodialysis.

BMC Nephrol 2019 06 7;20(1):210. Epub 2019 Jun 7.

Department of Nephrology, Nagasaki University Hospital, Nagasaki, Japan.

Background: High serum calcium levels should be avoided in patients on hemodialysis (HD) because they can induce cardiovascular diseases and worsen the patient's prognosis. In contrast, low serum calcium levels worsen the prognosis of patients with cerebral hemorrhage in the general population. So far, whether serum calcium levels in patients on HD are associated with cerebral hemorrhage remains unknown. This study aimed to reveal the association between serum calcium and cerebral hemorrhage in patients on HD, including in-hospital death, volume of hematoma, and onset of cerebral hemorrhage.

Methods: This cross-sectional case-control study included 99 patients on HD with cerebral hemorrhage at a single center between July 1, 2007 and December 31, 2017. Controls included 339 patients on HD at a single HD center between July 1, 2011 and June 30, 2012. Data on serum calcium level, patient demographics, and comorbid conditions were collected, and associations between cerebral hemorrhage and subsequent death were evaluated by multivariate logistic regression analysis. Further, the association of these backgrounds and hematoma volume was evaluated by multiple regression analysis.

Results: Of the 99 patients, 32 (32%) died from cerebral hemorrhage. The corrected serum calcium level (odds ratio [OR], 2.49; 95% confidence interval [CI], 1.43-4.35; P < 0.001) and antiplatelet drug use (OR, 3.95; 95% CI, 1.50-10.4; P = 0.005) had significant effects on the prognosis. Moreover, the corrected serum calcium (P = 0.003) and antiplatelet drug use (P = 0.01) were significantly correlated with hematoma volume. In the patients, the corrected serum calcium level (OR, 1.54; 95% CI, 1.07-2.22; P = 0.02) was associated with the onset of cerebral hemorrhage, as was pre-hemodialysis systolic blood pressure (per 10 mmHg) (OR, 1.40; 95% CI, 1.23-1.59; P < 0.001).

Conclusions: Although the precise mechanisms remain unknown, a high serum calcium level is associated with cerebral hemorrhage in patients on HD. Thus, we should pay attentions to a patient's calcium level.
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http://dx.doi.org/10.1186/s12882-019-1400-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6555959PMC
June 2019

Impact of basal ganglia damage after successful endovascular recanalization for acute ischemic stroke involving lenticulostriate arteries.

J Neurosurg 2019 May 31;132(6):1880-1888. Epub 2019 May 31.

Departments of1Neurosurgery.

Objective: Regional ischemic vulnerability of the brain reportedly differs between the cortex and basal ganglia and has been poorly assessed in the setting of endovascular mechanical thrombectomy. This study was conducted to determine the fate of an ischemic basal ganglia and its contribution to the clinical outcome after successful endovascular recanalization for acute ischemic stroke with large vessel occlusion involving the lenticulostriate arteries.

Methods: Clinical and radiological findings were retrospectively analyzed in consecutive patients with acute ischemic stroke characterized by large vessel occlusion involving the lenticulostriate arteries. Mechanical thrombectomy was performed in all patients using a stent retriever. The fate of ischemic basal ganglia based on location (lentiform nucleus, caudate nucleus, and internal capsule) and insular cortex was assessed according to the Alberta Stroke Programme Early CT Score (ASPECTS).

Results: Of 170 patients with large intracranial vessel occlusion who achieved successful endovascular recanalization, defined as a thrombolysis in cerebral infarction grade of ≥ 2B, involvement of the lenticulostriate arteries was seen in 55 patients (internal carotid artery, n = 35; proximal middle cerebral artery, n = 20). Preoperative infarction was detected in the lentiform nucleus (66.7%), internal capsule (11.1%), and caudate nucleus (33.3%), all of which showed secondary advancement despite successful recanalization (85.4%, 27.3%, and 54.5%, respectively; p < 0.05). Lenticulostriate arteries with a lateral proximal and/or medial proximal origin significantly affected the development of mature infarction in the lentiform nucleus. Postoperative hemorrhagic transformation was detected in 25 of 55 patients, mostly in the lentiform nucleus. Involvement of insular ribbon infarction was significantly high in patients with hemorrhagic transformation in the basal ganglia. Age, initial National Institutes of Health Stroke Scale (NIHSS) score, initial ASPECTS, postoperative ASPECTS, postoperative infarction in the insular ribbon, and lesions in the middle cerebral artery area (M1-M6) were significantly different between patients with good and poor modified Rankin Scale scores. Interestingly, no differences were detected in postoperative infarction or hemorrhagic transformation in the basal ganglia. Multivariate analysis showed that only age (p = 0.02, OR 0.88) and the initial NIHSS score (p = 0.01, OR 0.86) independently affected favorable clinical outcomes.

Conclusions: The basal ganglia are vulnerable and readily develop secondary infarction and hemorrhagic transformation despite successful recanalization. However, this does not have a significant impact on the clinical outcome of acute ischemic stroke with large vessel occlusion involving the lenticulostriate arteries.
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http://dx.doi.org/10.3171/2019.3.JNS182909DOI Listing
May 2019

[A case of secondary central nervous system lymphoma presenting marked hypoglycorrhachia].

Rinsho Shinkeigaku 2019 Jun 29;59(6):365-370. Epub 2019 May 29.

Department of Neurology, Nagasaki Harbor Medical Center.

A 67-year-old male was transferred to our hospital with diplopia, decreased deep tendon reflex and ataxia. He had been suspected Fisher syndrome because of previous upper respiratory tract infection. A cerebrospinal fluid examination showed marked hypoglycorrhachia, pleocytosis and elevated protein, and cytological examination suggested malignant lymphoma. Abdominal computed tomography revealed a left adrenal mass. A biopsy of the left adrenal mass revealed diffuse large B-cell lymphoma. He was treated with a combination of R-CHOP (rituximab, cyclophosphamide, doxorubicin hydrochloride, oncovin and prednisolone) and intrathecal administration of methotrexate, cytarabine and prednisolone. Neurological symptoms were gradually improved. Malignancy should be considered in addition to bacterial, fungal or tuberculous meningitis in a case with marked hypoglycorrhachia.
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http://dx.doi.org/10.5692/clinicalneurol.cn-001284DOI Listing
June 2019

Large aortic arch plaques correlate with CHADS and CHADS-VASc scores in cryptogenic stroke.

Atherosclerosis 2019 05 20;284:181-186. Epub 2019 Mar 20.

Department of Neurology, Juntendo University Urayasu Hospital, Chiba, Japan.

Background And Aims: Current trends have suggested covert atrial fibrillation as a mechanism of cryptogenic stroke. However, etiological heterogeneity regarding the underlying embolic sources remains a critical issue in cryptogenic stroke.

Methods: CHALLENGE ESUS/CS (Mechanisms of Embolic Stroke Clarified by Transesophageal Echocardiography for Embolic Stroke of Undetermined Source/Cryptogenic Stroke) is a multicenter observational registry of cryptogenic stroke patients admitted to participating hospitals, who underwent transesophageal echocardiography between April 2014 and December 2016. We obtained baseline characteristics, radiological and laboratory data, and echocardiographic findings, especially for embolic sources demonstrated on transesophageal echocardiography, and conducted comparisons according to CHADS and CHADS-VASc scores (0-1 vs. ≥2, respectively). This study was registered at http://www.umin.ac.jp/ctr/(UMIN000032957).

Results: The study comprised 677 patients (age, 68.7 ± 12.8 years; 455 males; median National Institutes of Health Stroke Scale score, 2) with cryptogenic stroke. On multiple logistic regression analysis, large aortic arch plaque ≥4 mm (odds ratio [OR], 2.25; 95% confidence interval [CI], 1.51-3.36; p < 0.001), with ulcerative or mobile components (OR, 2.37; 95%CI, 1.38-4.06; p = 0.002), was associated with CHADS score ≥2. Large aortic arch plaque ≥4 mm (OR, 3.88; 95%CI, 2.07-7.27; p < 0.001) and ulcerative or mobile components (OR, 3.25; 95%CI, 1.44-7.34; p = 0.005) were linked to CHADS-VASc score ≥2.

Conclusions: The CHALLENGE ESUS/CS registry is a large TEE registry, and clarifies potential embolic etiologies of cryptogenic stroke using TEE. Large aortic arch plaques were associated with high CHADS and CHADS-VASc scores, and represented important embolic sources in cryptogenic stroke.
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http://dx.doi.org/10.1016/j.atherosclerosis.2019.03.009DOI Listing
May 2019

A score using left ventricular diastolic dysfunction to predict 90-day mortality in acute ischemic stroke: The DONE score.

J Neurol Sci 2019 Mar 17;398:157-162. Epub 2019 Jan 17.

Department of Neurology and Strokology, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan.

Purpose: The aim of this study was to identify whether diastolic dysfunction predicts death at 90 days after acute ischemic stroke.

Methods: We retrospectively analyzed patients with ischemic stroke. All patients underwent transthoracic echocardiography to evaluate systolic function and diastolic function by means of assessing ejection fraction and septal E/e'. We evaluated the initial National Institute of Health Stroke Scale (NIHSS) score, arterial occlusion, and laboratory data. We used multivariate regression models to identify independent predictors of 90-day mortality.

Results: Among 1208 patients, the overall 90-day mortality rate was 8%. In multivariate logistic regression analysis, a higher initial NIHSS score, plasma D-dimer level and E/e', and occlusion of internal carotid artery or basilar artery were independent predictors of 90-day mortality. The DONE score derived from these valuables showed good discrimination with area under the curve (AUC) value of 0.82 (95% confidence interval [CI], 0.78-0.87) to predict 90-day mortality. The DONE score also predicted poor outcome (modified Rankin scale score, 4-6) at 90 days (AUC, 0.82; 95% CI 0.80-0.85).

Conclusions: Higher E/e', indicating diastolic dysfunction, may be associated with 90-day mortality in patients with acute ischemic stroke. The DONE score could readily predict poor outcome after acute ischemic stroke.
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http://dx.doi.org/10.1016/j.jns.2019.01.021DOI Listing
March 2019

Assessment of veins in T2*-weighted MR angiography predicts infarct growth in hyperacute ischemic stroke.

PLoS One 2018 4;13(4):e0195554. Epub 2018 Apr 4.

Department of Neurosurgery, Graduate School of Biomedical Sciences, Nagasaki University, Nagasaki, Japan.

Background And Purpose: T2*-weighted magnetic resonance angiography (SWAN) detects hemodynamic insufficiency as hypointense areas in medullary or cortical veins. We therefore investigated whether SWAN can help predict ischemic penumbra-like lesions in patients with acute ischemic stroke (AIS).

Materials And Methods: Magnetic resonance imaging (MRI) records-including SWAN, diffusion-weighted imaging (DWI), and magnetic resonance angiography (MRA)-of consecutive patients with major vessel occlusion within 6 h from AIS onset were analyzed. Acute recanalization was defined as an arterial occlusive lesion score of 2-3. A modified Alberta Stroke Program Early CT Score (mASPECTS) was used to evaluate ischemic areas revealed by SWAN and DWI. SWAN- and DWI-based mASPECTSs were calculated, and correlations between DWI-SWAN mismatches with final infarct lesions or clinical outcomes were evaluated.

Results: Among the 35 patients included in this study, we confirmed cardioembolic stroke in 26, atherothrombotic stroke in 4, and unknown stroke etiology in 5. Overall, recanalization was achieved in 23 patients, who showed a higher follow-up DWI-based mASPECTS and lower modified Rankin Scale (mRS) score at 90 days than patients without recanalization. Initial SWAN- and follow-up DWI-based mASPECTSs were significantly higher for atherothrombotic stroke than for cardioembolic stroke. Of 12 patients without recanalization, DWI-SWAN mismatch was significantly correlated with infarct growth. Patients with recanalization showed no such correlation. In the assessment of clinical outcome, follow-up DWI-based mASPECTS and patient's age were significantly correlated with mRS at 90 days after stroke. A multivariate logistic regression analysis revealed that the follow-up DWI-based mASPECTS was independently associated with a favorable outcome 90 days after stroke.

Conclusions: For patients with AIS, DWI-SWAN mismatch might show penumbra-like lesions that would predict infarct growth without acute recanalization. Assessment of ischemic lesions from the venous side appears to be useful for considering the etiology and revascularization therapy.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0195554PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5884555PMC
July 2018

Early Diagnosis of Infective Endocarditis by Brain T2*-Weighted Magnetic Resonance Imaging.

Circ J 2018 01 23;82(2):464-468. Epub 2017 Sep 23.

Department of Neurosurgery, Nagasaki University School of Medicine.

Background: Because infective endocarditis (IE) carries a high risk of morbidity and mortality, rapid diagnosis and effective treatment are essential to achieving a good patient outcome. However, the diagnosis of IE is often difficult in patients presenting with nonspecific clinical manifestations. An association between IE and hypointense signal spots on brain T2*-weighted magnetic resonance imaging (MRI) has been reported, but the clinical significance remains unclear.Methods and Results:To assess the clinical importance of silent lesions in the brains of IE patients, hypointense signal spots detected on their brain T2*-weighted MRI scans were investigated in a retrospective review of 44 consecutive patients with definite or suspected IE evaluated by MRI between June 2006 and January 2014. Hypointense signal spots on T2*-weighted MRI were detected in 37 (84%) patients; of these, 21 (46%) had ischemic lesions, 10 (22%) had subarachnoid hemorrhage, 4 (9%) had intraparenchymal hemorrhage, and 4 (9%) had infectious aneurysm. The hypointense signal spots on T2*-weighted images were preferentially distributed in cortical areas.

Conclusions: T2*-weighted hypointense signal spots are highly frequent in patients with IE and their presence may be informative in the monitoring of IE-associated brain lesions, even those that are neurologically asymptomatic. The strong association between IE and T2*-weighted hypointense signal spots supports the need to consider additional criteria in the diagnosis of IE.
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http://dx.doi.org/10.1253/circj.CJ-17-0212DOI Listing
January 2018

YAMATO Study (Tissue-Type Plasminogen Activator and Edaravone Combination Therapy).

Stroke 2017 03 24;48(3):712-719. Epub 2017 Jan 24.

From the Department of Neurological Science, Graduate School of Medicine, Nippon Medical School, Tokyo, Japan (J.A., K.K.); Department of Stroke Medicine, Kawasaki Medical School, Kurashiki, Japan (J.A., K.K., T. Inoue); Department of Radiology, National Cerebral and Cardiovascular Center, Suita, Japan (N. Morita); Department of Radiology, Institute of Biomedical Sciences, Tokushima University, Japan (M.H.); Hirosaki Stroke and Rehabilitation Center, Japan (N. Metoki); Department of Neurology and Strokology, Nagasaki University Hospital, Japan (Y. Tateishi); Department of Neurology, Kobe City Medical Center General Hospital, Japan (K.T., H.Y.); Fukui-ken Saiseikai Hospital, Fukui, Japan (K.H.); Department of Clinical Neuroscience, Institute of Biomedical Sciences, Tokushima University, Japan (Y. Terasawa, K.F., N.Y.); Department of Neurology, Saitama Medical University International Medical Center, Hidaka, Japan (I.D., N.T.); Japanese Red Cross Okayama Hospital, Japan (T. Iwanaga); Okinawa Kyodo Hospital, Japan (N.K.); Department of Neurology, The Jikei University School of Medicine, Tokyo, Japan (H.M., Y.I.); Shinko Hospital, Kobe, Japan (Y.U., Y.K.); Department of Neurology, Faculty of Medicine, Fukuoka University, Japan (T.O.); Department of Cerebrovascular Medicine, Stroke Center, Steel Memorial Yawata Hospital, Kitakyushu, Japan (S.F.); Department of Neurology, Yokohama Sakae Kyosai Hospital, Japan (M.Y.); and Department of Neurosurgery, Institute of Biomedical Sciences, Tokushima University, Tokushima, Japan (S.N.).

Background And Purpose: We investigated whether administration of edaravone, a free radical scavenger, before or during tissue-type plasminogen activator (tPA) can enhance early recanalization in a major arterial occlusion.

Methods: The YAMATO study (Tissue-Type Plasminogen Activator and Edaravone Combination Therapy) is an investigator-initiated, multicenter (17 hospitals in Japan), prospective, randomized, and open-label study. Patients with stroke secondary to occlusion of the M1 or M2 portion of the middle cerebral artery and within 4.5 hours of the onset were studied. The subjects were randomly allocated to the early group (intravenous edaravone [30 mg] was started before or during tPA) and the late group (edaravone was started after tPA and the assessment of early recanalization).

Results: One-hundred sixty-five patients (96 men; median age [interquartile range], of 78 [69-85] years) were randomized 1:1 to either the early group (82 patients) or the late group (83 patients). Primary outcome, defined as an early recanalization 1.5 hour after tPA, was observed in 53% of the early group and in 53% of the late group (=1.000). About secondary outcomes, the rate of significant recanalization of ≥50% was not different between the 2 groups (28% versus 34%; =0.393). The symptomatic intracerebral hemorrhage has occurred in 4 patients (5%) in the early group and in 2 patients (2%) in the late group (=0.443). The favorable outcome (modified Rankin Scale score of 0-2) at 3 months was also similar between the groups (53% versus 57%; =0.738).

Conclusions: The timing of edaravone infusion does not affect the rate of early recanalization, symptomatic intracerebral hemorrhage, or favorable outcome after tPA therapy.

Clinical Trial Registration: URL: http://www.umin.ac.jp/ctr/index-j.htm. Unique identifier: UMIN000006330.
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http://dx.doi.org/10.1161/STROKEAHA.116.015042DOI Listing
March 2017

Subacute lesion volume as a potential prognostic biomarker for acute ischemic stroke after intravenous thrombolysis.

J Neurol Sci 2016 Oct 3;369:77-81. Epub 2016 Aug 3.

Department of Neurology and Strokology, Nagasaki University Hospital, 1-7-1 Sakamoto, Nagasaki City, Nagasaki 852-8501, Japan.

Background: The aim of this study was to identify whether subacute diffusion-weighted imaging (DWI) lesion volume could predict long-term outcome in patients who had undergone intravenous thrombolysis.

Method: Patients underwent DWI at baseline and 7days after thrombolysis. Outcomes included complete independence (modified Rankin scale [mRS] score 0 to 1), unfavorable outcome (mRS score 4 to 6) at 90days, and mortality within 90days. Multivariate logistic regression analysis was used to identify outcome predictors.

Results: Of 164 patients, 72 patients (43%) achieved complete independence. Poor outcomes were observed in 45 patients (27%) with an unfavorable outcome and 10 patients (6%) who died. Subacute DWI lesion volume was 3.4mL (interquartile range, 1.1-11.6) in patients with complete independence, 90.1mL (23.8-180.2) in patients with unfavorable outcome and 155.5mL (78.4-377.5) in patients who died. In multivariate logistic regression analysis, subacute DWI lesion volume was an independent predictor of complete independence (odds ratio [OR], 0.939; 95% confidence interval [CI], 0.914-0.965; p<0.001), unfavorable outcome (OR, 1.023; 95% CI, 1.014-1.033; p<0.001), and mortality (OR, 1.016; 95% CI, 1.005-1.028; p=0.005).

Conclusion: Subacute DWI lesion volume is a critical determinant of 90-day functional outcome and mortality after thrombolysis.
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http://dx.doi.org/10.1016/j.jns.2016.08.006DOI Listing
October 2016

Acute stroke with major intracranial vessel occlusion: Characteristics of cardioembolism and atherosclerosis-related in situ stenosis/occlusion.

J Clin Neurosci 2016 Oct 6;32:24-9. Epub 2016 Aug 6.

Department of Neurosurgery, Nagasaki University School of Medicine, 1-7-1 Sakamoto, Nagasaki 852-8501, Japan.

Acute ischemic stroke with major intracranial vessel occlusion is commonly due to cardioembolic or atherosclerosis-related in situ stenosis/occlusion, and immediate identification of these subtypes is important to establish the optimal treatment strategy. The aim of this study was to clarify the differences in clinical presentation, radiological findings, neurological temporal courses, and outcomes between these etiologies, which have not been fully evaluated. Consecutive emergency patients with acute ischemic stroke were retrospectively reviewed. Among them, patients with stroke with major intracranial vessel occlusion were analyzed with a focus on clinical and radiological findings, and a comparison was performed for those with cardioembolic or atherosclerosis-related in situ stenosis/occlusion. Of 1053 patients, 80 had stroke with acute major intracranial vessel occlusion (45 with cardioembolic and 35 with atherosclerosis-related in situ stenosis/occlusion). Interestingly, the susceptibility vessel sign (SVS) on T2-weighted MR angiography was more frequently detected in cardioembolic stroke (80.0%) than in atherosclerosis (in situ stenosis: 5.9%, chronic occlusion: 14.3%). Moreover, the proximal intra-arterial signal (IAS) on arterial spin labeling MRI and the distal IAS on fluid attenuated inversion recovery MRI was less frequently detected in chronic occlusion (27.3% and 50.0%, respectively) than in acute occlusion due to cardioembolic or in situ stenosis. Multivariate regression analysis showed that the SVS was significantly related to cardioembolism (adjusted odds ratio (OR): 21.68, P=0.004). Clinical characteristics of acute stroke with major intracranial vessel occlusion differ depending on the etiology. The SVS and proximal/distal IAS on MRI are useful to distinguish between cardioembolic and atherosclerotic-related in situ stenosis/occlusion.
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http://dx.doi.org/10.1016/j.jocn.2015.12.043DOI Listing
October 2016

Safety and efficacy of non-vitamin K oral anticoagulant treatment compared with warfarin in patients with non-valvular atrial fibrillation who develop acute ischemic stroke or transient ischemic attack: a multicenter prospective cohort study (daVinci study).

J Thromb Thrombolysis 2016 Nov;42(4):453-62

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

The safety and efficacy of non-vitamin K oral anticoagulant (NOAC) compared with warfarin in treating patients with non-valvular atrial fibrillation (NVAF) who developed acute ischemic stroke or transient ischemic attack (AIS/TIA), particularly those receiving tissue-plasminogen activator (tPA) therapy, remains unclear. Between April 2012 and December 2014, we conducted a multicenter prospective cohort study to assess the current clinical practice for treating such patients. We divided the patients into two groups according to the administration of oral anticoagulants (warfarin or NOACs) and tPA therapy. The risk of any hemorrhagic or ischemic event was compared within 1 month after the onset of stroke. We analyzed 235 patients with AIS/TIA including 73 who received tPA therapy. Oral anticoagulants were initiated within 2-4 inpatient days. NOACs were administered to 49.8 % of patients, who were predominantly male, younger, had small infarcts, lower NIHSS scores, and had a lower all-cause mortality rate (0 vs. 4.2 %, P = 0.06) and a lower risk of any ischemic events (6.0 vs. 7.6 %, P = 0.797) compared with warfarin users. The prevalence of all hemorrhagic events was equivalent between the two groups. Early initiation of NOACs after tPA therapy appeared to lower the risk of hemorrhagic events, although there was no significant difference (0 vs. 5.6 %, P = 0.240). Although more clinicians are apt to prescribe NOACs in minor ischemic stroke, NOAC treatment may provide a potential benefit in such cases. Early initiation of NOACs after tPA therapy may reduce the risk of hemorrhagic events compared with warfarin.
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http://dx.doi.org/10.1007/s11239-016-1376-xDOI Listing
November 2016

Association between adult short stature and cerebral microbleeds.

Int J Stroke 2016 Feb;11(2):NP27-9

Department of Island and Community Medicine, Nagasaki University Graduate School of Biomedical Science, Goto, JapanDepartment of Community Medicine, Nagasaki University Graduate School of Biomedical Science, Sakamoto, Japan.

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http://dx.doi.org/10.1177/1747493015620810DOI Listing
February 2016

Duplex Ultrasonography-Detected Positional Vertebral Artery Occlusion in Upper Cervical Rheumatoid Arthritis.

Spine (Phila Pa 1976) 2016 Jan;41(1):26-31

*Cerebrovascular Center, Department of Neurology and Strokology, Nagasaki University Hospital, Nagasaki, Japan †Department of Orthopedic Surgery, Nagasaki University Hospital, Nagasaki, Japan ‡First Department of Internal Medicine, Nagasaki University Hospital, Nagasaki, Japan.

Study Design: Prospective imaging study.

Objective: To clarify the frequency of positional vertebral artery (VA) occlusion using duplex ultrasonography in patients with rheumatoid arthritis (RA).

Summary Of Background Data: Some patients with upper cervical RA develop thromboembolic stroke related to positional and transient VA occlusions; however, whether RA patients have positional VA occlusion without neurological symptoms is unclear.

Methods: Outpatients with RA were enrolled. Clinical data were collected, and radiograph examinations were performed to measure the anterior atlantodental interval (AADI), the posterior atlantodental interval (PADI), and the Ranawat method. Patients underwent duplex ultrasonography during rotation to the contralateral side of the examination side, flexion, and extension of their neck. If positional VA occlusion was detected, CT angiography was conducted in the neutral position and in the same position that showed VA occlusion on duplex ultrasonography. Clinical and radiological data were compared between the VA occlusion (VAO) group and the non-VAO group. Sensitivity-specificity curve analyses were performed to clarify optimal threshold values of AADI, PADI, and the Ranawat method for predicting positional VA occlusion.

Results: Of the 132 RA patients, dynamic duplex ultrasonography showed positional VA occlusion in eight (6%) patients. Patients in the VAO group had a greater AADI (median, 7.4 vs. 2.3 mm; P < 0.001), a shorter PADI (median, 13.7 vs. 19.6 mm; P = 0.002), and a lower Ranawat value (median, 13.7 vs. 16.8 mm; P = 0.006) than those in the non-VAO group. Cut-off values of AADI, PADI, and the Ranawat method for predicting positional VA occlusion were 6.5, 14.0, and 15.5 mm, respectively.

Conclusion: A subset of RA patients developed positional VA occlusion associated with cervical spine involvement.
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http://dx.doi.org/10.1097/BRS.0000000000001136DOI Listing
January 2016

Communication of inwardly projecting neovessels with the lumen contributes to symptomatic intraplaque hemorrhage in carotid artery stenosis.

J Neurosurg 2015 Nov 19;123(5):1125-32. Epub 2015 Jun 19.

Departments of 1 Neurosurgery.

Object: Recent studies have demonstrated that plaque morphology can contribute to identification of patients at high risk of carotid artery atherosclerosis as well as the degree of stenosis in those with carotid atherosclerosis. Neovascularization of carotid plaques is associated with plaque vulnerability. However, the mechanism of neovascularization in intraplaque hemorrhage (IPH) and its clinical contribution remain undetermined. In this study, the authors aimed to clarify the characteristics of neovessel appearance with a focus on inwardly projecting neovessels, which are reportedly important in plaque advancement.

Methods: Consecutive patients with moderate to severe carotid atherosclerosis who underwent carotid endarterectomy were prospectively analyzed from 2010 to 2014. The neovessel appearance was categorized into 3 groups based on intraoperative indocyanine green (ICG) videoangiography: early appearance of neovessels from the endothelium (NVe), late appearance of neovessels from the vasa vasorum (NVv), and no appearance of vessels. Each neovessel pattern was evaluated with respect to clinical, radiological, and pathological findings including IPH, neovascularization, hemosiderin spots, and inflammation.

Results: Of 57 patients, 13 exhibited NVe, 33 exhibited NVv, and 11 exhibited no neovessels. Overall, the interobserver and intraobserver reproducibilities of neovessel appearance were substantial for ICG videoangiography (κ=0.76) and at 7 days postoperatively (κ=0.76). There were no significant differences in baseline characteristics among the 3 groups, with the exception of a higher percentage of symptomatic presentations in patients with NVe (artery-to-artery embolic infarction in 61.5% and transient ischemic attack in 23.1%). Moreover, patients with NVe exhibited larger infarctions than did those with NVv (9675.0±5601.9 mm3 vs 2306.6±856.9 mm3, respectively; p=0.04). Pathologically, patients with NVe had more severe IPH (47.2±8.3 mm2 vs 19.8±5.2 mm2, respectively; p<0.01), hemosiderin spots (0.5±0.2 mm2 vs 0.2±0.1 mm2, respectively; p=0.04), neovessels (0.4±0.7 mm2 vs 0.1±0.4 mm2, respectively; p=0.11), and inflammation (1.0±1.1 mm2 vs 0.6±0.9 mm2, respectively; p=0.26) around the endothelium than did patients with NVv, and all of these parameters were correlated with hyperintensity on time-of-flight MRI. However, the neovessel and inflammation differences were nonsignificant. Interestingly, inflammation was significantly correlated with neovessel formation (r=0.43, p=0.0008), hemosiderin spots (r=0.62, p<0.0001), and IPH (r=0.349, p=0.0097), suggesting that inflammation may be a key factor in plaque vulnerability.

Conclusions: Communication of inwardly projecting neovessels with the lumen and inflammation synergistically contribute to IPH and symptomatic presentations in patients with carotid stenosis and are more specific than the vasa vasorum. This condition could be a new therapeutic target, and regression of luminal neovessel sprouting and inflammation may help to prevent IPH development and a symptomatic presentation.
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http://dx.doi.org/10.3171/2014.12.JNS142371DOI Listing
November 2015

Large deep white matter lesions may predict futile recanalization in endovascular therapy for acute ischemic stroke.

Interv Neurol 2015 Jan;3(1):48-55

Cerebrovascular Center, Cleveland Clinic, Cleveland, Ohio, USA.

Objective: This study investigated whether large ischemic lesions in the deep white matter (DWM) on pretreatment diffusion-weighted MRI (DWI) predict futile recanalization.

Methods: Consecutive acute stroke patients with anterior circulation ischemia who underwent successful arterial recanalization with thrombolysis in cerebral infarction grade 2b or 3 were enrolled. A large DWI-DWM lesion was defined as a hyperintense lesion in the DWM on initial DWI, located mainly between the anterior and posterior horns of the lateral ventricle. The Alberta Stroke Program Early CT score on CT and DWI and stroke volume on initial DWI were recorded. Stroke severity was assessed using the National Institutes of Health Stroke Scale (NIHSS) score. Futile recanalization was defined as a 30-day modified Rankin scale score of 3-6 despite successful recanalization. Univariate and multivariate regression analyses were performed to identify predictors of futile recanalization.

Results: In 35 of 46 patients (76%) with successful recanalization, futile recanalization was observed in 20 patients (57%). Patients with futile recanalization were older (median age 74 vs. 58 years; p = 0.053), had higher initial NIHSS scores (median 17 vs. 9; p = 0.042), and a higher prevalence of large DWI-DWM lesions (45 vs. 9%; p = 0.022). Logistic regression analysis showed that a large DWI-DWM lesion was an independent predictor of futile recanalization (OR 13.97; 95% CI 1.32-147.73; p = 0.028).

Conclusion: Patients with large preintervention DWI-DWM lesions may be poor candidates for endovascular therapy.
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http://dx.doi.org/10.1159/000369835DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4436528PMC
January 2015

Predictors of infarct growth after endovascular therapy for acute ischemic stroke.

J Stroke Cerebrovasc Dis 2015 Feb 12;24(2):401-7. Epub 2014 Dec 12.

Cerebrovascular Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio. Electronic address:

Background: Intra-arterial (IA) thrombectomy for acute ischemic stroke has an excellent recanalization rate but variable outcomes. The core infarct also grows at a variable rate despite recanalization. We aim to study the factors that are associated with infarct growth after IA therapy.

Methods: We reviewed the hyperacute ischemic stroke imaging database at Cleveland Clinic for those undergoing endovascular thrombectomy of anterior circulation from 2009 to 2012. Patients with both pretreatment and follow-up magnetic resonance imaging were included. Seventy-six patients were stratified into quartiles by infarct volume growth from initial to follow-up diffusion-weighted imaging (DWI) measure by a region of interest demarcation.

Results: The median infarct growth of each quartile was .6 cm(3) (no-growth group), 13.8, 37, and 160.2 cm(3) (large-growth group). Pretreatment stroke severity was comparable among groups. Compared with the no-growth group, the large-growth group had larger initial infarct defined by computed tomography (CT) Alberta Stroke Program Early CT score (median 10 versus 8, P = .032) and DWI volume (mean 13.8 versus 29.2 cm(3), P = .034), lack of full collateral vessels on CT angiography (36.8% versus 0%, P = .003), and a lower recanalization rate (thrombolysis in cerebral infarction ≥2b, P = .044). The increase in infarct growth is associated with decrease in favorable outcomes defined by a modified Rankin Scale score of 0-2 at 30 days: 57.9%, 42.1%, 21.1%, and 5.3%, respectively (P < .001). DWI reversal was observed in 11 of 76 patients, translating to 82% favorable outcome.

Conclusions: Infarct evolution after endovascular thrombectomy is associated with an outcome. DWI reversal or no growth translated to a favorable outcome. Small initial ischemic core, good collateral support, and better recanalization grades predict the smaller infarct growth and favorable outcome after endovascular thrombectomy.
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http://dx.doi.org/10.1016/j.jstrokecerebrovasdis.2014.09.004DOI Listing
February 2015

Collateral flow and brain changes on computed tomography angiography predict infarct volume on early diffusion-weighted imaging.

J Stroke Cerebrovasc Dis 2014 Nov-Dec;23(10):2845-2850. Epub 2014 Oct 16.

Cerebrovascular Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio.

Background: We investigated whether a computed tomography (CT)-based score could predict a large infarct (≥ 80 mL) on early diffusion-weighted magnetic resonance imaging (DWI).

Methods: Acute stroke patients considered for endovascular therapy within 8 hours of the onset of symptoms were included. The Alberta Stroke Program Early Computed Tomography Score (ASPECTS) was determined on noncontrast CT and computed tomography angiography source images (CTA-SI). Limited collateral flow was defined as less than 50% collateral filling on CTA-SI.

Results: Fifty-six patients were analyzed. National Institutes of Health Stroke Scale score was 20 (15-24) in the large infarct group and 16 (11-20) in the small infarct group (P = .049). ASPECTS on noncontrast CT and CTA-SI was 5 (3-8) and 3 (2-6) in the large infarct group and 9 (8-10) and 8 (7-9) in the small infarct group (both P < .001), respectively. Limited collateral flow was frequent in the large infarct group than in the small infarct group (92% vs. 11%, P < .001). Multivariate analysis found that CTA-SI ASPECTS less than or equal to 5 (odds ratio [OR], 40.55; 95% confidence interval [CI], 1.10-1493.44; P = .044) and limited collateral flow (OR, 114.64; 95% CI, 1.93-6812.79; P = .023) were associated with a large infarct. Absence of ASPECTS less than or equal to 5 and limited collateral flow on CTA-SI predicted absence of a large infarct with a sensitivity of .89, specificity of 1.00, positive predictive value of 1.00, and negative predictive value of .71.

Conclusions: Assessment of ASPECTS and collateral flow on CTA-SI may be able to exclude a patient with large infarct on early DWI.
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http://dx.doi.org/10.1016/j.jstrokecerebrovasdis.2014.07.015DOI Listing
November 2015

Bow Hunter's Stroke Due to Stretching of the Vertebral Artery Fenestration: A Case Report.

NMC Case Rep J 2015 Jan 29;2(1):9-11. Epub 2014 Sep 29.

Department of Neurosurgery, Nagasaki University School of Medicine, Sakamoto, Nagasaki.

Bow Hunter's syndrome is an unusual symptomatic vertebrobasilar insufficiency resulting from intermittent mechanical compression of the vertebral artery, and is rarely a trigger for cerebral infarction following thrombus formation on the damaged endothelial vessels (Bow Hunter's stroke). The authors present an extremely rare case of a 45-year-old man showing Bow Hunter's stroke due to congenital vertebral artery fenestration stretching and sliding between C1 and C2 after head rotation to the right. Congenital vertebral artery anomaly rarely causes cerebral infarction, but could cause embolic strokes by mechanical stretching without bony abnormalities.
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http://dx.doi.org/10.2176/nmccrj.2014-0075DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5364926PMC
January 2015

Cardiac diastolic dysfunction predicts in-hospital mortality in acute ischemic stroke with atrial fibrillation.

J Neurol Sci 2014 Oct 12;345(1-2):83-6. Epub 2014 Jul 12.

Department of Neurosurgery, The Nagasaki University Hospital, 1-7-1 Sakamoto, Nagasaki City, Nagasaki 852-8501, Japan.

Background: The aim of this study was to identify whether diastolic dysfunction predicts in-hospital death in ischemic stroke patients with atrial fibrillation.

Method: We retrospectively analyzed data from enrolled patients with ischemic stroke patients with atrial fibrillation who presented within 24h of onset. All patients underwent transthoracic echocardiography to evaluate diastolic filling pressure estimated as the ratio of early transmitral flow velocity (E) to mitral annular velocity (e') within 24h of admission. We evaluated initial ischemic lesion volume and National Institute of Health Stroke Scale (NIHSS) score.

Results: Two hundred and sixty-six patients were enrolled. During hospitalization, 30 patients (11%) died. The deceased group had a higher NIHSS score, a higher D-dimer level, a higher creatinine level, a larger initial ischemic lesion volume and a higher E/e' ratio than those in the survival group. In a multivariate analysis, a higher E/e' ratio was an independent predictor of in-hospital death. The cutoff value for the E/e' ratio for prediction in-hospital death was 20 with the sensitivity of 75% and specificity of 86%.

Conclusion: Diastolic dysfunction may be associated with in-hospital death in ischemic stroke patients with atrial fibrillation.
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http://dx.doi.org/10.1016/j.jns.2014.07.011DOI Listing
October 2014

The location of pretreatment hyperdense middle cerebral artery sign predicts the outcome of intraarterial thrombectomy for acute stroke.

J Neuroimaging 2015 Mar-Apr;25(2):263-268. Epub 2014 Apr 7.

Cerebrovascular Center, Neurological Institute, Cleveland Clinic, Cleveland, OH.

Background And Purpose: Intraarterial (IA) mechanical thrombectomy has an excellent recanalization rate but does not always correlate with good clinical outcomes. We aimed to investigate whether hyperdense middle cerebral artery sign (HMCAS) on preintervention nonenhanced CT (NECT) predicts IA therapy outcome for acute stroke.

Methods: Data were abstracted from our Hyperacute Ischemic Stroke database. Patients with occlusion in ICA, MCA, or MCA M2 branches who underwent IA therapy were included.

Results: Among 126 patients who underwent IA treatment, 64 (51%) had hyperdense M1 MCA sign (M1 HMCAS), 11 (9%) had hyperdense M2, and 51 (40%) had No HMCAS (NHMCAS).M1 HMCAS and NHMCAS group has comparable baseline stroke severity and infarct volume (P > .05); and the differences of favorable outcome (modified Rankin Score 0-2) at 30 days were not significant (21% vs. 30%, P = .259). For those with HMCAS, favorable 30-day outcome was most frequent in Distal HMCAS (39%), followed by hyperdense M2 (27%), HMCAS proximal (11%), and HMCAS full length (0%).

Conclusions: For acute ischemic stroke due to large vessel occlusion, the lack of HMCAS on NECT does not predict favorable outcome after IA therapy. Among those with HMCAS, proximal and longer HMCAS predicts unfavorable outcome.
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http://dx.doi.org/10.1111/jon.12115DOI Listing
April 2016
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