Usefulness of "AcT ratio" in diagnosis of internal carotid artery stenosis: a multicenter, retrospective, observational study

PURPOSE

The ratio of the internal carotid artery (ICA) to the common carotid artery (CCA), especially the "AcT ratio," which is a modified measurement method of acceleration time, is useful for diagnosing ICA-origin stenosis. However, previous studies were single-center studies. Therefore, this multicenter, retrospective, cross-sectional study aimed to determine whether a method using the AcT ratio is useful for estimating stenosis rates.

METHODS

This study included 461 vessels subjected to carotid artery ultrasonography and evaluation for ICA-origin stenosis via NASCET at four hospitals. The duration from the steep rise point to the inflection point or the first peak was defined as AcT on pulsed wave Doppler. The AcT ratio was calculated as AcT of ICA/AcT of ipsilateral CCA. The AcT ratio and rate of ICA-origin stenosis were analyzed using Pearson's correlation coefficient, simple regression analysis, and ROC curve.

RESULTS

A significant positive correlation was observed between the AcT ratio and NASCET stenosis. NASCET stenosis of ≥ 50% had a sensitivity, specificity, and negative predictive value (NPV) of 70.2%, 71.6%, and 91.5%, respectively, when the cut-off value of the AcT ratio was 1.17. NASCET stenosis of ≥ 70% had a sensitivity, specificity, and NPV of 70.5%, 72.1%, and 95.9%, respectively, when the cut-off value of the AcT ratio was 1.22.

CONCLUSIONS

The findings of this multicenter, retrospective, cross-sectional study suggest that the AcT ratio is useful for diagnosing ICA-origin stenosis, especially for diagnosis by exclusion. NASCET stenosis of ≥ 50% was considered unlikely if the Act ratio was ≤ 1.17, whereas NASCET stenosis of ≥ 70% was considered unlikely if it was ≤ 1.22.

High-risk patent foramen ovale and elderly in cryptogenic stroke

BACKGROUND

High-risk patent foramen ovale (PFO) could be pathological in cryptogenic stroke (CS), but its clinical characteristics have not been fully studied, especially in elderly patients.

METHODS

Patients with CS were enrolled in the CHALLENGE ESUS/CS registry, a multicenter registry of CS patients undergoing transesophageal echocardiography. Clinical characteristics were compared among three groups: high-risk PFO group, large shunt PFO (≥25 microbubbles) or PFO with atrial septal aneurysm (ASA); right-to-left shunt (RLS) group, RLS including PFO with <25 microbubbles or without ASA; and no-RLS group.

RESULTS

In total, 654 patients were analyzed: 91, 221, and 342 in the high-risk PFO, RLS, and no-RLS groups, respectively. In multinomial logistic regression analysis, the male sex (odds ratio [OR] 1.825 [1.067-3.122]) was independently associated with high-risk PFO, but hypertension (OR, 0.562 [0.327-0.967]), multiple infarctions (OR, 0.601 [0.435-0.830]), and other cardioaortic embologenic risks (OR, 0.514 [0.294-0.897]) were inversely associated with high-risk PFO compared with non-RLS. In 517 patients aged ≥60 years, multiple infarctions (OR, 0.549 [0.382-0.788]) and other cardioaortic embologenic risks (OR, 0.523 [0.286-0.959]) were inversely associated with high-risk PFO.

CONCLUSIONS

High-risk PFO had specific clinical characteristics and possible mechanistic associations, and this trend was consistent among CS patients aged ≥60 years.

CLINICAL TRIAL REGISTRATION INFORMATION

http://www.umin.ac.jp/ctr/ (UMIN000032957).

Satisfaction Survey for Regional Clinical Pathway for Stroke Patients in Acute and Rehabilitation Hospitals in Japan

Objectives

We collected opinions about the use of a stroke-specific regional clinical pathway for facilitating collaboration between acute and rehabilitation hospitals in Japan.

Methods

The study surveys were administered in acute hospitals designated as primary stroke centers and certified by the Japan Stroke Association (n=961) and in rehabilitation hospitals affiliated with the Kaifukuki Rehabilitation Ward Association (n=1237). The survey collected information on interfacility collaboration when caring for patients admitted during the acute phase following non-traumatic stroke from April 2020 to March 2021. We examined the pathway's usefulness and challenges relative to facility type using the χ² test.

Results

Of 422 acute hospitals and 223 rehabilitation hospitals that responded to our survey, 259 (62.1%) acute hospitals and 164 (85.4%) rehabilitation hospitals used the pathway. Fewer rehabilitation hospitals than acute hospitals considered that the pathway was useful (52.0% vs. 63.8%, P=0.02). Fewer rehabilitation hospitals did not experience pathway-related problems when compared with acute hospitals (38.0% vs. 55.8%, P<0.01).

Conclusions

Personnel at rehabilitation hospitals were less satisfied with the regional clinical care pathway than those in acute hospitals. These results suggest that the current stroke-specific regional clinical pathway could be improved.

Uric acid and neurological disease: a narrative review

Hyperuricemia often accompanies hypertension, diabetes, dyslipidemia, metabolic syndrome, and chronic renal disease; it is also closely related to cardiovascular disease. Moreover, several epidemiological studies have linked hyperuricemia and ischemic stroke. However, uric acid may also have neuroprotective effects because of its antioxidant properties. An association between low uric acid levels and neurodegenerative diseases has been suggested, which may be attributed to diminished neuroprotective effects as a result of reduced uric acid. This review will focus on the relationship between uric acid and various neurological diseases including stroke, neuroimmune diseases, and neurodegenerative diseases. When considering both the risk and pathogenesis of neurological diseases, it is important to consider the conflicting dual nature of uric acid as both a vascular risk factor and a neuroprotective factor. This dual nature of uric acid is important because it may help to elucidate the biological role of uric acid in various neurological diseases and provide new insights into the etiology and treatment of these diseases.

Stroke in Patients With Common Noncancerous Gynecologic Diseases: A Multicenter Study in Japan

Background and Objectives

Gynecologic diseases such as uterine fibroids, endometriosis, and adenomyosis are common in women of reproductive age. Case reports and small case series have reported ischemic stroke in women with such common noncancerous gynecologic diseases, and their cause of stroke is frequently attributed to cryptogenic stroke or unconventional mechanisms related to hypercoagulability. However, stroke etiology and prognosis are not well known. We assessed the prevalence of and stroke mechanisms related to common noncancerous gynecologic diseases using hospital-based clinical data.

Methods

We retrospectively identified consecutive female patients with common noncancerous gynecologic diseases (uterine fibroids, endometriosis, and adenomyosis) diagnosed with ischemic stroke/transient ischemic attack (TIA) between the ages of 20 and 59 years admitted to 10 stroke centers in Japan by reviewing prospectively collected data between 2017 and 2019. The clinical, laboratory, and neuroimaging features were evaluated and compared between patients with conventional stroke mechanisms (CSMs) (large artery atherosclerosis, small vessel occlusion, cardioembolism, and other determined etiology) and non-CSMs (cryptogenic stroke and causes related to hypercoagulability such as nonbacterial thrombotic endocarditis and paradoxical embolism) according to the Trial of Org 10172 in Acute Stroke Treatment criteria.

Results

Of the 470 female patients with ischemic stroke/TIA, 39 (8%) (37 ischemic stroke and 2 TIA) had common noncancerous gynecologic diseases. The most common gynecologic diseases were uterine fibroids in 24 (62%) patients, followed by endometriosis in 9 (23%) and adenomyosis in 6 (15%). Twenty patients (51%) were assigned to the non-CSMs group, and 19 patients (49%) were assigned to the CSMs group. Adenomyosis and endometriosis were more frequent in the non-CSMs group than in the CSMs group. CA125 and D-dimer levels were higher in the non-CSMs group than in the CSMs group. Multiple vascular territory infarcts were frequent in patients with adenomyosis (60%) and endometriosis (43%) in the non-CSMs group. No stroke recurrence or death was observed within 3 months after discharge in both the CSMs and non-CSMs groups. Outcomes at 3 months after discharge were similar in both groups.

Discussion

In patients with common noncancerous gynecologic diseases, hypercoagulopathy may play a role in the pathogenesis of ischemic stroke/TIA without CSMs.

Detection of Atrial Fibrillation Using Insertable Cardiac Monitors in Patients With Cryptogenic Stroke in Japan (the LOOK Study): Protocol for a Prospective Multicenter Observational Study

BACKGROUND

Paroxysmal atrial fibrillation (AF) is a probable cause of cryptogenic stroke (CS), and its detection and treatment are important for the secondary prevention of stroke. Insertable cardiac monitors (ICMs) are clinically effective in screening for AF and are superior to conventional short-term cardiac monitoring. Japanese guidelines for determining clinical indications for ICMs in CS are stricter than those in Western countries. Differences between Japanese and Western guidelines may impact the detection rate and prediction of AF via ICMs in patients with CS. Available data on Japanese patients are limited to small retrospective studies. Furthermore, additional information about AF detection, including the number of episodes, cumulative episode duration, anticoagulation initiation (type and dose of regimen and time of initiation), rate of catheter ablation, role of atrial cardiomyopathy, and stroke recurrence (time of recurrence and cause of the recurrent event), was not provided in the vast majority of previously published studies.

OBJECTIVE

In this study, we aim to identify the proportion and timing of AF detection and risk stratification criteria in patients with CS in real-world settings in Japan.

METHODS

This is a multicenter, prospective, observational study that aims to use ICMs to evaluate the proportion, timing, and characteristics of AF detection in patients diagnosed with CS. We will investigate the first detection of AF within the initial 6, 12, and 24 months of follow-up after ICM implantation. Patient characteristics, laboratory data, atrial cardiomyopathy markers, serial magnetic resonance imaging findings at baseline, 6, 12, and 24 months after ICM implantation, electrocardiogram readings, transesophageal echocardiography findings, cognitive status, stroke recurrence, and functional outcomes will be compared between patients with AF and patients without AF. Furthermore, we will obtain additional information regarding the number of AF episodes, duration of cumulative AF episodes, and time of anticoagulation initiation.

RESULTS

Study recruitment began in February 2020, and thus far, 213 patients have provided written informed consent and are currently in the follow-up phase. The last recruited participant (May 2021) will have completed the 24-month follow-up in May 2023. The main results are expected to be submitted for publication in 2023.

CONCLUSIONS

The findings of this study will help identify AF markers and generate a risk scoring system with a novel and superior screening algorithm for occult AF detection while identifying candidates for ICM implantation and aiding the development of diagnostic criteria for CS in Japan.

TRIAL REGISTRATION

UMIN Clinical Trial Registry UMIN000039809; https://tinyurl.com/3jaewe6a.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/39307.

Ultrasound diagnosis of carotid artery stenosis and occlusion

Carotid artery ultrasonography is capable of diagnosing or inferring the presence or absence of stenosis or occlusion of the internal carotid artery (ICA) and vertebral artery (VA), as well as the not directly observable distal ICA, middle cerebral artery (MCA), and basilar artery (BA). Stenosis at the origin of the ICA is mainly evaluated using the parameter peak systolic velocity (PSV), with values of ≥ 200-230 cm/s indicating severe stenosis. Recently, the acceleration time ratio has been reported for diagnosis of ICA origin stenosis. An indicator called the end-diastolic (ED) ratio can be used for diagnosing occlusion of the distal ICA or the M1 segment of the MCA. The PSV of stenosis can be used to diagnose stenosis at the beginning of the VA or V1, and mean flow velocity, mean ratio, and diameter ratio can be used to diagnose distal VA occlusion. Furthermore, the usefulness of the VA pulsatility index and resistance index has been suggested for diagnosing stenosis or occlusion of the BA. This review outlines diagnostic sonography criteria for stenosis and occlusion of extracranial and intracranial arteries.

Evaluating the Potential Pathology and Short-Term Outcomes of Cryptogenic Stroke Using the Etiological Classification System

AIM

Various embolic sources and pathogenetic mechanisms underlie cryptogenic stroke (CS). We investigated the association of etiological diversity with short-term outcomes in patients with CS using a modified atherosclerosis (A), small-vessel disease (S), cardiac pathology (C), other causes (O), and dissection (D) (ASCOD) system.

METHODS

Patients with CS who underwent transesophageal echocardiography were registered in this multicenter, observational study. In the modified classification system, O and D were inapplicable and thus excluded. Instead, atherosclerosis, small-vessel disease, cardiac pathology-CS classification was specifically constructed for the etiological diagnosis of CS. We utilized this system to explore the mechanism of CS by grading each pathology and evaluated its association with poorer modified Rankin Scale scores of 3-6 at hospital discharge.

RESULTS

A total of 672 patients (68.7±12.8 years, 220 females) were analyzed. In the multiple logistic regression model, female sex (odds ratio [OR], 1.87 [1.15-3.04]; P=0.012), body mass index (OR, 0.93 [0.88-0.99]; P=0.025), National Institute of Health Stroke Scale score (OR, 1.16 [1.12-1.21]; P＜0.001), CHADS2 score (OR, 1.56 [1.30-1.86]; P＜0.001), D-dimer (OR, 1.04 [1.01-1.08]; P=0.015), diffusion-weighted image (DWI) lesion size (OR, 1.44 [1.10-1.89]; P=0.009), and S＋C score (OR, 1.26 [1.03-1.56]; P=0.029) were associated with poor functional outcome at discharge whereas the S＋C score was marginally associated with poor functional outcome after excluding 137 patients with a premorbid modified Rankin Scale score of ≥ 3.

CONCLUSIONS

The coexistence of small-vessel disease and cardiac pathology might be associated with poor in-hospital functional outcome in CS.

Distinction in Prevalence of Atherosclerotic Embolic Sources in Cryptogenic Stroke With Cancer Status

Background

Cerebrovascular diseases are common comorbidities in patients with cancer. Although active cancer causes ischemic stroke by multiple pathological conditions, including thromboembolism attributable to Trousseau syndrome, the relationship between stroke and inactive cancer is poorly known. The aim of this study was to elucidate the different underlying pathogeneses of cryptogenic stroke in active and inactive patients with cancer, with detailed investigation by transesophageal echocardiography.

Methods and Results

CHALLENGE ESUS/CS (Mechanisms of Embolic Stroke Clarified by Transesophageal Echocardiography for Embolic Stroke of Undetermined Source/Cryptogenic Stroke) registry is a multicenter registry including data of patients initially diagnosed as having cryptogenic stroke and undergoing transesophageal echocardiography. Patients were divided into active cancer, inactive cancer, and noncancer groups, and their clinical features were compared. Of the total 667 enrolled patients (age, 68.7±12.8 years; 455 men), 41 (6.1%) had active cancer, and 51 (7.5%) had a history of inactive cancer. On multinomial logistic regression analysis, infarctions in multiple vascular territories (odds ratio [OR], 2.73; 95% CI, 1.39–5.40) and CRP (C‐reactive protein) (OR, 1.10; 95% CI, 1.01–1.19) were independently associated with active cancer, whereas age (OR, 1.05; 95% CI, 1.01–1.08), contralateral carotid stenosis from the index stroke lesion (OR, 4.05; 95% CI, 1.60–10.27), calcification of the aortic valve (OR, 2.10; 95% CI, 1.09–4.05), and complicated lesion of the aortic arch (OR, 2.13; 95% CI, 1.11–4.10) were significantly associated with inactive cancer.

Conclusions

Patients with cancer were not rare in cryptogenic stroke. Although patients with active cancer had more multiple infarctions, patients with inactive cancer had more atherosclerotic embolic sources potentially causing arteriogenic strokes.

Registration

URL: https://www.umin.ac.jp/ctr/; Unique identifier: UMIN000032957.

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

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.

[Bilateral Medial Medulla Infarction Mimicking Guillain-Barré Syndrome and its Variants]

A 70-year-old man presented with dizziness and unsteadiness when standing and was hospitalized in another hospital. Magnetic resonance imaging (MRI) of the brain on Day 1 showed no abnormalities. The patient developed respiratory failure on Day 1and flaccid tetraplegia on Day 3, and was transferred to our hospital. Progressive upper and lower limb weakness and bulbar symptoms suggested Guillain-Barré syndrome or its variant. Diffusion-weighted MRI on Day 6 disclosed high signal intensities in the bilateral medial portion of the medulla, and the patient was diagnosed with bilateral medial medulla infarction. Bilateral medial medulla infarction should be considered when a patient shows progressive tetraplegia, and bulbar palsy and follow-up MRI is important to confirm the diagnosis. (Received January 23, 2020; Accepted April 21, 2020; Published August 1, 2020).

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

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.

Relationship between brachial flow-mediated dilation and carotid intima-media thickness in patients with coronary artery disease

BACKGROUND

Although flow-mediated vasodilation (FMD) of brachial artery and carotid intima-media thickness (IMT) are important surrogate markers in the process of atherosclerosis, information about relationship between both markers is insufficient. In the present study, we assessed extensively the relationship in patients with coronary artery disease (CAD).

METHODS

The values of brachial FMD and carotid ultrasonography findings in 159 patients (67±8 years, 130 males) with angiographically verified CAD were retrospectively analyzed.

RESULTS

In all patients, mean carotid IMT tended to be correlated with FMD, although the correlation was not statistically significant (R=-0.149, P=0.061). Maximum IMT was not correlated with the FMD (R=0.053, P=0.508). In addition, carotid artery diameter was significantly correlated with the FMD (R=0.290, P=0.0002). Prevalence of high IMT value (≥1.0 mm) was higher in the abnormal FMD group (4%>; N.=67), compared with the normal FMD group (≥7%; N.=24; P<0.05). Carotid artery diameter was larger in abnormal FMD group, compared with both groups of normal FMD (P<0.01) and borderline FMD (4-7%; N.=68) (P<0.01). In all patients, receiver operating characteristics analysis demonstrated that cut-off value of FMD to predict the prevalence of ischemic stroke was 3.7% (AUC=0.735, P<0.001). The cut-off value of maximum IMT was 1.9 mm, but was not significant (AUC=0.522, P=0.829).

CONCLUSIONS

Brachial FMD and carotid IMT would be different in clinical significance as a surrogate marker for pathophysiology of atherosclerotic disease.

Underlying embolic and pathologic differentiation by cerebral microbleeds in cryptogenic stroke

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.

Suitable methods of measuring acceleration time in the diagnosis of internal carotid artery stenosis

Purpose

To enhance the utility of acceleration time (AcT) in the diagnosis of internal carotid artery (ICA) stenosis, we assessed the value of AcT measurements with different waveform patterns.

Methods

Ninety-three patients with acute atherothrombotic cerebral infarction were enrolled, and they underwent both carotid ultrasonography and digital subtraction angiography (DSA). AcT was determined by a conventional procedure (using the first peak point or the bending point) and the peak systolic velocity (PSV) procedure. The AcT ratio was calculated as (AcT of ICA)/(AcT of the ipsilateral common carotid artery). We evaluated the correlation of stenosis rate as assessed by the North American Symptomatic Carotid Endarterectomy Trial method using DSA (DSA-NASCET) with the AcT of ICA (ICA-AcT), the AcT ratio measured by the conventional procedure (conventional AcT ratio), and the AcT ratio measured by the PSV procedure (PSV AcT ratio). The area under receiver operating characteristic curves (AUC) for DSA-NASCET was calculated based on the ICA-AcT and AcT ratio.

Results

Forty-five vessels had 50% or greater ICA stenosis. DSA-NASCET was positively correlated with the conventional AcT ratio (r = 0.723), conventional ICA-AcT (r = 0.638), and PSV AcT ratio (r = 0.245). The corresponding AUCs for ICA stenosis ≥ 50% were 0.971, 0.886, and 0.572, respectively.

Conclusion

We demonstrated the usefulness of the conventional procedure for diagnosing stenosis of ICA origin using AcT and showed that the AcT ratio was a more beneficial parameter than AcT.

Sudden onset of sleep caused by hypothalamic infarction: a case report

Background

Hypothalamic lesions, such as tumors and demyelinating diseases, reportedly cause abnormal sleepiness. However, stroke involving the hypothalamus has rarely been described. Here, we report a patient with infarction restricted to the hypothalamus who presented with sudden onset of sleep.

Case presentation

A 42-year-old woman with a history of migraine without aura presented with irresistible sleepiness and developed several episodes of sudden onset of sleep. Neurological examinations were unremarkable except for partial left Horner syndrome. Brain magnetic resonance imaging (MRI) revealed a high-intensity lesion restricted to the left hypothalamus on diffusion-weighted and fluid-attenuated inversion recovery MRI images. Cerebrospinal fluid (CSF) orexin-A levels obtained on hospital day 3 after her sleepiness had resolved were normal (337 pg/mL; normal > 200 pg/mL). Serum anti-nuclear and anti-aquaporin 4 (AQP4) antibodies and CSF myelin basic protein and oligoclonal band were negative. A small hypothalamic infarction was suspected, and the patient was treated with intravenous edaravone and argatroban, as well as oral clopidogrel. Three months later, there had been no clinical relapse, and the hypothalamic lesion had almost disappeared on follow-up MRI. No new lesion suggestive of demyelinating disease or tumor was observed.

Conclusion

Hypothalamic stroke should be considered a cause of sudden onset of sleep.

Abstract TP368: Development of the Close the Gap-stroke in the J-aspect Study: A Nationwide Quality Improvement Initiative of Japan

Background: Improving the quality of stroke care is an urgent issue worldwide. To facilitate the measurement of quality of stroke care in Japan, we aimed to develop the Close The Gap-Stroke initiative in the J-ASPECT Study.

Methods and Results: Quality indicators (QIs) were developed by a multidisciplinary board between 2015 and 2017. The process involved a systematic review of domestic and international studies related to primary and comprehensive stroke care. Adherence rates for the defined QIs were calculated for 8,826 patients with acute ischemic stroke from 227 hospitals between 2013 to 2015. Seventeen and 12 measures were identified as QIs for primary and comprehensive stroke care (PSC and CSC), respectively. We analyzed adherence rates of all 17 QIs for PSC and 8 QIs for CSC related with acute ischemic stroke. We found NIHSS documentation (91.0 %), CT/MRI performed within 25min and 24hr (80.9 % and 99.1 %), evaluation of extracranial vascular imaging (90.4 %), treated in stroke unit (57.4 %), tPA administration (89.5 %), tPA performed within 1hr (37.4 %), early and discharge antithrombotics medication (75.1 % and 49.0 %), discharge anticoagulation for atrial fibrillation patients (76.2 %), discharge statin medication (32.7 %), discharge antihypertensive agents (54.3 %), deep vein thrombosis prophylaxis (34.5 %), early rehabilitation (57.0 %), dysphagia screening (76.6 %), smoking cessation (59.8 %) and stroke education (71.4 %) for primary stroke care; and median time to multimodal CT or MR brain and vascular imaging (33 min), proper endovascular recanalization (81.7 %), tPA before endovascular recanalization (65.7 %), TICI grade 2b/3 after endovascular recanalization (73.0 %), median time of door to puncture (105 min), symptomatic intracranial hemorrhage after thrombolytic or endovascular therapy (7.45 %), 90 days mRS documentation after thrombolytic or endovascular therapy (60.8 %), occurrence of complication within 24 hours of diagnostic neuroangiography (7.27 %) for comprehensive stroke care.

Conclusion: This is a promising first step to measure the QIs related to primary and comprehensive stroke care at a national level in Japan.

Evaluation of the effects of dapagliflozin, a sodium-glucose co-transporter-2 inhibitor, on hepatic steatosis and fibrosis using transient elastography in patients with type 2 diabetes and non-alcoholic fatty liver disease

AIMS

To investigate the effects of dapagliflozin on liver steatosis and fibrosis evaluated in patients with type 2 diabetes and non-alcoholic fatty liver disease (NAFLD).

MATERIALS AND METHODS

In a randomized, active-controlled, open-label trial, 57 patients with type 2 diabetes and NAFLD were randomized to a dapagliflozin group (5 mg/d; n = 33) or a control group (n = 24) and were treated for 24 weeks. Hepatic steatosis and fibrosis were assessed using transient elastography to measure controlled attenuation parameter (CAP) and liver stiffness, respectively.

RESULTS

Baseline liver stiffness measurement (LSM) was positively correlated with several markers and scoring systems for liver fibrosis. In week 24, there was a significant decrease in CAP from 314 ± 61 to 290 ± 73 dB/m (P = 0.0424) in the dapagliflozin group, while there was no significant change in the control group. In addition, LSM tended to decrease from 9.49 ± 6.05 to 8.01 ± 5.78 kPa in the dapagliflozin group. In 14 patients from this group with LSM values ≥8.0 kPa, indicating significant liver fibrosis, LSM decreased significantly from 14.7 ± 5.7 to 11.0 ± 7.3 kPa (P = 0.0158). Furthermore, serum alanine aminotransferase and γ-glutamyltranspeptidase levels decreased in the dapagliflozin group, but not in the control group, and visceral fat mass was significantly reduced in the dapagliflozin group.

CONCLUSIONS

Based on these findings, the sodium-glucose co-transporter-2 inhibitor dapagliflozin improves liver steatosis in patients with type 2 diabetes and NAFLD, and attenuates liver fibrosis only in patients with significant liver fibrosis, although the possibility cannot be excluded that a reduction in body weight or visceral adipose tissue by dapagliflozin may be associated with a decrease of liver steatosis or fibrosis.

[Triptan-responsive migraine-like headache caused by cavernous sinus dural arteriovenous fistula in a 69-year-old woman with a history of migraine without aura]

A 69-year-old woman with a previous history of migraine without aura developed throbbing headache in the right frontal region accompanied by nausea, lasting more than 4 hours a day. The headache intensity was more severe than that of usual her migraine headaches. Administration of eletriptan in the previous hospital improved her headaches. However, one month later the patient experienced more intense headaches in the same region and then was referred to our hospital. MR angiography showed abnormal signal intensities in the cavernous sinus. Cerebral angiography revealed blood reflux to the cavernous sinus, leading to diagnosis of cavernous sinus dural arteriovenous fistula. Transvenous embolization of cavernous sinus dural arteriovenous fistula was performed, which resulted in resolution of the patient's headache. We should be aware that patients with cavernous sinus dural arteriovenous fistula can manifest migraine-like headaches without being accompanied by cranial nerve palsies.

Conjugate eye deviation due to pontine infarction: Report of 2 cases

•We report 2 patients with pontine infarcts showing transient conjugate eye deviation.•Conjugate eye deviation resolved within a few days in both patients.•Small restricted dorsomedial pontine lesions can produce conjugate eye deviation.

Spreading Awareness of Stroke through School-Based Education: A Pooled Analysis of Three Community-Based Studies

BACKGROUND

Advancing school-based education is a promising means to spread knowledge pertaining to stroke. The aim of the current study was to clarify whether stroke lessons provided by schoolteachers could deliver stroke knowledge to children (aged 9-11 years) and their parents, at a similar level to when taught by medical staff.

METHODS

Schoolteachers conducted lessons on stroke for school children using the educational materials we prepared (i.e., the teacher group; 1051 children and 719 parents). This was compared with our previous data from Akashi city and Tochigi prefecture, in which the stroke lessons were conducted by medical staff (i.e., the medical group; 1031 children and 756 parents). Three campaigns were conducted between September 2014 and May 2016. Each child was given education materials to take home to discuss stroke with their parents. The children and their parents answered questionnaires on stroke knowledge, at baseline, immediately after the lesson, and at 3 months after the lesson.

RESULTS

Compared with the time point before the lesson, both children and parents instructed by the teacher group showed significant increases in the scores about stroke symptoms and risk factors, immediately and at 3 months after the lesson (P < .001). The combined analysis for the group instructed by medical personnel showed no significant differences in the stroke knowledge scores between the 2 groups at 3 months.

CONCLUSIONS

Teacher-led lessons, using our educational material, adequately delivered knowledge of stroke to children and parents, in a manner that was similar to when medical staff delivered this information.

Usefulness of acceleration time ratio in diagnosis of internal carotid artery origin stenosis

Purpose

The acceleration time (AcT) ratio of the internal carotid artery (ICA) is increased in ICA stenosis. However, there are few reports that have directly compared the AcT ratio to digital subtraction angiography (DSA) findings.

Methods

We evaluated 177 vessels with DSA and carotid artery ultrasonography. The AcT ratio was calculated as AcT of the ICA (ICA–AcT)/AcT of the ipsilateral common carotid artery (CCA). We evaluated the correlation of DSA–NASCET stenosis with the origin of the ICA or the peak systolic velocity (ICApsv) in the stenotic region, ICApsv/peak systolic velocity of the CCA (CCApsv), ICA–AcT, and AcT ratio. Sensitivity and specificity for stenosis ≥ 70% were calculated based on the ICApsv, ICApsv/CCApsv, ICA–AcT, and AcT ratio.

Results

Using NASCET criteria, 34 vessels had 70% or greater stenosis. DSA–NASCET showed a significant positive correlation with ICApsv, ICApsv/CCApsv, ICA–AcT, and AcT ratio (p < 0.0001). When the cut-off value for ICApsv was set at 176 cm/s, ICApsv/CCApsv at 2.42, ICA–AcT at 0.095 s, and the AcT ratio at 1.35, the sensitivity was 97.1, 97.1, 82.4, and 97.1%, and the specificity was 94.4, 91.0, 83.2, and 83.2%, for DSA–NASCET ≥ 70%, respectively.

Conclusion

The AcT ratio is a beneficial parameter for evaluating ICA stenosis as well as ICApsv and ICApsv/CCApsv.

Effects of a school-based stroke education program on stroke-related knowledge and behaviour modification-school class based intervention study for elementary school students and parental guardians in a Japanese rural area

OBJECTIVES

This study aimed to determine the effect of a stroke education programme on elementary school students and their parental guardians in a rural area in Japan that has high stroke mortality.

DESIGN

School class based intervention study.

SETTING

Eleven public elementary schools in Tochigi Prefecture, Japan.

PARTICIPANTS

268 students aged 11-12 years and 267 parental guardians.

INTERVENTIONS

Students received lessons about stroke featuring animated cartoons and were instructed to communicate their knowledge about stroke to their parental guardians using material (comic books) distributed in the lessons. Stroke knowledge (symptoms, risk factors and attitude towards stroke) and behavioural change for risk factors were assessed at baseline, immediately after the programme and at 3 months. We also evaluated behavioural change for risk factors among parental guardians.

RESULTS

The percentage of students with all correct answers for stroke symptoms, risk factors and the recommended response to stroke was significantly increased at 3 months P<0.001). We observed a significant increase in the percentage of guardians who chose all correct symptoms (P<0.001: 61.0% vs 85.4%) and risk factors (P<0.001: 41.2% vs 59.9%) at 3 months compared with baseline. The percentage of parental guardians with a high behavioural response to improving risk factors was significantly increased at 3 months compared with baseline (P<0.001).

CONCLUSIONS

In a rural population with high stroke mortality, stroke education can improve knowledge about stroke in elementary school students and their parental guardians.

ETHICS AND DISSEMINATION

We conducted the intervention as a part of compulsory education; this study was not a clinical trial. This study was approved by the Ethics Committee of the National Cerebral and Cardiovascular Center (M27-026).

Increased maximum common carotid intima-media thickness is associated with smoking and hypertension in Tochigi Prefecture residents

OBJECTIVE

We investigated maximum intima-media thickness of the common carotid artery (IMT-C_max) in residents of Tochigi Prefecture, who have been reported to have high stroke mortality.

METHOD

Our study included 840 individuals. All participants underwent carotid ultrasonography and answered a questionnaire during participation in a health festival in Tochigi Prefecture. The questionnaire was designed to collect information on age, gender, and risk factors for stroke. IMT-C_max was measured. Statistical analyses were performed to identify factors contributing to IMT-C_max values ≥1.1 mm.

RESULTS

In total, 117 subjects had an IMT-C_max value ≥1.1 mm. IMT-C_max correlated significantly with age, current smoking, hypertension, diabetes mellitus, heart disease, and previous symptomatic stroke (p < 0.05) in univariate analysis. Current smoking (p < 0.001, odds ratio 3.88) and hypertension (p = 0.0070, odds ratio 1.83) were seen as significant contributing factors to IMT-C_max ≥1.1 mm in logistic regression analysis adjusted by age, gender, and previous symptomatic stroke.

CONCLUSION

We identified current smoking and hypertension as the most significant contributing factors to increased IMT-C_max in residents of Tochigi Prefecture, emphasizing the importance of routine blood pressure monitoring and anti-smoking education in this population.

The relationship between right-to-left shunt and brain white matter lesions in Japanese patients with migraine: a single center study

BACKGROUND

There may be a link between right-to-left shunt (RLs) and brain white matter lesions (WMLs) in patients with migraine. In this study, we assessed the relationship between WMLs and RLs in Japanese migraine patients.

METHODS

A total of 107 consecutive patients with migraine with (MA) and without aura (MWOA) were included in this study. Contrast transcranial Doppler ultrasound was used to detect RLs. WMLs were graded using brain magnetic resonance imaging based on well-established criteria.

FINDINGS

The prevalence of RLs was significantly increased in the WMLs positive group (n = 24) compared with the WMLs negative group (n = 83) (75.0% vs. 47.0%, p = 0.015). In prevalence of WMLs between MA and MWOA patients, there were no statistical differences (p = 0.410). Logistic regression analysis adjusted by age and disease duration of migraine identified an RLs-positive status as the sole determinant for the presence of WMLs (OR = 6.15; 95% CI 1.82-20.8; p = 0.003) CONCLUSION: Our study suggests a possible link between RLs and WMLs in Japanese patients with migraine.

Prevalence of Right to Left Shunts in Japanese Patients with Migraine: A Single-center Study

Objective Several studies have shown an increased prevalence of right-to-left shunt (RLs) in migraine patients, particularly those with aura. However, the prevalence of RLs and its relation to Japanese patients with migraine are unknown. We investigated the prevalence of RLs in Japanese patients with migraine. Methods In total, 112 consecutive patients with migraine were recruited from our headache outpatient clinic. Migraine with aura (MA) and migraine without aura (MWOA) were diagnosed according to the International Classification of Headache Disorders, 3rd edition (beta-version). Contrast transcranial Doppler ultrasound was used to detect RLs, including patent foramen ovale (PFO). Then, the associations between RLs and patients' backgrounds and presence of aura were assessed. Results The overall prevalence of RLs and PFO in migraine patients was 54.5% and 43.8%, respectively. The prevalence of RLs and PFO in the MA group were significantly higher than in the MWOA group (RLs, 62.9% vs. 44.0%, p=0.046; PFO, 54.8% vs. 30.0%, p=0.008). There were no marked differences in the prevalence of large, middle and small shunts between MA and MWOA patients. Compared with the MWOA patients, the MA patients were younger (p=0.013) and had early onset age (p=0.013) and increased prevalence of photophobia (p=0.008). Conclusion RLs were found in over half of the Japanese patients with migraine. Our study suggests a possible link between RLs and MA.

An elderly man with progressive ataxia and palatal tremor presenting with dizziness and oculopalatal tremor

A 74-year-old man was referred to our department for dizziness and progressive unsteady gait over 6 years. His family history was unremarkable. Neurological examination showed dysarthria, saccadic eye movement, palatal tremor (1.7 Hz)-synchronous with rotational ocular movement, and truncal ataxia. T2-weighted magnetic resonance imaging (MRI) of the brain revealed hyperintense and hypertrophic bilateral inferior olivary nuclei at the medulla and mild cerebellar atrophy. On the basis of neurological findings of oculopalatal tremor and cerebellar ataxia with brain MRI findings, the diagnosis of progressive ataxia and palatal tremor (PAPT) was made. PAPT should be included in differential diagnosis of dizziness observed in elderly individuals.

Vertebral artery Doppler waveform patterns for exclusive diagnosis of basilar artery stenosis and occlusion

PURPOSE

The aim of this study was to evaluate the usefulness of vertebral artery (VA) pulsed Doppler waveform changes in excluding basilar artery (BA) stenosis/occlusion.

METHODS

One-hundred and twenty-two patients with time-averaged peak flow velocity (MV) of bilateral VAs <18 cm/s, measured by carotid ultrasonography, were included. The pulsatility index (PI) and resistive index (RI) of both VAs were measured. The maximum PI (Max PI) and maximum RI (Max RI) were used for analysis, respectively. BA stenosis/occlusion and fetal-type posterior cerebral artery (f-PCA) were evaluated using MR angiography.

RESULTS

Thirty-six patients had BA stenosis/occlusion. Acute infratentorial cerebral infarction (CI), f-PCA, Max PI, and Max RI were significantly higher in patients with BA stenosis/occlusion. Multiple logistic regression analysis revealed that "Max PI ≥2.00 or Max RI ≥0.82" had an odds ratio of 3.75 (95% CI 1.43-9.84) for diagnosing BA stenosis/occlusion, but the positive predictive value (PPV) was low (42.2%) and negative predictive value (NPV) was high (84.5%). Similarly, "Max PI ≥2.00 and Max RI ≥0.82" had an odds ratio of 2.96 (95% CI 1.18-7.39); PPV was low (44.9%) and NPV was high (80.8%).

CONCLUSION

Among the subjects with bilateral VA-MV <18 cm/s, PI and RI could contribute to excluding BA stenosis/occlusion.

Stereoscopic images of breast tumors using 3D real-time tissue elastography

PURPOSE

This study aimed at evaluating the usefulness of 3D real-time tissue elastography (RTE) images for diagnosing breast tumors.

METHODS

A total of 166 breast tumor patients who underwent conventional ultrasound and 2D and 3D RTE examinations were retrospectively analyzed. The 3D RTE images were divided into three types according to the occupancy of blue contrast images. Elastic scores (ES) were obtained by 2D RTE examination. The diagnostic accuracy of 3D and 2D RTE images in differentiating malignant from benign breast tumors was evaluated.

RESULTS

Of all cases, 89.4 % of the malignant cases were Type 3 and 86.6 % of the benign cases were Type 1 or 2 according to 3D RTE images. 3D RTE Type 3 and ES ≥ 4 on 2D RTE examination diagnosed malignant tumors with an accuracy of 87.4 and 88.6 %, respectively. In addition, among 34 patients with an ES of 3, the presence of 3D RTE Type 3 diagnosed malignant tumors with an accuracy of 82.4 %.

CONCLUSION

In this study, the utility of 3D RTE images was comparable to that of ES on 2D RTE examination in differentiating malignant from benign breast tumors. In addition, utilizing 3D RTE images in cases with an ES of 3 on 2D RTE may increase the diagnostic accuracy for breast tumors.

Recurrent juvenile ischemic stroke caused by bow hunter's stroke revealed by carotid duplex ultrasonography

Bow hunter's stroke (BHS) is a rare cause of vertebrobasilar insufficiency due to rotational vertebral artery (VA) occlusion associated with head turning. We report a juvenile patient presenting with recurrent ischemic stroke caused by BHS, which was revealed by carotid duplex ultrasonography. Carotid duplex ultrasonography performed in the neutral position showed normal findings. However, disappearance of end-diastolic blood flow of contralateral VAs was observed with head rotation. Digital subtraction angiography confirmed occlusion at C1/2 levels in the VA contralateral to the head rotation, bilaterally. Importantly, our patient did not recognize the association of head rotation and previous episodes of stroke. We suggest that BHS should be considered in patients with cryptogenic stroke occurring in the vertebrobasilar artery territory.

Effects of Stroke Education of Junior High School Students on Stroke Knowledge of Their Parents

Background and purpose—

Educating the youth about stroke is a promising approach for spreading stroke knowledge. The aim of this study was to verify communication of stroke knowledge to parents by educating junior high school students about stroke.

Methods—

We enrolled 1127 junior high school students (age, 13–15 years) and their parents in the Tochigi prefecture, Japan. All students received a stroke lesson, watched an animated cartoon, and read the related Manga comic as educational aids. The students took back home the Manga and discussed what they learned with their parents. Questionnaires on stroke knowledge were given to all at baseline and immediately after the lesson.

Results—

A total of 1125 students and 915 parents answered the questionnaires. In the students, the frequency of correct answers increased significantly for all questions on stroke symptoms except for headache, and for all questions on risk factors after the lesson. In the parents, the correct answer rates increased for stroke symptoms except for headache and numbness in one side of the body, and for all questions on risk factors except for hypertension. Ninety-one percent of students and 92.7% of parents correctly understood the Face, Arm, Speech, and Time (FAST) mnemonic after the lesson.

Conclusions—

Improvement of stroke knowledge immediately after the stroke lesson was observed in parents as well as their children, which indicated that our teaching materials using the Manga was effective in delivering the stroke knowledge to parents through their children.

Acute hemicerebellitis in a young adult: a case report and literature review

Acute hemicerebellitis, marked by headache with or without cerebellar signs, is a rare clinical entity involving a unilateral cerebellar hemisphere. The pathogenesis of acute hemicerebellitis remains unclear, and the disease rarely occurs in adults. Here, we report an 18-year-old woman who presented with a lack of coordination of the right hand and leg lasting longer than one week, following a pulsatile headache. A neurological examination disclosed ocular dysmetria, right-sided limb ataxia and slight truncal ataxia. Cerebrospinal fluid analysis showed mononuclear pleocytosis. The serology and autoimmune studies were unremarkable. Brain magnetic resonance imaging (MRI) revealed a focal signal change in the right cerebellar hemisphere and vermis. Acute hemicerebellitis was diagnosed, and the patient was treated with intravenous methylprednisolone sodium succinate and acyclovir. Subsequently, the headache resolved, and the cerebellar signs were markedly improved. Twenty days after admission, she became asymptomatic and brain MRI showed resolution of cerebellar hyperintensity on the right side. In conclusion, we identified only 6 additional patients with adult-onset acute hemicerebellitis from previous reports, highlighting the importance of recognizing this rare clinical entity. Its clinical outcome is usually favorable, but in the acute phase, attention should be directed toward clinical symptoms that are suggestive of increased intracranial pressure.

[Lateral medullary infarction presenting with truncal lateropulsion and decreased pain and temperature sensation below T10 sensory level]

A 45-year-old man noted a tendency to fall to the left side on standing following headache and vomiting. Neurological findings were unremarkable except for truncal lateropulsion to the left side. Brain magnetic resonance imaging (MRI) showed a small infarct in the left inferolateral part of medulla. Clinical and imaging findings suggested vertebral artery dissection as the cause of stroke. On hospital day 6, the patient developed decreased pain and temperature sensation in the right side below T10 sensory level and decreased sweating on the left side of the face with miosis of the left pupil. Brain MRI revealed an expanded lesion of the left inferolateral part of medulla. In our patient, the involvement of the spinocerebellar tract and the lateral spinothalamic tract likely contributed to the development of truncal lateropulsion and sensory disturbance below thoracic levels, respectively. Our case is clinically important in understanding a correlation between clinical symptoms and lateral medullary lesions.

Co-occurrence of multiple cerebral infarctions due to hypercoagulability associated with malignancy and meningeal carcinomatosis as the initial manifestation of gastric cancer

Background

Meningeal carcinomatosis and hypercoagulability associated with malignancy are typical late stage complications in cancer patients. The co-occurrence of meningeal carcinomatosis and cerebral infarction related to hypercoagulability associated with malignancy in an individual as the initial manifestation of malignancy has not been previously reported.

Case presentation

Herein, we report the case of an 80-year-old patient who presented with meningeal carcinomatosis and hypercoagulability related to malignancy as the initial manifestation of occult gastric cancer. The patient displayed consciousness disturbance, mild left facial paralysis, and bilateral positive Babinski’s sign. Using brain magnetic resonance imaging, the patient was diagnosed as having acute multiple cerebral infarctions. Cerebrospinal fluid (CSF) cytology showed adenocarcinoma and upper gastrointestinal endoscopy disclosed scirrhous gastric cancer. The patient presented with headache, fever, and meningeal irritation with a subacute course. Tuberculous or fungal meningitis was initially suspected; however, cytological evidence of adenocarcinoma in the CSF led to the diagnosis of meningeal carcinomatosis.

Conclusion

The comorbidity of hypercoagulability associated with malignancy and meningeal carcinomatosis should be considered in a patient presenting with multiple cerebral infarctions, progressive disturbance of consciousness, fever, and meningeal irritation.

Abstract W P356: The Effectiveness of the Stroke Educational Activities for Junior High School Students: The Tochigi Project

Background and Purpose: Bringing stroke lessons into the compulsory education is promising for spreading of stroke knowledge nationwide. We produced stroke teaching materials using the FAST mnemonic. The aim of this study is to verify the effectiveness of a stroke education project using our teaching materials for stroke enlightenment, the Tochigi project.

Methods: The subjects were 10,227 students of the 1 st to 3 rd grade (13-15 y.o.) in 53 public junior high schools in Tochigi prefecture, Japan. They were divided into 2 groups; 1,127 students in 9 schools received a 20-minute stroke lesson by their teachers and then watched our 10-minute animated cartoon and read our comic book for 10 minutes (group [[Unable to Display Character: &#1030;]]). The remaining 9,100 students in 44 schools had no teacher's lesson, but watched the animated cartoon and read the comic book (group II). Questionnaires on stroke knowledge were examined for all the students at baseline and immediately after the intervention.

Results: The numbers of questionnaires collected at immediately after the intervention were 1,125 (99.8%) in the group I, and 9,067 (99.6%) in the group II, respectively. In the group I, frequencies of the correct answers increased for all questionnaires except for headache (68.3 vs. 68.0%, p=0.87) as a symptom after the intervention. In the group II, the correct answer rates decreased for the questions of headache (70.9 vs. 32.5%, P<0.0001) and hemi-sensory disturbance (58.1 vs. 56.5%, P<0.05) and increased significantly for those of the other symptoms after the intervention. The correct answer rates increased significantly for questions except for arrhythmia (47.6 vs. 40.6%, P<0.0001) as risk factors after the intervention. Ninety-one % of students understood correctly the “FAST” mnemonic immediately after the intervention in the group I, being higher than the rate of 76% in the group II (p<0.001).

Conclusion: Our teaching materials of stroke enlightenment would be promising for conducting the FAST message to junior high school students.

Abstract T P145: Physiological Parameters and Radiological Findings of Cerebral Small Vessel Disease

Background and Purpose: Lacunar infarction and intracerebral hemorrhage (ICH) are closely related. Although they are classified as different stroke subtypes, both are associated with cerebral small-vessel disease (CSVD). Previous studies showed a positive correlation of CSVD with physiological parameters such as pulse wave velocity (PWV) or with radiographical findings such as cerebral microbleeds (CMB); however, the role of these parameters remains controversial. Therefore, we assessed whether there is a relationship between stroke subtypes and these potential CSVD-related parameters.

Methods: In a multicenter, prospective study from 8 hospitals, we enrolled 342 patients with a history of cerebral infarction or ICH who underwent both carotid ultrasound and MRI examination between February 2011 and December 2012. Ischemic stroke subtypes were determined based on the Trial of Org 10172 in Acute Stroke Treatment criteria, and patients with small vessel occlusion (SVO) or large artery atherosclerosis (LAA) were included in this study. We evaluated the PWV, ultrasonographic parameters [max-IMT, plaque score, pulsatility index (PI), and the diameter of common carotid artery (CCA)], and MRI findings [periventricular hyperintensity (PVH) and CMB]. The severity of PVH was determined according to the Fazekas classification.

Results: Of 342 patients, 130 (38%) were classified into the LAA group, 64 (19%) into the ICH group, and 148 (43%) into the SVO group. There were no significant differences in the parameters between the SVO and ICH groups; however, the parameters of the SVO or ICH groups were different from those of the LAA group. After adjustment for vascular risk factors, the following parameters in both SVO and ICH groups were significantly different from those in the LAA group: lower plaque score, higher PI of the internal carotid artery (ICA), higher PVH grade, and greater CMB frequency.

Conclusion: The SVO and ICH groups showed alterations in imaging parameters reflecting the underlying pathophysiology of CSVD, including lower plaque score, higher PI of ICA, greater CMB frequency, and higher PVH grade, compared with those of the LAA group.

Abstract W P340: Effects of Stroke Enlightenment on Guardians by Educating Junior High Students: the Tochigi Project

Background and Purpose: School-based interventions of stroke enlightenment are not only beneficial for students but also expected to deliver stroke message effectively to their parents. We produced stroke teaching materials using FAST mnemonic. The aim of this study is to verify the effectiveness of stroke education project (the Tochigi project) for delivering stroke message to their parents through their children, using our teaching materials of stroke enlightenment.

Methods: Subjects were guardians of 1,125 students (13-15 y.o.) in 9 public junior high schools in Tochigi prefecture, Japan. All students received a 20-minute stroke lesson by their teacher using the FAST mnemonic, and then watched a 10-minute animated cartoon and read the comic book. At the close of the lesson, the teacher asked the students to take back the comic book and talk about stroke with their guardians while showing the comic book. Questionnaires on stroke knowledge were examined for all the guardians before and immediately after the conversation about stroke with their children.

Results: There were 915 guardians (81.3%, 94%; parents) participated in the present study. Correct answer rates for the questions of headache (81.1 vs. 72.8%, p<0.0001) and hemi-sensory disturbance (69.3 vs. 72.5%, p=0.14) after the conversation were not improved compared with those before. Frequencies of correct answers increased for the other questionnaires of symptoms and risk factors except hypertension after the conversation. The rate of correct answer for hypertension was high before and after the conversation (91.0 vs. 91.7%). The number of the guardians with correct answer for the meaning of the “FAST” mnemonic was as same as that of students (92.7 vs. 91.0%).

Conclusions: Our teaching materials of stroke enlightenment for junior high school students would be promising means of delivering the stroke message effectively to their guardians.

Acceleration time ratio for the assessment of extracranial internal carotid artery stenosis

PURPOSE

To apply the acceleration time (AcT) ratio as an additional marker for diagnosing internal carotid artery (ICA) stenosis.

METHODS

Carotid artery sonography was performed in 140 patients, and the AcT ratio was calculated as the AcT of the ICA divided by the AcT of the ipsilateral common carotid artery, and compared with diameter stenosis.

RESULTS

There was a significant correlation between diameter stenosis and the AcT ratio. The receiver operating characteristic curve revealed a cutoff level of 1.5, with 90.0 % sensitivity and 93.5 % specificity for stenosis >65 %.

CONCLUSION

Our results indicate that applying the AcT ratio can help in the diagnosis of ICA stenosis.

Relationship between fatty liver disease and intracranial main artery stenosis

OBJECTIVE

The aim of this study was to evaluate the relationship between fatty liver disease (FLD) and cerebrovascular disease.

METHODS

We conducted a cross-sectional study of 76 consecutive healthy subjects who participated in a two-day hospitalized health checkup program. The maximal intima-media thickness (IMT) of the common carotid artery and bifurcation of the carotid artery as well as the plaque score (PS) were evaluated on carotid artery ultrasonography. Fluid attenuated inversion recovery brain MRI was used to determine the presence of asymptomatic cerebral lesions and periventricular hyperintensity. Brain MR angiography was used to evaluate the degree of intracranial main artery stenosis (ICAS). FLD was diagnosed based on the ultrasonographic pattern.

RESULTS

The PS and IMT did not differ between the FLD (n=24) and non-FLD (n=52) groups. There was a tendency toward a higher percentage of multiple lacunar lesions in the non-FLD group than in the FLD group. ICAS was significantly more frequent in subjects in the FLD group than those in the non-FLD group (25.0% vs. 5.8%). A logistic regression analysis revealed that age and FLD were significant determinants of ICAS.

CONCLUSION

Our study findings suggest a significant association between ICAS and FLD.

Effects of smoking on outcomes after acute atherothrombotic stroke in Japanese men

BACKGROUND

The effects of smoking on clinical outcomes following acute stroke remain controversial.

METHODS

We evaluated the influence of smoking on 90-day outcomes after acute atherothrombotic stroke in 292 Japanese men extracted from the database of the Edaravone and Argatroban Stroke Therapy for Acute Ischemic Stroke randomized parallel-group trial that tested the safety and efficacy of edaravone and argatroban therapy in 814 patients in 2004-2008. Smokers were matched with non-smokers of the same age for identical age distribution in the smoker and non-smoker groups. Poor 90-day outcomes (defined as death, Barthel index<60, or modified Rankin score>3) were evaluated using a logistic regression model. Significant variables (P<0.05) in univariate analysis were further evaluated by multivariate logistic regression analysis using a forward-selection method.

RESULTS

Body temperature, age, National Institute of Health Stroke Scale score at admission, systolic blood pressure, and smoking status were selected in the final model. Smokers had significantly increased odds of poor 90-day functional outcomes independent of other statistically significant predictor variables (adjusted odds ratio, 2.28; 95% confidence interval, 1.15-4.55; P=0.019).

CONCLUSIONS

In Japanese men, smoking leads to poor functional outcomes at 3 months after acute atherothrombotic stroke.

Isolated shoulder palsy due to cortical infarction: a case report and literature review of clinicoradiological correlations

Clinicoradiological correlations observed in patients with small cortical infarctions have supported somatotopic representation of different parts of body areas in primary motor cortex. However, isolated shoulder weakness because of infarction in precentral gyrus has rarely been described. We report an 80-year-old woman with isolated shoulder palsy because of cortical ischemic infarction in the base of the left precentral gyrus as confirmed by brain magnetic resonance imaging. In our patient, cardiogenic embolism or Trousseau syndrome associated with lung cancer was considered the cause of ischemic infarction. Physicians should consider small cortical infarction, when a patient complains of sudden onset of shoulder weakness without pain. In line with the previous reports, a responsible cortical lesion in our patient corresponded to motor shoulder area in the motor homunculus reported to be located more medially to the hand area.