Factors Encouraging Internal Medicine Specialists in Japan to Move towards Certification as General Practitioners

In Japan, a new medical specialist system started in 2018 and has established the "Comprehensive Medical Specialist" program. The Japan Medical Agency allows specially-appointed supervisors, such as specialists in particular branches of internal medicine, to transfer to the "general practitioner" program. These specialists are often considered as reserve general practitioners. In April 2016, we conducted a survey of 2,666 randomly selected specialists in 11 societies related to the Japanese Society of Internal Medicine. Of the 404 who responded (15.2% response rate), 142 (35.1%) were "certification-oriented." Logistic regression analysis with the outcome of desire for certification as a general practitioner (yes = 1) showed odds of 2.293 (95% confidence interval: 1.379-3.811) for "cannot take the necessary time to prepare" and 12.417 (95% confidence interval: 2.856-53.986) for "should be eligible to take the exam without leaving my current job." Creating an environment that allows specialists in internal medicine across various specialties to prepare for certification as a general practitioner, while continuing to work in their current positions, would help to increase the number of high-quality general practitioners to supply the need in Japan.

Time-outcome relationship in acute large-vessel occlusion exists across all ages: subanalysis of RESCUE-Japan Registry 2

Early reperfusion after endovascular thrombectomy is associated with an improved outcome in ischemic stroke patients; however, the time dependency in elderly patients remains unclear. We investigated the time–outcome relationships in different age subgroups. Of 2420 patients enrolled in the RESCUE-Japan Registry 2 study, a study based on a prospective registry of stroke patients with acute cerebral large-vessel occlusion at 46 centers, we analyzed the data of 1010 patients with successful reperfusion after endovascular therapy (mTICI of 2b or 3). In 3 age subgroups (< 70, 70 to < 80, and ≥ 80 years), the mRS scores at 90 days were analyzed according to 4 categories of onset-to-reperfusion time (< 180, 180 to < 240, 240 to < 300, and ≥ 300 min). In each age subgroup, the distributions of mRS scores were better with shorter onset-to-reperfusion times. The adjusted common odds ratios for better outcomes per 1-category delay in onset-to-reperfusion time were 0.66 (95% CI 0.55–0.80) in ages < 70 years, 0.66 (95% CI 0.56–0.79) in ages 70 to < 80 years, and 0.83 (95% CI 0.70–0.98) in ages ≥ 80 years. Early reperfusion was associated with better outcomes across all age subgroups. Achieving early successful reperfusion is important even in elderly patients.

Blood Pressure Level and Variability During Long-Term Prasugrel or Clopidogrel Medication After Stroke: PRASTRO-I

BACKGROUND AND PURPOSE

High blood pressure increases bleeding risk during treatment with antithrombotic medication. The association between blood pressure levels and the risk of recurrent stroke during long-term secondary stroke prevention with thienopyridines (particularly prasugrel) has not been well studied.

METHODS

This was a post hoc analysis of the randomized, double-blind, multicenter PRASTRO-I trial (Comparison of Prasugrel and Clopidogrel in Japanese Patients With Ischemic Stroke-I). Patients with noncardioembolic stroke were randomly assigned (1:1) to receive prasugrel 3.75 mg/day or clopidogrel 75 mg/day for 96 to 104 weeks. Risks of any ischemic or hemorrhagic stroke, combined ischemic events, and combined bleeding events were determined based on the mean level and visit-to-visit variability, including successive variation, of systolic blood pressure (SBP) throughout the observational period. These risks were also compared between quartiles of mean SBP level and successive variation of SBP.

RESULTS

A total of 3747 patients (age 62.1±8.5 years, 797 women), with a median average SBP level during the observational period of 132.5 mm Hg, were studied. All the risks of any stroke (146 events; hazard ratio, 1.318 [95% CI, 1.094-1.583] per 10-mm Hg increase), ischemic stroke (133 events, 1.219 [1.010-1.466]), hemorrhagic stroke (13 events, 3.247 [1.660-6.296]), ischemic events (142 events, 1.219 [1.020-1.466]), and bleeding events (47 events, 1.629 [1.172-2.261]) correlated with increasing mean SBP overall. Similarly, an increased risk of these events correlated with increasing successive variation of SBP (hazard ratio, 3.078 [95% CI, 2.220-4.225] per 10-mm Hg increase; 3.051 [2.179-4.262]; 3.276 [1.172-9.092]; 2.865 [2.042-4.011]; 2.764 [1.524-5.016], respectively). Event rates did not differ between the clopidogrel and prasugrel groups within each quartile of SBP or successive variation of SBP.

CONCLUSIONS

Both high mean SBP level and high visit-to-visit variability in SBP were significantly associated with the risk of recurrent stroke during long-term medication with either prasugrel or clopidogrel after stroke. Control of hypertension would be important regardless of the type of antiplatelet drugs. Registration: URL: https://www.clinicaltrials.jp; Unique identifier: JapicCTI-111582.

Transient ischemic attack without self-awareness of symptoms witnessed by bystanders: analysis of the PROMISE-TIA registry

Background and purpose

A transient ischemic attack (TIA) can occur without self‐awareness of symptoms. We aimed to investigate characteristics of patients with a tissue‐based diagnosis of TIA but having no self‐awareness of their symptoms and whose symptoms were witnessed by bystanders.

Methods

We used data from the multicenter registry of 1414 patients with a clinical diagnosis of TIA. For patients without evidence of ischemic lesions on imaging, clinical characteristics were compared between patients with and without self‐awareness of their TIA symptoms.

Results

Among 896 patients (559 men, median age of 70 years), 59 (6.6%) were unaware of their TIA symptoms, but had those symptoms witnessed by bystanders. Patients without self‐awareness of symptoms were older and more frequently female, and more likely to have previous history of stroke, premorbid disability, and atrial fibrillation, but less likely to have dyslipidemia than those with self‐awareness. Patients without self‐awareness of symptoms arrive at hospitals earlier than those with self‐awareness (P < 0.001). ABCD² score was higher in patients without self‐awareness of symptoms than those with self‐awareness (median 5 vs. 4, P = 0.002). Having no self‐awareness of symptoms was a significant predictor of ischemic stroke within 1 year after adjustment for sex, ABCD² score, and onset to arrival time (hazard ratio = 2.44, 95% confidential interval: 1.10–4.83), but was not significant after further adjustment for arterial stenosis or occlusion.

Conclusions

Patients with a TIA but having no self‐awareness of their symptoms might have higher risk of subsequent ischemic stroke rather than those with self‐awareness, suggesting urgent management is needed even if patients have no self‐awareness of symptoms.

Efficacy and Safety of Prasugrel by Stroke Subtype: A Sub-Analysis of the PRASTRO-I Randomized Controlled Trial

Aims: The efficacy of antiplatelet therapy may vary among different disease subtypes. Prasugrel is generally a more potent, consistent, and fast-acting platelet inhibitor than clopidogrel. This sub-analysis of the phase III comparison of PRAsugrel and clopidogrel in Japanese patients with ischemic STROke (PRASTRO-I) trial aimed to assess the differences in efficacy of these treatments for each stroke subtype.

Methods: In the PRASTRO-I trial, a total of 3,753 patients with ischemic stroke were recruited from 224 centers throughout Japan and randomized (1:1) to prasugrel (3.75 mg/day) or clopidogrel (75 mg/day) for 96 weeks. For the sub-analysis, strokes were classified as large-artery atherosclerosis, small-artery occlusion (lacunar), stroke of other etiology, and stroke of undetermined etiology. The cumulative incidence of primary events (ischemic stroke, myocardial infarction, and death from other vascular cause) and hazard ratios (HRs) were calculated for each subgroup.

Results: For patients with large-artery atherosclerosis, the primary event incidence was 3.8% in the prasugrel group and 4.8% in the clopidogrel group (HR 0.79; 95% confidence interval [CI] 0.45–1.41). For patients with small-artery occlusion, the incidence was 3.3% in the prasugrel group and 3.9% in the clopidogrel group (HR 0.82; 95% CI 0.45–1.50). For patients with stroke of undetermined etiology, the incidence was 4.6% in the prasugrel group and 3.0% in the clopidogrel group (HR 1.56; 95% CI 0.90–2.72). The incidence of bleeding was similar across subtypes.

Conclusions: Although statistical significance was not reached, the efficacy of prasugrel was potentially different between stroke subtypes, warranting further studies.

Clinical Outcome of Patients With Large Vessel Occlusion and Low National Institutes of Health Stroke Scale Scores

Background and Purpose—

The treatment and prognosis of acute large vessel occlusion with mild symptoms have not been sufficiently studied. The present study aimed to investigate the clinical or radiological predictors of clinical outcome in patients with stroke with mild symptoms due to acute large vessel occlusion.

Methods—

Of 2420 patients with acute large vessel occlusion in the RESCUE-Japan Registry 2 (Recovery by Endovascular Salvage for Cerebral Ultra-Acute Embolism-Japan Registry 2), a multicenter prospective registry in Japan, patients with modified Rankin Scale scores of 0 to 2 before onset and initial National Institutes of Health Stroke Scale (NIHSS) scores of 0 to 5 were examined in post hoc analysis. We examined the clinical and radiological characteristics associated with a favorable outcome (modified Rankin Scale score, 0–2 at 90 days) using multivariate analysis, as well as the factors associated with a favorable outcome in patients treated with endovascular therapy.

Results—

We analyzed 272 patients (median age, 73 years; median NIHSS score on admission, 3). Eighty-six (31.6%) patients were treated with intravenous recombinant tissue-type plasminogen activator, 54 (19.9%) underwent endovascular therapy, and 208 (76.5%) showed a favorable outcome. In multivariate analysis, age <75 years (odds ratio [OR], 2.42 [95% CI, 1.30–4.50]), initial NIHSS score 0 to 3 (OR, 3.08 [95% CI, 1.59–5.98]), intravenous recombinant tissue-type plasminogen activator (OR, 2. 86 [95% CI, 1.32–6.21]), and blood glucose level ≤140 mg/dL (OR, 2.37 [95% CI, 1.22–4.60]) were independently associated with a favorable outcome. However, endovascular therapy was not associated with a favorable outcome (OR, 1.65 [95% CI, 0.71–3.88]). Among 54 patients treated with endovascular therapy, good reperfusion status was more common in the favorable outcome group (88.6% versus 60.0%; P <0.05).

Conclusions—

Younger age, lower initial NIHSS score, intravenous recombinant tissue-type plasminogen activator, and absence of hyperglycemia were independently associated with a favorable outcome in patients with acute large vessel occlusion with low NIHSS scores.

Registration—

URL: https://www.clinicaltrials.gov ; Unique identifier: NCT02419794.

Cost-effectiveness of rivaroxaban versus warfarin for stroke prevention in non-valvular atrial fibrillation in the Japanese healthcare setting

Aims: This article aimed to examine the cost-effectiveness of rivaroxaban in comparison to warfarin for stroke prevention in Japanese patients with non-valvular atrial fibrillation (NVAF), from a public healthcare payer's perspective.Materials and methods: Baseline event risks were obtained from the J-ROCKET AF trial and the treatment effect data were taken from a network meta-analysis. The other model inputs were extracted from the literature and official Japanese sources. The outcomes included the number of ischaemic strokes, myocardial infarctions, systemic embolisms and bleedings avoided, life-years, quality-adjusted life-years (QALYs), incremental costs and incremental cost-effectiveness ratio (ICER). The scenario analysis considered treatment effect data from the same network meta-analysis.Results: In comparison with warfarin, rivaroxaban was estimated to avoid 0.284 ischaemic strokes per patient, to increase the number of QALYs by 0.535 per patient and to decrease the total costs by ¥118,892 (€1,011.11) per patient (1 JPY = 0.00850638 EUR; XE.com, 7 October 2019). Consequently, rivaroxaban treatment was found to be dominant compared to warfarin. In the scenario analysis, the ICER of rivaroxaban versus warfarin was ¥2,873,499 (€24,446.42) per QALY.Limitations: The various sources of data used resulted in the heterogeneity of the cost-effectiveness analysis results. Although, rivaroxaban was cost-effective in the majority of cases.Conclusion: Rivaroxaban is cost-effective against warfarin for stroke prevention in Japanese patients with NVAF, giving the payer WTP of 5,000,000 JPY.

Spin structure and spin Hall magnetoresistance of epitaxial thin films of the insulating non-collinear antiferromagnet SmFeO3

We report a combined study of imaging the antiferromagnetic (AFM) spin structure and measuring the spin Hall magnetoresistance (SMR) in epitaxial thin films of the insulating non-collinear antiferromagnet SmFeO₃. X-ray magnetic linear dichroism photoemission electron microscopy measurements reveal that the AFM spins of the SmFeO₃(1 1 0) align in the plane of the film. Angularly dependent magnetoresistance measurements show that SmFeO₃/Ta bilayers exhibit a positive SMR, in contrast to the negative SMR expected in previously studied collinear AFMs. The SMR amplitude increases linearly with increasing external magnetic field at higher magnetic fields, suggesting that field-induced canting of the AFM spins plays an important role. In contrast, around the coercive field, no detectable SMR signal is observed, indicating that the SMR of the AFM and canting magnetization components cancel out. Below 50 K, the SMR amplitude increases sizably by a factor of two as compared to room temperature, which likely correlates with the long-range ordering of the Sm ions. Our results show that the SMR is a sensitive technique for non-equilibrium spin systems of non-collinear AFMs.

Effect of Standard vs Intensive Blood Pressure Control on the Risk of Recurrent Stroke: A Randomized Clinical Trial and Meta-analysis

Importance

The Systolic Blood Pressure Intervention Trial (SPRINT) demonstrated that a systolic blood pressure (BP) target less than 120 mm Hg was superior to less than 140 mm Hg for preventing vascular events. This trial excluded patients with prior stroke; therefore, the ideal BP target for secondary stroke prevention remains unknown.

Objective

To assess whether intensive BP control would achieve fewer recurrent strokes vs standard BP control.

Design, Setting, and Participants

Randomized clinical trial (RCT) of standard vs intensive BP control in an intent-to-treat population of patients who had a history of stroke. Patients were enrolled between October 20, 2010, and December 7, 2016. For an updated meta-analysis, PubMed and the Cochrane Central Library database were searched through September 30, 2018, using the Medical Subject Headings and relevant search terms for cerebrovascular disease and for intensive BP lowering. This was a multicenter trial that included 140 hospitals in Japan; 1514 patients who had a history of stroke within the previous 3 years were approached, but 234 refused to give informed consent.

Interventions

In total, 1280 patients were randomized 1:1 to BP control to less than 140/90 mm Hg (standard treatment) (n = 640) or to less than 120/80 mm Hg (intensive treatment) (n = 640). However, 17 patients never received intervention; therefore, 1263 patients assigned to standard treatment (n = 630) or intensive treatment (n = 633) were analyzed.

Main Outcomes and Measures

The primary outcome was stroke recurrence.

Results

The trial was stopped early. Among 1263 analyzed patients (mean [SD] age, 67.2 [8.8] years; 69.4% male), 1257 of 1263 (99.5%) completed a mean (SD) of 3.9 (1.5) years of follow-up. The mean BP at baseline was 145.4/83.6 mm Hg. Throughout the overall follow-up period, the mean BP was 133.2/77.7 (95% CI, 132.5-133.8/77.1-78.4) mm Hg in the standard group and 126.7/77.4 (95% CI, 125.9-127.2/73.8-75.0) mm Hg in the intensive group. Ninety-one first recurrent strokes occurred. Nonsignificant rate reductions were seen for recurrent stroke in the intensive group compared with the standard group (hazard ratio [HR], 0.73; 95% CI, 0.49-1.11; P = .15). When this finding was pooled in 3 previous relevant RCTs in a meta-analysis, the risk ratio favored intensive BP control (relative risk, 0.78; 95% CI, 0.64-0.96; P = .02; absolute risk difference, -1.5%; 95% CI, -2.6% to -0.4%; number needed to treat, 67; 95% CI, 39-250).

Conclusions and Relevance

Intensive BP lowering tended to reduce stroke recurrence. The updated meta-analysis supports a target BP less than 130/80 mm Hg in secondary stroke prevention.

Trial Registration

ClinicalTrials.gov identifier: NCT01198496.

Cerebral Microbleeds Detected Using 3.0T Magnetic Resonance Imaging in 2,003 Patients with Ischemic or Hemorrhagic Stroke

Introduction:

Compared with 1.5T magnetic resonance imaging (MRI), using 3.0T MRI makes it easier to detect cerebral microbleeds (CMBs). We used 3.0T MRI to investigate the backgrounds, risk factors, and number and location of CMBs in patients with ischemic or hemorrhagic stroke.

Methods:

We extracted data on clinical characteristics, risk factors, and number and location of CMBs in 2,003 patients treated between January 2010 and December 2014 within one week of stroke occurrence. We then carried out multivariate analysis of the data.

Results:

CMBs were present in 1,025 patients. The numbers of CMBs in ischemic stroke and hemorrhagic stroke patients were 9,410 and 6,419, respectively. Patients with CMBs showed significantly higher rates of cognitive impairment (p < 0.001, odds ratio [OR] = 1.514), hypertension (p < 0.001, OR = 3.145), previous history of stroke (p < 0.001, OR = 1.782), and presence of hemorrhagic stroke (p < 0.001, OR = 2.066). The use of antithrombotic medication before the stroke did not affect the incidence of CMBs. In ischemic stroke patients, patients with small vessel occlusion had a significantly greater rate of previous history of hemorrhagic stroke (p = 0.046) and number of patients with CMBs (p < 0.001) than those with cardioembolism.

Conclusions:

CMBs were well observed in patients with small vessel disease, and hypertension was an important factor in ischemic and hemorrhagic stroke. Antithrombotic medication is not associated with the development of CMBs if adequate antihypertensive therapy is provided.

Spontaneous Intracranial Hypotension Associated with Postural Tachycardia Syndrome

Postural tachycardia syndrome (POTS) can cause orthostatic headache. However, it is difficult to differentiate POTS from spontaneous intracranial hypotension (SIH) caused by cerebrospinal fluid (CSF) leaks. We herein report a 53-year-old woman who presented with SIH associated with POTS. A cervicothoracic and lumbar epidural blood patch rapidly improved not only the headache but also the orthostatic tachycardia, suggesting POTS secondary to SIH. This case suggests that a CSF leak can cause secondary POTS. Therefore, POTS should be considered in patients with orthostatic headaches, even in the presence of a CSF leak.

Impact of Endovascular Therapy in Patients With Large Ischemic Core

Background and Purpose—

Endovascular therapy (EVT) is strongly recommended for acute cerebral large vessel occlusion with the Alberta Stroke Program Early CT Score (ASPECTS) ≥6 due to occlusion of the internal carotid artery or M1 segment of the middle cerebral artery. However, the effect of EVT for patients who have ischemic core with ASPECTS ≤5 (0–5) was not established. The purpose of this study was to elucidate the outcomes of EVT for patients with large ischemic core.

Methods—

Based on the data of The Recovery by Endovascular Salvage for Cerebral Ultra-Acute Embolism Japan Registry 2, patients with internal carotid artery or M1 segment of the middle cerebral artery occlusion and pretreatment ASPECTS 0 to 5 on noncontrast CT or diffusion-weighted image were extracted, and the outcomes by EVT were analyzed. Primary end point was defined as a good functional outcome (modified Rankin Scale score of ≤2) after 90 days.

Result—

Among 2420 registered patients, 504 patients were with internal carotid artery or M1 segment of the middle cerebral artery occlusion and ASPECTS 0 to 5. Among these 504 patients, 172 (34.1 %) were treated with EVT (EVT group) and 332 (65.9 %) without (no-EVT group). In the no-EVT group, elderly patients, females, poor prestroke modified Rankin Scale, high National Institutes of Health Stroke Scale, low ASPECTS, and late admission were significantly more observed. Good functional outcomes were significantly more observed in the EVT group than in the no-EVT group (19.8 % versus 4.2 %; P <0.0001; adjusted odds ratio, 2.33; 95% CI, 1.10–4.94). The incidences of symptomatic intracranial hemorrhage within 72 hours did not significantly different between the EVT group and the no-EVT group (3.7 % versus 4.9%; P =0.55; adjusted odds ratio, 0.50; 95% CI, 0.14–1.73).

Conclusions—

Although outcomes in this group of patients were usually poor, the data suggested EVT may increase the likelihood of a good functional outcome.

Small vessel occlusion is a high-risk etiology for early recurrent stroke after transient ischemic attack

Background

Recent prospective registration studies of transient ischemic attack in Western countries demonstrated that large artery atherosclerosis is the highest risk etiology for early stroke recurrence under urgent evaluation and treatment. On the other hand, some limited transient ischemic attack studies from East Asian countries showed transient ischemic attack patients due to small vessel occlusion were at a higher early stroke risk.

Aims

We aimed to assess the risk for early stroke in small vessel occlusion-transient ischemic attack patients in a Japanese large transient ischemic attack registry.

Methods

We analyzed the data of a prospective Japanese transient ischemic attack registry including 1320 transient ischemic attack patients within seven days after onset. Small vessel occlusion-transient ischemic attack was defined as the presence of lacunar transient ischemic attack syndrome, without other etiologies. The outcome measure was recurrent stroke within 30 days after transient ischemic attack. The predictors of 30-day recurrent stroke were estimated using the Cox proportional hazards model.

Results

The study population had a mean age of 69 ± 12 years and 470 were women. Recurrent stroke was observed in 61 patients (4.6%), and the highest rate was observed with small vessel occlusion-transient ischemic attack (7.8%), followed by large artery atherosclerosis (5.4%). In multivariate analysis, recurrent stroke was independently associated with small vessel occlusion-transient ischemic attack (hazard ratio (HR): 2.01, 95% confidence interval (CI): 1.19–3.35), higher systolic blood pressure (HR: 1.18, 95% CI: 1.08–1.28), and presentation within 3 h after onset (HR: 2.21, 95% CI: 1.27–4.04). Furthermore, small vessel occlusion-transient ischemic attack with acute small deep infarct on diffusion-weighted imaging was a stronger predictor of recurrent stroke (HR: 4.87, 95% CI: 2.09–10.0).

Conclusion

Small vessel occlusion-transient ischemic attack, especially with acute small deep infarct, had a higher early stroke risk compared with other etiologies in Japanese transient ischemic attack patients who received early management.

The Exacerbation of Hemicrania Continua Mimics Trigeminal Neuralgia

We report the case of a 46-year-old man with hemicrania continua presenting as exacerbations mimicking trigeminal neuralgia. The patient was tentatively diagnosed with trigeminal neuralgia, and treatment with various combinations of drugs was performed after the onset of pain. However, when the condition of the patient did not improve, we suspected hemicrania continua, and treatment with indomethacin was initiated. There was a marked alleviation of his pain within 24 hours. Thus, clinicians should be aware that the duration and frequency of exacerbations of hemicrania continua are variable.

[Recombinant tissue plasminogen activator therapy for acute ischemic stroke in older patients]

AIM

As the number of aged stroke patients increases in Japan, the proportion of older patients who receive recombinant tissue plasminogen activator (rt-PA, 0.6 mg/kg) is also rising. However, the Japanese stroke guideline indicates that rt-PA therapy must be administered very carefully in older patients (i.e. ≥81 years of age) because of serious complications after the therapy. We retrospectively assessed the clinical outcomes of rt-PA therapy in older patients.

METHODS

This study included 321 patients who received rt-PA therapy for acute cerebral infarction at our hospital between April 2007 and April 2017. The outcomes (modified Rankin Scale [mRS] score at 3 months after treatment) and symptomatic intracerebral hemorrhaging (sICH) were compared and analyzed between patients ≥81 years of age (group A) and those <81 years of age (group B). In addition, propensity score matching was performed for the factors shown to have significant differences by a univariate analysis in order to adjust for confounding factors, and the outcomes were compared.

RESULTS

There were 58 patients in group A (18.1%) and 263 patients in group B (81.9%). The rate of favorable outcomes (mRS 0-1) was lower in group A (12.1%) than in group B (44.1%) (P<0.01). The mortality rate was higher in group A (17.2%) than in group B (4.6%) (P=0.002). No marked differences were observed between the 2 groups regarding the rate of sICH (group A, 3.4%; group B, 3.0%; P=1.00). After propensity score matching, the proportion of patients with favorable outcomes was significantly lower in group A (13.2%) than in group B (36.8%) (P=0.032). There were no marked differences in the mortality rates between the groups (group A, 17.2%; group B, 4.6%) (P=0.200), and no patients in either group had sICH.

CONCLUSION

No marked differences in the incidence of ICH were observed between the older and younger groups receiving intravenous rt-PA therapy. However, in terms of efficacy, the proportion of patients with favorable outcomes was significantly lower in the older group than in the younger group.

Significance of Nonfocal Symptoms in Patients With Transient Ischemic Attack

Background and Purpose- Patients with transient ischemic attack (TIA) occasionally show nonfocal symptoms, such as unconsciousness, amnesia, and unsteadiness. The purpose of this study was to clarify the characteristics and prognosis of patients with TIA with nonfocal symptoms, using data from the PROMISE-TIA (Prospective Multicenter Registry to Identify Subsequent Cardiovascular Events After Transient Ischemic Attack). Methods- Patients with TIA within 7 days of onset were consecutively enrolled in the Japanese nationwide registry. Factors associated with nonfocal symptoms and 1-year risks of ischemic stroke and coronary artery diseases were assessed in multivariate-adjusted models. Results- We studied 1362 patients with TIA (879 men; mean age, 69±12 years), including 219 (16%) with nonfocal symptoms. Patients with TIA with nonfocal symptoms were more likely to show acute ischemic lesions in the posterior circulation on diffusion-weighted imaging (multivariate-adjusted odds ratio, 3.07; 95% confidence interval, 1.57-5.82) and arterial stenosis or occlusion in the posterior circulation on vascular examination (odds ratio, 1.94; 95% confidence interval, 1.19-3.09) than those without nonfocal symptoms. Although 1-year risk of ischemic stroke did not differ significantly between groups (adjusted hazard ratio, 0.79; 95% confidence interval, 0.42-1.37), risk of coronary artery disease was higher in patients with TIA with nonfocal symptoms (hazard ratio, 3.37; 95% confidence interval, 1.14-9.03). Conclusions- Both acute ischemic lesions and arterial stenosis and occlusion in the posterior circulation were more frequently observed in patients with TIA with nonfocal symptoms.

Selection of Oral Anticoagulants in Ischemic Stroke Patients with Nonvalvular Atrial Fibrillation

BACKGROUND

Anticoagulant therapy is indicated for management of ischemic stroke patients with nonvalvular atrial fibrillation. We retrospectively investigated how oral anticoagulants were selected for ischemic stroke patients with nonvalvular atrial fibrillation.

METHODS

This study included 297 stroke patients with nonvalvular atrial fibrillation admitted to our hospital between September 2014 and December 2017, and who were subsequently transferred to other institutions or discharged home. Baseline clinical characteristics were compared between patients prescribed warfarin and those prescribed direct-acting oral anticoagulants.

RESULTS

In total, 280 of 297 (94.3%) patients received oral anticoagulant therapy, including 36 with warfarin, while 244 received direct oral anticoagulants. Age, percentage of heart failure, CHADS₂ score before stroke onset, percentage of treatment with warfarin on admission, percentage of feeding tube at hospital discharge, and modified Rankin Scale at hospital discharge were significantly higher in the warfarin group versus the direct oral anticoagulants group, while creatinine clearance was significantly higher in the direct oral anticoagulant group. By multiple logistic regression, taking warfarin at admission and higher modified Rankin Scale at hospital discharge were associated with warfarin selection, while higher creatinine clearance was associated with direct oral anticoagulant selection (warfarin: odds ratio [OR] 7.10 [95% confidence interval {CI} 2.83-17.81]; modified Rankin Scale at hospital discharge: [OR] 1.47 [95% {CI} 1.06-2.04]; creatinine clearance: [OR] .97 [95% {CI} .95-.99]).

CONCLUSIONS

Selection of oral anticoagulants in acute ischemic stroke patients with nonvalvular atrial fibrillation was influenced by warfarin use at admission, clinical severity at hospital discharge, and renal function.

Cough Headache Presenting with Reversible Cerebral Vasoconstriction Syndrome

Cough headache can be a primary benign condition or secondary to underlying etiologies. We herein describe a case of a 52-year-old woman with cough headache that presented as reversible cerebral vasoconstriction syndrome (RCVS). Some cases of RCVS are caused by an aberrant sympathetic response to activities that cause an intracranial pressure surge. Therefore, cough headache should be recognized as a possible presentation of RCVS, even without thunderclap headache or neurological deficits.

Endovascular Therapy in Ischemic Stroke With Acute Large-Vessel Occlusion: Recovery by Endovascular Salvage for Cerebral Ultra-Acute Embolism Japan Registry 2

BACKGROUND

Endovascular therapy has been shown to be effective in patients with acute cerebral large-vessel occlusion, but real-world efficacies are unknown.

METHODS AND RESULTS

We conducted a prospective registry at 46 centers between October 2014 and January 2017. Eligible patients were those who were aged 20 years or older, with acute cerebral large-vessel occlusion, and who were hospitalized within 24 hours of the onset. We enrolled both consecutive patients who were treated with or without endovascular therapy. Endovascular therapy included thrombectomy, balloon angioplasty, stenting, local fibrinolysis, and piercing. The primary outcome was a favorable outcome as defined by a modified Rankin Scale of 0 to 2 at 90 days after onset. Secondary outcomes were modified Rankin Scale of 0 to 1 and mortality. Safety outcomes were intracerebral hemorrhage or a recurrence of ischemic stroke. We constructed the 2242 (1121 each) propensity score-matched patients cohort based on a propensity score for endovascular therapy and estimated the adjusted odds ratio, followed by sensitivity analyses on original 2399 (1278 in endovascular therapy versus 1121 in no endovascular therapy) patients. In the propensity score-matched cohort, favorable outcomes were observed in 35.3% and 30.7% of patients in the endovascular therapy and no endovascular therapy groups, respectively (P=0.02). The adjusted odds ratio for the favorable outcome was 1.44 (95% confidence interval, 1.10-1.86, P=0.007). The efficacy of endovascular therapy in achieving favorable outcomes did not differ between our subgroups and in the sensitivity analyses.

CONCLUSIONS

Endovascular therapy decreased disabilities at 90 days in real-world patients with acute cerebral large-vessel occlusion.

CLINICAL TRIAL REGISTRATION

URL: http://www.clinicaltrials.gov. Unique identifier: NCT02419794.

RBC Aggregometer head as a Warning Monitor of Flow Disturbance in Extracorporeal Systems

A simple photoelectric apparatus is described, to monitor the flow condition of whole blood in an extracorporeal system. It can raise an immediate alarm on disturbance of flow. The apparatus comprises an RBC aggregometer head, described previously, for measuring the rate of RBC aggregation in whole blood. Its construction was modified for easy attach-ability and detachability without causing tube damage. In practice, the apparatus was applied by hooking it to the tube of the extracorporeal system in animals and in a clinical case of blood dialysis in a patient with renal failure, in which stoppage of blood flow elicited a dramatic change in the baseline record of light transmission of the mobile blood. The signal of the apparatus was fed to an alarm system via a voltage comparator switch. The apparatus is inexpensive, solid and durable, easy to operate by untrained personnel, and has excellent stability and reproducibility.

The Dose of Direct Oral Anticoagulants and Stroke Severity in Patients with Acute Ischemic Stroke and Nonvalvular Atrial Fibrillation

BACKGROUND

The severity and the functional outcome of patients with stroke occurring during off-label underdosing of direct-acting oral anticoagulants (DOACs) remain uncertain.

METHODS

We studied 53 consecutive patients with acute ischemic stroke and nonvalvular atrial fibrillation who were treated with DOACs before the onset of stroke. Thirty patients were treated for primary prevention of stroke and 23 patients were treated for secondary prevention. DOAC treatments were categorized into 3 groups based on the following doses: (1) standard-dose group (n = 17), (2) low-dose group (n = 23), and (3) off-label underdose group (n = 13).

RESULTS

Age was significantly older in the low-dose group than in the standard-dose group (P = .026). The standard-dose group and the low-dose group showed higher CHA₂DS₂-VASc scores (median, 4) compared with the off-label underdose group (median, 3). More than half of the patients had a National Institutes of Health Stroke Scale score of less than 8, and many patients had a good outcome (modified Rankin Scale score ≤1). There were no differences in stroke severity and outcome among the 3 groups. The ratio of being discharged home was the highest in the standard-dose group.

CONCLUSIONS

This study shows that patients who have off-label underdosing of DOACs do not develop more severe stroke and a poorer outcome than those with the recommended dose. Careful attention to recommended doses is required for the full benefits from DOACs.

Abstract TP34: Real World Efficacy of Endovascular Thrombectomy in Patients With Acute Cerebral Large Vessel Occlusion in Japan - First Report From RESCUE-Japan Registry 2

Introduction: Several randomized trials showed the endovascular thrombectomy (EVT) was effective in patients with acute cerebral large vessel occlusion, but the efficacy to general patients were unknown.

Methods: Recovery by Endovascular Salvage for Cerebral Ultra-acute Embolism (RESCUE)-Japan Registry 2 was prospective registry of acute cerebral large vessel occlusion at centers in Japan. The patients were 20 years or elder and admitted within 24 hours after the onset of cerebral large vessel occlusion in both anterior and posterior circulation. Primary endpoint was good outcome defined by modified Rankin Scale (mRS) of 0-2 at 90 days after onset. Secondary endpoint was mortality. Adjusted odds ratio (OR) was estimated by logistic regression model accounted for potential confounders. Safety endpoints were all bleeding included intracerebral hemorrhage, gastrointestinal bleedings, recurrence of stroke, and other adverse events within 90 days.

Results: Consecutive 2420 patients were recruited from October 2014 to September 2016, and follow-up ended at January 2017. Excluding 12 patients who did not meet inclusion criteria, 1281 patients were treated with EVT and 1127 were without. Mean age was 75 and 77 years in EVT and no-EVT groups, respectively. Posterior circulation accounted for 13% in both groups. Intravenous alteplase was administered in 47% and 32% of EVT and no-EVT groups, respectively. Good outcome was observed in 41.7% and 30.7% the EVT group and no-EVT group, respectively (p<0.0001). Adjusted OR of good outcome of EVT relative to no-EVT was 1.79 (95%CI: 1.39-2.29). Prespecified subgroup analyses showed the EVT was effective in anterior circulation [adjusted OR 1.7 (95%CI 1.3-2.2)] while not effective in posterior circulation [adjusted OR 1.3. (95%CI 0.6-3.0)] (interaction p=0.34). The mortality was 8.8% and 13.6% in EVT group and no-EVT group (p=0.0002). Intracerebral bleeding occurred within 72 hours from onset in 26% in EVT group while 19% in no-EVT group (p<0.0001).

Conclusions: EVT was shown effective in general patients with acute cerebral large vessel occlusion in terms of mRS and mortality at 90 days. The indication of EVT for posterior circulation should be reconsidered. <!--EndFragment-->

Bilateral carotid-anterior cerebral artery anastomoses associated with bilateral ophthalmic arteries arising from the anastomotic arteries diagnosed by magnetic resonance angiography: a case report

Rarely, the anterior cerebral artery (ACA) arises from the ophthalmic segment of the internal carotid artery, a condition described as carotid-ACA anastomosis or infraoptic course of the ACA that generally demonstrates right-sided predominance. We diagnosed a case of bilateral anastomoses of the carotid and ACA vessels in which bilateral ophthalmic arteries arose from the origins of the anastomotic vessels using magnetic resonance (MR) angiography. Identification of rare arterial variations on MR angiography requires careful scrutiny of source images, and creation of partial volume-rendering images can aid visualization of detailed anatomic structures.

Clinical Study of Intravenous, Low-Dose Recombinant Tissue Plasminogen Activator for Acute Cerebral Infarction: Comparison of Treatment within 3 Hours versus 3-4.5 Hours

BACKGROUND

An intravenous recombinant tissue plasminogen activator (rt-PA, alteplase .6 mg/kg) for acute cerebral infarction within 3 hours of onset was approved in Japan in 2005. The treatment window was subsequently extended to within 4.5 hours of onset. However, few Japanese studies have compared the efficacy and safety of rt-PA therapy between patients treated within 3 hours and patients treated within 3-4.5 hours.

METHODS

This study included 323 patients who received rt-PA for acute cerebral infarction within 3 hours or 3-4.5 hours between April 2007 and March 2017. Patients' characteristics, outcomes (modified Rankin Scale [mRS] score at 3 months), and symptomatic intracranial hemorrhage (sICH) were retrospectively investigated.

RESULTS

Of the 323 patients, 219 were treated within 3 hours and 104 were treated at 3-4.5 hours. Among patients receiving rt-PA alone, 154 were treated within 3 hours (3-hour group), and 69 were treated at 3-4.5 hours (3-4.5-hour group). There was no difference in the sICH rate (3.9% versus 4.3%, respectively; P = 1.00) or mRS score of 0-1 (38.3% versus 40.6%, respectively; P = .76) between these groups. In patients receiving additional neuroendovascular therapy, 65 were in the 3-hour group and 35 were in the 3-4.5-hour group. There was no significant difference in the sICH rate (1.5% versus 0%, respectively; P = 1.00) or mRS score of 0-1 (30.8% versus 31.4%, respectively; P = 1.00) between these groups.

CONCLUSIONS

Low-dose rt-PA treatment from either 3 or 3-4.5 hours after acute cerebral infarction has the same efficacy and safety.

Naratriptan in the Prophylactic Treatment of Cluster Headache

Objective Naratriptan has been reported to reduce the frequency of cluster headache. The purpose of this study was to determine whether naratriptan is effective as a prophylactic treatment for cluster headache in Japan. Methods We retrospectively reviewed all 43 patients with cluster headache who received preventive treatment with naratriptan from April 2009 to April 2015. The International Classification of Headache Disorders, 3rd Edition (beta version) (ICHD-3 beta) was used to diagnose cluster headache. This study was conducted at 3 centers (Department of Neurology, Saitama Medical University; Saitama Neuropsychiatric Institute; Saitama Medical University International Medical Center). Patients were recruited from these specialized headache outpatient centers. Naratriptan was taken before the patient went to bed. Results The study population included 30 men (69.8%) and 13 women (30.2%). Twenty-two cases received other preventive treatments (51.2%), while 21 cases only received naratriptan (48.8%). Among the 43 cases, 37 patients (86.0%) achieved an improvement of cluster headache on naratriptan. Conclusion Naratriptan has been suggested as a preventive medicine for cluster headache because of the longer the biological half-life in comparison to other triptans. The internal use of naratriptan 2 hours before attacks appears to achieve a good response in patients with cluster headache.

Drip-and-Ship Thrombolytic Therapy for Acute Ischemic Stroke

BACKGROUND

Neuroendovascular therapy is a common treatment for patients with acute ischemic stroke of the anterior circulation who fail to respond to recombinant tissue plasminogen activator. However, although most hospitals can provide recombinant tissue plasminogen activator therapy, many cannot perform neuroendovascular therapy. Thus, use of a drip-and-ship treatment-liaison system allowing recombinant tissue plasminogen activator-treated patients to be transferred to facilities offering neuroendovascular therapy is important.

METHODS

We retrospectively analyzed 16 drip-and-ship patients transferred to our hospital for additional neuroendovascular therapy after they received intravenous recombinant tissue plasminogen activator at prior hospitals between June 2009 and March 2017.

RESULTS

The mean patient age was 68 ± 17 years. Ten patients had cardiogenic embolism and 6 had atherothrombosis. Additional neuroendovascular therapy was performed in 14 patients. Median National Institute of Health Stroke Scale and diffusion-weighted image-Alberta Stroke Program Early Computed Tomography Scores before recombinant tissue plasminogen activator therapy were 14 and 8, respectively. Occluded or stenotic lesions of the cerebral arteries were detected by magnetic resonance angiography in the internal carotid artery (n = 4), middle cerebral artery (n = 10), and basilar artery (n = 3) (1 patient had tandem lesions). Mean intervals from onset-to-recombinant tissue plasminogen activator, recombinant tissue plasminogen activator-to-our hospital (door), door-to-puncture, and onset-to-recanalization were 166, 65, 32, and 334 minutes, respectively. No patients showed symptomatic intracranial hemorrhage.

CONCLUSIONS

Magnetic resonance imaging/angiography performed in previous hospitals allows initiation of reperfusion therapy immediately after transfer. Thus, drip-and-ship plus neuroendovascular therapy is a safe and useful system for treatment of patients with acute infarcts.

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

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 ( P =1.000). About secondary outcomes, the rate of significant recanalization of ≥50% was not different between the 2 groups (28% versus 34%; P =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 ( P =0.443). The favorable outcome (modified Rankin Scale score of 0–2) at 3 months was also similar between the groups (53% versus 57%; P =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.

Abstract TMP36: Diabetes Mellitus Prevents The Complete Recanalization In Patients With Middle Cerebral Artery Occlusion

Introduction: The mechanism of the unfavorable outcome in diabetic patients treated with intravenous thrombolysis (tPA therapy) is still uncertain. We investigated the relationship of diabetes mellitus with early and delayed recanalization after tPA therapy.

Methods: Data on 165 patients from the prospective randomized control study, evaluated the efficacy of combined tPA and Edaravone therapy, were retrospectively analyzed. All patients had the middle cerebral occlusion before t-PA therapy. Based on a history of diabetes mellitus or hemoglobin A1c level of ≥6.5% on admission, all patients were classified into diabetes (D) or non-diabetes (ND) groups. The presence of arterial recanalization was assessed at 2 points: 1) early recanalization, defined as at least partial recanalization <50% within 2 h after tPA therapy; and 2) delayed complete recanalization at 24 h.

Results: Among the 165 (96 men; median age, 78 [69-85] years) patients, 33 (20%) patients were classified into the D group. Age, initial NIHSS score, DWI-ASPECTS, proximal occlusion, and the onset to needle time were not different between the 2 groups (p=0.118, 0.607, 0.586, 0.258, 0.238). Early recanalization was similarly observed in the D and ND groups (61% vs. 51%, p=0.435). However, complete recanalization at 24 h was significantly infrequent in the D group (13% vs. 44%, p=0.002). This tendency was consistent in patients with as well as without early recanalization. Regarding patients with early recanalization, 4 (22%) of the 18 patients in the D group and 34 (58%) of the 59 patients in the ND group had complete recanalization at 24 h (p=0.014). Among those without early recanalization, none (0%) of the 13 patients with the D group had complete recanalization at 24 h, while 18 (30%) of the 60 patients achieved it (p=0.029). By the multivariate regression analysis, diabetes mellitus was the independent negative factor for complete recanalization at 24 h (OR 0.17, 95%CI: 0.05-0.54, p=0.002). At 3 months, there is an increased mortality rate in the D group (19% vs. 6%, p=0.038).

Conclusion: Diabetes mellitus was an indicator of no complete recanalization at 24 h regardless of the early recanalization. This may explain the mechanism of the unfavorable outcome in patients with diabetes mellitus.

Progressive Bilateral Vertebral Artery Dissection in a Case of Osteogenesis Imperfecta

A 32-year-old woman with osteogenesis imperfecta (OI) was admitted to the hospital because of a right-sided occipital headache and facial paresthesia. She was diagnosed with lateral medullary syndrome due to right vertebral artery (VA) dissection. She was treated conservatively without antithrombotic therapy. She developed subarachnoid hemorrhage because of contralateral VA dissection 18 days later. This clinical course may reflect the underlying weakness of the vessel wall in OI. In patients with OI, occlusion of a unilateral VA could cause dissection and subsequent rupture of the contralateral VA. Early surgical treatment for lesions of the VA is required in such cases.

Timing of Treatment Initiation With Oral Anticoagulants for Acute Ischemic Stroke in Patients With Nonvalvular Atrial Fibrillation

BACKGROUND

Only a few studies have addressed the optimal start time for oral anticoagulants (OACs) after acute ischemic stroke in patients with nonvalvular atrial fibrillation (NVAF). The aim of this retrospective study was to analyze the time of OAC administration after stroke onset.Methods and Results:This study included 300 patients with NVAF who had acute ischemic stroke and were treated with OACs between April 2012 and March 2016. We investigated the time at which OACs were started by anticoagulant type and the relationship between the time of OAC administration and stroke severity (the National Institutes of Health Stroke Scale [NIHSS] score on admission). Of the 300 patients, 114 and 186 patients received warfarin and direct-acting OACs (DOACs), respectively. Patients in the DOAC group had OAC initiated therapy significantly sooner (3 days) than in the warfarin group (7 days; P<0.001). With regard to stroke severity (NIHSS score <8, mild; 8-16, moderate; >16, severe), the median time for starting therapy was 2, 7, and 11 days for mild, moderate, and severe stroke, respectively. Hemorrhagic events occurred in 3 patients in the warfarin group; however, no hemorrhagic events occurred in the DOAC group.

CONCLUSIONS

Our study revealed that neurologists began OACs earlier in patients with mild acute cerebral infarction. Even in patients with severe stroke, OACs were started earlier than expected.

De Novo Migraine With Aura After Surgical Repair of Aortic Coarctation

Coarctation of the aorta (CoA) is reported to be associated with an increased risk for migraine. We describe here the case of a 13-year-old female patient who presented migraine with aura after surgical repair of CoA with a stent. As possible reasons for her condition, we postulate host responses to stent placement and/or disturbed cerebral autoregulation related to intracranial hypertension before the surgical repair and hypotension afterward, leading to hypoperfusion. This case demonstrates that de novo migraine with aura can occur after surgical repair of CoA and should be recognized as a potential complication.

Special considerations for therapeutic choice of non-vitamin K antagonist oral anticoagulants for Japanese patients with nonvalvular atrial fibrillation

Nonvalvular atrial fibrillation (AF) is a risk factor for stroke in elderly patients. Although warfarin has been used to prevent AF-associated stroke for more than 50 years, non-vitamin K antagonist oral anticoagulants (NOACs) including dabigatran, rivaroxaban, apixaban, and edoxaban recently have been developed to overcome the disadvantages of warfarin. Based on the results of NOAC clinical trials, Savelieva and Camm made recommendations regarding selection of NOACs in patients with nonvalvular AF. Recent accumulating evidence indicates that NOACs work differently in Asian and non-Asian individuals. In this review, we discuss the results of the large, randomized, phase 3 international clinical trials on NOACs, the subanalyses of Asians, and a Japanese phase 3 clinical trial of rivaroxaban to discriminate Japanese patient-specific characteristics with regard to their responses to NOACs and make recommendations. Our analysis revealed that rivaroxaban decreased the incidence of gastrointestinal (GI) bleeding compared with warfarin in Japanese patients. The efficacy results showed that rivaroxaban significantly decreased the incidence of ischemic stroke (hazard ratio: 0.40, 95% confidence interval: 0.17-0.96) compared with warfarin. The lower incidence of GI bleeding and ischemic stroke may be specific to Japanese patients. Based on the present and previous results, the following recommendations regarding the selection of NOACs are added in the Camm chart for Japanese patients: edoxaban for patients with a high risk of bleeding and those with a previous stroke; and rivaroxaban for patients with a high risk of ischemic stroke and a low bleeding risk, and those with previous GI bleeding.

A case of anti-cyclic citrullinated peptides antibody positive rheumatoid meningitis without arthritis at the onset of neurological symptoms

We report an 84-year-old woman with rheumatoid meningitis. She developed weakness in her muscles and became cognitively impaired. However, physical examination revealed no evidence of rheumatoid arthritis. Levels of anti-cyclic citrullinated peptide antibodies were elevated. Brain magnetic resonance imaging (MRI) showed hyperintense lesions in the frontotemporoparietal subarachnoid space on fluid attenuated inversion recovery (FLAIR) images. Leptomeningeal enhancement was also evident on gadolinium-enhanced T1-weighted images. We suspected rheumatoid meningitis. A brain biopsy was performed and methylprednisolone pulse therapy was started. Subsequently, her symptoms and MRI findings rapidly improved.

Incidence, predictors, and etiology of subsequent ischemic stroke within one year after transient ischemic attack

Background Incidence and predictors of ischemic stroke in patients with transient ischemic attack (TIA) have not been fully clarified outside Europe and North America. Aims We undertook the present prospective, multicenter study to clarify the incidence, predictors, and etiology of ischemic stroke within one year of TIA onset in Japan. Methods The study subjects were patients within seven days of TIA onset who were enrolled in a prospective register from 57 hospitals between June 2011 and December 2013. The primary endpoint was occurrence of ischemic stroke. Results Of 1365 consecutive patients, 1245 were followed for one year after TIA onset; 101 (8.1%) experienced ischemic stroke during follow-up. The leading subtype of ischemic stroke was small-vessel occlusion (SVO) followed by large-artery atherosclerosis (LAA) attributable to intracranial artery diseases. When dividing ischemic stroke events between those occurring within the first 90 days after TIA onset and those occurring after the first 90 days, the leading subtype of ischemic stroke within the first 90 days after TIA onset was SVO, followed by LAA attributable to intracranial artery diseases. In comparison, the subtypes most commonly seen beyond the first 90 days after TIA onset were cardioembolic and LAA attributable to intracranial artery disease. The one-year risk of ischemic stroke increased significantly as ABCD² score increased, at 6.2% for 0-3 points, 7.2% for 4-5 points, and 11.6% for 6-7 points. Conclusions The one-year ischemic stroke risk after TIA was about 8% and was associated with the ABCD² score. The most common subtype of subsequent ischemic stroke was SVO.

Platelet-endothelial cell interaction in brain microvessels of angiotensin II type-2 receptor knockout mice following transient bilateral common carotid artery occlusion

The purpose of this study was to investigate the behavior of platelets (rolling and adhesion) in cerebral microvessels of angiotensin II type-2 receptor-knockout (AT2RKO) mice after transient bilateral carotid artery occlusion using intravital fluorescence microscopy. Twenty AT2RKO mice, consisting of 11 mice in the sham group and 9 mice in the ischemia reperfusion group (reperfusion after 15 min of bilateral, total carotid artery occlusion) were used in this study. The hole traversed the bone and dura mater, but arachnoid, pia mater, and cerebral parenchyma were preserved. Platelets were harvested from donor mice and stained using carboxyfluorescein diacetate succinimidyl ester. The number of platelets showing rolling and adhesion to pial vessels in AT2 deficient mice at 3 and 6 h after cerebral ischemia reperfusion was significantly higher than that in the sham group (P < 0.05). In addition, AT2 receptor has an inhibitory role in platelet rolling and adhesion after cerebral ischemia reperfusion.

Differences in Clinical Characteristics between Patients with Transient Ischemic Attack Whose Symptoms Do and Do Not Persist on Arrival

BACKGROUND

Symptoms of transient ischemic attack (TIA) persist on arrival and subsequently resolve in some patients admitted to hospitals early after onset. Differences in clinical characteristics between patients with acute TIA whose symptoms do and do not persist on arrival remain unclear.

METHODS

We retrospectively extracted data of consecutive TIA patients with an onset-to-door time (ODT) of 24 hours or less and without a history of stroke from a multicenter TIA database. Clinical characteristics were compared between patients with and without persisting symptoms on arrival.

RESULTS

Two hundred sixty-six patients (158 men, 68.0 ± 12.9 years) were included. Of the total number of patients, 105 (39.5%) had persisting symptoms with a mean National Institutes of Health Stroke Scale score of 2.4 (median, 1.0). Patients with persisting symptoms were more likely to have sensory disorder, ambulance-transported admission, long-duration TIA (≥60 minutes), and shorter ODT than those without. Multivariate analysis showed that sensory disorder (odds ratio [OR] 2.52, 95% confidence interval [CI] 1.35-4.77), ambulance-transported admission (OR 1.80, 95% CI 1.00-3.28), and long-duration TIA (OR 3.96, 95% CI 2.12-7.71) were positively associated and that an ODT of more than 12 hours (OR .18, 95% CI .04-.63) was inversely associated with the presence ofpersisting symptoms. Patients with persisting symptoms were more likely to be examined by a stroke physician at first (69% versus 57%, P = .049) and then hospitalized in a stroke unit (59% versus 43%, P = .010).

CONCLUSION

Clinical manifestations and management after admission might differ between patients with acute TIA whose symptoms do and do not persist on arrival.

[Management of blood pressure for stroke prevention]

Hypertension is a major risk factor for both cerebral infarction and intracerebral hemorrhage. The relationship between blood pressure (BP) and stroke risk is strong and continuous. Throughout the usual range of BPs, including the nonhypertensive range, the higher the BP is, the greater the risk of stroke. Regular BP screening and appropriate treatment of patients with hypertension, including life style modification and pharmacotherapy, are recommended. Patients who have hypertension should be treated with antihypertensive drugs to a target BP of < 140/90 mmHg. Successful reduction of BP is more important in reducing stroke risk than the choice of a specific agent, and treatment should be individualized on the basis of other patient characteristics and medication tolerance. In hypertensive patients with stroke, subjects to be treated with antihypertensive drugs and the target level of BP control are determined on the basis of clinical disease type, interval after onset, severity, age, and the use of antithrombotic. drugs. According to the guideline of the Japanese Society of Hypertension (JSH 2014), in the chronic phase of cerebral infarction, cerebral hemorrhage and subarachnoid hemorrhage, target BP should be < 140/ 90 mmHg. In patients with lacunar infarction, those taking antithrombotic drugs, cerebral hemorrhage and subarachnoid hemorrhage, a lower level, < 130/80 mmHg should be targeted if possible. Oral antihypertensive drugs such as Ca channel blockers, angiotensin-converting enzyme inhibitors, angiotensin II receptor blockers and diuretics are recommended for patients with stroke.