Special issue on Ischemic Stroke: A Cerebrovascular Accident
Department of Neurosurgery
Ischemic stroke and coronary heart disease (CHD) share common mechanisms through blood circulation, but their relationships with cholesterol levels are different. In the case of CHD, “the lower, the better” hypothesis with regards to cholesterol has prevailed so far in clinical fields, setting upper limits of cholesterol levels and advising maintenance of the levels below the limits. However, the mortality ratio of the highest to lowest cholesterol levels (relative risk, RR) varies much among selected populations. We interpreted that the RR value is a surrogate marker of the proportion of familial hypercholesterolemia (FH) cases in the population or subpopulation selected .
Stroke is now the fourth-ranked cause of death in Japan, with cancer, heart disease, and pneumonia in the first, second, and third place, respectively . Traditionally, the proportion of intraparenchymal hemorrhage is higher for Japanese than for Western populations: 20–30% versus 5–10% .
Ryuji Sakakibara1*, Jun Suzuki2, Yohei Tsuyusaki1, Fuyuki Tateno1, Masahiko Kishi1 and Takanobu Tomaru2
Abstract: Stroke is the most common cause of neurological disability and impairs quality of life, resulting in early institutionalization. Atherosclerosis is a major contributor to stroke, which can be prevented by early recognition and management. Cardio-ankle vascular stiffness index (CAVI) was introduced clinically as a novel, simple and non-invasive measure in the assessment of atherosclerosis. CAVI is easy to perform, and has adequate reproducibility for clinical use. As compared with healthy control subjects, CAVI is statistically greater in patients with ischemic cerebrovascular diseases, particularly with white matter lesions (WML), large-artery atherosclerosis, and small-vessel occlusion, but not in patients with transient ischemic attack (TIA). CAVI showed clear relationship with carotid ultrasound plaque score. CAVI is useful as a routine test for the early suspicion of ischemic cerebrovascular disease, particularly in clinical practice. It appears that CAVI.
Susumu Yamaguchi1*, Kentaro Hayashi1, Nobutaka Horie1, Yohei Tateishi2, Shuji Fukuda1, Tsuyoshi Izumo1, Akira Tsujino2 and Izumi Nagata1
Abstract: Acute basilar artery (BA) occlusion is associated with high morbidity and mortality rates. Progress has been made in endovascular treatments for acute ischemic stroke. Here, we present a case of acute basilar artery occlusion treated with stent placement. A 72-year-old man was referred to the emergency department of our hospital. Basilar occlusion was detected by magnetic resonance imaging. The patient was treated with intra-arterial urokinase; however, persistent severe BA stenosis was diagnosed. Percutaneous transluminal angioplasty was performed unsuccessfully because of vascular recoil or residual atherosclerosis. Because of the risk of reocclusion, a balloon expandable stent was placed at the BA stenosis. The postoperative course was good, and the patient was discharged 1 month later. In patients with acute BA occlusion, although intracranial stent placement for acute ischemic stroke has certain risks such as dissection, subacute thrombosis, and perforator infarction, it has great potential to recanalize the steno-occlusion associated with atherosclerosis.
Sei Sugata*, Fumikatsu Kubo, Shunichi Tanaka, Yumi Kashida, Shingo Fujio, Manoj Bohara, Ryosuke Hanaya, Hiroshi Tokimura, Kazunori Arita
Abstract: Newer anticoagulants such as dabigatran have been widely used for the prevention of ischemic stroke in patients with nonvalvular atrial fibrillation (AF). A 64-year-old man treated with dabigatran 110 mg twice daily for chronic AF presented with total aphasia, right homonymous hemianopsia, and right hemiparesis at 90 minutes after the last intake. His prothrombin time-international normalized ratio (PT-INR) was 1.14 (normal range: 0.7-1.5) and activated partial thromboplastin time (aPTT) was 33.8 seconds (normal range: 24-38 seconds). Clotting activity could not be measured because of the dabigatran intake; however, clotting activity was predicted to increase to its highest level at 90-120 minutes after the last dabigatran dose. Angiography results showed total occlusion of the left middle cerebral artery (MCA), and mechanical thrombectomy with the Penumbra System (Penumbra, Inc. ) was performed instead of intravenous administration of recombinant tissue plasminogen activator (rt-PA). The patient showed recanalization of the MCA and neurological improvement. Mechanical thrombectomy can be used as a supplement to intravenous administration of rt-PA for the treatment of acute ischemic stroke in patients receiving newer anticoagulants such as dabigatran. The indication of thrombolysis for acute ischemic stroke in patients taking dabigatran should be discussed after considering the aPTT value and the time since the last intake of dabigatran.
Chie Asai1 and Hirohide Asai2*
Abstract: Post-ischemic inﬂammation is an essential step in the progression of ischemic stroke. Infiltrating macrophages are known to serve as a key mediator of the innate immune response to danger-associated molecular pattern molecules (DAMPs) by their expression of Toll-like receptors (TLRs) because activation of TLRs of macrophages leads to the secretion of proinflammatory cytokines. This review focuses on the involvement of Toll-like receptors in ischemic stroke induced neuronal damage .
Aiki Marushima1*, Yasunobu Nakai1, Go Ikeda1, Wataro Tsuruta1, Hideo Tsurushima1, Kensuke Suzuki1,2 and Akira Matsumura1
Abstract: Retinal ischemia associated with carotid artery stenosis is an important clinical sign for the prevention of repeated retinal and cerebral ischemic attacks. In this study, we compared the cerebro-cardiovascular risk factors of patients with symptomatic carotid artery stenosis presented with retinal ischemia and with cerebral ischemia. Forty-six patients were diagnosed with symptomatic carotid artery stenosis for five years in our institute. Sixteen patients (34.8%) presented with retinal ischemia, and 30 patients (65.2%) presented with cerebral ischemia. Retinal ischemia was divided into retinal artery occlusion (RAO: n=7, 15.2%), retinal vein occlusion (RVO: n=5, 10.9%) and retinal transient ischemic attack (RTIA: n=4, 8.7%). Stenosis more than 70% in the internal carotid artery was recognized in 62.5% of the patients with retinal ischemia (RAO: n=4, RVO: n=2, AF: n=4) and 73.3% of the patients with cerebral ischemia (p=0.45), and vulnerable plaque evaluated by ultrasonography was recognized in 42.9% of the patients with retinal ischemia (RAO: n=5, RVO: n=2, RTIA: n=2) and 33.3% of patients with cerebral ischemia (p=0.33). No significant difference were seen in the cardiovascular risk factors for hypertension, diabetes mellitus, dyslipidemia, smoking and previous cardiovascular events, and in the cerebrovascular risk factors for stenosis rate, vulnerable plaque, cerebral white matter lesions (WMLs), and impaired cerebrovascular reserve (CVR), between the patients with retinal ischemia and cerebral ischemia. Attentions to the future’s stroke should be paid for patients with retinal ischemia of RAO, RVO and RTIA as well as patients with cerebral ischemia, because both patients could possess equivalent cerebro-cardiovascular risk factors.
Shoji Honda1,6, Yutaka Kai2,6*, Masaki Watanabe3, Teruyuki Hirano4, Koichirou Usuku5, Yukio Ando3 and Jun-ichi Kuratsu2
Abstract: In the Aso area of Kumamoto Prefecture in Japan there are no hospitals where stroke patients can receive acute-period revascularization treatments. As transfer to an out-of-area hospital takes approximately an hour, the interval between stroke onset and arrival at the distant care facility is long and of 11 patients transferred in 2010, only one received recombinant tissue plasminogen activator (rt-PA) therapy. Therefore, to make it possible to deliver rt-PA therapy at the primary emergency hospital we developed a telemedicine system that uses smartphones for communication between the out-of-area comprehensive stroke center and the primary emergency hospital. Patients with acute ischemic stroke are taken to the primary emergency hospital where the physician in charge uses the smartphone “RDICOM” application to upload the NIH stroke scale and a head CT image on a server. The stroke neurologist at the comprehensive stroke center then assesses the case and uses “RDICOM” information to make it possible to deliver rt-PA therapy at the primary hospital (“drip”). Patients requiring special treatment are transferred to a comprehensive stroke center (“ship”); during transfer rt-PA is delivered via intravenous drip infusion. Between June 2012 and August 2013, fourteen patients with acute ischemic stroke were taken to a primary emergency hospital in the Aso area. Of these, 6 underwent successful rt-PA therapy under the telemedicine-facilitated direction of an out-of-area stroke neurologist. At the time of admission, the mean NIH stroke scale of these 6 patients was 14.5. After rt-PA treatment it was 3.2. No patients suffered hemorrhagic complications. With the remote support provided by our smartphone telemedicine system it is possible to deliver rt-PA therapy even in areas where such treatment was formerly not possible.
Hidetoshi Ooigawa*, Ririko Takeda, Toshiki Ikeda, Hiroyuki Nakajima, Shinishiro Yoshikawa, Munehiro Otsuka and Hiroki Kurita
Abstract: Background and purpose: Moyamoya disease is a progressive occlusive disease of the cerebral arteries. Various vascular reconstruction surgeries have been reported, but the most appropriate procedure remains unclear. We have preferred to perform a combined direct and indirect bypass to the Rolandic region to prevent ischemic stroke. The purpose of this study was to evaluate the surgical results of our method using cerebral blood flow (CBF) from single photon emission computed tomography (SPECT).
Methods: This study examined 29 hemispheres in 21 patients (6 males, 15 females; mean age, 33.25 ± 19.26 years; range, 9-67 years). All patients underwent combined vascular reconstruction using a superficial temporal artery (STA) -middle cerebral artery (MCA) anastomosis and encephaloduromyosynangiosis. Regional CBF (rCBF) and cerebrovascular reserve (CVR) were measured using N-isopropyl-p-[123I]-iodoamphetamine (123I-IMP) SPECT before and after the procedure.
Results: Postoperatively, 28 direct bypasses were patent, but one became occluded within 3 months after surgery. Preoperative symptoms completely resolved in all except one case. Three months postoperatively, improvement of rCBF at rest was not evident in the ipsilateral frontal lobe after surgery, but CVR was widely and significantly improved in the frontal lobe involving the motor cortex (preoperative CVR, -1.1 ± 16.1%; postoperative CVR, 14.3 ± 19.7%, p<0.001) and premotor area (preoperative CVR, -2.14 ± 15.9%; postoperative CVR, 10.2 ± 15.9%, p<0.001).
Conclusions: Our combined direct and indirect bypass effectively reduced ischemic symptoms of moyamoya disease and increased CVR. The possibility that transient ischemic attack was more strongly affected by CVR than by CBF was suggested.
Abstract: This study was performed to evaluate the preventive effect of cilostazol on bradycardia attacks during the carotid angioplasty with stenting (CAS) procedure. Among the 38 CAS procedures performed by the first author between April 2004 and May 2008, we analyzed 18 cases in which a hypotension attack occurred during the procedure. Of the 18 patients valuated, 9 received cilostazol before the procedure (Cil (+) group), and the remaining 9 did not (Cil (-) group). In all procedures, 0.5mg of atropine was administered just before stent placement or balloon inflation. If a hypotension attack occurred, intravenous fluid loading or vasopressors such as ephedrine or catecholamine were used. A hypotension attack in this study was defined as the need for special treatment for low blood pressure. Pre-procedural heart rate (HR) was significantly higher in the of Cil (+) group than in the Cil (-) group (mean HR: 95.0 vs. 77.6, P<0.01). Intra-procedural minimum HR was significantly higher in the Cil (+) group than in the Cil (-) group (mean HR: 90.1 vs. 67.8, P<0.01). A statistically significant change in HR from pre-procedural HR to the minimum intra-procedural HR was observed in the Cil (-) group. Whereas the difference did not reach statistical significance in the Cil (+) group. Pre-procedural administration of cilostazol is an easy and useful method for the prevention of bradycardia attacks during the CAS procedure.