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OBJECTIVEImproved outcomes in patients with subarachnoid hemorrhage (SAH) treated at high-volume centers have been reported. The authors sought to examine whether hospital case volume and comprehensive stroke center (CSC) capabilities affect outcomes in patients treated with clipping or coiling for SAH.METHODSThe authors conducted a nationwide retrospective cohort study in 27,490 SAH patients who underwent clipping or coiling in 621 institutions between 2010 and 2015 and whose data were collected from the Japanese nationwide J-ASPECT Diagnosis Procedure Combination database. The CSC capabilities of each hospital were assessed by use of a validated scoring system based on answers to a previously reported 25-item questionnaire (CSC score 1–25 points). Hospitals were classified into quartiles based on CSC scores and case volumes of clipping or coiling for SAH.RESULTSOverall, the absolute risk reductions associated with high versus low case volumes and high versus low CSC scores were relatively small. Nevertheless, in patients who underwent clipping, a high case volume (> 14 cases/yr) was significantly associated with reduced in-hospital mortality (Q1 as control, Q4 OR 0.71, 95% CI 0.55–0.90) but not with short-term poor outcome. In patients who underwent coiling, a high case volume (> 9 cases/yr) was associated with reduced in-hospital mortality (Q4 OR 0.69, 95% CI 0.53–0.90) and short-term poor outcomes (Q3 [> 5 cases/yr] OR 0.75, 95% CI 0.59–0.96 vs Q4 OR 0.65, 95% CI 0.51–0.82). A high CSC score (> 19 points) was significantly associated with reduced in-hospital mortality for clipping (OR 0.68, 95% CI 0.54–0.86) but not coiling treatment. There was no association between CSC capabilities and short-term poor outcomes.CONCLUSIONSThe effects of case volume and CSC capabilities on in-hospital mortality and short-term functional outcomes in SAH patients differed between patients undergoing clipping and those undergoing coiling. In the modern endovascular era, better outcomes of clipping may be achieved in facilities with high CSC capabilities.

BACKGROUND In Japan there is no consensus on how to efficiently measure quality indicators (QIs), defined as a standard of care, for acute ischemic stroke (AIS). Using information from a health insurance claims database and electronic medical records, we evaluated the feasibility and validity of measuring QIs for AIS patients who received intravenous recombinant tissue plasminogen activator (IV rt-PA) or endovascular therapy (EVT).Methods and Results:AIS patients receiving rt-PA or EVT between 2013 and 2015 were identified. We selected 17 AIS QI measures for primary stroke centers (PSCs) and 8 for comprehensive stroke centers (CSCs). Defined QIs were calculated for each hospital and then averaged. In total, the data of 8,206 patients (rt-PA 83.7%, EVT 34.9%) from 172 hospitals were obtained. Median National Institute of Health Stroke Scale score at admission was 14, and 37.7% of the patients were functionally independent at discharge. All target QIs were successfully measured with fewer missing values, and the accuracy of preset data was about 90%. Adherence rates were low (

Background: Postoperative cerebral hyperperfusion syndrome (CHS) may occur after superficial temporal artery (STA)-middle cerebral artery (MCA) bypass for moyamoya disease (MMD). Predicting postoperative CHS is challenging; however, we previously reported the feasibility of using a hyperspectral camera (HSC) for monitoring intraoperative changes in brain surface hemodynamics during STA-MCA bypass. Objective: To investigate the utility of HSC to predict postoperative CHS during STA-MCA bypass for patients with MMD. Methods: Hyperspectral images of the cerebral cortex of 29 patients with MMD who underwent STA-MCA bypass were acquired by using an HSC before and after anastomosis. We then analyzed the changes in oxygen saturation after anastomosis and assessed its correlation with CHS. Results: Five patients experienced transient neurological deterioration several days after surgery. 123I-N-Isopropyl-iodoamphetamine single-photon emission computed tomography scan results revealed an intense, focal increase in cerebral blood flow at the site of anastomosis without any cerebral infarction. Patients with CHS showed significantly increased oxygen saturation (SO2) in the cerebral cortex after anastomosis relative to those without CHS (33 ± 28 vs. 8 ± 14%, p < 0.0001). Receiver operating characteristic analysis results show that postoperative CHS likely occurs when the increase rate of cortical SO2 value is >15% (sensitivity, 85.0%; specificity, 81.3%; area under curve, 0.871). Conclusions: This study indicates that hyperspectral imaging of the cerebral cortex may be used to predict postoperative CHS in patients with MMD undergoing STA-MCA bypass.

Background Although endovascular coiling of unruptured aneurysms is widely accepted, the endovascular treatment of wide-neck bifurcation aneurysms remains one of the most challenging morphologies. Our purpose was to describe our experience with 24-month follow-up for the treatment of unruptured intracranial bifurcation aneurysms using the PulseRider (Cerenovus, New Brunswick, NJ). Methods This study is a single-center, single-arm registry performed under institutional review board control to evaluate efficacy and safety of the PulseRider. Patients with bifurcation aneurysms were identified and enrolled prospectively. Angiography immediately after treatment and at 6 months, and magnetic resonance imaging and magnetic resonance angiography at 12- and 24-month follow-up were retrospectively analyzed. A modified Rankin score was obtained prior to procedure, at discharge, and at 6-, 12- and 24-month follow-up visits. Results Eight patients with a mean age of 66 years were treated with the PulseRider. All patients had bifurcation aneurysms (2 anterior communicating, 2 carotid terminus, and 4 basilar apex). The aneurysm diameters ranged from 4.6 to 13.6 mm (mean 7.4 mm) with dome/neck ratio ranging from 1.4 to 2.2 (mean 1.6). In all cases, the PulseRider was successfully deployed. Complete occlusion was demonstrated at 6-month follow-up on 6 of 8 (75%), near complete occlusion in 1 of 8 (12.5%), and residual aneurysm in 1 of 8 (12.5%) patients. There was no change or recurrence on magnetic resonance angiography, nor clinical complication after the procedure through 24-month follow-up. Conclusions Our experience with 24-month follow-up demonstrated favorable efficacy in the treatment of intracranial wide-neck bifurcation aneurysms using the PulseRider.

Japan has a rapidly aging population and the application of neuroendovascular therapy (NET) for cerebrovascular diseases among elderly patients has increased, but feasibility and safety of NET for elderly patients are still debated. Therefore, this study aimed to elucidate feasibility and safety of NET by analyzing the Japanese nationwide database, the Japanese Registry of Neuroendovascular Therapy 3 (JR-NET 3). In total, 35,972 patients in the JR-NET 3 were analyzed retrospectively. "Elderly patients" were defined as those aged ≥75 years. Approximately one-quarter of patients who received NET were elderly patients. The proportion of patients with modified Rankin Scale (mRS) 0-2 before treatment and 30 days after NET was significantly low across all diseases in the elderly patients. Technical success rates were generally high across all procedures, but complication rate was significantly higher among elderly patients; ischemic complications were significantly higher with NET for unruptured aneurysms (UA) and carotid artery stenosis (CAS). Multivariate analysis revealed that mRS 0-2 before treatment [odds ratio (OR): 0.56, 95% confidence interval (CI): 0.34-0.94, P = 0.03], middle cerebral artery aneurysm (OR: 0.33, 95% CI: 0.12-0.92, P = 0.04), and complete obliteration (OR: 0.66, 95% CI: 0.44-0.97, P = 0.03) were associated with ischemic complications with NET for UA. Moreover, mRS 0-2 before treatment (OR: 0.55, 95% CI: 0.36-0.86, P < 0.01), high intensity with time-of-flight magnetic resonance angiography (OR: 1.55, 95% CI: 1.03-2.32, P = 0.04), open-cell stent (OR: 2.20, 95% CI: 1.50-3.22, P

To evaluate the performance of acceleration-selective arterial spin labeling (AccASL) MR angiography in the visualization of brain arteriovenous malformations (AVMs) in comparison with digital subtraction angiography (DSA) and time-of-flight (TOF) MR angiography. Twenty-one patients with brain AVM (mean age 31.1 ± 18.6 years; 11 males, 10 females) underwent TOF and AccASL MR angiography and DSA. Two neuroradiologists conducted an observer study for detection, nidus size, eloquence, venous drainage pattern, and Spetzler-Martin (SM) grade. The evaluations included the visualization of each AVM component with reference to DSA and assessments of contrast-to-noise ratio (CNR). The kappa statistic, repeated measures analysis of variance, Wilcoxon matched pairs test, and paired t test were used. Both observers detected more AVMs with AccASL (95.2%, 90.5% for Observers 1 and 2) than with TOF (76.2% and 71.4%, respectively). The inter-modality agreement between AccASL and DSA was almost perfect for the eloquence, venous drainage pattern, and SM grade for Observer 1 and moderate for the venous drainage pattern and substantial for the eloquence and SM grade for Observer 2. The visualization scores were higher with AccASL than with TOF for the feeding artery (AccASL, 4.5 ± 1.0 vs. TOF, 3.9 ± 1.5, p = 0.0214), nidus (4.6 ± 1.1 vs. 3.2 ± 1.5, p = 0.0006), and draining vein (4.6 ± 1.0 vs. 2.2 ± 1.1, p

Intracranial Hemorrhage is a common brain injury that leads to a high mortality rate without prompt recognition. To address these issues, computer-aid diagnosis tools are rapidly being developed along with neural-network-based techniques to provide fast, reliable analysis and achieve accurate diagnosis decisions based on medical images. One of the most interesting applications in computer-aid diagnosis is Image Registration due to its practical features in clinical diagnosis and treatment planning. In this study, we present the non-rigid image registration for the 3D Computed Tomography image dataset of the Intracranial Hemorrhage Brain. By utilizing the affine transformation and a neural network model, we aim to predict the deformation vector field, map the real-world-collected dataset to the reference space and overcome the shifting data problem between the data analysis experiment on standard and real-world medical image analysis. Our test results gave that good registration performance is obtained in a very short time by using a neural network model, and the affine transformation significantly improves the real-world image registration. In addition, according to the distance from the hematoma area change ratio to the brain area change ratio, the characteristics of the major structure are determined to be preserved.

BackgroundThe efficacy of combined stent retriever (SR) and aspiration catheter (AC; combined technique: CBT) use for acute ischemic stroke (AIS) is unclear. We investigated the safety and efficacy of single-unit CBT (SCBT)—retrieving the thrombus as a single unit with SR and AC into the guide catheter—compared with single use of either SR or contact aspiration (CA).MethodsWe analysed 763 consecutive patients who underwent mechanical thrombectomy for AIS between January 2013 and January 2020, at six comprehensive stroke centers. Patients were divided into SCBT and single device (SR/CA) groups. The successful recanalization with first pass (SRFP) and other procedural outcomes were compared between groups.ResultsOverall, 240 SCBT and 301 SR/CA (SR 128, CA 173) patients were analyzed. SRFP (modified Thrombolysis In Cerebral Infarction (mTICI) ≥2c, 43.3% vs 27.9%, pConclusionsSCBT increases the SRFP rate and shortens the puncture-to-reperfusion time without increasing procedural complications.

Intracerebral hematoma (ICH) is the cause of intracerebral hemorrhage. Acute enlargement of the ICH is high risk, and emergency surgical treatment is required. Therefore, prediction of ICH enlargement is essential to improve a survival rate and outcome. The purpose of this study is to find factors to predict the ICH enlargement with thick slice head CT images. We propose three kinds of feature extraction methods, (1) shape and texture features, (2) layered texture features, and (3) anatomical location features. In addition, we introduce an ICH enlargement prediction method using support vector machine (SVM) and feature selection. The experimental results showed that the angular second order moment of the texture feature was the most effective in predicting the ICH enlargement. By using this feature, we were able to predict the ICH enlargement with an accuracy of 75.7%. In addition, we found that normalization of the location and posture improved the prediction accuracy by 2.7% compared to that without normalization.

BACKGROUNDThe authors document the first case of pure arterial malformations (PAMs) of the posterior communicating artery (PCoA), which were successfully treated with microsurgical clipping of the main body of the PAMs. PAMs are defined as dilated, overlapping, and tortuous arteries with a coil-like appearance and/or a mass of arterial loops without any associated venous component. Although PAMs usually have a benign history and are often incidental findings, this case presented with acute progression of visual field impairment.OBSERVATIONSBecause the patient’s right optic tract was affected by the loop of PAMs of the PCoA, the authors performed microsurgical clipping of the main body of the PAMs using endoscopy, which ceased the progression of symptoms without any complications.LESSONSThere have been several reports of PAMs receiving surgical treatment for accompanying lesions. However, in this case, the lesion to the main body of PAMs was the cause of visual field impairment and was successfully treated with microsurgical clipping.

ObjectivesComprehensive stroke centre (CSC) capabilities are associated with reduced in-hospital mortality due to acute stroke. However, it remains unclear whether there are improving trends in the CSC capabilities or how hospital-related factors determine quality improvement. This study examined whether CSC capabilities changed in Japan between 2010 and 2018 and and whether any changes were influenced by hospital characteristics.DesignA hospital-based cross-sectional study.SettingWe sent out questionnaires to the training institutions of the Japan Neurosurgical Society and Japan Stroke Society in 2010, 2014 and 2018.Participants749 hospitals in 2010, 532 hospitals in 2014 and 786 hospitals in 2018 participated in the J-ASPECT study, a nationwide survey of acute stroke care capacity for proper designation of a comprehensive stroke centre in Japan.Main outcome measuresCSC capabilities were assessed using the validated scoring system (CSC score: 1–25 points) in 2010, 2014 and 2018 survey. The effect of hospital characteristics was examined using multiple logistic regression analysis.ResultsAmong the 323 hospitals that responded to all surveys, the implementation of 13 recommended items increased. The CSC score (median and IQR) was 16 (13–19), 18 (14–20) and 19 (15–21) for 2010, 2014 and 2018, respectively (pConclusionsThere was a significant improvement in CSC capabilities between 2010 and 2018, which was mainly related to the availability of endovascular treatment and multidisciplinary care. Our findings may be useful to determine which hospitals should be targeted to improve CSC capabilities in a defined area.

Background and Purpose: Recent studies have demonstrated that endovascular reperfusion therapy improves clinical outcomes at 90 days after ischemic stroke. However, the effects on long-term outcomes are not well known. We hypothesized that successful reperfusion might be associated with long-term improvement beyond 90 days after endovascular therapy. To assess the long-term effects beyond 90 days, we analyzed the association of successful reperfusion with a temporal change in modified Rankin Scale (mRS) score from 90 days to 1 year after endovascular therapy. Methods: We retrospectively analyzed a database of consecutive patients with acute ischemic stroke who received endovascular therapy between April 2006 and March 2016 at 4 centers. We compared the incidences of improvement and deterioration in patients with successful reperfusion (i.e., modified thrombolysis in cerebral infarction score of 2b or 3) with those in patients with unsuccessful reperfusion. We defined improvement and deterioration as decrease and increase on the mRS score by 1 point or more from 90 days to 1 year after endovascular therapy respectively. Results: A total of 268 patients were included in the current study. The rate of patients with improvement tended to be higher in patients with successful reperfusion than in patients with unsuccessful reperfusion (20% [34/167 patients] vs. 12% [12/101], p = 0.07). The rate of patients with deterioration was lower in patients with successful reperfusion than in patients with unsuccessful reperfusion (25% [42/167] vs. 42% [42/101], p < 0.01). After adjustment for confounders, successful reperfusion was associated with improvement (adjusted OR 2.65; 95% CI 1.23–5.73; p < 0.05) and deterioration (adjusted OR 0.33; 95% CI 0.18–0.62; p < 0.01), independent of the 90-day mRS score. Conclusions: Successful reperfusion has further beneficial legacy effects on long-term outcomes beyond 90 days after stroke.

To evaluate the performance of four-dimensional pseudo-continuous arterial spin labeling (4D-pCASL)-based angiography using CENTRA-keyhole and view sharing (4D-PACK) in the visualization of flow dynamics in distal cerebral arteries and leptomeningeal anastomosis (LMA) collaterals in moyamoya disease in comparison with contrast inherent inflow-enhanced multiphase angiography (CINEMA), with reference to digital subtraction angiography (DSA). Thirty-two cerebral hemispheres from 19 patients with moyamoya disease (mean age, 29.7 ± 19.6 years; five males, 14 females) underwent both 4D-MR angiography and DSA. Qualitative evaluations included the visualization of anterograde middle cerebral artery (MCA) flow and retrograde flow via LMA collaterals with reference to DSA. Quantitative evaluations included assessments of the contrast-to-noise ratio (CNR) on these vessels. The linear mixed-effect model was used to compare the 4D-PACK and CINEMA methods. The vessel visualization scores were significantly higher with 4D-PACK than with CINEMA in the visualization of anterograde flow for both Observer 1 (CINEMA, 3.53 ± 1.39; 4D-PACK, 4.53 ± 0.80; p < 0.0001) and Observer 2 (CINEMA, 3.50±1.39; 4D-PACK, 4.31 ± 0.86; p = 0.0009). The scores were higher with 4D-PACK than with CINEMA in the visualization of retrograde flow for both Observer 1 (CINEMA, 3.44 ± 1.05; 4D-PACK, 4.47 ± 0.88; p < 0.0001) and Observer 2 (CINEMA, 3.19 ± 1.20; 4D-PACK, 4.38 ± 0.91; p < 0.0001). The maximum CNR in the anterograde flow was higher in 4D-PACK (40.1 ± 16.1, p = 0.0001) than in CINEMA (27.0 ± 16.6). The maximum CNR in the retrograde flow was higher in 4D-PACK (36.1 ± 10.0, p < 0.0001) than in CINEMA (15.4 ± 8.0). The 4D-PACK provided better visualization and higher CNRs in distal cerebral arteries and LMA collaterals compared with CINEMA in patients with this disease. • The 4D-PACK enables good visualization of distal cerebral arteries in moyamoya disease. • The 4D-PACK enables direct visualization of leptomeningeal collateral vessels in moyamoya disease. • Vessel visualization by 4D-PACK can be useful in assessing cerebral hemodynamics.

The 2016 edition of the World Health Organization Classification of Tumors of the Central Nervous System introduced "diffuse midline glioma H3 K27M mutant" as a new diagnostic entity. These tumors predominately affect pediatric patients and arise from midline structures such as the brainstem, thalamus and spinal cord. Here, we report a rare patient with spinal ganglioglioma carrying an H3 K27M mutation. A 10-year-old boy presented with an intramedullary tumor in the cervical spinal cord. The lesion was partially removed and histologically diagnosed as ganglioglioma. After the remnant tumor grew within 3 months after surgery, the patient underwent radiotherapy. Genetic analyses revealed an H3F3A K27M mutation but no other genetic alterations such as IDH and BRAF mutations. This case may point to pathological heterogeneity in gliomas with H3 K27M mutations.

ObjectivesThis cross-sectional survey explored the characteristics and outcomes of direct oral anticoagulant (DOAC)–associated nontraumatic intracerebral hemorrhages (ICHs) by analyzing a large nationwide Japanese discharge database.MethodsWe analyzed data from 2,245 patients who experienced ICHs while taking anticoagulants (DOAC: 227; warfarin: 2,018) and were urgently hospitalized at 621 institutions in Japan between April 2010 and March 2015. We compared the DOAC- and warfarin-treated patients based on their backgrounds, ICH severities, antiplatelet therapies at admission, hematoma removal surgeries, reversal agents, mortality rates, and modified Rankin Scale scores at discharge.ResultsDOAC-associated ICHs were less likely to cause moderately or severely impaired consciousness (DOAC-associated ICHs: 31.3%; warfarin-associated ICHs: 39.4%; p = 0.002) or require surgical removal (DOAC-associated ICHs: 5.3%; warfarin-associated ICHs: 9.9%; p = 0.024) in the univariate analysis. Propensity score analysis revealed that patients with DOAC-associated ICHs also exhibited lower mortality rates within 1 day (odds ratio [OR] 4.96, p = 0.005), within 7 days (OR 2.29, p = 0.037), and during hospitalization (OR 1.96, p = 0.039).ConclusionsThis nationwide study revealed that DOAC-treated patients had less severe ICHs and lower mortality rates than did warfarin-treated patients, probably due to milder hemorrhages at admission and lower hematoma expansion frequencies.

Purpose To evaluate and compare the performance of acceleration-selective arterial spin labeling (AccASL) magnetic resonance (MR) angiography in the visualization of cerebral arteries and collateral vessels in patients with Moyamoya disease with that of time-of-flight (TOF) MR angiography, with digital subtraction angiography (DSA) as the reference standard. Materials and Methods Thirty-six cerebral hemispheres from 22 patients with Moyamoya disease underwent TOF and AccASL MR angiography and DSA. Qualitative evaluations included imaging of the terminal internal carotid artery (ICA), distal middle cerebral arteries (MCAs), Moyamoya vessels, and leptomeningeal anastomosis (LMA) collaterals with reference to DSA. Quantitative evaluations included assessment of contrast-to-noise ratio (CNR) and number of vessels in MCA branches. The linear mixed-effect model was used to compare the two methods. Results Mean scores for qualitative evaluation were significantly higher with AccASL angiography than with TOF angiography for imaging distal MCAs (3.9 ± 0.3 [standard deviation] vs 2.9 ± 1.1; P.001), Moyamoya vessels (3.6 ± 0.6 vs 2.7 ± 0.9, P.001), and LMA collaterals (3.8 ± 0.6 vs 1.8 ± 0.7, P.001). Scores for steno-occlusive degree around the terminal ICAs were better with TOF angiography than with AccASL angiography (2.6 ± 0.5 vs 2.4 ± 0.6, P = .023). CNRs in the M4 segment were significantly higher with AccASL angiography (11.9 ± 12.9, P.001) than with TOF angiography (4.1 ± 7.9). The number of vessels was significantly higher with AccASL angiography (18.3 ± 5.0, P.001) than with TOF angiography (8.9 ± 4.9). The increase in the number of vessels from TOF angiography to AccASL angiography was greater in patients with severe ICA steno-occlusion (late ICA stage group, 11.4 ± 4.5; early ICA stage group, 6.8 ± 4.0; P = .007) and well-developed leptomeningeal anastomosis (mildly developed LMA group, 7.1 ± 4.3; well-developed LMA group, 11.3 ± 4.5; P = .011). Conclusion AccASL MR angiography enables better visualization of distal cerebral arteries and collateral vessels in patients with Moyamoya disease than does TOF MR angiography, while TOF MR angiography enables better visualization of stenosis of proximal arteries. Both methods work in a mutually beneficial manner in the assessment of cerebral arteries.

Background and Purpose: Treatment for cerebral infarction beyond the indication of reperfusion therapy has not yet been established, and novel approaches are needed. It has been reported that platelet-derived growth factor (PDGF)-B played a neuroprotective role by enhancing cell survival and tissue repair for a long period after cerebral infarction in experimental animal models. However, PDGF-B is difficult to administer at effective concentrations in infarct area. In general, nanoparticles are very small and stable, making them prone to accumulation without being metabolized in infarct area. Therefore, we converted PDGF-B into nanoparticles and examined its therapeutic effect for cerebral infarction. Methods: PDGF-B nanoparticles (PDGF-B NP) and wild-type nanoparticles (wNP) were injected one day after transient middle cerebral artery occlusion (tMCAO) using the CB-17 mouse model. We analyzed temporal histological changes and neurological function recovery. Fucntional recovery was assess using Cylinder test at 3 and 7 days after the tMCAO. As for the mechanism of neuroprotective effect, phosphorylation of Akt, neurotrophin-3 (NT-3), and expression of angiogenesis were also examined in the infarct area and compared them with wNP control at 7 days after tMCAO. Result: We found that PDGF-B NP was distributed specifically in the infarct area. As compared with wNP group, PDGF-B NP group significantly suppressed cerebral infarct volume and improved neurological function at 3 and 7 days after cerebral infarction compared with wNP group. Akt was strongly phosphorylated in the infarction area with PDGF-B NP administration compared with wNP. Moreover, PDGF-B NP significantly induced angiogenesis, NT-3 expression, and reduced cell apoptosis after cerebral infarction compared with wNP. Conclusion: PDGF-B NP activated PDGF-B-Akt signaling in infarct area and played various important roles leading to neuroprotection after cerebral infarction. Our results suggested that treatment with PDGF-B NP may be useful for cerebral infarction beyond reperfusion therapy.

Background and Purpose: There is no consensus about efficiently measuring quality indicators (QIs) of acute ischemic stroke (AIS) in Japan. To evaluate feasibility and reliability of measuring QIs for AIS patients who received intravenous recombinant tissue plasminogen activator (rt-PA) or endovascular therapy (ET), by combining information from health insurance claims database and medical chart. Methods: AIS patients who received rt-PA or ET between 2013 and 2015 were identified from the J-ASPECT Diagnosis Procedure Combination (DPC) database. The 17 and 8 QI measures for primary and comprehensive stroke centers (PSCs and CSCs) were selected for AIS, respectively. More than 60% of data for calculating the QIs were obtained from the DPC database and preset in the tool. Responsible physicians were asked to review accuracy of preset data and add necessary information from medical chart. Adherence rates or performance measures for each QI were calculated for patient- and hospital-levels. Associations between adherence rates and hospital characteristics were analyzed using hierarchical logistic regression analysis. Result: In total, data of 8,506 patients (rt-PA 83.5%, ET 34.9%) from 173 hospitals were obtained. The median age was 76 (interquartile range 65–83) years, and 42.1% were women. Median National Institute of Health Stroke Scale (NIHSS) score at admission was 14 (7-21). All of the target QIs were successfully measured. Among PSC QIs, adherence rates were low (< 60 minutes 37.9%) and intermediate (50-75%) (e.g. stroke unit care 58.7%) in 4 each. For CSC QIs, median door-to-puncture time was 105 (76-147) minutes and TICI grade 2b and 3 recanalization were achieved in 73%. A higher number of stroke discharge was associated with greater adherence to stroke unit care, early rehabilitation and stroke education. Conclusion: Measuring QIs of AIS by this novel approach was feasible and reliable to provide a national benchmark.

Background and Purpose: Heart disease is a common comorbid condition among patients undergoing carotid endarterectomy (CEA) and carotid artery stent placement (CAS). However, the outcomes of patients with heart disease who were treated with CEA/CAS have not been fully examined. We investigated the impact of heart disease on outcomes of CEA and CAS in general practice using the Japanese nationwide data from J-ASPECT study. Methods: We analyzed data from 23,366 patients of CEA or CAS (CEA 8,514, CAS 14,809) who had been hospitalized in the period from April 2012 to March 2017. We extracted data from the Japanese nationwide DPC database for patients who underwent CEA or CAS which were identified from procedural coding with Japanese original K-codes (CEA: K6092, CAS: K609-2). For further categorization of carotid artery stenosis patients with or without heart disease, we used the ICD-10 code (ischemic heart disease, valvular disease cardiomyopathy, conduction disturbance, cardiac arrhythmia, atrial fibrillation/atrial flutter and heart failure) to identify the presence of heart disease. Outcome (death within 30days) was compared between the patient who underwent CEA or CAS and patient with or without heart disease after adjustment for patient characteristics by using the logistic regression analysis. Results: Of the patients who underwent CAS or CEA, 2495 (29.3%) in CEA and 3930 (26.5%) in CAS were complicated with heart disease. Heart disease was not associated with the risk of death within 30days in both patients undergoing CEA (OR, 1.38; 95% CI, 0.54-3.55, p=0.5) or CAS (OR, 1.42; 95% CI, 0.93-2.16, p=0.099). Among heart disease, valvular disease was associated with increased the risk of death within 30days in patients undergoing CEA (OR, 6.71; 95% CI, 1.89-23.77, p=0.0032) and CAS (OR, 2.94; 95% CI, 1.05-8.20, p=0.004) after adjustment for potential confounders. Especially of the patients with valvular disease, aortic valve disease was significantly increased the risk of death within 30days (CEA: OR, 11.2; 95% CI, 3.13-39.8, p=0.0002, CAS: OR, 3.53; 95% CI, 1.07-11.6, p=0.038). Conclusion: Patients who were complicated with valvular disease, especially aortic valve disease had a high risk of death within 30 days after CEA or CAS.

Background: Superficial temporal artery (STA)-middle cerebral artery (MCA) bypass is the important treatment of moyamoya disease and other cerebral ischemic situations. However, cerebral hyperperfusion syndrome (HPS) may occur after vascular reconstructive surgery including STA-MCA bypass. 123 I-IMP-SPECT is useful to diagnose HPS after surgery, but there is no intraoperative device to predict HPS. Using intraoperative hyperspectral imaging data captured by hyperspectral camera (HSC), we can get the oxygen saturation value (SO2) of brain surface during surgery. We may predict HPS by analyzing intraoperative cerebral cortex SO2. Objective: To investigate whether the data from HSC during surgery is useful for prediction of postoperative HPS. Methods: 10 consecutive patients performed STA-MCA bypass were collected hyperspectral images of cerebral cortex by HSC before and after bypass. We got the SO2 data and analyzed the rate of change and correlation with HPS. Results: 3 patients presented temporary neurological deterioration several days after surgery and 123 I-IMP SPECT revealed focal intense increase in CBF at the sites of anastomosis. In these HPS patients, the rate of change of SO2 of cerebral cortex before and after bypass significantly increased in comparison with the patients didn’t present HPS (1.524 vs 1.089, P=0.0017). The receiver operating characteristic curve reveals if the rate of change of SO2 is more than 1.17, postoperative HPS is likely to occur (sensitivity=83%, AUC=0.81). Conclusions: Using the HSC, we may predict the occurrence of HPS after STA-MCA bypass. HSC can be the useful device in postoperative treatment for prevention of HPS.

Objectives: To examine whether hospital case volume and comprehensive stroke centre(CSC) capabilities affect patient outcomes of clipping and coiling for subarachnoid haemorrhage (SAH). Methods: We conducted a nationwide retrospective cohort study. Using the J-ASPECT Diagnosis Procedure Combination database, we identified 27,490 SAH patients who underwent clipping or coiling in 621 institutions between 2010 and 2015. The CSC capabilities of each hospital were assessed using a validated scoring system (CSC score: 1-25 points). We classified the hospitals into quartiles based on CSC score and case volume of clipping or coiling for SAH. Results: In clipped patients, a high case volume ( > 14 cases / year) was significantly associated with reduced in-hospital mortality (Q1 as control, Q4 odds ratios (ORs) 0.71 [95% confidence interval 0.55 - 0.90]) but not poor outcome. In coiled patients, a high case volume ( > 9 cases / year) was associated with reduced in-hospital mortality (Q4 0.69 [0.53 - 0.90]) and poor outcomes (Q3 ( > 5 cases / year) 0.75 [0.59 - 0.96], Q4 0.65 [0.51 - 0.82]). A high CSC score ( > 19 points) was significantly associated with reduced in-hospital mortality of clipped (0.68 [0.54 - 0.86]) but not coiled patients. There was no association between CSC capabilities and poor outcomes. Conclusions: The effect of case volume and CSC capabilities on in-hospital mortality and short-term functional outcomes in SAH patients was different between clipping and coiling. In the modern endovascular era, better outcomes of clipping may be achieved in facilities with high CSC capabilities.

To evaluate the usefulness of 4D-MR angiography based on super-selective pseudo-continuous ASL combined with keyhole and view-sharing (4D-S-PACK) for vessel-selective visualization and to examine the ability of this technique to visualize brain arteriovenous malformations (AVMs). In this retrospective study, 15 patients (ten men and five women, mean age 44.0 ± 16.9 years) with brain AVMs were enrolled. All patients were imaged with 4D-PACK (non-selective), 4D-S-PACK, and digital subtraction angiography (DSA). Observers evaluated vessel selectivity, identification of feeding arteries and venous drainage patterns, visualization scores, and contrast-to-noise ratio (CNR) for each AVM component. Measurements were compared between the MR methods. Vessel selectivity was graded 4 in 43/45 (95.6%, observer 1) and 42/45 (93.3%, observer 2) territories and graded 3 in two (observer 1) and three (observer 2) territories. The sensitivity and specificity for identification of feeding arteries for both observers was 88.9% and 100% on 4D-PACK, and 100% and 100% on 4D-S-PACK, respectively. For venous drainage, the sensitivity and specificity was 100% on both methods for observer 1. The sensitivity and specificity for observer 2 was 94.4% and 83.3% on 4D-PACK, and 94.4% and 91.7% on 4D-S-PACK, respectively. The CNRs at the timepoint of 1600 ms were slightly lower in 4D-S-PACK than in 4D-PACK for all AVM components (Feeding artery, p = .02; nidus, p = .001; and draining artery, p = .02). The visualization scores for both observers were not significantly different between 4D-PACK and 4D-S-PACK for all components. 4D-S-PACK could be a useful non-invasive clinical tool for assessing hemodynamics in brain AVMs. • The 4D-MR angiography based on super-selective pseudo-continuous arterial spin labeling combined with CENTRA-keyhole and view-sharing (4D-S-PACK) enabled excellent vessel selectivity. • The 4D-S-PACK enabled the perfect identification of feeding arteries of brain arteriovenous malformation (AVM). • 4D-S-PACK could be a non-invasive clinical tool for assessing hemodynamics in brain AVMs.

Objective We sought to examine whether the effect of treatment modality and drugs for cerebral vasospasm on clinical outcomes differs between elderly and non-elderly subarachnoid hemorrhage (SAH) patients in Japan. Methods We analyzed the J-ASPECT Study Diagnosis Procedure Combination database (n = 17,343) that underwent clipping or coiling between 2010 and 2014 in 579 hospitals. We stratified patients into two groups according to their age (elderly [≥75 years old], n = 3,885; non-elderly, n = 13,458). We analyzed the effect of treatment modality and anti-vasospasm agents (fasudil hydrochloride, ozagrel sodium, cilostazol, statin, eicosapentaenoic acid [EPA], and edaravone) on in-hospital poor outcomes (mRS 3–6 at discharge) and mortality using multivariable analysis. Results The elderly patients were more likely to be female, have impaired levels of consciousness and comorbidity, and less likely to be treated with clipping and anti-vasospasm agents, except for ozagrel sodium and statin. In-hospital mortality and poor outcomes were higher in the elderly (15.8% vs. 8.5%, 71.7% vs. 36.5%). Coiling was associated with higher mortality (odds ratio 1.43, 95% confidence interval 1.2–1.7) despite a lower proportion of poor outcomes (0.84, 0.75–0.94) in the non-elderly, in contrast to no effect on clinical outcomes in the elderly. A comparable effect of anti-vasospasm agents on mortality was observed between non-elderly and elderly for fasudil hydrochloride (non-elderly: 0.20, 0.17–0.24), statin (0.63, 0.50–0.79), ozagrel sodium (0.72, 0.60–0.86), and cilostazol (0.63, 0.51–0.77). Poor outcomes were inversely associated with fasudil hydrochloride (0.59, 0.51–0.68), statin (0.84, 0.75–0.94), and EPA (0.83, 0.72–0.94) use in the non-elderly. No effect of these agents on poor outcomes was observed in the elderly. Conclusions In contrast to the non-elderly, no effect of treatment modality on clinical outcomes were observed in the elderly. A comparable effect of anti-vasospasm agents was observed on mortality, but not on functional outcomes, between the non-elderly and elderly.

BackgroundLimited national-level information on temporal trends in comprehensive stroke center capabilities and their effects on acute ischemic stroke patients exists.AimsTo examine trends in in-hospital outcomes of acute ischemic stroke patients and the prognostic influence of temporal changes in comprehensive stroke center capabilities in Japan.MethodsThis retrospective study used the J-ASPECT Diagnosis Procedure Combination database and identified 372,978 acute ischemic stroke patients hospitalized in 650 institutions between 2010 and 2016. Temporal trends in patient outcomes and recombinant tissue plasminogen activator (rt-PA) and mechanical thrombectomy usage were examined. Facility comprehensive stroke center capabilities were assessed using a validated scoring system (comprehensive stroke center score: 1–25 points) in 2010 and 2014. The prognostic influence of temporal comprehensive stroke center score changes on in-hospital mortality and poor outcomes (modified Rankin Scale: 3–6) at discharge were examined using hierarchical logistic regression models.ResultsOver time, stroke severity at admission decreased, whereas median age, sex ratio, and comorbidities remained stable. The median comprehensive stroke center score increased from 16 to 17 points. After adjusting for age, sex, comorbidities, consciousness level, and facility comprehensive stroke center score, proportion of in-hospital mortality and poor outcomes at discharge decreased (from 7.6% to 5.0%, and from 48.7% to 43.1%, respectively). The preceding comprehensive stroke center score increase (in 2010–2014) was independently associated with reduced in-hospital mortality and poor outcomes, and increased rt-PA and mechanical thrombectomy use (odds ratio (95% confidence interval): 0.97 (0.95–0.99), 0.97 (0.95–0.998), 1.07 (1.04–1.10), and 1.21 (1.14–1.28), respectively).ConclusionsThis nationwide study revealed six-year trends in better patient outcomes and increased use of rt-PA and mechanical thrombectomy in acute ischemic stroke. In addition to lesser stroke severity, preceding improvement of comprehensive stroke center capabilities was an independent factor associated with such trends, suggesting importance of comprehensive stroke center capabilities as a prognostic indicator of acute stroke care.

Background We aimed to develop quality indicators (QIs) related to primary and comprehensive stroke care and examine the feasibility of their measurement using the existing Diagnosis Procedure Combination (DPC) database. Methods and results We conducted a systematic review of domestic and international studies using the modified Delphi method. Feasibility of measuring the QI adherence rates was examined using a DPC-based nationwide stroke database (396,350 patients admitted during 2013-2015 to 558 hospitals participating in the J-ASPECT study). Associations between adherence rates of these QIs and hospital characteristics were analyzed using hierarchical logistic regression analysis. We developed 17 and 12 measures as QIs for primary and comprehensive stroke care, respectively. We found that measurement of the adherence rates of the developed QIs using the existing DPC database was feasible for the 6 QIs (primary stroke care: early and discharge antithrombotic drugs, mean 54.6% and 58.7%; discharge anticoagulation for atrial fibrillation, 64.4%; discharge antihypertensive agents, 51.7%; comprehensive stroke care: fasudil hydrochloride or ozagrel sodium for vasospasm prevention, 86.9%; death complications of diagnostic neuroangiography, 0.4%). We found wide inter-hospital variation in QI adherence rates based on hospital characteristics. Conclusions We developed QIs for primary and comprehensive stroke care. The DPC database may allow efficient data collection at low cost and decreased burden to evaluate the developed QIs.

Visual Abstract, Treatment options for cerebral infarction beyond the time window of reperfusion therapy are limited, and novel approaches are needed. PDGF-B is considered neuroprotective; however, it is difficult to administer at effective concentrations to infarct areas. Nanoparticles (NPs) are small and stable; therefore, we modified PDGF-B to the surface of naturally occurring heat shock protein NPs (HSPNPs) to examine its therapeutic effect in cerebral infarction. PDGF-B modified HSPNPs (PDGF-B HSPNPs) were injected 1 d after transient middle cerebral artery occlusion (t-MCAO) in CB-17 model mice. We analyzed the infarct volume and motor functional recovery at 3 and 7 d. PDGF-B HSPNPs were specifically distributed in the infarct area, and compared with HSPNPs alone, they significantly reduced infarct volumes and improved neurologic function 3 and 7 d after administration. PDGF-B HSPNP administration was associated with strong phosphorylation of Akt in infarct areas and significantly increased neurotrophin (NT)-3 production as well as reduced cell apoptosis compared with HSPNPs alone. Moreover, astrogliosis in peri-infarct area was significantly upregulated with PDGF-B HSPNPs compared with HSPNPs alone. Treatment with PDGF-B HSPNPs might be a novel approach for treating cerebral infarction.

Carotid web is a nonatherosclerotic shelf-like projection located in the posterior wall of the proximal internal carotid artery and is considered an atypical variant of fibromuscular dysplasia. It is recognized as an important cause of ischemic stroke, especially cryptogenic stroke. Antithrombotic treatment and carotid revascularization with endarterectomy or stenting are performed, but the optimal treatment strategy is still controversial. In our presented case, ischemic stroke recurred despite medical treatment with antiplatelet and anticoagulant therapies, but treatment with carotid artery stenting was successful. Carotid revascularization with stenting might be a potential treatment option for the patient with carotid web resistant to medical treatment.

The development of stent-like devices has increased treatment options for complex internal carotid artery (ICA) aneurysms, but the optimal treatment remains unclear. The purpose of this study was to evaluate the safety and efficacy of endovascular parent-artery occlusion (PAO) for ICA aneurysms. We retrospectively reviewed 28 patients with unruptured ICA aneurysms ⩾10mm treated with PAO between April 2002 and March 2015 at our institution. Patients who developed neurologic symptoms or with venous-phase delay >2s during balloon test occlusion were not treated by PAO. Patients with venous-phase delays of 1-2s underwent superficial temporal artery to middle cerebral artery (STA-MCA) bypass prior to PAO. The median patient age was 65 (range, 26-84)years. Nineteen aneurysms (68%) were located in the cavernous segment. The median aneurysm size was 25 (range 11-40)mm. Venous-phase delay of 1-2s was observed in five patients. Perioperative ischemic complications (N=9, 32%), which occurred within 30days after treatment, were significantly associated with venous-phase delays of 1-2s (p

The epidemiology of patients with traumatic brain injury (TBI) has changed dramatically over recent decades as a result of rapid advances in aging societies. We assessed the influence of age on outcomes of patients with TBI and sought to identify prognostic factors for in-hospital mortality of TBI among elderly patients.Using a nationwide database, we analyzed data from 5651 patients with TBI. Univariate analysis was conducted to compare patient demographics, neurologic status on admission, radiologic findings, systemic complication rates, length of hospital stay, in-hospital mortality, and home discharge rates between elderly and nonelderly groups. Multivariable analysis was conducted to determine prognostic factors for in-hospital mortality among elderly patients.Overall in-hospital mortality was significantly higher in elderly patients (12.8% vs. 19.3%; P0.001). In-hospital mortality of elderly patients with mild TBI increased significantly at7 days after admission, whereas that of elderly patients with moderate or severe TBI was significantly higher immediately after admission. Age (odds ratio [OR], 1.62; P = 0.024), male sex (OR, 1.30; P = 0.004), Japan Coma Scale score on admission (OR, 5.95, P0.001), and incidence of acute subdural hematoma (OR, 1.89; P0.001) were associated with in-hospital mortality in elderly patients with TBI.Elderly patients with TBI showed significantly higher in-hospital mortality. Delayed increases in in-hospital mortality were observed among elderly patients with mild TBI. Level of consciousness on admission was the strongest predictor of in-hospital mortality among elderly patients.

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.

Pericytes are mural cells abundantly present in cerebral microvessels and play important roles, including the formation and maintenance of the blood–brain barrier. Nox4 is a major source of reactive oxygen species in cardiovascular cells and modulate cellular functions, particularly under pathological conditions. In the present study, we found that the expression of Nox4 was markedly induced in microvascular cells, including pericytes, in peri-infarct areas after middle cerebral artery occlusion stroke models in mice. The upregulation of Nox4 was greater in a permanent middle cerebral artery occlusion model compared with an ischemia/reperfusion transient middle cerebral artery occlusion model. We performed permanent middle cerebral artery occlusion on mice with Nox4 overexpression in pericytes (Tg-Nox4). Infarct volume was significantly greater with enhanced reactive oxygen species production and blood–brain barrier breakdown in peri-infarct areas in Tg-Nox4, compared with littermate controls. In cultured brain pericytes, Nox4 was significantly upregulated by hypoxia and was promptly downregulated by reoxygenation. Phosphorylation of NFκB and production of matrix metalloproteinase 9 were significantly increased in both cultured pericytes overexpressing Nox4 and in peri-infarct areas in Tg-Nox4. Collectively, Nox4 is upregulated in pericytes in peri-infarct areas after acute brain ischemia and may enhance blood–brain barrier breakdown through activation of NFκB and matrix metalloproteinase 9, thereby causing enlargement of infarct volume.

Background and purpose: In the rapidly aging society of Japan, improvement of the emergency medical care system for stroke is an urgent concern. In prehospital care for stroke, appropriate triage, selection of the delivery facility, and decreased transport time contribute directly to prognosis. The standard treatment for acute ischemic stroke (AIS) has changed dramatically. With the introduction of new thrombectomy devices, proper placement of comprehensive stroke centers (CSCs) should be reconsidered. Accordingly, a nationwide survey is needed to develop an efficient prehospital care system. The aim of this study was to elucidate problems in prehospital care for stroke in Japan, using a nationwide fire department (FD) questionnaire survey. Materials and methods: We conducted a questionnaire survey of 733 FDs in Japan with the cooperation of the Japanese Society of Emergency Medicine and the Emergency Planning Office of the Fire and Disaster Management Agency. The questionnaires evaluated utilization status of the Prehospital Stroke Life Support (PSLS) protocol and prehospital stroke scale (PSS), awareness of standard treatment with new devices, information on delivery facilities and transportation, use of information and communication technology (ICT), and the retraining system for paramedics. Results: Data obtained from 664 FDs (91%) were analyzed. The PSLS protocol and PSS were used by 47.2% and 59.6%, respectively. Surprisingly, only 35.6% of FDs had knowledge about the latest treatment for AIS, and half of the FDs did not have an opportunity to learn about treatment. The proportion of FDs with a CSC in their jurisdictions was decreased in rural areas compared with urban areas (19.2% vs. 49.8%). However, helicopter transportation and ICT were not adequately utilized even in rural areas. Only half of the FDs urged paramedics to attend a PSLS course. Conclusion: We demonstrated problems with prehospital care for stroke in Japan using a nationwide FD questionnaire survey. Placement of CSCs, adequacy of the transportation system, and communication between physicians and paramedics should be reevaluated.

Background: Many studies have reported that high-volume center was associated with the favorable outcomes in subarachnoid hemorrhage (SAH) patients with treatment. However, in Japan, the effect of the case volume of the hospital in SAH patients remains elusive. The aim of this study is to investigate the associations between case volume and outcomes of clipping or coiling using data obtained from the Japanese Diagnosis Procedure Combination [DPC]-based Payment System. Methods: Of the 847 certified training institutions of the Japan Neurosurgical Society, 327 institutions agreed to participate in this DPC discharge database study. Data on patients hospitalized for SAH between April 1, 2012 and March 31, 2013 were obtained from the DPC database. Patients hospitalized because of SAH were identified using International Classification of Diseases-10 diagnosis codes (I60.0-9). The case volumes of clipping and coiling in each hospital were divided into quintiles (Q1-Q4). Odd ratios (ORs) of in-hospital mortality and modified Rankin Scale (mRS) at discharge were estimated after adjustment for age, sex, comorbidities, and SAH severity. The category of Q1 was assigned a reference for OR. Results: A total of 5214 patients with SAH (3624 clipping, 1590 coiling) were analyzed. Mortality was 9.8%, and proportion of discharge mRS3-6 was 44.0%. No significant associations were found between case volume and in-hospital mortality in both the clipping (Q2, Q3, and Q4; OR = 0.97, 0.69, and 0.77; P = 0.902, 0.148, and 0.263) and coiling group (Q2, Q3, and Q4; OR = 0.94, 1.62, and 0.84; P = 0.864, 0.140, and 0.586). No significant associations were found between case volume and discharge mRS3-6 in both the clipping (Q2, Q3, and Q4; OR = 1.28, 1.27, and 1.09; P = 0.194, 0.189, and 0.619) and coiling group (Q2, Q3, and Q4; OR = 0.89, 1.15, and 0.78; P = 0.691, 0.599, and 0.315). Conclusion: In Japan, case volume did not show the correlation with outcomes in SAH patients. This nationwide database study reflects the real-world practice.

Although in-stent protrusion is a potential risk factor for thromboembolism following carotid artery stenting, the correlation between in-stent protrusion and postoperative ipsilateral stroke has not been well examined.We retrospectively reviewed 342 consecutive carotid artery lesions in 319 patients who underwent carotid artery stenting between April 2008 and April 2015. After excluding cases with carotid artery dissection and acute occlusion, 301 lesions in total of 277 patients were included in the analysis. We examined the association between in-stent protrusion, which was detected by intravascular ultrasound, and postoperative ipsilateral stroke within 30 days.In-stent protrusion was observed in 47 (15.6%) lesions, of which postoperative ipsilateral stroke within 30 days occurred with 4 (8.5%) lesions. All these events occurred within 10 days after treatment. On the other hand, only 1 (0.39%) of the 256 lesions without in-stent protrusion showed this symptom, and the event occurred at 30days after treatment. Thus, lesions with in-stent protrusion had a higher cumulative risk of ipsilateral stroke than those without in-stent protrusion (8.5% vs 0.4% at 30 days, log-rank P 0.001). In-stent protrusion, which was more often seen in symptomatic lesions, was associated with a vulnerable plaque assessed by MRI. After adjustment for postoperative stroke risks such as symptomatic lesions, plaque vulnerability, age or sex, in-stent protrusion was still significantly associated with postoperative ipsilateral stroke within 30 days (OR = 27.03, P = 0.001).Postoperative ipsilateral stroke was observed more frequently in patients with demonstrated in-stent protrusion (ISP) following CAS.

Background Although extracranial-intracranial (EC-IC) bypass is an effective treatment strategy for symptomatic moyamoya disease, surgeons need to be cautious regarding the possibility of postoperative hemorrhagic complications in patients with a concurrent coagulation disorder. Here, we describe a case of EC-IC bypass for moyamoya disease concurrent with von Willebrand disease type 1. Case Description Following perioperative replacement of the von Willebrand factor, the patient showed an uneventful and uncomplicated clinical course. Conclusion This is the first reported case of EC-IC bypass being performed for moyamoya disease in a patient with concurrent von Willebrand disease. We emphasize the importance of appropriate management with replacement of the von Willebrand factor during the perioperative period to avoid hemorrhagic complications.

Objective: We previously demonstrated comprehensive stroke care (CSC) capabilities of the hospitals affect in-hospital mortality of patients with acute stroke. With the advent of unprecedented aging society, proper implementation of stroke centers requires understanding of geographical disparity of patient characteristics as well as stroke care capabilities. The aim of this study was to elucidate such geographical disparity regarding acute stroke care in Japan using a nationwide database. Materials and methods: We analyzed the data obtained from the Japanese Diagnosis Procedure Combination-based Payment System in 445 institutions between 2010 and 2012. Patients hospitalized emergently for ischemic stroke(IS), non-traumatic intracerebral hemorrhage(ICH) and non-traumatic subarachnoid hemorrhage(SAH) were identified using International Classification of Diseases-10 diagnosis codes. We classified the location of the hospitals into 4 areas, “Metropolitan Employment Area-Central (MEA-C)”, “ Metropolitan Employment Area-Outlying (MEA-O)”, “Micropolitan Employment Area-Central (McEA-C)”, and “ Micropolitan Employment Area-Outlying (McEA-O)”. We investigated patient characteristics, medical backgrounds, interventions and outcomes for each area. Results: Data obtained from a total of 214,910 patients with acute strokes (136,753 IS, 60,379 ICH and 17,778 SAH) were analyzed. As for patient characteristics, elderly patients and those with hypertension were more common in McEA-C and McEA-O, and stroke severity was more severe in McEA-C in all stroke types. As for hospital characteristics, proportion of admission by ambulance and CSC capabilities of the hospitals were smaller in all stroke types. Moreover, emergent interventions such as intravenous rt-PA infusion were performed at a lesser extent and in-hospital mortality was higher in McEA-C and McEA-O, and severe disability with mRS 3-6 was more often noted in McEA-C in all stroke types. Conclusion: We demonstrated geographical disparity of acute stroke care in Japan from a nationwide database. For proper implementation of stroke centers, centralization of acute stroke care capabilities should be considered in the rural areas to improve outcomes of acute stroke.

Background: The effectiveness of comprehensive stroke center (CSC) capabilities on outcome of carotid endarterectomy (CEA) and carotid artery stenting (CAS) remains uncertain. We performed a nationwide study to examine whether CSC capabilities influenced in-hospital outcome of CEA and CAS. Methods: We analyzed 12,943 carotid artery stenosis patients treated with CEA or CAS in 350 certified training hospitals in Japan. Data between April 1, 2013 and May 31, 2015 was obtained from Japanese Diagnosis Procedure Combination Database. Among the institutions that responded, outcome was assessed by in-hospital mortality, ischemic stroke and myocardial infarction. CSC capabilities were evaluated from the 749 certified training institutions in Japan, which responded to a questionnaire survey regarding CSC capabilities that queried the availability of personnel, diagnostic techniques, specific expertise, infrastructure, and educational components recommended for CSCs. Total CSC scores of the participating hospitals were classified into quartiles (Q1: 0-15, Q2: 16-17, Q3: 18-19, Q4: 20-24). Results: The proportion of CEA and CAS were 5068 and 7875 (2013: 1685 and 2590, 2014: 1668 and 2564, 2015: 1715 and 2721). Between CEA and CAS, mortality rates were 0.24% and 0.75%, ischemic stroke were 8.41% and 7.56% and myocardial infarction were 0.76% and 0.17%. These outcomes had no differences among the years. There was tendency that mortality rates were lower with high total CSC scores in patients with CEA (Q1: 0.42%, Q2: 0.26%, Q3: 0.12%, Q4: 0%, P=0.16), but there were no differences with CAS (Q1: 1.0%, Q2: 0.74%, Q3: 0.63%, Q4: 0.83%, P=0.73). Ischemic stroke were significantly lower with high CSC scores in CEA (Q1: 9.76%, Q2: 10.77%, Q3: 9.14%, Q4: 6.59%, P Conclusion: It is reported using the data of Nationwide Inpatient Sample that operator volume was an important predictor of postprocedural outcomes in CAS. We demonstrated that CSC capabilities were associated with reduced in-hospital ischemic stroke in patients with CEA and CAS.

Background and purpose: The incidence of non-traumatic intracranial hemorrhage (ICH) during treatment with direct oral anticoagulants (DOACs) is lower than that during warfarin treatment. The characteristics of intracranial hemorrhage during DOAC therapy, however, remain unclear. Therefore, we performed a nationwide survey in Japan to examine the clinical characteristics and outcomes of DOAC-associated ICH using data obtained from the Japanese Diagnosis Procedure Combination (DPC)-based Payment System. Methods: We analyzed the data of 1,567 patients with ICH (DOAC-associated ICH, 88; warfarin-associated ICH, 1,479) who were urgently hospitalized at 575 institutions across Japan from April 2010 to March 2013 for whom prescription data before admission were available. Results: The annual number of patients with all anticoagulant (DOAC or warfarin)- associated ICH in each year from 2010 to 2013 was 226, 252, 426, and 663, representing 15.7%, 15.4%, 16.1%, and 16.1% of all ICH cases in the same period, respectively. There was an increase in the proportion of patients who presented with DOAC-associated ICH in all anticoagulant-associated ICH in each year from 2010 to 2013 (0%→0.4%→3.8%→10.7%). The proportion of patients with impaired consciousness (three-digit score on Japan Coma Scale) at admission (DOAC, 19.3%; Warfarin, 25.4%; P=0.20), in-hospital mortality within 7 days (DOAC, 11.4%; Warfarin, 19.5%; P=0.06), and mRS score of 5-6 at discharge (DOAC, 27.3%; Warfarin, 37.4%; P=0.06) were lower in the patients with DOAC-associated ICH. The rates of surgery for hematoma removal were significantly lower in the patients with DOAC-associated ICH (NOAC, 2.3%; Warfarin, 9.7%; P=0.019). Conclusions: This is the largest nationwide study of DOAC-associated ICH in a real-world situation in Japan, revealing that the patients with DOAC-associated ICH had better clinical outcomes compared with warfarin-associated ICH, probably due to milder hemorrhage at admission.

Background and purpose: The outcomes of subarachnoid hemorrhage (SAH) in aged patients are more severe than those in non-aged patients. There are few reports about the relationship between the age and the effect of perioperative care for SAH patients. We performed a nationwide survey in Japan to determine the relationship between perioperative care and SAH outcomes in aged and non-aged patients. Methods: We analyzed 17,343 subarachnoid hemorrhage (SAH) patients treated with clipping or coiling in 579 hospitals who participated in the J-ASPECT study. Data between 2010 and 2013 were obtained from the Japanese Diagnosis Procedure Combination Database. We stratified patients into two groups according to their age (aged group >75 y.o., n=3885; non-aged group < 75 y.o., n=13,458) and analyzed the association between perioperative care and poor outcome (modified Rankin Scale score 3-6 at the time of discharge). With respect to perioperative care, we evaluated time from onset to surgery (days), treatment (clipping or coiling), and drugs delivered after surgery (fasudil hydrochloride, ozagrel sodium, cilostazol, statin, EPA, edaravone). Results: In the non-aged group, coiling (OR=0.84; P Conclusion: Coiling and treatment with fasudil hydrochloride, statins, and EPA improved outcomes of non-aged patients. Although perioperative care did not improve the outcome of aged SAH patients, in cases of relatively mild SAH, perioperative care had the potential to improve the outcome.

Intracranial artery dissection (IAD) is a relatively rare cause of stroke, but it has been recognized increasingly with recent advances of the neuroimaging technique. Since rebleeding occurs frequently in the acute stage in the ruptured IAD, urgent surgical treatment should be performed to prevent rebleeding. On the other hand, surgical treatment for unruptured IAD is controversial because it has little risk for bleeding. However, surgical treatment for unruptured IAD may be considered if the formation or enlargement of the aneurysmal dilatation has been confirmed. Since there are several proposed surgical strategies for IAD, it is important to select an appropriate strategy on a case-by-case basis. If the risk of infarction due to vessel occlusion is high, combined bypass surgery should be considered.

Infants with acute hydrocephalus often present with nonspecific neurological signs, and cystic choroid plexus papilloma (CPP) is a very rare cause of acute obstructive hydrocephalus. The authors present the case of a 1-year-old girl who became irritable, started vomiting, and became comatose within a day. Magnetic resonance (MR) imaging revealed a cystic lesion in the third ventricle as well as hydrocephalus. Although the aqueduct appeared to be patent, phase-contrast MR imaging showed no pulsatile flow of cerebrospinal fluid in the ventricles. An emergent endoscopic third ventriculostomy was performed. Endoscopic examination revealed a highly mobile cyst attached by a pedicle to the choroid plexus adjacent to the Monro foramen in the lateral ventricle. The cyst was totally excised during the endoscopic procedure and was subsequently diagnosed as a CPP on the basis of histopathological findings. Purely cystic CPP is a very rare pathological entity; however, when it does occur, it can cause obstructive hydrocephalus which, without rapid diagnosis and surgical intervention, could lead to sudden death.

症例は45歳男性. 42歳時に噴門側部分胃切除を施行.術後,眼球運動障害と四肢脱力,体幹失調を2回繰り返した.頭部MRIで両側視床および中脳水道周囲に異常信号域を認め,血中ビタミンB1が著明に低下していた.入院当日よりビタミンB1を投与開始したところ2日目には眼球運動障害は消失, 2週間後には歩行可能となった.大酒家でなくても胃切除の既往を有する例では少量のアルコール摂取でも繰り返しWernicke脳症を起こす可能性が考えられた.

A preprocessing method, called image screening, is presented to improve the recognition rate and efficiency in statistical image recognition. The problem of detecting a specified object in input images is treated as a two-class classification problem in which the image falls into both a set of subimages in the target object (figure) class and the other set of subimages in the ground class. An image screening algorithm based on projection pursuit selects a candidate set of subimages that is similar to the object class, it rejects the remaining set using screening filters whose design is based on projection pursuit. The feature space for recognition is obtained from the selected subimages. Two kinds of measures to evaluate the performance of image screening are defined. The error rate in image screening is related to the total recognition rate of the system and the rejection rate of the noise image is related to the recognition efficiency. Two kinds of experiments were conducted, one to detect the eye and mouth areas in a face image and the other to detect the text area in a document image. Experimental results for these two tasks demonstrate that our method improves the recognition accuracy and efficiency.

Two cases of abdominal aortic aneurysm concurrent with horseshoe kidney are described. Both 66- and 75-year-old men were seen at the hospital because of an abdominal tumor which was pointed out at another hospital during the therapy for another disease. In each case, ultrasonography, CT, and aortography revealed an abdominal aneurysm and horseshoe kidney overlying on the ventral surface of the aneurysm. The isthmus of horseshoe kidney was composed of normal parenchyma. In both cases, two pairs of arteries running to the left or right side of the kidney wee demonstrated by the aortogram, but the fifth relatively small artery originating from the aortic bifurcation or common iliac artery was only found intraoperatively. Aneurysmectomy was performed successfully without dividing the isthmus of horseshoe kidney in both patients. One of the renal arteries in case 1 was reconstructed after cutting, but the lowest one to the left kidney in case 1 and that to the right kidney in case 2 were cut and ligated without significant renal damage. In the operation there are two problems that whether the isthmus should be cut, and how treatment should be given to the renal artery, and we are often obliged to make the final decision during surgery. We should entertain and prepare for all possibilities including the existence of abnormal renal arteries before operation.