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Background and Purpose: The failure of neuroprotective treatment-related clinical trials may be partially caused by unestablished animal models. Existing animal models are less likely to provide occlusion confined to the middle cerebral artery (MCA), making transarterial intervention difficult. We aimed to develop a novel focal stroke model using a microcatheter and zirconium dioxide that is non-magnetic under fluoroscopic guidance, which can monitor MCA occlusion and can improve hemorrhagic complications. Methods: Using male Sprague Dawley rats (n=8), a microcatheter was navigated from the caudal ventral artery to the left internal carotid artery using digital subtraction angiography to establish local occlusion. Results: All rat cerebral angiographies were successful. No rats had hemorrhagic complications. Six (75%) rats underwent occlusion of the MCA bifurcation by zirconium dioxide. Accidentally, the left posterior cerebral artery was failure embolized in 2 rats (25%) via the posterior communicating artery. The median operating time was 8.5 min. Moreover, 2% 2,3,5-triphenyl tetrazolium chloride staining showed that the median infarct volume (mm3) was 280 (interquartile range; 267-333) 24 hours after the left MCA bifurcation occlusion. Conclusions: We present a novel rat model for focal stroke using a microcatheter and zirconium dioxide which does not affect the MRI. The model is predictable and reproducible, which is well confined within the territory supplied by the MCA. Fluoroscopy was able to identify which the MCA occlusion and model success while creating the model. It permitted exclusion of animals with complications from the experiment.

Introduction: The failure of neuroprotective treatment-related clinical trials may be partially caused by unestablished animal models. We aimed to develop a novel focal stroke model using a cell-implantable radiopaque hydrogel micro fiber. The micro fiber is made of barium alginate hydrogel containing zirconia, and fabricated in a dual coaxial laminar flow microfluidic device. Methods: Using male Sprague Dawley rats (n=10), a catheter (ID 0.42mm, OD 0.55mm) was navigated from the caudal ventral artery to the left internal carotid artery using digital subtraction angiography. A radiopaque hydrogel micro fiber (0.4 mm in diameter, 1 mm in length) was advanced in the catheter by slow injection of heparinized physiological saline to establish local occlusion. 9.4-T MRI and 2% 2,3,5-triphenyl tetrazolium chloride staining were performed 24 hours after the creation of the stroke model. Results: The anterior cerebral artery-middle cerebral artery bifurcation was selectively embolized at all rats. The median operating time was 8.5 min (interquartile range; 6.25-12 min). The median infarct volume (mm 3 ) was 262 (interquartile range; 260-274) 24 hours after occlusion. Conclusions: We present a novel rat model for focal infarct only in the middle cerebral artery territory using a radiopaque hydrogel micro fiber. Furthermore, this model can be used for regeneration research of cerebral infarction because the hydrogel micro fiber can encapsulate stem cell.Figure Legends A: Puncture of the caudal ventral artery in a rat. B: Cerebral angiography of a rat. C: Occlusion of the anterior cerebral artery-middle cerebral artery bifurcation by a radiopaque hydrogel fiber (arrowhead). D: MR angiography detected selective occlusion of left middle cerebral artery. E: T2-weighted image showed infarct only in the middle cerebral artery after 24 hours occlusion. A radiopaque fiber did not affect the 9.4-T MRI. F: Radiopaque hydrogel fiber encapsulated HeLa cells.

Background and Purpose: The association between the cerebral microbleed (CMB) count and outcomes in ischemic stroke has not been fully clarified. The aim of this study was to investigate the relationship between the CMB count and functional outcomes in patients with a minor ischemic stroke treated with antiplatelet therapy. Methods: Non-cardiogenic minor ischemic stroke (NIHSS score 4), and their clinical outcomes were compared. Deep white matter hyperintensities (DWMHs) were assessed using the Fazekas scale, and the relationship between DWMH burden and the CMB count was evaluated. A poor outcome was defined as a modified Rankin scale (mRS) score of 3-6 90 days after symptom onset. Logistic regression analysis was performed to evaluate whether the CMB count contributes to poor outcomes. Results: A total of 240 patients were enrolled, and their pre mRS scores were matched based on CMB presence. The median CMB count increased linearly with the Fazekas scale grade (P4 CMB group, P=0.002). Multivariate logistic regression analysis performed with well-known risk factors including DWMH showed that CMB burden (subgroups) was the independent factor associated with poor outcomes (odds ratio 1.75, 95% confidence interval 1.13-2.72, P=0.012), whereas the DWMH burden was not. Conclusion: The CMB count contributes independently to poor outcomes in minor ischemic stroke patients treated with antiplatelet therapy.

Introduction: The correlation between serum polyunsaturated fatty acids (PUFAs) such as Eicosapentaenoic Acid (EPA), Docosahexaenoic Acid (DHA), Arachidonic Acid (AA) and Dihomogammalinolenic Acid (DHLA) levels and clinical outcomes of cardiovascular disease are previously reported. The aim was to investigate serum PUFAs including AA levels to clinical outcome in intracerebral hemorrhage (ICH) patients. Method: From Nov 2012 to Nov 2019, ICH patients within 24 hours from the onset were enrolled. All patients underwent radiological investigations and laboratory examinations including measurement of serum PUFAs levels on admission. We divided patients into two groups, favorable outcome group (mRS at 3 months 0-3) and poor outcome group (mRS at 3 months 4-6). We compared baseline variables including serum PUFAs levels between two groups. Result: We enrolled 142patients (87 male, median age 60 years old, median NIHSS score 8). Of them, 113 patients (80%) were favorable outcome group and 29 patients (20%) were poor outcome group. Higher NIHSS score and larger size of hematoma on admission were found in poor outcome group (median NIHSS score 6 of favorable outcome vs. 14 of poor outcome, p Conclusion: Serum AA levels may play an important role in predicting the outcome in ICH.

Background and Purpose: Recent several studies demonstrated that percutaneous patent foramen ovale (PFO) closure reduced the risk of stroke recurrence for patients with cryptogenic stroke (CS) and PFO. Our aim of this retrospective study is to survey the frequency of CS, which can be an indication of PFO closure. Methods: Subjects were consecutive stroke patients with symptomatic ischemic lesion detected by magnetic resonance imaging. Of them, CS were extracted according to exclusion of small-vessel collusion, large-artery atherosclerosis, cardioembolism, definite case of aortogenic embolism, and distinctive causeof ischemic stroke such as arterial dissection, hypercoagulable state and so on. After that, we selected patients in accordance with clinical guideline of PFO closure recommended by the Japanese Stroke Association (Figure). We analyzed the prevalence of CS with right-to-left shunt (RLS) as a good and recommended candidates for PFO closure. Results: Among 1,374 ischemic stroke patients from October 2012 to September 2019 , CS were 240 patients (83 females, mean age of 66 years, 17% of subjects). Of them, 100 patients (42%) had RLS (PFO; 65, atrial septal defect; 1, pulmonary arteriovenous fistula; 1, positive on transcranial Doppler (not performed in TEE) including 21 cases of definite of paradoxical embolism. In 65 patients of CS with PFO, 30 patients younger than 60 years (13% of CS) were good candidates for PFO closure. Moreover, 22 of 1,374 (1.6%) patients who were recommended candidates had one or more high risk factors of PFO, for example large shunt, atrial septal aneurysm, and the presence of shunt at rest (Figure). Conclusions: In our preliminary survey, 2% of acute ischemic stroke should be PFO closure candidates.

A 60-year-old man developed aphasia and transient right upper limb paresis in the presence of chronic subdural hematoma and was transferred to our hospital at an early stage. Cranial MRI within an hour after onset showed diffusion-weighted image (DWI) hyperintensity in the left parietal, temporal, and insular cortex and the pulvinar, and decreased apparent diffusion coefficient (ADC) in the left parietal cortex and pulvinar, suggesting a differential diagnosis of hyper-acute ischemic stroke. However, the distribution and timing of the MRI abnormalities were considered to be atypical for hyper-acute ischemic stroke. The area with both DWI hyperintensity and decreased ADC included the cerebral cortex adjacent to the hematoma and the ipsilateral pulvinar, and fluid-attenuated inversion recovery (FLAIR) hyperintensity co-existed with DWI hyperintensity within only an hour from onset. Furthermore, FLAIR images showed infiltration of the hematoma content into the subarachnoid space, which might have triggered the attack. These findings collectively led us to diagnose an epileptic seizure. The present case suggests that the distribution and timing of MRI abnormalities are essential to differentiate epileptic seizures from hyper-acute ischemic stroke.

Surgery in humans is continuously evolving and promoted minimally invasive treatment. On the other hand, despite the importance of the 3Rs principles for experimental animals is well documented, no reports describe specific methodologies for implementing "refinement" in practice. Here, we describe a new technique, the "Ohta Method" for caudal arthrocentesis in the pursuit of the 3Rs for animal experiments and the development of innovative methods for investigating systemic organ arteries through minimally invasive procedures. This procedure requires only a percutaneous puncture of the caudal artery without any injury to the limb or body trunk. In addition, it does not cut down the artery, making hemostasis easier and recovering arterial damage easier. We will show multiple organ artery angiographies in marmoset for the first time in the world. The principle described in this paper could also be applied to many other small animals, such as rats. Moreover, using this method, multiple doses of the drug or cells can be administered to the target organ at the time of therapeutic intervention, thereby enabling the establishment of more sophisticated and complex therapeutic intervention studies as translational research.

BACKGROUND Telestroke has developed rapidly as an assessment tool for patients eligible for reperfusion therapy. OBJECTIVE To investigate whether vascular neurologists can diagnose intracranial large vessel occlusion (LVO) as quickly and accurately using a smartphone application compared to a hospital-based desktop PC monitor. METHODS We retrospectively enrolled 108 consecutive patients with acute ischemic stroke in the middle cerebral artery territory who underwent magnetic resonance imaging (MRI) within 24 hours of their stroke onset. Two vascular neurologists, blinded to all clinical information, independently evaluated magnetic resonance angiography and fluid-attenuated inversion recovery images for the presence or absence of LVO in the internal carotid artery and middle cerebral artery (M1, M2, or M3) on both a smartphone application (Smartphone-LVO) and a hospital-based desktop PC monitor (PC-LVO). To evaluate the accuracy of an arterial occlusion diagnosis, interdevice variability between Smartphone-LVO and PC-LVO was analyzed using κ statistics, and image interpretation time was compared between Smartphone-LVO and PC-LVO. RESULTS There was broad agreement between Smartphone-LVO and PC-LVO evaluations regarding the presence or absence of arterial occlusion (Reader 1: κ=0.94; PP CONCLUSIONS The results indicate the evaluation of neuroimages using a smartphone application can provide an accurate and timely diagnosis of anterior intracranial arterial occlusion that can be shared immediately with members of the stroke team to support the management of patients with hyperacute ischemic stroke.

BACKGROUND AND AIMS Correlations between serum levels of polyunsaturated fatty acids (PUFAs) such as eicosapentaenoic acid (EPA), docosahexaenoic acid (DHA), arachidonic acid (AA) and dihomogammalinolenic acid (DHLA) and outcomes following cardiovascular disease have been reported. This study aimed to investigate the relationship between serum levels of PUFAs (including AA) and functional outcomes among intracerebral hemorrhage (ICH) patients. METHODS From November 2012 to July 2020, ICH patients within 24 h from onset were enrolled. Patients were divided into a good functional outcome group (modified Rankin Scale [mRS] score at 3 months, 0-3) and a poor functional outcome group (mRS score at 3 months, 4-6). We compared baseline variables between groups. RESULTS Participants comprised 133 patients (mean age, 60 years), with 106 patients (80%) in the good functional outcome group and 27 patients (20%) in the poor functional outcome group. Higher National Institutes of Health Stroke Scale (NIHSS) score and larger hematoma on admission were more frequent in the poor functional outcome group (median NIHSS score 6 vs. 14, p

Background: Orthostatic hypotension (OH) at an early stage of Parkinson’s disease (PD) predicts poor prognosis, which may suggest degeneration of dopaminergic neurons affects sympathetic function, causing OH. Objective: We tested the hypothesis that striatal dopaminergic depletion is associated with OH in PD. Methods: Out of 99 patients with newly diagnosed untreated PD, 81 patients were enrolled according to our selection criteria. All patients underwent head-up tilt-table testing and striatal 123I-2β-carbomethoxy-3β-(4-iodophenyl)-N-(3-fluoropropyl) nortropane (123I-FP-CIT) dopamine transporter single photon emission computed tomography (DAT-SPECT). DaTQUANT software (GE Healthcare) was used as a semi-quantitative tool to analyze DAT-SPECT data. The association between hemodynamic changes and 123I-FP-CIT uptake was examined. Results: 123I-FP-CIT uptake in the putamen, especially the anterior part and left side, was related not only to motor severity but also to OH. Change in systolic blood pressure correlated negatively with 123I-FP-CIT uptake in bilateral anterior putamen (left: p

Objectives To investigate the differences in clinical backgrounds, especially weekly variations of stroke occurrence, between hyper-acute ischemic stroke patients with and without regular employment (RE), as well as the impact of RE on outcome. Materials and methods Symptomatic ischemic stroke patients with ≤4.5 h from onset to door were enrolled. First, we divided patients into the RE and non-RE group to analyze differences in clinical characteristics, especially relation between weekly variations of stroke occurrence and RE. Second, we divided the same patients into those with and without favorable outcomes (modified Rankin Scale score of 0 to 2 at 3 months from stroke onset) to analyze the impact of RE on outcomes. Results We screened 1,249 consecutive symptomatic ischemic stroke patients and included 377 patients (284 [75%] males; median age, 67 years). Of these patients, 248 (66%) were included in RE group. First, RE was independently associated with occurrence of stroke on Monday in reference to Sunday or a public holiday (OR 2.562, 95% CI 1.004-6.535, p = 0.049). Second, RE (OR 2.888 95% CI 1.378-6.050, p = 0.005) was a factor independently associated with a favorable outcome. Conclusions Patients with RE were more likely to have a hyper-acute ischemic stroke on Monday in reference to Sunday or a public holiday. However, RE before stroke onset appears to have a positive impact on outcome.

Delayed orthostatic hypotension (DOH), a fall in blood pressure after a 3-min cutoff, is clinically meaningful. The aim of this study was to elucidate the clinical and neuroendocrinological characteristics of DOH in patients with Parkinson’s disease (PD). A total of 132 patients with newly diagnosed PD were enrolled. Baseline clinical characteristics, including olfactory function, and changes in norepinephrine (NE) and vasopressin (ADH) concentrations during the head-up tilt test (HUT), were examined. Fifty-five patients (42%) had classical orthostatic hypotension (COH), and 19 patients (14%) had DOH. Patients with COH and DOH tended to have more severe hyposmia than patients without OH. A multivariate linear regression model showed that hyposmia was associated with DOH and COH. The increase of heart rate against the fall in blood pressure was significantly lower in patients with COH and DOH than those without OH. The NE levels at supine rest and after upright tilting were lower in the COH group than in the PD without OH and DOH groups. The levels of ADH were higher in the DOH group than in the COH group at supine rest and higher than in the PD without OH group after upright tilting. There was no significant difference in the cardiac 123I-MIBG scintigraphy between the COH and DOH groups. Compared with patients without OH, patients with DOH had severe hyposmia. Relatively preserved peripheral sympathetic nervous system function in patients with DOH suggests that DOH might be an early and milder form of OH in PD.

Spontaneously disappearing lesions on magnetic resonance imaging (MRI) has been described in primary central nervous system lymphoma. In this case, we report our experience of spontaneously changing MRI findings of primary central nervous system vasculitis (PCNSV) confirmed histopathologically. A 69-year-old man presented with sudden unsteady gait. Fluid-attenuated inversion recovery (FLAIR) images showed high-intensity areas in the right deep white matter. Contrast-enhanced T1-weighted MRI demonstrated a nodular lesion in the white matter of the left occipitoparietal lobe. On repeat MRI 7 days later, FLAIR hyperintense lesions had spontaneously disappeared and contrast-enhanced lesions had progressed, with new contrast lesions in the right corpus callosum. Repeat MRI 14 days after admission demonstrated contrast-enhancing lesions either increased or decreased in intensity in both occipitoparietal lobes. Contrast-enhancing lesions were therefore biopsied. Histopathological examination revealed vasculitis with fibrinoid necrosis. PCNSV was diagnosed without any signs of inflammation in blood vessels other than cerebral blood vessels. Spontaneously changing MRI findings may play an important role in diagnosing PCNSV.

Background and Purpose: The relationship between cerebral microbleeds (CMBs) and prognosis in patients with ischemic stroke is still unclear. Our aim here was to verify the relationship between CMBs and functional outcomes in patients with minor ischemic stroke treated with antiplatelet therapy. Methods: We retrospectively reviewed consecutive patients with a non-cardiogenic minor ischemic stroke (NIHSS

Early hematoma expansion (HE) is seen in approximately 30% of patients with intracerebral hemorrhage (ICH), but detecting patients with a high HE risk is challenging.The NAG scale is a simple predictive scale for HE in acute ICH patients. Multi-institutional validation of the usefulness of this scale was the aim of this study.We retrospectively reviewed 142 consecutive primary ICH patients admitted to our hospital between September 2016 and December 2018. The NAG scale consists of three factors: National Institutes of Health Stroke Scale (NIHSS) score ≥ 10, anticoagulant use, and glucose ≥133 mg/dl (1 point each). Patients underwent non-contrast computed tomography (CT) within 24 h of symptom onset and follow-up CT 6 h, 24 h, and 7 days after admission. We defined HE as increased hemorrhage volume 33% or an absolute increase of6 mL on follow-up CT. Poor prognosis was defined as a modified Rankin scale score of 4-6 at discharge. We performed logistic regression analysis and created receiver operating characteristic curves to determine the discrimination ability of the NAG score.Patients constituted 96 men and 46 women (median age: 64 years; median NIHSS: 11), and HE was observed in 38/142 patients (27%). Higher NAG sores were associated with HE (P .001), poor prognosis (P .001), and in-hospital death (P .001). The C statistic was 0.72 (95% confidence interval [CI]: 0.63-0.82) for HE, 0.67 (95% CI: 0.58-0.76) for poor prognosis, and 0.85 (95% CI: 0.74-0.95) for in-hospital death. Multivariate logistic regression analysis with known risk factors showed that NAG scale score was an independent risk factor for HE (odds ratio: 2.95; 95% CI: 1.57-5.52; P = .001).The NAG scale showed good discrimination in our multi-institutional validation.

Background: The failure of clinical trials on neuroprotective treatment may be partially caused by unestablished animal models. To verify a trans-arterial regeneration therapy, our project is aimed at developing a brand-new focal stroke model using micro catheter. Methods: Using Sprague-Dawley rats (n=8), a micro catheter (ID 0.26mm, OD 0.35mm) was navigated from the caudal ventral artery to the middle cerebral artery in order to establish local occlusion under digital subtraction angiography apparatus. Results: We succeeded in brain angiography by percutaneous tail artery puncture and occlusion of the middle cerebral artery by a radiopaque micro bead with 6 rats (75%). Ischemic stroke lesion volume is 480.3 mm3±84.2 mm3 on sustained 1% TTC solution after 24 hours occlusion. Conclusion: We present a new rat model for focal stroke using micro catheter under fluoroscopic control. The model is capable of repeated super selective administration of therapeutics directly to cerebral artery, and practice the 3Rs principles in experimental animals because of minimal invasive.Figure Legend- A: A sheath is inserted through the ventral midline, approximately 5 cm from the root of the tail of the rat, with a sharp angle. B: Cerebral angiography of rats. Arrowhead pointe middle cerebral artery. C: Occlusion of the middle cerebral artery by a radiopaque micro bead (arrowhead). D: Brain is sliced and stained 1% TTC solution after 24 hours occlusion.

Introduction: No lesion on admission DWI but delayed appearance in the follow-up DWI are not uncommon in acute stroke. Our aim is to investigate clinical features of patients with delayed-high intensity area (DHIA) on follow-up DWI. Methods: We enrolled 1) TIA patients and 2) clinically suspected stroke patients sustaining a neurological deficit over 24 hours without ischemic lesion on initial DWI. Follow-up DWI was performed in 7 days after admission. We divided into two groups as follows; DHIA group and no hyper-intense lesion on initial and second DWI (NHIA group). Univariate and multivariate logistic regression analysis were conducted on backgrounds, clinical courses including time from onset to MRI, symptom duration, and favorable outcome (mRS 0-1) in 3 months in both groups. Results: One hundred seventy-two cases were identified (male 68%, median age 66 yo, median NIHSS score 1, delayed-HIA group; 48 patients) between October 2012 and March 2019. DHIA group was older (72 yo vs 64 yo, p Conclusion: Follow-up DWI may play an important role of outcome biomarker in TIA and initially suspected stroke. Repeated MRI should be performed for elder and severe neurological deficits.

Background and Purpose: We aimed to investigate the differences in weekly variations of stroke occurrence between hyper-acute ischemic stroke patients with and without regular employments (RE), and the impact of RE on outcome. Methods: Consecutive symptomatic ischemic stroke patients with < 4.5 h from onset to door between October 2012 and May 2018 were enrolled. All the situations of employment on admission were obtained from interviews with the participant or substitute guardians. First, we divided the patients into with and without RE to evaluate the differences in weekly variations of stroke occurrence. Second, we divided the same patients into with and without favorable outcome (mRS score of 0 to 2 at 3 months from the onset) to evaluate the impact of RE on outcome. Results: We screened 1,249 consecutive symptomatic ischemic stroke patients, including 385 patients (292 (76%) male, median age 67 years) with hyper-acute ischemic stroke. Of all, 251 patients (65%) were included in RE group. In the multivariate analysis, patients with RE were more likely to develop strokes on Monday compared to that on Sunday and public holiday (OR 2.841, 95% CI 1.145-7,049, p = 0.024, Figure A). In the multivariate analysis, the factors associated with favorable outcome were low NIHSS score on admission (OR 0.909, 95% CI 0.857-0.964, p = 0.001), not receiving endovascular therapy (OR 0.175 95% CI 0.069-0.444, p p = 0.039, Figure B). Conclusions: There were dramatic differences in weekly variations of hyper-acute ischemic stroke occurrence between patients with and without RE. Monday seems to be “a black day” for ischemic stroke patients with RE. RE had a positive impact on outcome in hyper-acute ischemic stroke.

Background and Purpose: Hyperintense vessel sign on FLAIR (HVS) has been described in hyperacute stroke patients with arterial occlusion. It’s a surrogate marker for stroke severity in patients with acute ischemic stroke of the anterior circulation. We aimed to reveal the clinical significance of HVS in patients with acute posterior circulation infarction. Methods: This observational study is based on a single-center prospective registry study. Inclusion criteria were: symptomatic ischemic stroke patients who have lesions only in posterior circulation; and taken initial MRI within 14 days from onset.An unfavorable outcome was defined as mRS score of 2 to 6 at 3 months from the onset. First investigation is to estimate whether HVS could be related to the subtype of acute ischemic stroke (cohort A). Second, the correlation between HVS and mRS at 3 months was evaluated (cohort B). Results: From October 2012 to May 2019, consecutive 1,079 ischemic stroke subjects were screened, including 277 in cohort A (191 male, median age 64 years) and 240 in cohort B (165 male, median age 66 years, Figure A). In cohort A, HVS was independently associated with intracranial artery dissection (OR 5.228; 95% CI 2.270-12.039; p = 0.001) and large-artery atherosclerosis (OR 3.582; 95% CI 1.244-10.317; p = 0.018, Figure B). In cohort B, HVS was not a factor independently associated with unfavorable outcome (OR 2.925; 95% CI 0.881-9.714; p = 0.080). Conclusions: HVS in patients with posterior circulation infarct suggests intracranial artery dissection or large-artery atherosclerosis, but does not have impact on their clinical courses.

Background and Purpose: Early hematoma expansion (HE) is seen in about 30% of intracerebral hemorrhage (ICH) patients, but detecting those patients with high risk of HE is challenging. The NAG scale was previously published as the simple predictive scale for HE in acute ICH patients. Multi-institutional validation for utility of the scale was the aim of this study. Methods: We retrospectively reviewed consecutive primary ICH patients, who were admitted between September 2016 and December 2018 to Jikei University Hospital or Kashiwa Hospital, Japan. NAG scale is consist of 3 factors based on examination on admission; NIHSS ≥10, Anticoagulant agents use, Glucose ≥133 mg/dl, with 1 point assigned for each parameter. Patients received an initial non-contrast computed tomography (CT) scan within 24 hours from symptom onset, and underwent follow-up CT scans at 6 hours, 24 hours, and 7 days after admission. The HE was defined as an increment in hemorrhage volume >33% or an absolute increase >6 mL on follow-up CT scans. Poor prognosis was defined as modified Rankin Scale 4-6 at discharge. We performed logistic regression analysis and receiver operating characteristic curves to determine discrimination ability of the score. Results: A total of 142 patients (96 men; median age 64 years; median NIHSS 11) were included in our study, and HE was observed in 38 patients (27%). Higher NAG sores were related to HE (P The C statistic was 0.72 (95% confidence interval [CI], 0.63-0.82) for HE, 0.67 (95% CI, 0.58-0.76) for poor prognosis, and 0.85 (95% CI, 0.74-0.95) for in-hospital death. Multivariate logistic regression analysis with known risk factors showed the NAG scale was the independent factor for HE (Odds ratio, 2.95; 95% CI, 1.57-5.52; P = 0.001). Conclusion: Multi-institutional validation of the NAG scale showed good discrimination.

Background and Purpose: To determine the parameters of transcranial color-coded duplex sonography (TCCS) related to unfavorable outcomes, and further to clarify the correlation between those parameters and heart functions in acute ischemic stroke without vessel stenosis. Methods: Patients were selected from a comprehensive stroke center between October 2012 and June 2019. Inclusion criteria were: acute ischemic stroke or TIA; able to measure blood flow of either the left or right middle cerebral artery (M1) by TCCS with ≤7 days from onset; and have no vessel stenoses or occlusions assessed by MRA and carotid artery ultrasonography. An unfavorable outcome was defined as mRS score of 2 to 6 at 3 months from the onset. First, we investigated the parameters of TCCS related to unfavorable outcomes (cohort A). Second, the correlation between those parameters and heart functions assessed by transthoracic echocardiography was evaluated (cohort B). Results: We screened 1,529 consecutive ischemic stroke patients, including 173 in cohort A (146 (84%) male, median age 59 years) and 192 in cohort B (162 (84%) male, median age 60 years) (Figure A). In cohort A, high M1 pulsatility index (PI) (OR 0.043; 95% CI 0.005-0.407; p = 0.006) was independently associated with an unfavorable outcome (Figure B). In cohort B, higher age (OR 1.532; 95% CI 1.118-2.009; p = 0.008), higher E/e' (OR 1.143; 95% CI 1.011-1.292; p = 0.033), and aortic valve regurgitation (AR > mild) (OR 4.780; 95% CI 1.261-18.114; p = 0.021) were factors independently associated with high M1 PI (Figure C). Conclusions: High M1 PI predicts an unfavorable outcome and correlates with high E/e' suggesting diastolic heart dysfunction and aortic valve regurgitation in acute ischemic stroke without vessel lesion.

Background and Purpose Early hematoma expansion (HE) is not rare in intracerebral hemorrhage (ICH) patients, but detecting those patients with high risk of HE is challenging. The aim of this retrospective study was to investigate the factors associated with HE in acute ICH patients, and to develop a simple predictive scale for HE. Methods We retrospectively reviewed consecutive patients with primary ICH, who received an initial non-contrast computed tomography (CT) scan within 24 hours from symptom onset. Patients underwent follow-up CT scans at 6 hours, 24 hours, and 7 days after admission. We compared the clinical characteristics of patients with and without HE (defined as an increase in intracerebral hemorrhage volume >33% or an absolute increase >6 mL on follow-up CT scans), and performed a logistic regression analysis to determine the predictors of HE. Results A total of 118 patients (78 men; median age 63 years; interquartile range 54–73) were included in our study. HE was observed in 30 patients (25%). HE patients showed higher rates of anticoagulant use (20% vs. 2%, respectively; P=0.003), high National Institutes of Health Stroke Scale on admission (13 vs. 7, respectively; P=0.001), and high plasma glucose (141 mg/dl vs. 113 mg/dl, respectively; P=0.001) compared with patients without HE. After multivariate logistic regression analysis, we selected three factors for defining the NAG scale (1 point as baseline National Institutes of Health Stroke Scale ≥10, 1 point as anticoagulant use, and 1 point as plasma glucose ≥133 mg/dL). The frequencies of HE associated with the NAG scale scores were as follows: score 0, 4%; score 1, 25%; score 2, 60%; score 3, 100%. Conclusion Stroke severity, hyperglycemia, and anticoagulation use were factors independently associated with HE. The NAG scale consists of readily available factors and can predict HE.

In general, involuntary movements after stroke are due to a disturbance in the unilateral cortico-basal ganglia loop and appear contralateral to stroke lesions. Crossed involuntary movements after unilateral stroke are very rare. We observed a case of crossed involuntary movements in the left upper limb and right lower limb after a right thalamic hemorrhage expanded to the right subthalamic nucleus. We considered a possible three-step theory as the basis of crossed choreoathetosis. This case informs our better understanding of the cortico-basal ganglia loop and involuntary movements after stroke.

The association between the cerebral microbleed (CMB) count and outcomes in ischemic stroke has not been fully clarified. The aim of this study was to investigate the relationship between the CMBs count and functional outcomes in patients with a minor ischemic stroke treated with antiplatelet therapy METHODS: Non-cardiogenic minor ischemic stroke (NIHSS score 4 on admission) patients who were treated with antiplatelet therapy were enrolled. The patients were divided into four groups based on the number of CMBs (absent, 1, 2-4, and 4), and their clinical outcomes were compared. A poor outcome was defined as a modified Rankin scale (mRS) score of 3-6 90 days after symptom onset. Logistic regression analysis was performed to evaluate whether the CMBs count contributes to poor outcomes with well-known risk factors such as age, NIHSS score on admission, ischemic stroke recurrence, large artery atherosclerosis stroke subtype, and DWMHs.A total of 240 patients were enrolled, and their pre mRS scores were matched based on CMB presence. A higher burden of CMBs was linearly correlated with the incidence of poor outcomes (4% in the absent group, 8% in the 1 CMB group, 13% in the 2-4 CMB group, and 20% in the 4 CMB group, P = 0.002). Multivariate logistic regression analysis showed that CMBs count was one of the independent factor associated with poor outcomes (odds ratio 1.07, 95% confidence interval 1.02-1.12, P = 0.003).The CMBs count contributes independently to poor outcomes in minor ischemic stroke patients treated with antiplatelet therapy.

Background and Purpose— This study’s objective is to determine if nonstenotic carotid plaque of Methods— This was a cross-sectional observational study. We identified consecutive patients with anterior circulation embolic stroke of undetermined source (ESUS), excluding stroke in multiple vascular territories. Using ultrasonography, we measured the internal carotid plaque size and stenosis for each patient. We dichotomized the plaque size at several predefined thresholds and calculated the frequency of the plaque size and morphology above each threshold ipsilateral versus contralateral to the stroke site. Results— We included 53 patients with unilateral anterior circulation ESUS. Initially, we found that plaque with a thickness ≥1.5 mm was present ipsilateral to the stroke site in 59% of the patients, and present contralateral to the stroke site in 42% of the patients (31/53 versus 22/53 patients; P =0.049). Plaque with low echo likewise had a similar prevalence when present ipsilateral (9%) and contralateral (4%) to the stroke site (5/53 versus 2/53; P =0.25). Conclusions— Internal carotid artery plaque with a thickness ≥1.5 mm but that is nonstenotic (

Sympathetic nervous denervation may be associated with the development of anemia. We aimed to investigate the association between sympathetic nervous denervation and hemoglobin levels in patients with Parkinson’s disease (PD). As indices of sympathetic nervous denervation, we investigated resting norepinephrine levels, increased norepinephrine levels after tilt-up, cardiac uptake of 123I-metaiodobenzylguanidine, supine blood pressure, and the degree of orthostatic hypotension in 132 patients with de novo PD. Older age, female sex, severe motor dysfunction, and lower body mass index were associated with decreased hemoglobin levels. After adjustment for these covariables, resting norepinephrine levels were negatively associated with hemoglobin levels. Hemoglobin levels were not associated with cardiac sympathetic denervation or orthostatic intolerance. Hemoglobin levels in PD seem to be closely related to noradrenergic nervous activity and nigrostriatal dopaminergic degeneration. In contrast to expectations, decreased hemoglobin levels were associated with increased whole-body sympathetic nervous activity in PD.

Objective To determine the predictors of unfavorable outcomes in acute minor ischemic stroke patients with large vessel occlusion. Methods The derivation cohort included ischemic stroke patients admitted to a comprehensive stroke center within 7 days after onset with large vessel occlusion and an initial National Institutes of Health Stroke Scale score of 5 or less. An unfavorable outcome was defined as dependency (modified Rankin Scale score of 3 to 6) at 3 months from the onset. The predictive values of factors related to an unfavorable outcome were evaluated. External validation was performed from a stroke registry of a tertiary medical center. Results In the derivation cohort, 3839 consecutive patients were screened; a total of 130 patients were included. Twenty-four (18%) patients had unfavorable outcomes. In multivariate analysis, D-dimer ≥1900 μg/l (odds ratio (OR) 3.31, 95% confidence interval (CI) 1.14–9.61, p = .028) and age (OR 2.01, 95% CI 1.05–3.86, p = .035) were independently associated with an unfavorable outcome. No significant differences were observed regarding occluded vessel sites. In the validation cohort, 850 consecutive patients were screened; a total of 74 patients were included. D-dimer ≥1900 μg/l (OR 8.78, 95% CI 1.41–54.61, p = .020) was the only factor independently associated with an unfavorable outcome, as in the derivation cohort. Conclusions A high D-dimer level on admission could help predict unfavorable outcomes in patients with a minor ischemic stroke with large vessel occlusion.

BACKGROUND High-quality neuroimages can be viewed using a medical app installed on a smartphone. Although interdevice agreement between smartphone and desktop PC monitor was found to be favorable for evaluating computed tomography images, there are no interdevice agreement data for diffusion-weighted imaging (DWI). OBJECTIVE The aim of our study was to compare DWI interpretation using the Join smartphone app with that using a desktop PC monitor, in terms of interdevice and interrater agreement and elapsed interpretation time. METHODS The ischemic change in the DWI of consecutive patients with acute stroke in the middle cerebral artery territory was graded by 2 vascular neurologists using the Join smartphone app and a desktop PC monitor. The vascular neurologists were blinded to all patient information. Each image was categorized as either Diffusion-Weighted Imaging–Alberta Stroke Program Early Computed Tomography Scores (DWI-ASPECTS) ≥7 or DWI-ASPECTS RESULTS We analyzed the images of 111 patients (66% male; median age=69 years; median National Institutes of Health Stroke Scale score on admission=4). Interdevice agreement regarding DWI-ASPECTS between the smartphone and the desktop PC monitor was favorable (vascular neurologist 1: κ=0.777, PPPPP=.64); vascular neurologist 2: 2.4 min vs 2.0 min; P=.14). CONCLUSIONS The use of a smartphone app enables vascular neurologists to estimate DWI-ASPECTS accurately and rapidly. The Join medical smartphone app shows great promise in the management of acute stroke.

The precise mechanisms underlying the expansion of lacunar and giant lacunar infarction remain unclear. We aimed to determine risk factors for lacunar and giant lacunar infarction and to clarify differences in pathophysiological mechanisms for these two groups.Patients were selected from a comprehensive stroke center with ≤24 h from onset to initial magnetic resonance imaging with lacunar and giant lacunar infarction. All patients underwent a second magnetic resonance imaging during hospitalization. Infarct size was calculated and compared by the positive region on diffusion-weighted imaging. Factors related to infarct expansion were evaluated separately in the two groups.We screened 1558 consecutive ischemic stroke patients, including 154 patients with small vessel disease (lacunar infarction, 81 patients; giant lacunar infarction, 73 patients). Age (odds ratio (OR), 0.899; 95% confidence interval (CI), 0.824-0.981, p = 0.016), higher cardio-ankle vascular index (OR, 6.011; 95%CI, 2.319-15.581, p 0.001), higher uric acid (OR, 2.584; 95%CI, 1.091-6.121, p = 0.031), and lower/normal low-density lipoprotein (LDL)-cholesterol (OR, 0.718; 95%CI, 0.557-0.926, p = 0.011) were independently associated with infarct expansion in lacunar infarction patients. Concerning giant lacunar infarction, higher LDL-cholesterol (OR 1.509, 95%CI 1.083-2.103; p = 0.015) and lower/normal body mass index (OR 0.725, 95%CI 0.567-0.926; p = 0.010) were factors independently associated with infarct expansion.Risk factors for infarct expansion differed between lacunar and giant lacunar infarction. The underlying pathophysiological mechanisms for infarct expansion in these two groups should be recognized individually.

Background: The relationship between cerebral microbleeds (CMBs) and risk of early recurrence of ischemic stroke in patients with transient ischemic attack (TIA) or ischemic stroke is still controversial, and as is the effect for the prognosis. Our aim is to verify the relationship between CMBs and outcome in patients with TIA and minor ischemic stroke. Methods: We retrospectively reviewed consecutive patients with non-cardiogenic TIA and minor ischemic stroke (NIHSS Results: A total of 374 patients (279 men, median age 67 years old) were enrolled in our study. CMBs was observed in 152 patients (41%). Outcome was significantly poor in patients with CMBs (11% vs 3%, P=0.002). Stroke recurrence was frequently observed in patients with CMBs (13% vs 7%, P=0.041). Increased CMBs burden is lineally associated with poor outcome in comparison with absent CMBs (Figure 1). The multivariate analysis revealed that the CMBs was independently associated with poor outcome (OR, 3.86; 95%CI, 1.29-11.53; P=0.015). Conclusion: CMBs is the important factor for poor outcome in TIA and minor ischemic stroke, especially in increased CMBs burden patients.

Background and Purpose: The purpose of this study was to determine risk factors for lacunar and giant lacunar infarction and to clarify differences in pathophysiological mechanisms for these two groups. Methods: Patients were selected from a comprehensive stroke center with ≤24 h from onset to initial magnetic resonance imaging (MRI) with lacunar and giant lacunar infarction. All patients underwent second MRI during hospitalization. Infarct expansion was defined as present when the area of the diffusion-weighted imaging (DWI)-positive region on second MRI exceeded that on the initial MRI. To calculate the area of the DWI-positive region, we manually traced each region of interest and calculated the DWI-positive region area in each slice. Infarct size was calculated and compared by the positive region on DWI. Factors related to infarct expansion were evaluated separately in the two groups. Results: We screened 950 consecutive ischemic stroke patients, including 106 patients with small vessel disease (lacunar infarction, 54 patients; giant lacunar infarction, 52 patients). High cardio-ankle vascular index (odds ratio, 6.255; 95% confidence interval, 1.791-21.846; p = 0.004) was independently associated with infarct expansion in lacunar infarction patients (Figure 1A). Concerning giant lacunar infarction, high concentration of low-density lipoprotein-cholesterol (odds ratio, 1.923; 95% confidence interval, 1.158-3.194; p = 0.012) and low/normal body mass index (odds ratio, 0.714; 95% confidence interval, 0.515-0.989; p = 0.042) were factors independently associated with infarct expansion (Figure 1B). Conclusions: Risk factors for infarct expansion differed between lacunar and giant lacunar infarction. The underlying pathophysiological mechanisms for infarct expansion in these two groups should be recognized individually.

Background and Purpose: Nontraumatic convexal subarachnoid hemorrhage (cSAH) rarely occurs concomitant with acute ischemic stroke. The purpose of this study was to investigate the incidence, imaging findings, clinical backgrounds, and outcomes of hyperacute ischemic stroke with cSAH. Methods: Patients were selected from a comprehensive stroke center with ≤4.5 h from onset to door with symptomatic ischemic stroke between October 2012 and May 2018. All patients underwent CT and/or MRI on admission and we reviewed them to identify cSAH. Follow-up CT and/or MRI were also reviewed. cSAH caused by trauma, detected after thrombolysis or endovascular treatment, and accompanied with intracerebral hemorrhage was excluded. Retrospective review of cSAH incidence, imaging findings, clinical backgrounds, and outcomes was performed. Results: We screened 1249 consecutive symptomatic ischemic stroke patients, including 466 patients with ≤4.5 h from onset to door (342 (73%) male, median age 68 years). Of 466 hyperacute ischemic stroke patients, cSAH was observed in 5 (1.1%) patients (5 male, median age 49 years): 3 were detected on admission and the other was detected at follow-up. None had any meningeal irritation signs, and all were detected incidentally. Four patients (case 1-4) were diagnosed as arterial infarction, and 1 as venous infarction. Of the 4 arterial infarction patients, arterial stenosis or occlusion was observed ipsilaterally to the cSAH (Figure). In addition, of the 4 arterial infarction patients, hyperintense vessel signs were observed on FLAIR imaging on admission suggesting retrograde flow via collateral vessels, or slow flow (Figure). In all, cSAH disappeared gradually, and outcomes were favorable (modified Rankin Scale 0-1 at 3 months from the onset). Conclusions: cSAH was accompanied with approximately 1% of hyperacute ischemic stroke. Patients with arterial infarction and cSAH had arterial stenosis or occlusion ipsilaterally to cSAH.

Background and Objectives: Bland new smartphone application (JOIN) provides sharing text, neuroimaging, photos and videos and we are securely able to communicate among stroke team. Our aim is to investigate whether JOIN would shorten the duration from admission to thrombolysis and mechanical thrombectomy in hyper-acute ischemic stroke patients. Methods: Between October 2012 to March 2018, acute ischemic stroke patients with thrombolysis and/or mechanical thrombectomy were enrolled. We divided all patients into two groups, 1) pre-JOIIN group as conventional communication system was conducted until September 2015, and 2) JOIN group as we started to use JOIN on smartphone after October 2015. We compared door to image time (DIT), image to needle time (INT), door to needle time (DNT) for thrombolysis, and DIT, image to puncture time (IPT), door to puncture time (DTP) for thrombectomy between pre-JOIN group and JOIN group. Results: We retrospectively enrolled 129 patients (66% male, median age 69 years-old, median NIHSS score 8). JOIN group was 53 patients and pre-JOIN group was 76 patients. In all patients, Thrombolysis was 99 patients (alone 69), thrombectomy was 60 patients (alone 30), and combined thrombolysis and thrombectomy was 30 patients. There was no significant difference of DIT between JOIN group and pre-JOIN group (22 min vs. 24 min, p=0.484). Interestingly, DNT, DPT, INT, and IPT in JOIN group were significantly shorter than that of pre-JOIN group (DNT; 62 min for JOIN group vs. 72 min for pre-JOIN group, p=0.039; INT 41 min vs. 48 min, p=0.005; DPT 106 min vs. 129 min, p=0.046; IPT 89 min vs. 117 min, p=0.004; Figure). Conclusion: JOIN should play an important role in shortening the elapsed time for reperfusion therapy, especially after undergoing initial brain image.

Purpose Vertebral artery hypoplasia (VAH) is a common congenital anatomical variation. In previous reports, it was unclear whether VAH was an independent risk factor for posterior circulation ischemia. The purpose of this study was to evaluate the impact of VAH on posterior circulation ischemia. Methods Subjects were patients with acute ischemic stroke who underwent brain magnetic resonance imaging (MRI) and carotid ultrasonography. Diagnostic criteria for VAH were as follows: (1) Vertebral artery (VA) diameter less than 2.5 mm; (2) VA diameter less than 3.0 mm and a difference in length equal to or greater than 1:1.7; (3) VA diameter less than 3.0 mm, peak systolic velocity less than 40 cm/second, and resistance index value greater than .75. The patients were categorized by the location of the ischemic stroke on MRI as follows: lesion in posterior circulation (P group), lesion in anterior circulation (A group), and multiple lesions in both the anterior and posterior circulations (AP group). Results We evaluated 129 consecutive patients. VAH was seen in 39, and VA occlusion was found in 15. The prevalence of VAH in the P group (44.4%) was significantly higher than that in the A + AP group (24.7%, P = .034). Multivariate regression analysis showed that large-artery atherosclerosis (odds ratio, 6.3; 95% confidence interval [CI], 1.3-30.1), posterior circulation ischemia (odds ratio, 12.0; 95% CI, 2.8-51.2), and VAH (odds ratio, 4.2; 95% CI, 1.2-15.0) were independent factors related to VA occlusion. Conclusion VAH was an independent factor related to VA occlusion. Therefore, VAH likely plays a role in posterior circulation ischemia.

Background High-quality neuroimages can be viewed using a medical app installed on a smartphone. Although interdevice agreement between smartphone and desktop PC monitor was found to be favorable for evaluating computed tomography images, there are no interdevice agreement data for diffusion-weighted imaging (DWI). Objective The aim of our study was to compare DWI interpretation using the Join smartphone app with that using a desktop PC monitor, in terms of interdevice and interrater agreement and elapsed interpretation time. Methods The ischemic change in the DWI of consecutive patients with acute stroke in the middle cerebral artery territory was graded by 2 vascular neurologists using the Join smartphone app and a desktop PC monitor. The vascular neurologists were blinded to all patient information. Each image was categorized as either Diffusion-Weighted Imaging–Alberta Stroke Program Early Computed Tomography Scores (DWI-ASPECTS) ≥7 or DWI-ASPECTS Results We analyzed the images of 111 patients (66% male; median age=69 years; median National Institutes of Health Stroke Scale score on admission=4). Interdevice agreement regarding DWI-ASPECTS between the smartphone and the desktop PC monitor was favorable (vascular neurologist 1: κ=0.777, P Conclusions The use of a smartphone app enables vascular neurologists to estimate DWI-ASPECTS accurately and rapidly. The Join medical smartphone app shows great promise in the management of acute stroke.

Background: Although subcortical infarction patients sometimes show larger infarction size than the definition of small vessel occlusion (SVO), there are no specific predictors of larger size. The aim of this study was to identify the factors, including magnetic resonance imaging (MRI) and ultrasonographic parameters, to predict larger subcortical infarction. Methods: Consecutive patients with acute supratentorial subcortical infarction were studied. Patients were classified into 2 groups (L: larger group, ≥15 mm and ≥3 slices; S: smaller group, SVO based on the TOAST classification). Clinical information, MRI findings including the presence of microbleeds, and ultrasonography findings were evaluated and compared between the 2 groups. Results: A total of 120 patients (81 male, mean 67 years old) were enrolled. The L group included 22 patients (18%), and the S group had 98 patients (82%). On neuroimaging, microbleeds were seen less frequently in the L group than in the S group (23 vs. 53%, p = 0.017), and peak systolic velocity (PSV) by transcranial color-coded sonography was faster in the L group than in the S group (121 ± 39.8 vs. 83.4 ± 25.4 cm/s, p = 0.002). On multivariate logistic regression analysis, no evidence of microbleeds (OR 4.4, 95% CI 1.41–13.68, p = 0.011) and PSV over 92 cm/s (OR 3.1, 95% CI 1.007–9.719, p = 0.049) were found to be independently associated with larger size. Conclusion: Microbleeds is related to smaller size and middle cerebral artery PSV > 92 cm/s indicate larger size in supratentorial subcortical infarcts.

Background and Purpose: The availability of direct-acting oral anticoagulants (DOACs) for nonvalvular atrial fibrillation (NVAF) and venous thromboembolism (VTE) has changed the therapeutic landscape of anticoagulation therapy, but the guideline-based recommendation of anticoagulation therapy for the acute stroke patients with VTE is unclear. Our aim of this study is to survey clinical characteristics of acute stroke patients with VTE in new treatment paradigms including DOACs. Methods: Subjects were acute stroke patients within 7 days from onset with VTE detected by enhanced CT and/or ultrasound of leg veins. VTE evaluation was performed for the patients as follows; presence of right-to-left shunts by transcranial Doppler, elevation of D-dimer, and suspected embolic stroke of undetermined source. We analyzed the following information: 1) the prevalence of VTE among acute stroke patients, 2) clinical information of VTE (i.e. subtype and symptom of VTE), 3) treatment details for stroke and VTE, 4) hemorrhagic complication after VTE treatment. Results: From October 2012 to June 2017, we registered 1077 acute stroke patients. We underwent the VTE evaluation for 226 patients (21%). Of them, 65 patients (39 female, mean age of 76 years, 6% of all patients, and 29% of patients with examination) had VTE (deep vein thrombosis (DVT); 52, pulmonary embolisms (PE); 2, DVT+PE; 11). In 65 patients with VTE, ischemic stroke was 60 cases. Antiplatelet agents were given for 35 of these 60 cases before starting therapy for VTE. Medications for VTE were as follows; 29 cases with DOACs, 14 with warfarin, 7 with warfarin following heparin, and 9 with heparin alone. Hemorrhagic complication occurred in 3 of 60 case of ischemic stroke with VTE (5%). One case had intraventricular hemorrhage after starting DOAC following 200mg aspirin, and muscle hematoma was found in the other two cases using warfarin following heparin. Conclusions: Prevalence of VTE was 6% of acute stroke patients in our preliminary survey. After medication for acute ischemic stroke with VTE, 5% of them had hemorrhagic complication. We should choose anticoagulation therapy for acute stroke patients with VTE focused on former use of antiplatelet drug and hemorrhagic complication.

Background and Objectives: Bland new smartphone application (JOIN) can provide sharing text, neuroimagings, photos, and videos among stroke team with high security. Our aim is to investigate the diagnostic accuracy and agreement of DWI-ASPECTS between JOIN and conventional PC monitor. Methods: This study used the MRI images of consecutive acute stroke patients having main artery blockage (ICA and/or MCA). After concealing patient backgrounds, two vascular neurologist independently graded ischemic change on DWI-ASPECT by using JOIN and conventional PC monitor, respectively. All patients were estimated DWI-ASPECT≥6 or Results: We analyzed the cases of 50 subject patients (67% male, average age 66 ± 11, median NIHSS score 7). Between JOIN and PC monitor, the inter-device agreement of DWI cut-line was significantly excellent (vascular neurologist 1;κ=0.80, p Conclusion: By using smartphone App, stroke neurologists are able to estimate DWI-ASPECTS precisely and quickly. Outstanding App “JOIN” should yield a profit of acute stroke care.

Purpose We developed a novel probe (pastable soft ultrasound probe; PSUP) attached to the neck for right-to-left shunt (RLS) detection. The purpose of this study was to evaluate the diagnostic ability of the PSUP for RLS detection by comparison with transesophageal echocardiography (TEE). Methods The subjects were patients with ischemic strokes and transient ischemic attacks who underwent TEE. Based on TEE, patients with patent foramen ovale (PFO) were divided into two groups by the number of microbubbles (MBs): small PFO (1–29 MBs) and large PFO (≥30 MBs). Then, PSUP examination of one common carotid artery (CCA) was started using a procedure similar to TEE. RLS was diagnosed by PSUP when one or more microembolic signals were found in the CCA. The detection rate by size of PFO was compared between TEE and PSUP, and the diagnostic accuracy of PSUP was calculated. Results From May 2014 to July 2016, 84 patients (63 males, median age 63 years) were included; 41 (49%) were diagnosed with PFO by TEE, while PSUP detected PFO in 31 (37%). Using TEE findings as the reference, PSUP for PFO showed sensitivity of 68%, specificity of 93%, and accuracy of 81%. On TEE, 22 patients had large PFOs, and 19 patients had small PFOs. The PSUP could identify large PFOs in grade I and II of International Consensus Criteria more accurately than small ones (58 and 86% vs. 29 and 14%, P = 0.003). Conclusions The PSUP has considerable accuracy for diagnosing large PFOs. PSUP should play an important role in detecting large PFOs.

Background/Aims: The factors related to cerebrovascular complications in cerebral venous sinus thrombosis (CVST) are controversial. We focused on venous stasis and investigated its relationship with cerebrovascular complications in CVST. Methods: CVST patients between June 2013 and October 2016 were enrolled. Relationships between cerebrovascular complications, defined as cerebral venous infarction, intracerebral hemorrhage, or subarachnoid hemorrhage, and cerebrum venous stasis and other clinical information were retrospectively analyzed. Venous stasis was evaluated by the prominence of the veins on susceptibility-weighted imaging (SWI). The cerebrum was divided into 10 regions according to the venous drainage territories, and venous stasis was quantified by adding one point for venous prominence on SWI for each region (CVST SWI score). Results: All 5 cases in the noncomplicated group had a CVST SWI score of 0. The 3 patients with CVST SWI scores higher than 0 had cerebrovascular complications. The CVST SWI scores were higher in the complicated group than in the noncomplicated group (3.0 vs. 0, p = 0.010). Seizures were seen in all patients with complications and in none of the patients without complications (3 vs. 0, p = 0.018). Conclusion: Venous stasis evaluated by SWI can help predict cerebrovascular complications in CVST. A seizure is an important initial symptom that suggests cerebrovascular complications in CVST.

Introduction: While the examination for the evaluation of right-to-left shunt (RLS) using contrast transcranial Doppler (TCD) is useful, insufficient temporal bone window interrupts the adequate TCD examination for precise diagnosis of RLS. Thus, we developed a novel probe (paste-able soft ultrasound probe; PSUP) attached to the cervix for RLS diagnosis. Hypothesis: Monitoring at carotid artery using PSUP can detect greater number of contrast microembolic signals (cMES) than that of TCD. Methods: Subjects were patients with ischemic stroke or transient ischemic attack who had one and more cMES in middle cerebral artery detected by screening test of TCD on admission. PSUP was a 2.0-MHz center frequency and had an equal property with TCD transducer. The shape was thin, soft, and square modified for adequate attachment to the neck. We monitored blood flow of unilateral middle cerebral artery by TCD and ipsilateral common carotid artery by PSUP simultaneously. After injection of saline agitated with air in the right antecubital vein, we performed single test without Valsalva maneuver (VM) and triple tests with VM. And then, we compared the number of cMES between PSUP and TCD among each patient. Results: We performed 48 simultaneous PSUP and TCD examination (12 studies without VM, and 36 studies with VM) on 12 patients (11 male, median age of 49 years) without any complication. The number of cMES on PSUP was significantly larger than that of TCD in all of 48 examination (345 vs. 206, p Conclusions: In order to evaluate the RLS, PSUP examination at common carotid artery is a powerful approach in comparison with TCD. For patients without sufficient temporal bone window, PSUP should play an important role of RLS diagnosis.