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Background: Quality indicators (QIs) are an accepted tool for measuring a hospital’s performance in routine care. We examined national trends in adherence to the QIs developed by the Close The Gap-Stroke program by combining data from the health insurance claims database and electronic medical records, and the association between adherence to these QIs and early outcomes in patients with acute ischemic stroke in Japan. Methods: In the present study, patients with acute ischemic stroke who received acute reperfusion therapy in 351 Close The Gap-Stroke-participating hospitals were analyzed retrospectively. The primary outcomes were changes in trends for adherence to the defined QIs by difference-in-difference analysis and the effects of adherence to distinct QIs on in-hospital outcomes at the individual level. A mixed logistic regression model was adjusted for patient and hospital characteristics (eg, age, sex, number of beds) and hospital units as random effects. Results: Between 2013 and 2017, 21 651 patients (median age, 77 years; 43.0% female) were assessed. Of the 25 defined measures, marked and sustainable improvement in the adherence rates was observed for door-to-needle time, door-to-puncture time, proper use of endovascular thrombectomy, and successful revascularization. The in-hospital mortality rate was 11.6%. Adherence to 14 QIs lowered the odds of in-hospital mortality (odds ratio [95% CI], door-to-needle Conclusions: We demonstrated national marked and sustainable improvement in adherence to door-to-needle time, door-to-puncture time, and successful reperfusion from 2013 to 2017 in Japan in patients with acute ischemic stroke. Adhering to the key QIs substantially affected in-hospital outcomes, underlining the importance of monitoring the quality of care using evidence-based QIs and the nationwide Close The Gap-Stroke program.

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.

ObjectivesTo examine the national, 6-year trends in in-hospital clinical outcomes of patients with subarachnoid haemorrhage (SAH) who underwent clipping or coiling and the prognostic influence of temporal trends in the Comprehensive Stroke Center (CSC) capabilities on patient outcomes in Japan.DesignRetrospective study.SettingSix hundred and thirty-one primary care institutions in Japan.ParticipantsForty-five thousand and eleven patients with SAH who were urgently hospitalised, identified using the J-ASPECT Diagnosis Procedure Combination database.Primary and secondary outcome measuresAnnual number of patients with SAH who remained untreated, or who received clipping or coiling, in-hospital mortality and poor functional outcomes (modified Rankin Scale: 3–6) at discharge. Each CSC was assessed using a validated scoring system (CSC score: 1–25 points).ResultsIn the overall cohort, in-hospital mortality decreased (year for trend, OR (95% CI): 0.97 (0.96 to 0.99)), while the proportion of poor functional outcomes remained unchanged (1.00 (0.98 to 1.02)). The proportion of patients who underwent clipping gradually decreased from 46.6% to 38.5%, while that of those who received coiling and those left untreated gradually increased from 16.9% to 22.6% and 35.4% to 38%, respectively. In-hospital mortality of coiled (0.94 (0.89 to 0.98)) and untreated (0.93 (0.90 to 0.96)) patients decreased, whereas that of clipped patients remained stable. CSC score improvement was associated with increased use of coiling (per 1-point increase, 1.14 (1.08 to 1.20)) but not with short-term patient outcomes regardless of treatment modality.ConclusionsThe 6-year trends indicated lower in-hospital mortality for patients with SAH (attributable to better outcomes), increased use of coiling and multidisciplinary care for untreated patients. Further increasing CSC capabilities may improve overall outcomes, mainly by increasing the use of coiling. Additional studies are necessary to determine the effect of confounders such as aneurysm complexity on outcomes of clipped patients in the modern endovascular era.

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 We sought to examine the presentation, treatment, and outcomes of anterior cerebral artery (ACA) occlusions in patients undergoing mechanical thrombectomy (MT). Methods Two-hundred ninety-eight consecutive patients with large-vessel occlusion treated with MT were analyzed to identify all patients with acute ACA occlusion who underwent MT. The primary end point was defined as achieving a thrombolysis in cerebral infarction score ≥2b. The secondary end point included the 90-day modified Rankin Scale (mRS) score and symptomatic intracranial hemorrhage. Results Nine patients with a median National Institutes of Health Stroke Scale score of 24 presented with acute ACA occlusion. The median time from onset to recanalization was 229 minutes. The ACA occlusion was a primary embolic occlusion in 5 patients, secondary to an interventional maneuver in 4 patients. Recanalization (thrombolysis in cerebral infarction ≥2b) was achieved in 9 of 9 patients (100%) without procedural complications. All patients had a 90-day mRS score ≥3, and 2 patients had an mRS score of 6. Two patients developed hemorrhagic infarction, and 1 patient had subarachnoid hemorrhage. Conclusions Although MT can be considered in patients with ACA occlusions, our data suggest that future clinical trials are needed to determine the efficacy of MT for ACA occlusions. Unfavorable outcomes in our study were considered to occur because of a larger infarct volume due to internal carotid artery, middle cerebral artery, and anterior cerebral artery territory infarction. The time from onset to recanalization was longer because MT was performed for occlusions of multiple arteries.

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: Limited national-level information on temporal trends in comprehensive stroke center (CSC) capabilities and their effects on acute ischemic stroke (AIS) patients exists. Aims: To examine trends in in-hospital outcomes of AIS patients and the prognostic influence of temporal changes in CSC capabilities in Japan. Methods: This retrospective study used the J-ASPECT Diagnosis Procedure Combination database and identified 372,978 AIS patients hospitalized in 650 institutions between 2010 and 2016. Temporal trends in patient outcomes and recombinant tissue plasminogen activator (rt-PA) and mechanical thrombectomy (MT) usage were examined. Facility CSC capabilities were assessed using a validated scoring system (CSC score: 1-25 points) in 2010 and 2014. The prognostic influence of temporal CSC score changes on in-hospitalmortality and poor outcomes (modified Rankin Scale: 3-6) at discharge were examined using hierarchical logistic regression models. Results: Over time, stroke severity at admission decreased, whereas median age, sex ratio, and comorbidities remained stable. During the study period, usage of rt-PA and MT in rural areas remained lower than that of urban areas, but in 2016, the differences in their use were within 1%. The median CSC score increased from 16 to 17 points. After adjusting for age, sex, comorbidities, consciousness level, and facility CSC score, proportion of in-hospitalmortality and poor outcomes at discharge decreased (from 7.6% to 5.0%, and from 48.7% to 43.1%, respectively). The preceding CSC score increase (in 2010-2014) was independently associated with reduced in-hospital mortality and poor outcomes, and increased rt-PA and MT use (odds ratio (95% confidence interval): 0.97(0.95-0.99), 0.97(0.95-1.00), 1.07(1.04-1.10), and 1.21(1.14-1.28) , respectively). Conclusions: This nationwide study revealed six-year trends in better patient outcomes and increased use of rt-PA and MT in AIS. In addition to lesser stroke severity, preceding improvement of CSC capabilities was an independent factor associated with such trends, suggesting importance of CSC capabilities as a prognostic indicator of acute stroke care.

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.

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.

Chronic subdural hematoma (CSDH) is a highly recurrent disorder. Although some predictors including the use of antithrombotic agents such as aspirin and warfarin have been proposed, the pathogenic mechanism involved remains unclear. Moreover, the link between direct oral anticoagulant (DOAC) agent use and CSDH recurrence has not been reported. The aim of this study was to investigate factors including DOAC use that could potentially be associated with CSDH recurrence.The authors analyzed 787 patients with CSDH who underwent surgery for CSDH with 1 burr-hole irrigation at Baba Memorial Hospital from January 2012 to November 2017. The patients were divided into recurrence and nonrecurrence groups and anticoagulant, antiplatelet, and control groups. Recurrence was defined as ipsilateral hemorrhage within 90 days from the original operation. Variables with P0.1 in the univariate analysis were included in a multivariate logistic regression model.CSDH recurrence was observed in 12.2% of patients, and significantly more men (80.2%) than women experienced recurrence. Age, sex, and warfarin use were entered in the multivariate analysis, and it was revealed that age and male sex were independently associated with CSDH recurrence. Antithrombotic agent use including use of DOACs was not associated with increased CSDH recurrence.The present study found that age and male sex were independently associated with CSDH recurrence, while the use of antithrombotic agents was not.

Background Basilar artery occlusion (BAO) is a rare, potentially fatal cause of ischemic stroke. It is often challenging to diagnose, especially when the presenting symptom is “seizures”. We present 3 cases of patients with BAO presenting with seizures. Case Description The first patient was a 53-year-old man with clonic convulsions. On angiography, BAO was detected and mechanical thrombectomy (MT) was performed. The modified Rankin Scale score at 3 months after treatment was 1. The second patient was a 64-year-old man with generalized convulsions. He was diagnosed with BAO and vertebral artery dissection and was treated with MT, percutaneous transluminal angioplasty, and stenting. The modified Rankin Scale score at 3 months after treatment was 3. The third patient was a 77-year-old man with tonic convulsions. He was diagnosed with BAO and treated with MT. However, he did not survive. Conclusions BAO is devastating; however, it is a treatable disease. Our report suggests that BAO should be suspected in patients presenting with initial convulsive seizures.

Background: In pediatric patients with minor head trauma, computed tomography (CT) is often performed beyond the scope of recommendations that are based on existing algorithms. Herein, we evaluated pediatric patients with minor head trauma who underwent CT examinations, quantified its frequency, and determined how often traumatic findings were observed in the intracranial region or skull. Methods: We retrospectively reviewed the medical records and neuroimages of pediatric patients (0–5 years) who presented at our hospital with minor head trauma within 24 h after injury. Results: Of 2405 eligible patients, 1592 (66.2%) underwent CT examinations and 45 (1.9%) had traumatic intracranial hemorrhage or skull fracture on CT. No patient underwent surgery or intensive treatment. Multivariate analyses revealed that an age of 1–5 years (vs. P < 0.001), Glasgow Coma Scale (GCS) score of 14 (vs. a score of 15; P = 0.008), sustaining a high-altitude fall (P < 0.001), using an ambulance (P < 0.001), and vomiting (P < 0.001) were significantly associated with the performance of CT examination. In addition, traumatic abnormalities on CT were significantly associated with the combination of an age of under 1 year (P = 0.042), GCS score of 14 (P < 0.001), and sustaining a high-altitude fall (P = 0.004). Conclusion: Although slightly broader indications for CT use, compared to the previous algorithms, could detect and evaluate minor traumatic changes in pediatric patients with minor head trauma, over-indications for CT examinations to detect only approximately 2% of abnormalities should be avoided and the indications should be determined based on the patient’s age, condition, and cause of injury.

An 87-year-old man hospitalized for subarachnoid hemorrhage showed a ruptured aneurysm arising from fenestration of the posterior inferior cerebellar artery. Endovascular treatment was selected and the aneurysm and superior limb were embolized completely using three coils. Fenestration of the posterior cerebellar artery is exceedingly rare. In addition, we present a first case of aneurysm as fenestration of the posterior inferior cerebellar artery that was definitively identified as a cause of bleeding.

Background and purposeOptimal thresholds for ischemic penumbra detected by CT perfusion (CTP) in patients with acute ischemic stroke (AIS) have not been elucidated. In this study we investigated optimal thresholds for salvageable ischemic penumbra and the risk of hemorrhagic transformation (HT).MethodsA total of 156 consecutive patients with AIS treated with mechanical thrombectomy (MT) at our hospital were enrolled. Absolute (a) and relative (r) CTP parameters including cerebral blood flow (aCBF and rCBF), cerebral blood volume (aCBV and rCBV), and mean transit time (aMTT and rMTT) were evaluated for their value in detecting ischemic penumbra in each of seven arbitrary regions of interest defined by the major supplying blood vessel. Optimal thresholds were calculated by performing receiver operating characteristic curve analysis in 47 patients who achieved Thrombolysis In Cerebral Infarction (TICI) grade 3 recanalization. The risk of HT after MT was evaluated in 101 patients who achieved TICI grade 2b–3 recanalization.ResultsAbsolute CTP parameters for distinguishing ischemic penumbra from ischemic core were as follows: aCBF, 27.8 mL/100 g/min (area under the curve 0.82); aCBV, 2.1 mL/100 g (0.75); and aMTT, 7.30 s (0.70). Relative CTP parameters were as follows: rCBF, 0.62 (0.81); rCBV, 0.83 (0.87); and rMTT, 1.61 (0.73). CBF was significantly lower in areas of HT than in areas of infarction (aCBF, pConclusionsCTP may be able to predict treatable ischemic penumbra and the risk of HT after MT in patients with AIS.

Background: The natural history of basilar artery occlusion (BAO) is devastating, with morbidity rates increasing up to 80%. However, the efficacy of recanalization therapy for BAO has not been established as yet. Objective: We analyzed consecutive cases of BAO treated with mechanical thrombectomy (MT) to evaluate its safety and efficacy and to determine factors associated with the prognosis. Methods: Between October 2011 and September 2016, MT was performed in 34 patients with BAO. MT was performed using the Penumbra system and stent retriever. CT perfusion was used for evaluating patients. Cerebral blood flow (CBF) maps and cerebral blood volume (CBV) maps were evaluated. CBF/CBV mismatch was defined as ≥50% penumbra. Clinical outcomes were correlated with demographic, clinical, and radiographic findings. Results: The median baseline National Institutes of Health Stroke Scale score was 29 (14-33). The recanalization rate (≥thrombolysis in cerebral infarction grades 2b) was 100%. The median onset to recanalization time (OTR) was 197 (160-256) min. Favorable outcomes (modified Rankin Scale ≤2) at 90 days occurred in 56% (n = 19 of 34). The mortality rate at 90 days was 12% (n = 4 of 34). In univariate analysis, intravenous (IV) recombinant tissue-type plasminogen activator (rt-PA) use, and OTR were significantly associated with favorable outcomes. In a multivariate logistic regression model, IV rt-PA use and lower National Institute of Health Stroke Scale score were significantly related to favorable outcomes. Conclusion and Relevance: Multimodal endovascular therapy using the Penumbra system and stent retriever demonstrated a high recanalization rate and favorable outcomes for BAO. Both devices were feasible and effective in the treatment of BAO. An approach combining MT with IV thrombolysis provided a better recanalization rate and more favorable clinical outcomes.

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.

Objective To investigate the clinical effectiveness of mechanical thrombectomy (MT) for basilar artery occlusion (BAO) and to ascertain whether outcomes for patients with BAO were comparable to those with anterior circulation large vessel occlusion (ACS). Methods A total of 345 patients who underwent MT between 2011 and 2018 were grouped by occlusion site (295 patients with ACS and 50 patients with BAO). Patients' baseline characteristics, procedural times, complications, symptomatic intracranial hemorrhage, modified Rankin Scale score, and mortality at 90 days were analyzed. Results Male preponderance (66.0% vs. 48.8%; P = 0.0316), younger age (72.5 years [interquartile range (IQR), 64.75–78.5 years] vs. 77 years [IQR 69–84 years]; P = 0.0297), higher National Institutes of Health Stroke Scale score (24.5 [IQR, 13–32] vs. 18 [IQR 13–22]; P = 0.0015) and higher reperfusion rate (100% vs. 84.7%; P = 0.0010) were observed in patients with BAO. We found no significant difference in favorable outcomes (modified Rankin Scale score ≤2) between patients with BAO and patients with ACS (64.3% vs. 49.3%; P = 0.0914). In multivariate analysis, Alberta Stroke Program Early Computed Tomography Score (odds ratio [OR], 1.282; 95% confidence interval [CI], 1.090–1.524; P = 0.0024), time from onset to reperfusion (OTR) (OR, 0.9950; 95% CI, 0.992–0.998; P = 0.0008), successful reperfusion (OR, 6.953; 95% CI, 1.576–48.729; P = 0.0092), and hemorrhagic complication (OR, 0.352; 95% CI, 0.151–0.797; P = 0.0122) were associated with a favorable outcome at 90 days in patients with ACS. In patients with BAO, only OTR (OR, 0.9879; 95% CI, 0.974–0.999; P = 0.0314) was associated with a favorable outcome at 90 days. Conclusions MT may be considered the standard care for patients with BAO. OTR was the only common significant predictor for favorable outcomes in both patient cohorts.

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 It is debatable whether mechanical thrombectomy has benefits in a real-world setting outside the more rigid and selective clinical trial environment. OBJECTIVE To evaluate clinical outcomes, efficacy, and safety of mechanical thrombectomy in single-center retrospective cohort case series. METHODS We reviewed prospectively collected data from our large-vessel occlusion stroke database to identify patients undergoing mechanical thrombectomy using Penumbra catheters (Penumbra, Almeida, California) as first-line devices. The primary outcomes were the modified Rankin Scale score at 90 d and recanalization rate. The secondary outcomes included the rates of hemorrhagic complications and mortality. RESULTS The entire study population included 298 patients. Thrombolysis in Cerebral Infarction Scale ≥2b was achieved in 86.6% of patients. Fifty-five patients (18.5%) were outside the 6 hr time window and 82 patients (27.5%) were over 80-yr old. The posterior circulation thrombectomy rate was 12.4%. At 90 d from onset, 49.3% of patients had favorable outcomes. The parenchymal hemorrhage type 2 (PH2) and subarachnoid hemorrhage rates were 2.3% and 11.7%, respectively. In multivariate analyses, cerebral blood flow/cerebral blood volume mismatch (odds ratio [OR] = 9.418; 95% confidence interval [CI], 3.680-27.726; P

Intraprocedural coil migration during endovascular treatment for an aneurysm that might carry serious ischemic complications is well known. On the other hand, delayed coil migration after endovascular treatment for an aneurysm is very rare. A 77-year-old woman was incidentally diagnosed with unruptured aneurysm associated with distal azygos anterior cerebral artery (ACA). The aneurysm was located at the distal bifurcation of the azygos ACA and was wide necked (approximately 7 mm in diameter). Endovascular coil embolization was selected and the aneurysm was occluded successfully, but 29 days after endovascular therapy, follow-up computed tomography (CT) and magnetic resonance (MR) angiography revealed distal coil migration in the peripheral portion of the ACA. In addition, CT on day 57 after therapy revealed the migrated coil had moved more distally. Fortunately, in the course of these events, the patient remained asymptomatic. To the best of our knowledge, this represents the first case of delayed distal coil migration associated with relatively rare azygos ACA aneurysm, and also the first report confirming more distal coil movement over time. In the future, a large number of patients could develop this complication as more aneurysms are aggressively treated with endovascular treatment. Knowledge regarding the possibility of delayed coil migration is thus important.

Many studies describe aneurysms measuring ≤3mm as "very small" or "tiny, " with a risk of intraoperative rupture higher than that of most cerebral aneurysms. We evaluated the results of endovascular coil embolization for very small aneurysms with diameter ≤3mm.The same interventional neurosurgeon performed coil embolization for 14 tiny aneurysms in 14 patients(8male and 6 females)at our institution between May 2015 and June 2017. Patient age range was 42-88 years(average 65.6 years). Five aneurysms had ruptured and 9 were unruptured. Of the 9 unruptured aneurysms, 3 were associated with a previous ruptured aneurysm. We assessed the procedural complications, type of microcatheter and coils used, total number and length of coils, and angiographic results immediately after the procedure.In 14 aneurysm cases, 8 used only 1 pre-shaped microcatheter, 4 used 2, and 2 used 3;cases using multiple microcatheters added final shaping. Only one case used a helical first coil and the remaining 13 cases used a 3-dimensional coil. The number of coils used was 1 in 3 cases, 2 in 7 cases, 3 in 2 cases, and 4 in 2 cases. The total length of coils inserted was5 cm in 5 cases, 5-10 cm in 5 cases, and10 cm in 4 cases. The total length of coils used was10cm in 70% of cases. Immediately after coil embolization, complete occlusion and a neck remnant were achieved in 11 and 3 cases, respectively. Ballooning was induced by intentionally introducing a balloon-assist technique during surgery in 7 cases, and the balloon was actually inflated in 4 cases. Complications were seen in 2 ruptured cases;1 had an intraoperative rupture, the other had parent artery occlusion, and both patients recovered.Coil embolization for tiny aneurysms can be performed comparatively safely by understanding the pitfalls and by using appropriate procedures and tools. Placing the catheter tip at the aneurysm neck is the first step and endovascular treatment is usually performed with ≤3 coils measuring ≤10 cm in total length. Complete embolization should be attempted, but even incomplete embolization is acceptable. More delicate coil embolization is required.

Background and Purpose: Basilar artery occlusion (BAO) is an infrequent cause of stroke, accounting for 1.1% of acute ischemic stroke cases. The natural history of patients with BAO is devastating, with morbidity rates of up to 80%. No previous randomized controlled studies on the efficacy of recanalization therapy have been reported. Methods: In the present single-center study, consecutive BAO patients were treated with mechanical thrombectomy (MT) using the stent retriever and the Penumbra system. Computed tomography perfusion was used for patient evaluation. Clinical outcomes were correlated with demographic, clinical, and radiographic findings. Results: Between October 2011 and March 2017, MT was performed in 37 patients with BAO (mean age 70.1±10.9). Mean baseline National Institutes of Health Stroke Scale was 23±11. Recanalization rate (≧thrombolysis in cerebral infarction 2b) was 100%. Mean onset to recanalization time (OTR) was 226.3±117.8minutes. Favorable outcome at 90 days (modified Rankin scale≦2) was 60.6%. Mortality rate at 90 days was 10.8%. In an univariate analysis, IV rt-PA use, and OTR were significantly associated with favorable outcomes. In a multivariate logistic regression model, IV rt-PA use and lower NIHSS score were significantly related to favorable outcomes. Conclusions: Multimodal endovascular therapy using the Penumbra system and/or stent retriever demonstrated high recanalization rates and improved outcomes in BAO. Both devices were feasible and effective in the treatment of BAO. An approach combining MT with IV thrombolysis provided better recanalization rates and improved clinical outcomes.

The stabilization of a guiding catheter is a very important factor for successful endovascular treatment. However, it is sometimes difficult to obtain sufficient stabilization because of the tortuosity of the approach route. A Goose Neck Snare is useful for the retrieval of intravascular foreign bodies and can be used to hold the guiding catheter. We describe five cases of endovascular treatment performed while using the Goose Neck Snare via the brachial artery to hold the guiding catheter. We discuss the utility of this strategy.

Involuntary movement is a rare clinical manifestation of transient ischemic attack (TIA). However, limb-shaking TIA is well described presentation of carotid occlusive disease. We present the case of a patient who developed limb-shaking TIA associated with high-grade stenosis of middle cerebral artery (M1), which was treated with percutaneous transluminal angioplasty (PTA). The procedure was performed successfully without complication and the symptom disappeared immediately after the procedure. The patient remained free of symptoms at the 38-month follow-up. There was no tendency of restenosis of M1. In this case, PTA was technically feasible and beneficial for limb-shaking TIA with M1 stenosis. Limb-shaking TIA can be a symptom of high-grade stenosis of M1.

Before treating an arteriovenous fistula, it is important to understand its features, particularly the shunting point, sinus form, and drainage route. However, this can often be difficult owing to the large number of vessels that accumulate in the fistula region. In this study, we employed image fusion technology to understand the pathology of cavernous sinus dural arteriovenous fistulas (CSdAVFs) prior to treatment. We performed the following three types of fusions on the workstation: three-dimensional rotation angiography (3DRA) images from different feeding arteries to gain a detailed understanding of fistula architecture and shunting points; three-dimensional computed tomography (3DCT) and 3DRA images for determining the correlation between the skull base bone and the sinus shunt to predict the point of shunt access;and time-of-flight magnetic resonance imaging (TOF MRI) scans and 3DRA source images for investigating retrograde leptomeningeal venous drainage. Compared to individual images, the fused images more effectively provided a detailed understanding of CSdAVFs. Herein, we report our experience with image fusion for CSdAVF and review the relevant literature.