Mode of Imaging Study and Endovascular Therapy for a Large Ischemic Core: Insights From the RESCUE-Japan LIMIT / 대한뇌졸중학회지

Background@#and Purpose Differences in measurement of the extent of acute ischemic stroke using the Alberta Stroke Program Early Computed Tomographic Score (ASPECTS) by non-contrast computed tomography (CT-ASPECTS stratum) and diffusion-weighted imaging (DWI-ASPECTS stratum) may impact the efficacy of endovascular therapy (EVT) in patients with a large ischemic core. @*Methods@#The RESCUE-Japan LIMIT (Recovery by Endovascular Salvage for Cerebral Ultra-acute Embolism Japan–Large IscheMIc core Trial) was a multicenter, open-label, randomized clinical trial that evaluated the efficacy and safety of EVT in patients with ASPECTS of 3–5. CT-ASPECTS was prioritized when both CT-ASPECTS and DWI-ASPECTS were measured. The effects of EVT on the modified Rankin Scale (mRS) score at 90 days were assessed separately for each stratum. @*Results@#Among 183 patients, 112 (EVT group, 53; No-EVT group, 59) were in the CT-ASPECTS stratum and 71 (EVT group, 40; No-EVT group, 31) in the DWI-ASPECTS stratum. The common odds ratio (OR) (95% confidence interval) of the EVT group for one scale shift of the mRS score toward 0 was 1.29 (0.65–2.54) compared to the No-EVT group in CT-ASPECTS stratum, and 6.15 (2.46–16.3) in DWI-ASPECTS stratum with significant interaction between treatment assignment and mode of imaging study (P=0.002). There were significant interactions in the improvement of the National Institutes of Health Stroke Scale score at 48 hours (CT-ASPECTS stratum: OR, 1.95; DWIASPECTS stratum: OR, 14.5; interaction P=0.035) and mortality at 90 days (CT-ASPECTS stratum: OR, 2.07; DWI-ASPECTS stratum: OR, 0.23; interaction P=0.008). @*Conclusion@#Patients with ASPECTS of 3–5 on MRI benefitted more from EVT than those with ASPECTS of 3–5 on CT.

Global Impact of the COVID-19 Pandemic on Cerebral Venous Thrombosis and Mortality / 대한뇌졸중학회지

Background@#and Purpose Recent studies suggested an increased incidence of cerebral venous thrombosis (CVT) during the coronavirus disease 2019 (COVID-19) pandemic. We evaluated the volume of CVT hospitalization and in-hospital mortality during the 1st year of the COVID-19 pandemic compared to the preceding year. @*Methods@#We conducted a cross-sectional retrospective study of 171 stroke centers from 49 countries. We recorded COVID-19 admission volumes, CVT hospitalization, and CVT in-hospital mortality from January 1, 2019, to May 31, 2021. CVT diagnoses were identified by International Classification of Disease-10 (ICD-10) codes or stroke databases. We additionally sought to compare the same metrics in the first 5 months of 2021 compared to the corresponding months in 2019 and 2020 (ClinicalTrials.gov Identifier: NCT04934020). @*Results@#There were 2,313 CVT admissions across the 1-year pre-pandemic (2019) and pandemic year (2020); no differences in CVT volume or CVT mortality were observed. During the first 5 months of 2021, there was an increase in CVT volumes compared to 2019 (27.5%; 95% confidence interval [CI], 24.2 to 32.0; P<0.0001) and 2020 (41.4%; 95% CI, 37.0 to 46.0; P<0.0001). A COVID-19 diagnosis was present in 7.6% (132/1,738) of CVT hospitalizations. CVT was present in 0.04% (103/292,080) of COVID-19 hospitalizations. During the first pandemic year, CVT mortality was higher in patients who were COVID positive compared to COVID negative patients (8/53 [15.0%] vs. 41/910 [4.5%], P=0.004). There was an increase in CVT mortality during the first 5 months of pandemic years 2020 and 2021 compared to the first 5 months of the pre-pandemic year 2019 (2019 vs. 2020: 2.26% vs. 4.74%, P=0.05; 2019 vs. 2021: 2.26% vs. 4.99%, P=0.03). In the first 5 months of 2021, there were 26 cases of vaccine-induced immune thrombotic thrombocytopenia (VITT), resulting in six deaths. @*Conclusions@#During the 1st year of the COVID-19 pandemic, CVT hospitalization volume and CVT in-hospital mortality did not change compared to the prior year. COVID-19 diagnosis was associated with higher CVT in-hospital mortality. During the first 5 months of 2021, there was an increase in CVT hospitalization volume and increase in CVT-related mortality, partially attributable to VITT.

Early Physical Therapy Intervention for Frail Patients Isolated with COVID-19 / 日本農村医学会雑誌

Few reports have described assessment methods or exercise interventions in detail for patients isolated with COVID-19. Here, we report our experience of providing physical therapy to these patients based on motor assessment with consideration of infection control. This study involved 4 patients with COVID-19 who needed physical therapy due to a fall or frailty during isolation. The assessment method used was intended to minimize physical contact, to be easily performed, and to reflect muscle strength and balance. Based on the assessment, we created exercise programs and provided exercise intervention to the patients in cooperation with nurses. One patient was discharged early; the other 3 patients showed improved motor function and activities of daily living as a result of the intervention in the acute ward. However, they needed ongoing rehabilitation in the rehabilitation ward. No physical therapists showed signs of COVID-19 infection. Performing motor assessments and providing exercise intervention to these patients isolated with COVID-19 contributed to motor improvement and enabled us to promptly determine whether they needed ongoing rehabilitation.

Serial Changes in Score on the Japanese Version of the Trail Making Test (TMT-J) After Minor Ischemic Stroke / 日本農村医学会雑誌

The Trail Making Test (TMT) is a widely used measure of attention impairment. The time needed to complete the TMT (TMT score) is longer with greater impairment of attention in patients with brain diseases. TMT score becomes large in a proportion of patients with minor ischemic stroke. The Japanese version of the TMT- (TMT-J) was published in 2019. The purpose of this study was to clarify serial changes in TMT-J scores in patients with minor ischemic stroke. We retrospectively reviewed the TMT-J scores in those patients who completed the test both 8-14 days and 29-35 days after stroke onset. On initial evaluation, 1 of 21 patients could not complete TMT-J Part A. TMT-J Part A scores had a mean of 67 s and were abnormally large in 45% of the 20 patients who completed this part. Two of these 20 patients could not complete TMT-J Part B. TMT-J Part B scores had a mean of 135 s and were abnormally large in 61% of the 18 patients who completed this part. On second evaluation, scores on Part A and Part B improved in 76% and 73% of patients, respectively. This study demonstrated that abnormal TMT-J scores 8-14 days after onset of minor ischemic stroke improved over time in most patients.

Physical Therapy for a Patient with Parkinson's Disease Treated With Levodopa/Carbidopa Intestinal Gel: A Case Report / 日本農村医学会雑誌

A 60-year-old woman with Parkinson disease (PD) treated by Levodopa / carbidopa intestinal gel (LCIG) began physical therapy (PT). Before inducing LCIG therapy, she had six hours off time a day, and she have not walked outside for six years due to the fear of off time freezing. Scores for depression and anxiety on the Hospital Anxiety and Depression Scale (HADS) were 14 and 11, respectively. Symptoms of depression and anxiety as well as impaired endurance and balance were confirmed. While maintaining LCIG treatment, physical therapy (PT) was started with a focus on tasks to improve endurance and balance. Activity goals were decided with the patient. She stopped experiencing episodes of off time four months after PT was introduced and her HADS scores for depression and anxiety decreased to 6 and 3, respectively. She achieved the activity goals she had set, and outings became part of her daily routine. When introducing PT alongside LCIG treatment, patients and therapists should decide the activity goals together and work on activities that address the problems identified by the pre-PT assessment.

Consensus Guides on Stroke Thrombolysis for Anticoagulated Patients from Japan: Application to Other Populations / 대한뇌졸중학회지

Development of direct oral anticoagulants and their antidotes has led to the need to reconsider the eligibility of acute stroke patients who have been taking oral anticoagulants for intravenous thrombolysis. Officially authorized Japanese guidelines on this issue were revised twice at the time of approval for clinical use of direct oral anticoagulants and idarucizumab, a specific reversal agent for dabigatran. A unique recommendation in the latest Japanese clinical guides was that thrombolysis can be recommended if the time of the last dose of direct oral anticoagulants exceeds 4 hours and if commonly available anticoagulation markers are normal or subnormal, i.e., international normalized ratio of prothrombin time < 1.7 and activated partial thromboplastin time < 1.5 times the baseline value (≤40 seconds only as a guide). These criteria are partly supported by the findings of domestic multicenter and single-center surveys that symptomatic or asymptomatic intracranial hemorrhage following thrombolysis was rare under the conditions of the criteria. Even for dabigatran users, stroke thrombolysis can be considered without pretreatment by idarucizumab if patients meet the above criteria. If not, direct mechanical thrombectomy can be considered without pretreatment by idarucizumab or thrombolysis, and use of idarucizumab, followed immediately by thrombolysis, can be considered only when thrombectomy cannot be quickly performed. These clinical guides are practical and to some extent economical, but they have some limitations, including lack of corroborating information from sufficient numbers of relevant cases. The guides will be further modified based on the results of future research.

Intracranial Large Artery Disease of Non-Atherosclerotic Origin: Recent Progress and Clinical Implications / 대한뇌졸중학회지

Intracranial large artery disease (ILAD) is the major cause of stroke worldwide. With the application of recently introduced diagnostic techniques, the prevalence of non-atherosclerotic ILAD is expected to increase. Herein, we reviewed recent reports and summarized progress in the diagnosis and clinical impact of differentiation between ILAD of atherosclerotic and non-atherosclerotic origin. Our review of the literature suggests that more careful consideration of non-atherosclerotic causes and the application of appropriate diagnostic techniques in patients with ILAD may not only provide better results in the treatment of patients, but it may also lead to more successful clinical trials for the treatment of intracranial atherosclerosis.

Advanced Dementia with Lewy Bodies Showing Remarkable Improvement of Activities of Daily Living by Interventions in the Recovery Rehabilitation Unit / 日本農村医学会雑誌

    A 76-year-old woman with dementia with Lewy bodies (DLB) was transferred to our Recovery Rehabilitation Unit because of systemic muscle weakness due to disuse. She had been bed-ridden for about 6 months because of treatment for deep venous thrombosis and urinary tract infection. Weakness and features of parkinsonism were severe and she could barely turn over in bed. On admission, she needed considerable assistance to sit up and have meals. Her Unified Parkinson's Disease Rating Scale (UPDRS) score was 129 and Functional In de pendence Measure (FIM) score was 27 at the first evaluation. The doctor organized the dose of the drugs for DLB, and physical rehabilitation therapists performed repeated arm stretching exercises using Red Cord, raising the body, and standing exercises. Recreational activities such as ball-throwing games and singing songs gradually made her feel positive. She returned home on day 84 after admission. On discharge, she could stand and transfer to a wheelchair by slight assistance. The final evaluation showed that her UPDRS and FIM scores were 105 and 43, respectively. The outcome in this case suggests that adequate interventions in recovery rehabilitation units can improve ADL in patients with advanced neurodegenerative disease.

Cerebral Small Vessel Disease and Chronic Kidney Disease / 대한뇌졸중학회지

Chronic kidney disease, defined by a decreased glomerular filtration rate or albuminuria, is recognized as a major global health burden, mainly because it is an established risk factor for cardiovascular and cerebrovascular diseases. The magnitude of the effect of chronic kidney disease on incident stroke seems to be higher in persons of Asian ethnicity. Since the kidney and brain share unique susceptibilities to vascular injury due to similar anatomical and functional features of small artery diseases, kidney impairment can be predictive of the presence and severity of cerebral small vessel diseases. Chronic kidney disease has been reported to be associated with silent brain infarcts, cerebral white matter lesions, and cerebral microbleeds, independently of vascular risk factors. In addition, chronic kidney disease affects cognitive function, partly via the high prevalence of cerebral small vessel diseases. Retinal artery disease also has an independent relationship with chronic kidney disease and cognitive impairment. Stroke experts are no longer allowed to be ignorant of chronic kidney disease. Close liaison between neurologists and nephrologists can improve the management of cerebral small vessel diseases in kidney patients.

Factors Associated with Early Hospital Arrival in Patients with Acute Ischemic Stroke / 대한뇌졸중학회지

BACKGROUND AND PURPOSE: Factors associated with early arrival may vary according to the characteristics of the hospital. We investigated the factors associated with early hospital arrival in two different stroke centers located in Korea and Japan. METHODS: Consecutive patients with ischemic stroke arrived hospital within 48 hours of onset between January 2011 and December 2012 were identified and the clinical and time variables were retrieved from the prospective stroke registries of Severance Hospital of Yonsei University Health System (YUHS; Seoul, Korea) and National Cerebral and Cardiovascular Center (NCVC; Osaka, Japan). Subjects were dichotomized into early (time from onset to arrival 4.5 hours) arrival groups. Univariate and multivariate analyses were performed to evaluate factors associated with early hospital arrival. RESULTS: A total of 1,966 subjects (992 from YUHS; 974 from NCVC) were included in this study. The median time from onset to arrival was 6.1 hours [interquartile range, 1.7-17.8 hours]. In multivariate analysis, the factors associated with early arrival were atrial fibrillation (Odds ratio [OR], 1.505; 95% confidence interval [CI], [1.168-1.939]), higher initial National Institute of Health Stroke Scale scores (OR, 1.037; 95% CI [1.023-1.051]), onset during daytime (OR, 2.799; 95% CI [2.173-3.605]), and transport by an emergency medical service (OR, 2.127; 95% CI [1.700-2.661]). These factors were consistently associated with early arrival in both hospitals. CONCLUSIONS: Despite differences between the hospitals, there were common factors related to early arrival. Efforts to identify and modify these factors may promote early hospital arrival and improve stroke outcome.

Physical Therapy and Treatment Outcome in 2 Patients with Fracture of the Distal Patella / 日本農村医学会雑誌

　　While physical therapy following the treatment with the Zuggurtung method enables the active flexion movement of the knee joint to enhance bone union at an early stage, the active extension movement may impose stress on the fractured segments toward their separation; thus due caution must be exercised. The treatment outcome of patella Fractures has been improved since the introduction of the Zuggurtung method;however, this method is not always applicable depending on the fracture type, and accordingly, risks of physical therapy would differ between cases treated with and without the Zuggurtung method. This paper reports on the cases of 2 patients with fractures of the distal patella who were not appropriate to the Zuggurtung method. Treatment outcomes similar to those of treatment with the Zuggurtung method were observed by clarifying accompanying risks and aggressively maintaining flexibility and smoothness of the supra-patella tissues during and after knee brace fixation. It was thought essential to proceed physical therapy after considering associated risks based on the details and characteristics of an open reduction and internal fixation (ORIF) performed for each patient’s patella fractures.

Epidemiology and Registry Studies of Stroke in Japan / 대한뇌졸중학회지

Stroke is the most prevalent cardiovascular disease in Japan. This review introduces two epidemiologic studies and four registry studies of stroke in Japan. The Hisayama Study was begun as a population-based prospective cohort study of cerebrovascular and cardiovascular diseases in 1961 in the town of Hisayama. Most of the deceased subjects of the study underwent autopsy examinations from the beginning of the study. Changes in stroke trends in the last 50 years were clarified by comparison of data from different study cohorts registered every 13 to 14 years. The Suita Study was based on a random sampling of Japanese urban residents. Several reports from this study showed the significance of pre-hypertension, as well as hypertension, as a risk factor for stroke by itself and in combination with other underlying characteristics. In addition, the Japan Multicenter Stroke Investigators' Collaboration (J-MUSIC), the Japan Standard Stroke Registry Study, the Fukuoka Stroke Registry, and the Stroke Acute Management with Urgent Risk-factor Assessment and Improvement (SAMURAI) rt-PA Registry are explained as registry studies involving Japanese stroke patients.