Re-evaluation of clinical features and risk factors of acute ischemic stroke in Japanese longevity society.

Age is an important factor correlated with stroke prevalence and independently influences stroke outcome especially in Japanese longevity society. To re-evaluate the characteristics of acute ischemic stroke in the old-old, analyses of clinical data on 426 patients registered at a Japanese tertiary emergency hospital were performed under appropriate statistical methods. Clinical features, stroke subtypes, current-known risk factors for stroke, time from onset to arrival, the National Institute of Health Stroke scale (NIHSS) score on admission, length of hospital stay, modified Rankin Scale (mRS) at discharge were compared between two stratified groups by age-at-onset (≧75 and < 75 years old). Significant differences were demonstrated in categories of sex, NIHSS score, length of hospital stay and m-RS. Current-known risk factors for stroke except atrial fibrillation were not prominent in the elderly group. Our study revealed that clinical phenotype and outcome in stroke patients would have been modified and re-evaluation of risk factors is necessary for prevention of ischemic stroke in Japanese longevity society.

Hospital-based study of the care and cost of acute ischemic stroke in Japan.

BACKGROUND AND PURPOSE: To evaluate the current status of care and cost of acute ischemic stroke in Japan, we performed a hospital-based analysis at a tertiary emergency hospital with a 24-hour neurology-neurosurgery team and care unit. METHODS: During the 12-month period of October 2000 to September 2001, we collected data on 179 patients consecutively hospitalized with acute ischemic stroke within 7 days of onset. We examined demographic data, in-hospital care, length of hospital stay, outcome at discharge, and hospital costs. The medical cost data were collected from official hospital medical cost charts, which calculated direct medical costs for beds, staff, examinations, medications, and rehabilitation. RESULTS: The mean age was 70 years, and 69% were male. Hospital arrival was within 3 hours of onset in 30% of the patients. A history of stroke was present in 37%. The mean initial National Institutes of Health Stroke Scale score was 8.3 points (median, 6 points). Using the Trial of Org 10172 in Acute Stroke Treatment classification, 25% were lacunar, 27% were atherothrombotic, 33% were cardioembolic, and 15% were of unknown origin. All patients underwent neuroimaging studies during hospitalization; 96% and 92% underwent CT and MRI with MR angiography, respectively. Antithrombotic medications were given in 94%, none of whom received thrombolysis. A newly licensed neuroprotective agent, edaravone, was given in 16%. More than half of the patients (55%) were initially admitted to the neurological intensive care unit. Overall, 64% received in-hospital rehabilitation. Mean length of stay was 33 days. In-hospital mortality rate was 3%. On the modified Rankin Scale (mRS), 63% were independent (mRS, 0 to 2) and 34% were dependent (mRS, 3 to 5) at discharge. Two thirds of the patients (65%) went directly back home. The mean hospital cost per patient was $6887 ($209/d), of which 69% was attributable to the costs for beds and staff, 12% for medications, 7% for rehabilitation, 6% for imaging studies, 5% for laboratory examinations, and 1% for other costs. CONCLUSIONS: Despite the single hospital-based analysis, this study provided current, precise data on short-term inpatient care and costs of acute ischemic stroke in Japan. Because stroke often carries a permanent dependence, long-term cost-effective stroke care should be established.

[Dropped head plus syndrome; a case report].

We reported a patient with so-called "dropped head plus syndrome", a non-progressive myopathy characterized by striking neck extensor weakness followed by progressive limb weakness which is well controlled by azathioprine. This 74-year-old man complained of neck and shoulder fatigue followed by progressive neck extensor weakness over 7 months. On physical examination, neck extensor strength was 4/5 on the MMT scale, but the remainder of the neurological examination and blood tests were normal. Needle EMG showed myopathic changes in the right trapezius and biceps brachialis muscles. Without any treatment, he developed weakness of upper and lower limb muscles about 8 months later, and Gowers' sign was positive. Blood test and needle EMG was unchanged. Muscle biopsy of the left trapezius, deltoid and supraspinatus muscles disclosed nonspecific myopathic changes consisting of variation in fiber size with disorganized intermyofibrillar networks in all the fibers, and there were rimmed vacuoles in some fibers of the deltoid muscle. There was no change on corticosteroids, but there was a dramatic improvement with azathioprine and his muscle symptoms disappeared. We, therefore, made the diagnosis of "dropped head plus syndrome". This appears to be the first such case in Japan.

[Dysphagia due to giant cervical osteophytes].

We reported a patient with isolated dysphagia due to an esophageal canal stenosis compressed by focal cervical spondylotic osteophytes. The patient was a 63-year-old male who developed swallowing disturbance of predominantly solid materials. The neurological examination showed subjectively isolated dysphagia unassociated with any significant cranial nerve signs. Cervical magnetic resonance imaging and X-ray demonstrated giant cervical spurs focally at the ventral portion of the C 5/6 vertebral bodies, protruding ventrally and compressing mildly to the esophageal canal. The intervertebral disc formation was relatively preserved between the osteophytes. At the neck flexion portion, the esophagus was severely compressed between the osteophytes and the epiglottis. Videofluoroscopic examination of swallowing function showed a congestion of the contrast medium at the portion of the epiglottic vallecula, unassociated with aspiration into the trachea. The endoscopic examination showed erosion of the posterior wall of the esophagus at the portion compressed by the osteophytes. The anti-inflammatory medication improved the symptom of dysphagia, and the patient has been carefully followed-up without a surgical procedure. The presence of giant osteophyte should be considered in the differential diagnosis of subjectively isolated dysphagia unassociated with any significant cranial nerve signs.

[Dide-Botcazo syndrome associated with Anton's syndrome after a cardioembolic infarction in the distribution of the bilateral posterior cerebral arteries].

Dide-Botcazo syndrome (Rev Neurol, 1902) is a unique neuropsychological syndrome, characterized by combinations of cortical blindness, amnesia, and topographical disorientation. We report 82-year-old right-handed man manifesting such syndrome associated with Anton's syndrome after a cardioembolic infarction in the distribution of the bilateral posterior cerebral arteries. The MRI study demonstrated recent extensive infarctions bilaterally in the occipital lobes and the medial temporal lobes, and thalamus. Following the resolution of unconsciousness and tetraparesis, the patient persistently presented with denial of cortical blindness (Anton's syndrome), profound anterograde amnesia and retrograde amnesia of about 50 years, severe topographical disorientation, and partial impairment of the tactile and auditory naming for objects. The bilateral extensive damages to the visual area, the memory area, and the connecting areas including the occipital lobe of the non-dominant hemisphere possibly responsible for topographical disorientation, may account for producing Dide-Botcazo syndrome. The syndrome may clinically occur following the "top of the basilar" syndrome.

[Early ischemic lesion demonstrated by ictal diffusion-weighted MRI during prior TIA in a patient with cerebral infarction].

We reported a patient with transient ischemic attack (TIA), subsequently evolving to a cerebral infarction, in whom ictal diffusion-weighted magnetic resonance imaging (MRI) detected early ischemic lesion in the left hemisphere. The patient was a 30-year-old right-handed male medical doctor, who had an in-hospital episode of TIA with obtundation and right hemiparesis, which lasted for 150 minutes. Ictal diffusion-weighted MRI obtained 110 minutes after symptom onset demonstrated an area of high signal intensity in the left striatum and corona radiata, whereas T 2-weighted and FLAIR images were entirely normal. Ictal magnetic resonance angiography (MRA) showed occlusive lesions in the M 2 branches of the left middle cerebral artery. The second MRA obtained 90 minutes after resolution of the symptoms showed nearly complete recanalization of the left middle cerebral artery, suggesting that the TIA was embolic mechanism. However the patient rapidly developed similar neurological symptoms again 58.5 hours after the TIA episode, evolving finally to a completed stroke. A brain CT obtained 1 hour after the second episode demonstrated diffuse hypodense lesions in the left basal ganglia and corona radiata, and in the left temporal lobe. MRIs 3 and 7 days later displayed completed infarcts, of which distribution was consistent with that of the hypodense lesions on the earlier CT. The left middle cerebral artery remained patent on the follow-up MRAs. The patient fairly recovered and returned to his premorbid position as medical doctor with a mild residual right hand clumsiness. In this patient, ictal and post-ictal MRAs documented an occlusion and a reopening of the middle cerebral artery. The embolic mechanism remains unknown despite detailed cardiac, vascular, and hematological examinations. In addition to recurrent embolism, we would like to point out that the reperfusion injury, secondary delayed neuronal death, and other factors may be involved in the second exacerbation evolving to the completed stroke.