Masahiro Oomura

Aim: The benefit of mechanical thrombectomy (MT) for acute ischemic stroke in patients with pre‐stroke moderate‐to‐severe disability is difficult to evaluate using the modified Rankin Scale (mRS) alone. We developed and evaluated the SMILE‐Stroke score as a patient‐centered outcome measure. Methods: We conducted a retrospective cohort study of 31 patients with pre‐stroke mRS scores of 3–5 who underwent MT. The 10‐point SMILE‐Stroke score, comprising Speech, Mobility, Ingestion, Lavatory, and Engagement domains, was assessed at discharge; a score ≥ 4 was prespecified as favorable. Interrater reliability, convergent validity with the Barthel Index, associations with discharge disposition and mRS, and pre‐stroke SMILE‐Stroke scores were evaluated. Results: Twelve patients (38.7%) achieved a favorable SMILE‐Stroke outcome. Interrater reliability was excellent for the total score (single‐rater intraclass correlation coefficient = 0.957) and dichotomized outcome (Fleiss' κ = 0.863). The score correlated strongly with the discharge Barthel Index (Spearman's ρ = 0.86, p < 0.001) and showed a graded association with discharge disposition (Kruskal–Wallis p = 0.0012). For distinguishing discharge to home/original residence or rehabilitation hospital from long‐term care hospital or death, the SMILE‐Stroke score yielded an AUC of 0.82. Notably, 6 of 19 patients (31.6%) with 90‐day mRS scores of 4–5 achieved a favorable SMILE‐Stroke outcome. Conclusions: The SMILE‐Stroke score was feasible, reproducible, and associated with established functional and discharge outcomes in selected MT‐treated patients with pre‐stroke disability. It may complement the mRS by identifying preserved or regained patient‐centered functional domains within poor mRS categories.

Background: Autoimmune encephalitis therapy requires adjusting the regimen based on therapeutic response; however, clinical indicators of this response remain unknown. Aim: To determine the predictive capability of cerebrospinal fluid (CSF), electroencephalography (EEG), and brain magnetic resonance imaging (MRI) in identifying responders to initial treatment for autoimmune encephalitis. Methods: We retrospectively selected patients diagnosed with autoimmune encephalitis and treated at our hospital between April 1, 2015, and September 30, 2023. Patients were divided into initial first‐line treatment (FT) responders (those who did not require additional immunotherapy after the initial FT) and initial FT non‐responders (those who required two or more FT sessions or second‐line therapy). CSF, EEG, and brain MRI findings were analyzed before treatment initiation and at the first follow‐up examination. Duration of hospitalization and modified Rankin Scale (mRS) scores were compared between groups. Results: Overall, 16 of the 27 selected patients with autoimmune encephalitis were classified as first FT responders, whereas 11 were non‐responders. CSF examination revealed a significantly lower interleukin‐6 (IL‐6) ratio (follow‐up IL‐6/pre‐FT IL‐6) in all responders (IL‐6 ratio < 1). No significant differences were observed between responders and non‐responders in background EEG rhythm frequency, the presence of epileptic discharges, or chronological MRI changes. The length of hospital stay and mRS scores at discharge were significantly lower in the initial FT responder group. Conclusion: A lower CSF IL‐6 ratio may be a good predictive marker for response to initial therapy.

The superiority of percutaneous transluminal angioplasty (PTA) over maximal medical therapy for symptomatic intracranial artery stenosis in terms of secondary prevention has yet to be proved. However, several studies have reported that PTA can improve cortical symptoms and cognitive dysfunctions in selected patients with intracranial artery stenosis. Recently, we experienced a 75‐year‐old woman with acute ischemic stroke due to right middle cerebral artery stenosis, presenting with hemispatial neglect of the left side as well as left hemiparesis, which was treated with PTA in the subacute stage. She showed improvement of the hemispatial neglect after PTA, which accelerated the rehabilitation, resulting in a good prognosis. It is known that the presence of neglect syndrome hampers rehabilitation and is associated with a poor outcome. To our knowledge, this is the first report of the performance of PTA to improve hemispatial neglect for successful rehabilitation.

It is known that the traditional Japanese way of bathing can trigger stroke events. We report a patient with internal carotid artery pseudo‐occlusion who presented with transient ischemic attack only after bathing.

Background: Dual antiplatelet therapy (DAPT) with clopidogrel is one of the initial treatment regimens for early neurological deterioration (END) in branch atheromatous disease (BAD). However, its effectiveness is affected by cytochrome P450 2C19 polymorphism. Prasugrel, with reduced cytochrome P450 2C19 interactions, has been approved for cerebrovascular diseases in Japan.Aim: To explore the efficacy of DAPT with prasugrel and with clopidogrel in preventing END.Methods: Patients with BAD, admitted within 48 h of symptom onset between June 2022 and September 2023, were enrolled. The primary endpoint was the proportion of patients with END within 7 days, which was defined as an increase of 1 point or more on the National Institutes of Health Stroke Scale (NIHSS). Patients meeting specific magnetic resonance imaging (MRI) criteria, including lesions of ≥15 mm in the lenticulostriate artery (LSA) region or infarcts extending to the ventral side of the paramedian pontine region, were included. The patients were randomly assigned to the clopidogrel with loading and prasugrel without loading groups and administered common medications.Results: The study included 9 and 10 patients in clopidogrel and prasugrel groups, of whom 56% and 50% had END, respectively. The prasugrel group had earlier exacerbations after admission (days 0–1) than that of the clopidogrel group (days 1–2). The bleeding complications of both groups were not significantly different.Conclusion: The two groups had similar proportions of patients with END, suggesting comparable efficacies of both drugs for patients with BAD.

We herein report a case of acute neurological symptoms and a fever initially suspected of being encephalitis but later revealed to be dural arteriovenous fistula (dAVF). An 84-year-old woman had a fever and cerebral edema and was initially treated for encephalitis. A review of her magnetic resonance imaging findings revealed abnormal blood flow signals. After cerebral angiography, the patient was finally diagnosed with left transverse-sigmoid sinus dAVF. The present case showed that dAVF can also present with an acute onset and a fever, mimicking acute encephalitis. Because the treatments for encephalitis and dAVF differ greatly, the possibility of dAVF should also be considered when diagnosing encephalitis.

Internal carotid artery occlusion rarely recanalizes spontaneously. Awareness of signs of recanalization is important, as it may necessitate changing the treatment strategy. We report a case of new cortical infarction outside the border zone, which led to the realization of internal carotid artery recanalization and revascularization. A 76-year-old woman presented with mild dysarthria. Magnetic resonance imaging showed cerebral infarction in the left-hemispheric border zone and occlusion of the internal carotid artery origin. Cerebral angiography performed showed complete occlusion of the internal carotid artery origin and intracranial collateral blood flow from the external carotid artery through the ophthalmic artery. She was diagnosed with infarction due to a hemodynamic mechanism caused by internal carotid artery occlusion and was treated with supplemental fluids and antithrombotic drugs. Four days after hospitalization, the right paralysis worsened and a new cerebral infarction was observed in the cortex, outside the border zone. This infarction appeared to be embolic rather than hemodynamic; thus, we suspected recanalization of the internal carotid artery. The patient underwent emergency cerebral angiography again, which revealed slight recanalization. Thus, emergency revascularization and carotid artery stenting were performed. New cortical infarcts outside the border zone in patients with complete internal carotid artery occlusion is an important finding, suggesting spontaneous recanalization of the occluded internal carotid artery.