The Stroke Center, Tokyo Rosai Hospital

“From hyperacute care to return to work.”

24 hours a day, 365 days a year, we provide medical treatment for stroke.

 

• Primary Stroke Center certified by the Japan Stroke Association
• Training and education facility certified by the Japanese Society of Stroke Medicine
• Training facility certified by the Japanese Society for Neuroendovascular Therapy

Neurologists and neurosurgeons collaborate in stroke center

Staff members are dispatched from the Department of Neurology and Stroke Intensive Care Unit of Nippon Medical School, a leader in emergency stroke care, and the Department of Neurosurgery of Showa University, which has inherited advanced techniques in cerebrovascular surgery and endovascular surgery. The unique feature of the Stroke Center at Tokyo Rosai Hospital is that internists and surgeons work together to provide emergency stroke care.

What is stroke?

Stroke is a disease that can happen to anyone at any time. The word “stroke” means “sudden” and “middle” means “to hit. In English, the word “stroke” is the same as the origin of the word “swinging something hard” when hitting a ball with a racket or club, or when swimming in water. Suddenly, the patient becomes unable to move, speak, or have a headache. The cause is a clogged or ruptured blood vessel in the brain, which causes the cranial nerves to cease functioning. Stroke is classified into the following three conditions;

Cerebral infarction: Blood vessels circulating from the heart to the brain become blocked, preventing blood flow to the brain and causing cranial nerve necrosis.

Cerebral hemorrhage: A blood vessel in the brain breaks, causing bleeding into the brain parenchyma (formerly known as cerebral apoplexy).

Subarachnoid hemorrhage: a rupture of a bump in a cerebral blood vessel called a cerebral aneurysm causes hemorrhage that spreads throughout the brain.

Symptoms of Stroke

Brain functions differ depending on the area of the brain, so different symptoms such as paralysis, speech impairment, and memory impairment occur depending on the area and size of the injury. The brain consists of the cerebrum (frontal, parietal, temporal, and occipital lobes), cerebellum, and brainstem, and the functions of each region are as follows;

Frontal lobe: complex human-like functions such as thinking, feeling, attention, judgment, and motivation. There are also motor areas that move the body and motor speech areas that utter words. Because the brain controls opposite sides of the body, if the right side of the brain is damaged, symptoms will occur in the left half of the body; if the left side of the brain is damaged, symptoms will occur in the right half of the body. Damage to the frontal lobe can result in motor paralysis, motor aphasia (inability to speak), thought and emotion disorders, and higher functional impairment. Parietal lobe: involved in body sensation, spatial and three-dimensional perception. Disorders of the parietal lobe result in the inability to perceive three dimensions and the opposite side of space. This is called hemispatial neglect, which means that the patient is only able to recognize half of the world that he or she is supposed to see, and is unable to recognize half of his or her own body and does not try to use it. They also do not use the half of their body that they do not recognize. They eat food and leave the half that they don’t recognize. Temporal lobe: Involved in memory, speech recognition, and language comprehension. The hippocampus in the medial temporal lobe is involved in memory. Damage to the ectopia adjacent to the hippocampus can interfere with the ability to make instantaneous judgments and emotions based on experience and memory. Occipital lobe: Objects seen by the eyes are recognized in the occipital lobe via the optic nerve. It processes visual information and is involved in spatial perception together with the parietal lobe. Damage to the occipital lobe can cause narrowing of the visual field and impair recognition of what is seen. Cerebellum: This is a region located below the cerebrum. It is responsible for repetitive and familiar movements, fine motor skills, posture, balance, and speech fluency. Disorders can cause wobbliness, inability to stand or walk, dizziness, nausea, difficulty with fine motor skills, inability to perceive distance, tremors, and difficulty with speech.

Brainstem: The brainstem is the vital center function involved in respiration, circulation, consciousness, and swallowing. Injury to the brainstem can result in impaired consciousness, paralysis, sensory disturbance, and difficulty swallowing, and in cases of severe pressure or injury such as brain herniation, death can occur.

Because of the complex network in the brain, various symptoms such as higher functional disability may occur depending on the location and extent of brain damage. Physical movement and daily conversation may not be affected, but difficult decisions, staying focused, and social skills may become problematic. Inability to swallow is called dysphagia, which can also occur with bilateral brain damage. Swallowing increases with age, and aspiration pneumonia is more likely to occur with dysphagia. If the patient is unable to drink water or eat, a tube is inserted through the nose into the stomach to feed a liquid diet.

If the brain damage at the onset of stroke is severe, the patient may continue to suffer from a persistent disturbance of consciousness, a condition in which consciousness is not restored.

Treatments of Stroke

Prompt diagnosis and acute treatment are important for stroke.

If a stroke is suspected at the time of the 119 call, treatment begins with a rapid emergency transport system. In addition, the determination of “stroke” upon arrival at the scene by the EMS team is quick and accurate, and the patient is transported to the emergency room as a stroke response.

Treatment of cerebral infarction

If the stroke occurs within 4 hours and 30 minutes, a clot-dissolving drug called alteplase (t-PA) is infused over an hour. A blood clot is a blood clot that obstructs a blood vessel. If Alteplase does not dissolve the clot, a catheter is guided into the cerebral blood vessel and a stent or suction device is used to remove the clot. This is called thrombus retrieval therapy or acute recanalization therapy. Alteplase and thrombus retrieval therapy can only be performed in the hyperacute phase, before cranial nerve necrosis spreads. Thereafter, intravenous infusion of drugs to improve cerebral blood flow and protect the brain, oral medication to prevent recurrence, and rehabilitation are continued.

Treatment of cerebral hemorrhage

There are areas in the brain where blood vessels can easily rupture and cause bleeding. These include the putamen, thalamus, cerebellum, and brain stem. In cases of excessive bleeding, emergency surgery is performed to remove the hematoma.

Treatment of subarachnoid hemorrhage

Most subarachnoid hemorrhages are caused by ruptured cerebral aneurysms. If the aneurysm ruptures again, there is a risk of worsening of symptoms and death, so emergency surgery is necessary to prevent re-rupture. There are two types of aneurysm surgery: cerebral aneurysm clipping, in which the craniotomy is opened and the base of the aneurysm is occluded with a metal clip; and cerebral aneurysm coil embolization, in which a metal coil is inserted into the aneurysm via a catheter and the aneurysm is occluded. In cerebral aneurysm clipping, the skull is partially removed and the aneurysm is approached through a gap in the brain (between the frontal and temporal lobes or between the brain and skull base). The surgery is performed under a microscope due to the fine surgical manipulation. If there is a lot of bleeding and the brain pressure is high, the skin is closed while the skull is removed, and the skull is put back in at a later date after the brain pressure is reduced. If the patient has hydrocephalus, which is a buildup of spinal fluid circulating in the brain and spinal cord, ventricular drainage, which drains the spinal fluid, is also added.

In cerebral aneurysm coil embolization, a thin tube called a catheter is guided from the femoral artery at the base of the leg to a blood vessel in the brain. By advancing a thin microcatheter within a larger guiding catheter, it is possible to approach within the smaller vessels in the brain. The type of coil is selected according to the size and shape of the aneurysm, and several to ten coils are placed within the aneurysm.

Around 4-14 days after the onset of subarachnoid hemorrhage, a reaction called cerebral vasospasm occurs, in which the blood vessels in the brain thin out, and blood cannot reach the brain, which may cause a cerebral infarction. After surgery to prevent rebleeding, the patient is switched to treatment to improve cerebral blood flow to prevent cerebral vasospasm. Catheterization may be used to widen cerebral blood vessels.

Also, In the case of hydrocephalus, which is an ongoing cerebrospinal fluid circulation disorder, surgery is performed to drain excess spinal fluid from the brain and spinal cord into the abdominal cavity. A thin tube is implanted to drain spinal fluid from the ventricles of the brain or lumbar spine into the abdominal cavity. This is called a ventriculoperitoneal shunt or a lumbar shunt.

Return to daily life and society

When a stroke occurs and the cranial nerves are damaged, patients are left with impaired consciousness, motor paralysis, sensory impairment, speech impairment, apraxia, and higher functional impairment. Rehabilitation is performed to lessen the aftereffects and allow the patient to return to a form of life closer to that of before, and to live despite the limitations. In the past, it was believed that patients should rest after stroke onset, but now rehabilitation is started in the acute phase of stroke onset. Since the length of stay in an acute care hospital like ours is short, patients are transferred to a hospital that specializes in rehabilitation after the acute stage of treatment. Our medical social workers will help you prepare for the transfer, so you do not need to worry about it. We also collaborate with neighboring hospitals to ensure a smooth transition to a rehabilitation hospital and recovery phase rehabilitation. Although most patients are transferred to the southern Tokyo medical district (Shinagawa and Ota wards) where our hospital is located, or to the neighboring city of Kawasaki, we can also transfer patients to any area that they or their family members wish. Because of the proximity of Haneda Airport, many patients from all over the country and even from overseas are transported to our hospital as emergency patients. We also coordinate transfers to hospitals in various regions, including workers’ accident compensation hospitals nationwide, and take safety during transfers into consideration. In addition, there are various social resources available to patients when they become ill. These include the high-cost medical care cost system, the maximum amount applicable certificate, injury and illness allowance, disability pension, long-term care insurance, physical disability certificate, medical care system for services and supports for the physically disabled, and the livelihood welfare fund loan system. When a patient suddenly becomes unable to work, both the patient and his/her family may feel financially insecure, and it may be difficult to understand the systems in place. Our medical social workers will explain the financial support and systems available to you.

Support for balancing treatment and work

Stroke treatment has progressed year by year, and emergency medical care and rehabilitation systems have been established. However, those with severe aftereffects often require nursing care, and stroke is the second most common cause of requiring nursing care after dementia.

In addition, many people find it difficult to return to work even if they are able to lead their daily lives. There are various factors that prevent people from working even if they want to. They include inability to maintain the performance they had before the onset of the disease, impaired attention span due to higher dysfunction, inability to drive, and lack of an accepting environment in the workplace. Currently, the Japan Labor Health and Safety Organization’s nationwide workers’ compensation hospitals and occupational health centers are working to encourage society to allow patients to balance treatment for their illnesses and work. In stroke care, acute treatment is important and focused on, but it is only the beginning of treatment for the patient and his/her family. The goal of stroke treatment is to return to society. However, there are various problems that arise when a person’s ability to work after a stroke is impaired. Our hospital focuses on “support for balancing treatment and work” and is a “Model Project for Supporting Patients with Cardiovascular Diseases to Balance Treatment and Work” facility by the Ministry of Health, Labour and Welfare in the field of stroke. A specialized “work-life balance support coordinator” intervenes to help patients return to work, maintaining cooperation even after transferring from this hospital to a recovery-phase rehabilitation hospital, and sharing information and making adjustments with the workplace. The Japan Industrial Safety and Health Organization provides training for “coordinators for supporting work-life balance,” and as of March 2021, more than 7,500 people have completed the training nationwide.

Prevention of Recurrent Stroke

Cerebral infarction is caused by arteriosclerosis and arrhythmia, in which blood vessels become brittle due to hypertension, diabetes, dyslipidemia (hyperlipidemia), and other factors. Half of all cerebral infarctions recur within 10 years of onset. It is necessary to normalize blood pressure, blood sugar, and cholesterol to suppress the progression of arteriosclerosis, and to treat arrhythmia, such as atrial fibrillation, if present. It is also important to take antithrombotic medications to prevent blood from clotting.

In the case of cerebral hemorrhage, antithrombotic medications are not necessary, but blood pressure control is important.

In the case of subarachnoid hemorrhage, there is little concern if the cerebral aneurysm has been treated, but in rare cases, blood flow may resume in the aneurysm after coil embolization, so periodic examinations are performed. Smoking cessation is mandatory. If you have a family member who has had a cerebral aneurysm or subarachnoid hemorrhage, a head MRI is recommended to check for a cerebral aneurysm.