Factors Associated with Incidental Neuroimaging Abnormalities in New Primary Headache Patients

Background@#and PurposeDeciding whether or not to perform neuroimaging in primary headache is a dilemma for headache physicians. The aim of this study was to identify clinical predictors of incidental neuroimaging abnormalities in new patients with primary headache disorders. @*Methods@#This cross-sectional study was based on a prospective multicenter headache registry, and it classified 1,627 consecutive first-visit headache patients according to the third edition (beta version) of the International Classification of Headache Disorders (ICHD-3β). Primary headache patients who underwent neuroimaging were finally enrolled in the analysis. Serious intracranial pathology was defined as serious neuroimaging abnormalities with a high degree of medical urgency. Univariable and multivariable logistic regression analyses were conducted to identify factors associated with incidental neuroimaging abnormalities. @*Results@#Neuroimaging abnormalities were present in 170 (18.3%) of 927 eligible patients. In multivariable analysis, age ≥40 years [multivariable-adjusted odds ratio (aOR)=3.37, 95% CI=2.07–6.83], male sex (aOR=1.61, 95% CI=1.12–2.32), and age ≥50 years at headache onset (aOR=1.86, 95% CI=1.24–2.78) were associated with neuroimaging abnormalities. In univariable analyses, age ≥40 years was the only independent variable associated with serious neuroimaging abnormalities (OR=3.37, 95% CI=1.17–9.66), which were found in 34 patients (3.6%). These associations did not change after further adjustment for neuroimaging modality. @*Conclusions@#Incidental neuroimaging abnormalities were common and varied in a primary headache diagnosis. A small proportion of the patients incidentally had serious neuroimaging abnormalities, and they were predicted by age ≥40 years. These findings can be used to guide the performing of neuroimaging in primary headache disorders.

Headache Education and Assessment for Migraineurs

Migraine is a common neurologic disorder with recurrent headache and variable accompanying symptoms. Patients with migraine have suffered by an enormous burden on daily life and impairment of quality of life (QoL), but migraine is still underdiagnosed and undertreated. For early and better diagnosis and treatment of migraine, headache education and instruments for evaluation of headache outcomes including QoL and disability are essential. Nonpharmachological treatment like cognitive-behavior therapy, mindfulness-based stress reduction, lifestyle modification and trigger avoidance, biofeedback, relaxation training can reduce frequency of pain, disability, so headache education might be helpful. Headache diary and instruments for evaluation of QoL, disability and comorbidity like Migraine Disability Assessment Scale (MIDAS), Headache Impact Test-6 (HIT-6), Migraine-Specific Quality of Life Questionnaire (MSQ) are useful tools to decide plans of treatment. When nonpharmachological treatment and headache education are well applied and evaluation of the QoL and disability are reflected, it will help improve the quality of life for migraine patients.J Korean Neurol Assoc 38(3):169-174, 2020

Neuroimaging Findings of First-Visit Headache Patients

BACKGROUND: Neuroimaging can play a crucial role in discovering potential abnormalities to cause secondary headache. There has been a progress in the fields of headache diagnosis and neuroimaging in the past two decades. We sought to investigate neuroimaging findings according to headache disorders, age, sex, and imaging modalities in first-visit headache patients. METHODS: We used data of consecutive first-visit headache patients from 9 university and 2 general referral hospitals. The International Classification of Headache Disorders, third edition, beta version was used in headache diagnosis. We finally enrolled 1,080 patients undertook neuroimaging in this study. RESULTS: Among 1,080 patients (mean age: 47.7±14.3, female: 60.8%), proportions of headache diagnosis were as follows: primary headaches, n=926 (85.7%); secondary headaches, n=110 (10.2%); and cranial neuropathies and other headaches, n=43 (4.1%). Of them, 591 patients (54.7%) received magnetic resonance imaging (MRI). Neuroimaging abnormalities were found in 232 patients (21.5%), and their proportions were higher in older age groups and male sex. Chronic cerebral ischemia was the most common finding (n=88, 8.1%), whereas 76 patients (7.0%) were found to have clinically significant abnormalities such as primary brain tumor, cancer metastasis, and headache-relevant cerebrovascular disease. Patients underwent MRI were four times more likely to have neuroimaging abnormalities than those underwent computed tomography (33.3% vs. 7.2%, p <0.001). CONCLUSIONS: In this study, the findings of neuroimaging differed according to headache disorders, age, sex, and imaging modalities. MRI can be a preferable neuroimaging modality to identify potential causes of headache.

Chronic Daily Headache and Medication Overuse Headache in First-Visit Headache Patients in Korea: A Multicenter Clinic-Based Study

BACKGROUND AND PURPOSE: Chronic daily headache (CDH) is defined as a headache disorder in which headaches occur on a daily or near-daily basis (at least 15 days/month) for more than 3 months. Chronic migraine (CM) and medication overuse headache (MOH) are very disabling headaches that remain underdiagnosed. The aim of this study was to establish the frequency of CDH and its various subtypes, and examine the associations with MOH among first-visit headache patients presenting at neurology outpatient clinics in Korea. METHODS: Eleven neurologists enrolled first-visit patients with complaints of headaches into outpatient clinics for further assessment. Headache disorders were classified according to the International Classification of Headache Disorder (third edition beta version) by each investigator. RESULTS: Primary CDH was present in 248 (15.2%) of the 1,627 included patients, comprising CM (143, 8.8%), chronic tension-type headache (CTTH) (98, 6%), and definite new daily persistent headache (NDPH) (7, 0.4%). MOH was associated with headache in 81 patients (5%). The association with MOH was stronger among CM patients (34.5%) than patients with CTTH (13.3%) or NDPH (14.3%) (p=0.001). The frequency of CDH did not differ between secondary and tertiary referral hospitals. CONCLUSIONS: The frequencies of CDH and MOH diagnoses were 15.2% and 5%, respectively in first-visit headache patients presented at secondary or tertiary referral hospitals in Korea. CM was the most common subtype of CDH and was most frequently associated with MOH.

Comprehensive Application of the International Classification of Headache Disorders Third Edition, Beta Version

The purpose of this study was to test the feasibility and usefulness of the International Classification of Headache Disorders, third edition, beta version (ICHD-3beta), and compare the differences with the International Classification of Headache Disorders, second edition (ICHD-2). Consecutive first-visit patients were recruited from 11 headache clinics in Korea. Headache classification was performed in accordance with ICHD-3beta. The characteristics of headaches were analyzed and the feasibility and usefulness of this version was assessed by the proportion of unclassified headache disorders compared with ICHD-2. A total of 1,627 patients were enrolled (mean age, 47.4±14.7 yr; 62.8% female). Classification by ICHD-3beta was achieved in 97.8% of headache patients, whereas 90.0% could be classified by ICHD-2. Primary headaches (n=1,429, 87.8%) were classified as follows: 697 migraines, 445 tension-type headaches, 22 cluster headaches, and 265 other primary headache disorders. Secondary headache or painful cranial neuropathies/other facial pains were diagnosed in 163 patients (10.0%). Only 2.2% were not classified by ICHD-3beta. The main reasons for missing classifications were insufficient information (1.6%) or absence of suitable classification (0.6%). The diagnoses differed from those using ICHD-2 in 243 patients (14.9%). Among them, 165 patients were newly classified from unclassified with ICHD-2 because of the relaxation of the previous strict criteria or the introduction of a new diagnostic category. ICHD-3beta would yield a higher classification rate than its previous version, ICHD-2. ICHD-3beta is applicable in clinical practice for first-visit headache patients of a referral hospital.

Korean Version of Inventory of Complicated Grief Scale: Psychometric Properties in Korean Adolescents

We aimed to validate the Inventory of Complicated Grief (ICG)-Korean version among 1,138 Korean adolescents, representing a response rate of 57% of 1,997 students. Participants completed a set of questionnaires including demographic variables (age, sex, years of education, experience of grief), the ICG, the Children's Depression Inventory (CDI) and the Lifetime Incidence of Traumatic Events-Child (LITE-C). Exploratory factor analysis was performed to determine whether the ICG items indicated complicated grief in Korean adolescents. The internal consistency of the ICG-Korean version was Cronbach's alpha=0.87. The test-retest reliability for a randomly selected sample of 314 participants in 2 weeks was r=0.75 (P<0.001). Concurrent validity was assessed using a correlation between the ICG total scores and the CDI total scores (r=0.75, P<0.001). The criterion-related validity based on the comparison of ICG total scores between adolescents without complicated grief (1.2±3.7) and adolescent with complicated grief (3.2±6.6) groups was relatively high (t=5.71, P<0.001). The data acquired from the 1,138 students was acceptable for a factor analysis (Kaiser-Meyer-Olkin Measure of Sampling Adequacy=0.911; Bartlett's Test of Sphericity, chi2=13,144.7, P<0.001). After omission of 3 items, the value of Cronbach's alpha increased from 0.87 for the 19-item ICG-Korean version to 0.93 for the 16-item ICG-Korean version. These results suggest that the ICG is a useful tool in assessing for complicated grief in Korean adolescents. However, the 16-item version of the ICG appeared to be more valid compared to the 19-item version of the ICG. We suggest that the 16-item version of the ICG be used to screen for complicated grief in Korean adolescents.

Characteristics of Elderly-Onset (≥65 years) Headache Diagnosed Using the International Classification of Headache Disorders, Third Edition Beta Version

BACKGROUND AND PURPOSE: New-onset headache in elderly patients is generally suggestive of a high probability of secondary headache, and the subtypes of primary headache diagnoses are still unclear in the elderly. This study investigated the characteristics of headache with an older age at onset (≥65 years) and compared the characteristics between younger and older age groups. METHODS: We prospectively collected demographic and clinical data of 1,627 patients who first visited 11 tertiary hospitals in Korea due to headache between August 2014 and February 2015. Headache subtype was categorized according to the International Classification of Headache Disorders, Third Edition Beta Version. RESULTS: In total, 152 patients (9.3%, 106 women and 46 men) experienced headache that began from 65 years of age [elderly-onset group (EOG)], while the remaining 1,475 patients who first experienced headache before the age of 65 years were classified as the younger-age-at-onset group (YOG). Among the primary headache types, tension-type headache (55.6% vs. 28.8%) and other primary headache disorders (OPH, 31.0% vs. 17.3%) were more common in the EOG than in the YOG, while migraine was less frequent (13.5% vs. 52.2%) (p=0.001) in the EOG. Among OPH, primary stabbing headache (87.2%) was more frequent in the EOG than in the YOG (p=0.032). The pain was significantly less severe (p=0.026) and the frequency of medication overuse headache was higher in EOG than in YOG (23.5% vs. 7.6%, p=0.040). CONCLUSIONS: Tension-type headache and OPH headaches, primarily stabbing headache, were more common in EOG patients than in YOG patients. The pain intensity, distribution of headache diagnoses, and frequency of medication overuse differed according to the age at headache onset.

Timely Interventions can Increase Smoking Cessation Rate in Men with Ischemic Stroke

PURPOSE: Smoking cessation is strongly recommended for every smoker after ischemic stroke, but many patients fail to quit smoking. An improved smoking cessation rate has been reported with intensive behavioral therapy during hospitalization and supportive contact after discharge. The aim of this study was to demonstrate the usefulness of the timely interventions for smoking cessation in men with acute ischemic stroke. METHODS: Patients who participated in the timely interventions strategy (TI group) were compared with those who received conventional counseling (CC group). In the TI group, a certified nurse provided comprehensive education during admission and additional counseling after discharge. Outcome was measured by point smoking success rate and sustained smoking cessation rate for 12 months. RESULTS: Participants, 157 men (86 of the TI group and 71 of the CC group), were enrolled. Mean age was 58.25 ± 11.23 years and mean initial National Institutes of Health Stroke Scale score was 4.68 ± 5.46. The TI group showed a higher point smoking success rate compared with the CC group (p= .003). Multiple logistic regression analysis showed that the TI group was 2.96-fold (95% CI, 1.43~6.13) more likely to sustain smoking cessation for 12 months than the CC group. CONCLUSION: Findings indicate that multiple interventions initiated during hospital stay and regular follow-up after discharge are more effective than conventional smoking cessation counseling in men with acute ischemic stroke.

Factors Associated with Ischemic Stroke on Therapeutic Anticoagulation in Patients with Nonvalvular Atrial Fibrillation

PURPOSE: In this study, we investigated the stroke mechanism and the factors associated with ischemic stroke in patients with nonvalvular atrial fibrillation (NVAF) who were on optimal oral anticoagulation with warfarin. MATERIALS AND METHODS: This was a multicenter case-control study. The cases were consecutive patients with NVAF who developed cerebral infarction or transient ischemic attack (TIA) while on warfarin therapy with an international normalized ratio (INR) > or =2 between January 2007 and December 2011. The controls were patients with NVAF without ischemic stroke who were on warfarin therapy for more than 1 year with a mean INR > or =2 during the same time period. We also determined etiologic mechanisms of stroke in cases. RESULTS: Among 3569 consecutive patients with cerebral infarction or TIA who had NVAF, 55 (1.5%) patients had INR > or =2 at admission. The most common stroke mechanism was cardioembolism (76.0%). Multivariate analysis demonstrated that smoking and history of previous ischemic stroke were independently associated with cases. High CHADS2 score (> or =3) or CHA2DS2-VASc score (> or =5), in particular, with previous ischemic stroke along with > or =1 point of other components of CHADS2 score or > or =3 points of other components of CHA2DS2-VASc score was a significant predictor for development of ischemic stroke. CONCLUSION: NVAF patients with high CHADS2/CHA2DS2-VASc scores and a previous ischemic stroke or smoking history are at high risk of stroke despite optimal warfarin treatment. Some other measures to reduce the risk of stroke would be necessary in those specific groups of patients.

Factors Associated with Ischemic Stroke on Therapeutic Anticoagulation in Patients with Nonvalvular Atrial Fibrillation

PURPOSE: In this study, we investigated the stroke mechanism and the factors associated with ischemic stroke in patients with nonvalvular atrial fibrillation (NVAF) who were on optimal oral anticoagulation with warfarin. MATERIALS AND METHODS: This was a multicenter case-control study. The cases were consecutive patients with NVAF who developed cerebral infarction or transient ischemic attack (TIA) while on warfarin therapy with an international normalized ratio (INR) > or =2 between January 2007 and December 2011. The controls were patients with NVAF without ischemic stroke who were on warfarin therapy for more than 1 year with a mean INR > or =2 during the same time period. We also determined etiologic mechanisms of stroke in cases. RESULTS: Among 3569 consecutive patients with cerebral infarction or TIA who had NVAF, 55 (1.5%) patients had INR > or =2 at admission. The most common stroke mechanism was cardioembolism (76.0%). Multivariate analysis demonstrated that smoking and history of previous ischemic stroke were independently associated with cases. High CHADS2 score (> or =3) or CHA2DS2-VASc score (> or =5), in particular, with previous ischemic stroke along with > or =1 point of other components of CHADS2 score or > or =3 points of other components of CHA2DS2-VASc score was a significant predictor for development of ischemic stroke. CONCLUSION: NVAF patients with high CHADS2/CHA2DS2-VASc scores and a previous ischemic stroke or smoking history are at high risk of stroke despite optimal warfarin treatment. Some other measures to reduce the risk of stroke would be necessary in those specific groups of patients.

A Case of Cerebellar Infarction Caused by Acute Subclavian Thrombus Following Minor Trauma

Subclavian steal syndrome caused by an acute thrombus is very rare. We present a case of cerebellar infarction with proximal subclavian artery thrombosis. A 56-year-old woman was admitted for sudden vertigo. One day prior to admission, she received a shoulder massage comprised of chiropractic manipulation. On examination, her left hand was pale and radial pulses were absent. Blood pressure was weak in the left arm. Downbeat nystagmus and a right falling tendency were observed. Brain MRI showed multiple acute infarctions in the left cerebellum. The findings of Doppler ultrasonography in the left vertebral artery were compatible with a partial subclavian artery steal phenomenon. Digital subtraction angiography demonstrated a large thrombus in the left subclavian artery. After heparin infusion, thrombus size markedly decreased. Cerebellar infarction caused by acute subclavian thrombosis following minor trauma is rare, but the thrombus can be successfully resolved with anticoagulation.

Spontaneous Bilateral Carotid Artery Dissection Causing Abulia and Apathy

No abstract available.

Ischemic Stroke in Patients with Renal Transplantation / 대한뇌졸중학회지

BACKGROUND: Impaired renal function may contribute to development of stroke and small vessel pathology in the brain. We investigated whether stroke subtype, initial stroke severity, early neurologic outcomes, time to cerebral infarction occurrence, and the presence of small vessel pathology in the brain are different between patients with end stage renal disease (ESRD) and those with renal transplantation (RT). METHODS: A total of 57 consecutive de novo RT patients (RT group) and 120 patients undergoing dialysis due to ESRD (ESRD group) who developed a first-ever acute cerebral infarction were enrolled. We compared stroke subtypes based on the Trial of Org 10172 in Acute Stroke Treatment classification, the presence of small vessel pathology (cerebral microbleed, leukoaraiosis and silent lacunar infarction) on MRI, stroke severity based on the National Institutes of Health Stroke Scale (NIHSS) and in-hospital mortality between the groups. RESULTS: The stroke subtypes, NIHSS scores at admission and in-hospital mortality were not different between the two groups. On multivariate analysis, the presence of high grade periventricular white matter changes tended to be more frequently detected in the ESRD group than the RT (P=0.078). The time from starting dialysis to stroke was longer in the RT group (129.9+/-60.9 months) than in the ESRD group (51.1+/-46.1 months). CONCLUSIONS: The stroke patterns, severity and short term outcomes were not different between RT and ESRD. The risk of cerebral infarction and high grade periventricular white matter changes may be reduced after RT in patients with ESRD.

The Factors Associated with the Decision of r-tPA Use in Acute Ischemic Stroke Patients Aged 80 Years or Older / 대한뇌졸중학회지

BACKGROUND: Small proportions of all the elderly stroke patients receive recombinant tissue plasminogen activator (r-tPA) therapy, although old age is not a proven contraindication to intravenous thrombolytic therapy for acute ischemic stroke. The purpose of this study was to identify reasons for exclusion from r-tPA therapy and factors associated with the decision of r-tPA use in elderly patients with acute ischemic stroke. METHODS: From the acute stroke registries of 22 domestic university hospitals taking the r-tPA therapy from January 2007 to May 2010, we extracted data of all acute ischemic stroke patients who were aged 80 or over and arrived within onset 3 hours. For all patients, we assessed the eligibility of r-tPA therapy using National Institute of Neurological Disorders and Stroke (NINDS) r-tPA trial criteria. For eligible patients, we compared all clinical variables between patients who were treated with r-tPA and those who were not, and analyzed potential factors related to the decision of r-tPA use. RESULTS: A total of 494 patients were included in this study. 255 patients (51.6%) were excluded by NINDS r-tPA trial criteria and the major reasons for exclusion were minor neurological deficit (53.7%) and clinical improvement (17.3%). Among 239 patients who were eligible for r-tPA, 162 (32.8%) patients received r-tPA and 77 (15.6%) did not. Multivariable analysis showed that younger age, shorter time-delay from onset to admission, non-smoker, no history of prior stroke, good pre-stroke functional status and severe initial neurological deficit were independently associated with the decision of r-tPA use in the elderly stroke patients predictors for r-tPA treatment. CONCLUSION: In very elderly patients, mild neurological deficit on arrival and rapid clinical improvement in neurological symptoms were the main reasons for exclusion from thrombolytic therapy.

Increasing Frequency and Burden of Cerebral Artery Atherosclerosis in Korean Stroke Patients

PURPOSE: Koreans have been undergoing rapid lifestyle changes that may have an effect on patterns of cerebral artery atherosclerosis. This study was aimed at determining the frequency and distribution of atherosclerosis in the cerebral arteries and associated temporal changes over the past eight-year period among Korean stroke patients. MATERIALS AND METHODS: By using stroke registry data registered between April 1999 and March 2007, we investigated the presence, severity, and location of cerebral artery atherosclerosis as determined by angiographic findings. Their annual patterns and association with vascular risk factors were investigated. RESULTS: Of 1,955 patients, 1,517 patients (77.6%) demonstrated atherosclerosis in one or more arteries. A significantly increasing trend of atherosclerosis was observed during the past eight years, which was ascribed to an increase of combined extracranial (EC) and intracranial (IC) atherosclerosis. The number of atherosclerotic arteries increased as the number of risk factors increased. In the multivariate analysis, the year and vascular risk factors were independent predictors of the presence of atherosclerosis. CONCLUSION: We found that the atherosclerotic burden has been increasing for the past eight years in Korean stroke patients, particularly the combined EC and IC subtype. Lifestyle changes and increase in vascular risk factors may be contributing factors.

Increasing Frequency and Burden of Cerebral Artery Atherosclerosis in Korean Stroke Patients

PURPOSE: Koreans have been undergoing rapid lifestyle changes that may have an effect on patterns of cerebral artery atherosclerosis. This study was aimed at determining the frequency and distribution of atherosclerosis in the cerebral arteries and associated temporal changes over the past eight-year period among Korean stroke patients. MATERIALS AND METHODS: By using stroke registry data registered between April 1999 and March 2007, we investigated the presence, severity, and location of cerebral artery atherosclerosis as determined by angiographic findings. Their annual patterns and association with vascular risk factors were investigated. RESULTS: Of 1,955 patients, 1,517 patients (77.6%) demonstrated atherosclerosis in one or more arteries. A significantly increasing trend of atherosclerosis was observed during the past eight years, which was ascribed to an increase of combined extracranial (EC) and intracranial (IC) atherosclerosis. The number of atherosclerotic arteries increased as the number of risk factors increased. In the multivariate analysis, the year and vascular risk factors were independent predictors of the presence of atherosclerosis. CONCLUSION: We found that the atherosclerotic burden has been increasing for the past eight years in Korean stroke patients, particularly the combined EC and IC subtype. Lifestyle changes and increase in vascular risk factors may be contributing factors.

A Case of Neurologic Symptom in Association with Intoxication after Ingestion of Codfish Intestine

No abstract available.