Surgery versus radiofrequency ablation in patients with Child- Pugh class-A/single small (≤3 cm) hepatocellular carcinoma

Background/Aims@#We compared the post-treatment overall survival (OS) and recurrence-free survival (RFS) between patients with Child-Turcotte-Pugh (CTP) class-A and single small (≤3 cm) hepatocellular carcinoma (HCC) treated by surgical resection (SR) and radiofrequency ablation (RFA). @*Methods@#We retrospectively analyzed 391 HCC patients with CTP class-A who underwent SR (n=232) or RFA (n=159) as first-line therapy for single small (≤3 cm) HCC. Survival was compared according to the tumor size (≤2 cm/2–3 cm) and the presence of cirrhosis. Inverse probability of treatment weighting (IPW) method was used to estimate the average causal effect of treatment. @*Results@#The median follow-up period was 64.8 months (interquartile range, 0.1–162.6). After IPW, the estimated OS was similar in the SR and RFA groups (P=0.215), and even in patients with HCC of ≤2 cm (P=0.816) and without cirrhosis (P=0.195). The estimated RFS was better in the SR group than in the RFA groups (P=0.005), also in patients without cirrhosis (P<0.001), but not in those with HCC of ≤2 cm (P=0.234). The weighted Cox proportional hazards model with IPW provided adjusted hazard ratios (95% confidence interval) for OS, and the RFS after RFA versus SR were 0.698 (0.396–1.232) (P=0.215) and 1.698 (1.777–2.448) (P=0.005), respectively. @*Conclusions@#SR was similar for OS compared to RFA, but was better for RFS in patients with CTP class-A and single small (≤3 cm) HCC. The RFS was determined by the presence or absence of cirrhosis. Hence, SR rather than RFA should be considered in patients without cirrhosis to prolong the RFS, although there is no OS difference.

Partial Virological Response after 2 Years of Entecavir Therapy Increases the Risk of Hepatocellular Carcinoma in Patients with Hepatitis B Virus-Associated Cirrhosis

Background/Aims@#The clinical significance of partial virological response (PVR) in patients undergoing antiviral therapy is not well known. This study investigated whether PVR after 2 years of entecavir (ETV) therapy is associated with hepatocellular carcinoma (HCC) development in cirrhotic patients. @*Methods@#A total of 472 naïve patients with hepatitis B virus (HBV)-associated cirrhosis who were treated with ETV for at least 2 years were retrospectively enrolled. Clinical characteristics, laboratory data, PVR, and noninvasive fibrosis markers (aspartate aminotransferase to platelet ratio and FIB-4 index) at 2 years after ETV commencement were analyzed for HCC risk. @*Results@#After excluding those who developed HCC within 2 years of ETV therapy, 359 patients (mean age, 51±10 years; male 64.3%) were examined. During a median follow-up of 82 months, 80 patients developed HCC. In the univariate analysis, older age (hazard ratio [HR], 1.056; p<0.001), PVR (HR, 2.536; p=0.002), higher aspartate aminotransferase (HR, 1.018; p=0.005), lower albumin level (HR, 0.463; p<0.001), lower platelet count (HR, 0.993; p=0.01), and higher FIB-4 index (HR, 1.141; p<0.001) at 2 years after ETV commencement were risk factors for HCC. In the multivariate analysis, older age (HR, 1.046; 95% confidence interval [CI], 1.022 to 1.072; p<0.001), PVR (HR, 2.358; 95% CI, 1.310 to 4.245; p=0.004), and higher FIB-4 index (HR, 1.103; 95% CI, 1.035 to 1.177; p=0.003) were independent risk factors. @*Conclusions@#PVR and higher FIB-4 index after 2 years of ETV therapy were independent risk factors for HCC. Therefore, efforts to accomplish a complete virological response and reduce the FIB-4 index should be made.

Magnetic Resonance-Based Assessments Better Capture Pathophysiologic Profiles and Progression in Nonalcoholic Fatty Liver Disease

Background@#Several noninvasive tools are available for the assessment of nonalcoholic fatty liver disease (NAFLD) including clinical and blood biomarkers, transient elastography (TE), and magnetic resonance imaging (MRI) techniques, such as proton density fat fraction (MRI-PDFF) and magnetic resonance elastography (MRE). In the present study, we aimed to evaluate whether magnetic resonance (MR)-based examinations better discriminate the pathophysiologic features and fibrosis progression in NAFLD than other noninvasive methods. @*Methods@#A total of 133 subjects (31 healthy volunteers and 102 patients with NAFLD) were subjected to clinical and noninvasive NAFLD evaluation, with additional liver biopsy in some patients (n=54). @*Results@#MRI-PDFF correlated far better with hepatic fat measured by MR spectroscopy (r=0.978, P<0.001) than with the TE controlled attenuation parameter (CAP) (r=0.727, P<0.001). In addition, MRI-PDFF showed stronger correlations with various pathophysiologic parameters for cellular injury, glucose and lipid metabolism, and inflammation, than the TE-CAP. The MRI-PDFF and TE-CAP cutoff levels associated with abnormal elevation of serum alanine aminotransferase were 9.9% and 270 dB/m, respectively. The MRE liver stiffness measurement (LSM) showed stronger correlations with liver enzymes, platelets, complement component 3, several clinical fibrosis scores, and the enhanced liver fibrosis (ELF) score than the TE-LSM. In an analysis of only biopsied patients, MRE performed better in discriminating advanced fibrosis with a cutoff value of 3.9 kPa than the TE (cutoff 8.1 kPa) and ELF test (cutoff 9.2 kPa). @*Conclusion@#Our results suggest that MRI-based assessment of NAFLD is the best non-invasive tool that captures the histologic, pathophysiologic and metabolic features of the disease.

Partial Virological Response after 2 Years of Entecavir Therapy Increases the Risk of Hepatocellular Carcinoma in Patients with Hepatitis B Virus-Associated Cirrhosis

Background/Aims@#The clinical significance of partial virological response (PVR) in patients undergoing antiviral therapy is not well known. This study investigated whether PVR after 2 years of entecavir (ETV) therapy is associated with hepatocellular carcinoma (HCC) development in cirrhotic patients. @*Methods@#A total of 472 naïve patients with hepatitis B virus (HBV)-associated cirrhosis who were treated with ETV for at least 2 years were retrospectively enrolled. Clinical characteristics, laboratory data, PVR, and noninvasive fibrosis markers (aspartate aminotransferase to platelet ratio and FIB-4 index) at 2 years after ETV commencement were analyzed for HCC risk. @*Results@#After excluding those who developed HCC within 2 years of ETV therapy, 359 patients (mean age, 51±10 years; male 64.3%) were examined. During a median follow-up of 82 months, 80 patients developed HCC. In the univariate analysis, older age (hazard ratio [HR], 1.056; p<0.001), PVR (HR, 2.536; p=0.002), higher aspartate aminotransferase (HR, 1.018; p=0.005), lower albumin level (HR, 0.463; p<0.001), lower platelet count (HR, 0.993; p=0.01), and higher FIB-4 index (HR, 1.141; p<0.001) at 2 years after ETV commencement were risk factors for HCC. In the multivariate analysis, older age (HR, 1.046; 95% confidence interval [CI], 1.022 to 1.072; p<0.001), PVR (HR, 2.358; 95% CI, 1.310 to 4.245; p=0.004), and higher FIB-4 index (HR, 1.103; 95% CI, 1.035 to 1.177; p=0.003) were independent risk factors. @*Conclusions@#PVR and higher FIB-4 index after 2 years of ETV therapy were independent risk factors for HCC. Therefore, efforts to accomplish a complete virological response and reduce the FIB-4 index should be made.

Magnetic Resonance-Based Assessments Better Capture Pathophysiologic Profiles and Progression in Nonalcoholic Fatty Liver Disease

Background@#Several noninvasive tools are available for the assessment of nonalcoholic fatty liver disease (NAFLD) including clinical and blood biomarkers, transient elastography (TE), and magnetic resonance imaging (MRI) techniques, such as proton density fat fraction (MRI-PDFF) and magnetic resonance elastography (MRE). In the present study, we aimed to evaluate whether magnetic resonance (MR)-based examinations better discriminate the pathophysiologic features and fibrosis progression in NAFLD than other noninvasive methods. @*Methods@#A total of 133 subjects (31 healthy volunteers and 102 patients with NAFLD) were subjected to clinical and noninvasive NAFLD evaluation, with additional liver biopsy in some patients (n=54). @*Results@#MRI-PDFF correlated far better with hepatic fat measured by MR spectroscopy (r=0.978, P<0.001) than with the TE controlled attenuation parameter (CAP) (r=0.727, P<0.001). In addition, MRI-PDFF showed stronger correlations with various pathophysiologic parameters for cellular injury, glucose and lipid metabolism, and inflammation, than the TE-CAP. The MRI-PDFF and TE-CAP cutoff levels associated with abnormal elevation of serum alanine aminotransferase were 9.9% and 270 dB/m, respectively. The MRE liver stiffness measurement (LSM) showed stronger correlations with liver enzymes, platelets, complement component 3, several clinical fibrosis scores, and the enhanced liver fibrosis (ELF) score than the TE-LSM. In an analysis of only biopsied patients, MRE performed better in discriminating advanced fibrosis with a cutoff value of 3.9 kPa than the TE (cutoff 8.1 kPa) and ELF test (cutoff 9.2 kPa). @*Conclusion@#Our results suggest that MRI-based assessment of NAFLD is the best non-invasive tool that captures the histologic, pathophysiologic and metabolic features of the disease.

Seroreversion and Acute Decompensation in Chronic Hepatitis B after Discontinuation of Oral Nucleotide Analog in the Patients Achieving HBsAg Loss / 대한소화기학회지

Although rare patients with chronic hepatitis B can achieve HBsAg loss on oral nucleos(t)ide analog (NA), the optimal timing of stopping oral NAs safely has been considered when HBsAg and HBV DNA are negative in the serum because HBsAg loss induced by nucleos(t)ide analogs (NAs) appears to be durable if immunosuppressive therapy or chemotherapy are not done. On the other hand, the author experienced a case of HBsAg seroreversion and acute decompensation after the discontinuation of NA in a patient with HBsAg loss. This rare case highlights the need for the close monitoring of patients who achieved HBsAg loss and stopped NA.

Systematic Review with Meta-Analysis: Low-Level Alcohol Consumption and the Risk of Liver Cancer

Background/Aims@#Multiple meta-analyses and observational studies have reported that alcohol is a risk factor for liver cancer. However, whether there is a safe level of alcohol consumption remains unclear. We performed a systematic review and meta-analysis of the correlation between low-level alcohol consumption and the risk of liver cancer. @*Methods@#Nested case-control studies and cohort studies involving the general population published prior to July 2019 were searched. In total, 28 publications (31 cohorts) with 4,899 incident cases and 10,859 liver cancer-related deaths were included. The pooled odds ratios (ORs) with 95% confidence intervals (CIs) were calculated. @*Results@#Compared with those with low levels of alcohol consumption, moderate and heavy drinkers (≥1 drink/day for females and ≥2 drinks/day for males) had pooled ORs of 1.418 (95% CI, 1.192 to 1.687; p<0.001) for liver cancer incidence and 1.167 (95% CI, 1.056to 1.290; p=0.003) for liver cancer mortality. The pooled OR for liver disease-related mortality for those with more than low levels of alcohol consumption was 3.220 (95% CI, 2.116 to 4.898; p<0.001) and that for all-cause mortality was 1.166 (95% CI, 1.065 to 1.278; p=0.001). The sensitivity analysis showed that none of the studies had a strong effect on the pooled OR. The Egger test, Begg rank correlation test, and the funnel plot showed no overt indication of publication bias. @*Conclusions@#Continuous consumption of more than a low-level of alcohol (≥1 drink/day for females and ≥2 drinks/ day for males) is related to a higher risk of liver cancer.

Durability of Sustained Virologic Response and Improvement of Fibrosis Markers after Daclatasvir and Asunaprevir Treatment in Genotype 1b Hepatitis C Virus-Infected Patients: a Real Life and Multicenter Study

BACKGROUND: The long-term data with direct acting antiviral agents were rare. This study investigated the durability of a sustained virologic response (SVR) and the improvement of fibrosis after daclatasvir and asunaprevir (DCV/ASV) treatment in genotype 1b (GT1b) hepatitis C virus (HCV)-infected patients. METHODS: A total of 288 HCV GT1b patients without baseline non-structural 5A (NS5A) resistance-associated substitution (RAS) treated with DCV/ASV were enrolled. Virologic response was measured at 12 weeks and 1 year after treatment completion. In cirrhotic patients, liver function, aspartate transaminase to platelet ratio index (APRI), FIB-4 index, fibrosis index (FI), and liver stiffness measurement (LSM) at baseline and 1 year after treatment completion were evaluated. RESULTS: SVR12 was obtained in 278 patients (96.5%). Six patients who checked NS5A RAS after treatment failure were RAS positive. Only one patient showed no durability of SVR. In cirrhotic patients who achieved SVR12 (n = 59), the changes of albumin (3.8 [2.2–4.7] to 4.3 [2.4–4.9] g/dL; P < 0.001), platelet count (99 [40–329] to 118 [40–399] × 103/mm3; P < 0.001), APRI (1.8 [0.1–14.8] to 0.6 [0.1–4.8]; P < 0.001), FIB-4 index (5.45 [0.6–32.8] to 3.3 [0.4–12.2]; P < 0.001), FI (5.5 [0.6–32.8] to 3.3 [0.4–12.2]; P < 0.001), and LSM (17.2 [5.3–48.0] to 11.2 [3.7–28.1] kPa; P = 0.001) between baseline and 1 year after treatment completion were observed. CONCLUSION: DCV/ASV treatment for HCV GT1b infected patients without RAS achieved high SVR rates and showed durable SVR. Cirrhotic patients who achieved SVR12 showed the improvement of liver function and fibrosis markers.

Spontaneously Resolving of Huge Simple Hepatic Cyst / 대한소화기학회지

Simple hepatic cysts are common benign liver lesions that usually have no malignant capability. They are generally asymptomatic and are often found incidentally by abdominal imaging procedures. Treatment becomes necessary, however, when huge hepatic cysts cause symptoms and develop complications, such as hemorrhage, adjacent organ damage, and infection. Several therapeutic options have been performed for symptomatic and huge cysts, including the aspiration of cystic fluid, infusion of various sclerosing agents, and surgical intervention. The optimal management of huge hepatic cysts is controversial and each option has its complications and limitations. This paper reports a case of a 66-year-old woman diagnosed with a simple hepatic cyst 2 years earlier, who was referred to hospital due to abdominal pain. The diagnosis was a huge hepatic cyst with symptoms by abdominal imaging studies. During the follow-up period, the huge cysts resolved spontaneously without treatment.

Effect of Rifaximin on Hepatic Fibrosis in Bile Duct-ligated Rat Model / 대한소화기학회지

BACKGROUND/AIMS: The translocation of bacteria and their lipopolysaccharides from the gut can promote fibrosis in cirrhotic patients. The aim of this study was to investigate the effects of rifaximin on hepatic fibrosis in a bile duct-ligated rat model. METHODS: The bile duct ligation (BDL) was carried out for eight days (acute injury model: sham-operated rats [G1], BDL rats [G2], and BDL rats treated with rifaximin [G3]) or 22 days (chronic injury model: sham-operated rats [G4], BDL rats [G5], and BDL rats treated with rifaximin [G6]). Rifaximin (50 mg/kg/day) was administered daily via gavage after BDL. Liver function, serum tumor necrosis factor-alpha (TNF-α), and hepatic hydroxyproline levels were measured. Moreover, a histological analysis of fibrosis contents was performed using sirius red stain. RESULTS: In the acute injury model, the liver function and TNF-α level were not improved after the rifaximin treatment. The hydroxyproline levels (µg/g liver tissue) in G1, G2, and G3 were 236.4±103.1, 444.8±114.4, and 312.5±131.6, respectively; and fibrosis contents (%) were 0.22±0.04, 1.64±0.53, and 1.66±0.44, respectively. The rifaximin treatment did not ameliorate acute BDL-induced fibrosis. In the chronic injury model, the hydroxyproline levels in G4, G5, and G6 were 311.5±72.9, 1,110.3±357.9, and 944.3±209.3, respectively; and fibrosis contents (%) were 0.19±0.03, 5.04±0.18, and 4.42±0.68, respectively (G5 vs. G6, p=0.059). The rifaximin treatment marginally ameliorated chronic BDL-induced fibrosis. CONCLUSIONS: Rifaximin did not reduce inflammation and fibrosis in bile duct-ligated rat model.

Prevalence, Risk Factors and Clinical Characteristics in Patients with Genotype 6 Chronic Hepatitis C: A Single Institute Experience / 대한소화기학회지

BACKGROUND/AIMS: Hepatitis C genotypes 1 and 2 are widely distributed globally. In contrast, genotype 6 is found mainly in Southeast Asia, while genotype 6 is rare in Korea. This study aims to investigate the prevalence, risk factors and clinical characteristics of patients with genotype 6 chronic hepatitis C. METHODS: We retrospectively identified 133 HCV-infected patients who underwent HCV genotype analysis between January 2012 and December 2012, and analyzed the prevalence, risk factors and clinical characteristics of patients diagnosed with genotype 6 chronic hepatitis C. RESULTS: Among 133 patients, 53 patients (39.8%) were infected with genotype 1, 62 patients (46.6%) with genotype 2, 2 patients (1.5%) with genotype 3, 14 patients (10.5%) with genotype 6, and 2 patients (1.5%) with mixed genotypes (genotype 1 and 6). The risk factors associated with genotype 6 were acupuncture (n=4, 28.6%), intravenous drug use (n=3, 21.4%), tattoo (n=2, 14.3%), and transfusion (n=2, 14.3%). Of the 14 patients with genotype 6, 6 patients were treated with pegylated interferon and ribavirin. Five patients had reached the end of treatment. All patients reaching end of treatment for genotype 6 showed early virological response and sustained virological response. CONCLUSIONS: The prevalence of genotype 6 is 10.5% and mixed infections of genotype 1 and 6 are 1.5% in patients with chronic hepatitis C. A major potential risk factor is intravenous drug use and the treatment response rate to pegylated interferon plus ribavirin is high in patients with genotype 6 chronic hepatitis C. Large scale multicenter studies are needed.

Liver Abscess in Advanced Hepatocellular Carcinoma after Sorafenib Treatment / 대한소화기학회지

Hepatocellular carcinoma (HCC) is a critical global health issue and the third most common cause of cancer-related deaths worldwide. The majority of patients who present HCC are already at an advanced stage and their tumors are unresectable. Sorafenib is a multi-kinase inhibitor of the vascular endothelial growth factor pathway and was recently introduced as a therapy for advanced HCC. Furthermore, studies have shown that oral sorafenib has beneficial effects on survival. However, many patients experience diverse side effects, and some of these are severe. Liver abscess development has not been previously documented to be associated with sorafenib administration in HCC. Here, we report the case of a HCC patient that developed a liver abscess while being treated with sorafenib.

Duration of Prophylactic Therapy Affects the Frequency of Gout Flare

OBJECTIVE: To evaluate the effect of prophylactic therapy on gout flare during urate lowering treatment. METHODS: We retrospectively examined the data derived from 59 patients who had been treated with allopurinol for more than six months after stopping prophylactic medication at our rheumatology clinic. Demographic data (age, sex, disease duration, tophi and comorbidity), clinical and laboratory features, including presence of gout flare during urate lowering treatment, dose of allopurinol, serum uric acid level and creatinine clearance at initiation and six months later, were collected. For the subgroup analysis, the same data were collected in 46 patients who had been followed up at one year after stopping prophylactic medication. RESULTS: Twenty-eight patients among 59 (47.4%) had experienced at least 1 gouty attack during urate lowering therapy. The mean duration of prophylactic medication was not different between the flare group (3.8 months) and the non-flare group (5.9 months, p=0.617). Six months later, the mean serum uric acid level was 6.3 mg/dL (6.1 mg/dL vs. 6.5 mg/dL). According to the duration of prophylactic treatment ( or =6 months), there were more frequent flares in the or =6 months group (51.2% vs. 38.9% in the six month follow-up group, 70.6% vs. 50% in the one year follow-up group). CONCLUSION: Prophylactic medication for more than six months could be a favorable factor for the prevention of recurrent gout flare during urate lowering treatment.

Duration of Prophylactic Therapy Affects the Frequency of Gout Flare

OBJECTIVE: To evaluate the effect of prophylactic therapy on gout flare during urate lowering treatment. METHODS: We retrospectively examined the data derived from 59 patients who had been treated with allopurinol for more than six months after stopping prophylactic medication at our rheumatology clinic. Demographic data (age, sex, disease duration, tophi and comorbidity), clinical and laboratory features, including presence of gout flare during urate lowering treatment, dose of allopurinol, serum uric acid level and creatinine clearance at initiation and six months later, were collected. For the subgroup analysis, the same data were collected in 46 patients who had been followed up at one year after stopping prophylactic medication. RESULTS: Twenty-eight patients among 59 (47.4%) had experienced at least 1 gouty attack during urate lowering therapy. The mean duration of prophylactic medication was not different between the flare group (3.8 months) and the non-flare group (5.9 months, p=0.617). Six months later, the mean serum uric acid level was 6.3 mg/dL (6.1 mg/dL vs. 6.5 mg/dL). According to the duration of prophylactic treatment ( or =6 months), there were more frequent flares in the or =6 months group (51.2% vs. 38.9% in the six month follow-up group, 70.6% vs. 50% in the one year follow-up group). CONCLUSION: Prophylactic medication for more than six months could be a favorable factor for the prevention of recurrent gout flare during urate lowering treatment.

Reactivation of Hepatitis B Virus Following Systemic Chemotherapy for Malignant Lymphoma / 대한내과학회지

BACKGROUND/AIMS: Reactivation of hepatitis B virus (HBV) has been reported in HBV surface antigen (HBsAg)-positive patients undergoing chemotherapy, as well as HBsAg-negative patients with antibodies against HBV core antigen (HBcAg) and/or HBsAg (HBsAb). Chemotherapy-including rituximab-has recently been identified as a predictive factor for HBV reactivation in HBsAg-negative patients with malignant lymphoma. The aim of our study was to identify the factors predictive of HBV reactivation after chemotherapy in patients with malignant lymphoma. METHODS: We conducted a retrospective analysis of medical records from patients diagnosed with malignant lymphoma at Gachon University Gil Medical Center in City, County from January 2005 to December 2010. We subsequently determined HBsAg, HBsAb and anti-HBc status in the 196 patients treated with chemotherapy. RESULTS: The mean age of the patients was 57.3 +/- 14.5 years; 56.3% were male. A total of 172 of 196 (88%) patients in the study population were HBsAg (+) prior to chemotherapy. Three patients (3/11, 27.3%) in the HBsAg (+) group had confirmed HBV reactivation after chemotherapy. In addition, 26 of 196 (13%) patients in the study population tested HBcAg (+) positive prior to chemotherapy. One patient (1/15, 6.7%) in the HBsAg (-)/HBcAb (+) group had confirmed HBV reactivation. In the four patients with HBV reactivation, infection was resolved after treatment with 0.5 mg entecavir or 100 mg lamivudine. CONCLUSIONS: Reactivation of HBV after systemic chemotherapy can occur in HBsAg (-) patients. We recommend that malignant lymphoma patients undergoing chemotherapy be screened for HBV infection status, including HBcAg, and followed closely to prevent HBV reactivation.

Prevalence and Predictive Factors of Malignant Potential in Resected Gastric Subepithelial Tumors

BACKGROUND/AIMS: EUS is a useful method to differentiate malignant from benign gastric subepithelial tumors (SETs) and to determine resection. However, this results in unnecessary resections of benign gastric SETs. The aim of our study is 1. to investigate clinical factors that may predict malignancy in gastric SET and 2. to determine how many of them have malignant potential in resected gastric SETs. MATERIALS AND METHODS: We retrospectively identified 111 patients who underwent pathologic confirmation for gastric SETs by surgical (104/111, 93.6%) and endoscopic resection between February 2003 and April 2012 and analyzed the clinical, EUS findings and final pathologic diagnosis for these patients. RESULTS: The diagnostic accuracy of EUS for SETs was 58.6% (51/87) and the rate of resection for benign SETs was 31.5% (35/111). In multivariate analysis, old age (> or =65), as well as tumor size (> or =2 cm) and location (upper or middle) were significant predictive factors for malignant potential of gastric SETs. CONCLUSIONS: One-third of endoscopic and surgical resections are performed for benign SETs. Patient's age, tumor size, and location should be considered before resection of gastric SETs. In addition, more accurate tools for histologic confirmation should be developed in order to avoid unnecessary resection.

Correlation of Serum Total Bilirubin Levels and the Severity of Acute Ischemic Stroke / 대한뇌혈관외과학회지

OBJECTIVE: We evaluated whether serum total bilirubin levels were related to large artery atherosclerosis (LAA), classified by the Trial of Org 10172 in Acute Stroke Treatment (TOAST) classification, and stroke severity at admission in acute ischemic stroke. METHODS: We analyzed clinical features, laboratory tests, and radiologic findings such as brain MRI and MR angiography of patients admitted to our hospital within 24 hours of the onset of ischemic stroke between January 2004 and June 2007. By TOAST classification, 237 patients [115 with LAA and 122 with small artery occlusion (SAO)] were selected. We divided serum total bilirubin levels into three groups: Low (15). RESULTS: Total bilirubin levels were significantly higher in the Mild group than other groups, and high-sensitivity C reactive protein (hsCRP) levels were significantly higher in the Severe group than other groups in LAA. There were no differences for these factors in SAO. We found a significant correlation between total bilirubin levels and stroke severity in LAA (p=0.005). CONCLUSION: Higher serum total bilirubin levels were associated with lower stroke severity at admission in LAA but not SAO.