Smoking History and Clinical Features of Cluster Headache:Results from the Korean Cluster Headache Registry

Background@#and Purpose Epidemiologic data suggest that cluster headache (CH) is significantly associated with cigarette smoking. The aim of this study was to determine differences in features between patients with a smoking history and those who are never-smokers, using data from a prospective multicenter registry. @*Methods@#Data used in this study were obtained from the Korean Cluster Headache Registry that collected data from consecutive patients diagnosed with CH. We compared clinical and demographic features between ever-smokers (current or former smokers) and never-smokers. @*Results@#This study enrolled 250 patients who were diagnosed with CH, of which 152 (60.8%) were ever-smokers and 98 (39.2%) were never-smokers. The age at CH onset was significantly lower in the never-smoker group than in the ever-smoker group [27.1±12.9 years vs. 30.6± 10.9 years (mean±standard deviation), p=0.024]. Seasonal rhythmicity (58.1% vs. 44.7%, p= 0.038) and triptan responsiveness (100% vs. 85.1%, p=0.001) were higher in never-smokers, while other clinical features such as pain severity, duration, attack frequency, and associated autonomic symptoms did not differ significantly between the groups. The male-to-female ratio was markedly higher in ever-smokers (29.4:1) than in never-smokers (1.7:1). @*Conclusions@#Most of the clinical features did not differ significantly between patients with a smoking history and never-smokers. However, the age at CH onset, sex ratio, and seasonal rhythmicity were significantly associated with smoking history.

Smoking History and Clinical Features of Cluster Headache:Results from the Korean Cluster Headache Registry

Background@#and Purpose Epidemiologic data suggest that cluster headache (CH) is significantly associated with cigarette smoking. The aim of this study was to determine differences in features between patients with a smoking history and those who are never-smokers, using data from a prospective multicenter registry. @*Methods@#Data used in this study were obtained from the Korean Cluster Headache Registry that collected data from consecutive patients diagnosed with CH. We compared clinical and demographic features between ever-smokers (current or former smokers) and never-smokers. @*Results@#This study enrolled 250 patients who were diagnosed with CH, of which 152 (60.8%) were ever-smokers and 98 (39.2%) were never-smokers. The age at CH onset was significantly lower in the never-smoker group than in the ever-smoker group [27.1±12.9 years vs. 30.6± 10.9 years (mean±standard deviation), p=0.024]. Seasonal rhythmicity (58.1% vs. 44.7%, p= 0.038) and triptan responsiveness (100% vs. 85.1%, p=0.001) were higher in never-smokers, while other clinical features such as pain severity, duration, attack frequency, and associated autonomic symptoms did not differ significantly between the groups. The male-to-female ratio was markedly higher in ever-smokers (29.4:1) than in never-smokers (1.7:1). @*Conclusions@#Most of the clinical features did not differ significantly between patients with a smoking history and never-smokers. However, the age at CH onset, sex ratio, and seasonal rhythmicity were significantly associated with smoking history.

Effect of Sleep Quality on Headache-Related Impact in Primary Headache Disorders

Background@#and PurposeSleep disturbance is common in patients with primary headache disorders. We were interest in whether poor sleep quality affects patients directly or via increases in the frequency and severity of headaches. To that end, we investigated the direct and indirect effects of sleep quality on the headache-related impact among patients with primary headache disorders. @*Methods@#We analyzed migraine and tension-type headache (TTH) in patients included in the headache registry of our headache clinic from October 2015 to May 2018. We collected information on the headache frequency, severity, and psychological status. Sleep quality and headache-related impact were measured using the Pittsburgh Sleep Quality Index and Headache Impact Test-6, respectively. We performed path analyses with headache frequency and severity as covariates to determine the direct effect of sleep quality on the headache-related impact, and the indirect effects mediated by increases in the headache frequency and severity. @*Results@#This study included 915 patients: 784 with migraine and 131 with TTH. Worse sleep quality was independently associated with greater headache-related impact in both patients with migraine and those with TTH. Path analysis revealed a direct effect (β=0.207,p<0.001) of sleep quality and an indirect effect mediated by headache frequency and severity (β=0.067, p=0.004) on the headache-related impact in migraine. In TTH, only direct effects of sleep quality on the headache-related impact were significant (β=0.224, p=0.004). @*Conclusions@#We suggest that poor sleep quality can directly increase the headache-related impact in both patients with migraine and TTH as well as indirectly by increasing the headache frequency and severity in patients with migraine.

Development and Validation of the Cluster Headache Screening Questionnaire

BACKGROUND AND PURPOSE: Cluster headache (CH) is frequently either not diagnosed or the diagnosis is delayed. We addressed this issue by developing the self-administered Cluster Headache Screening Questionnaire (CHSQ). METHODS: Experts selected items from the diagnostic criteria of CH and the characteristics of migraine. The questionnaire was administered to first-visit headache patients at nine headache clinics. The finally developed CHSQ included items based on the differences in responses between CH and non-CH patients, and the accuracy and reliability of the scoring model were assessed. RESULTS: Forty-two patients with CH, 207 migraineurs, 73 with tension-type headache, and 18 with primary stabbing headache were enrolled. The CHSQ item were scored as follows: 3 points for ipsilateral eye symptoms, agitation, and duration; 2 points for clustering patterns; and 1 point for the male sex, unilateral pain, disability, ipsilateral nasal symptoms, and frequency. The total score of the CHSQ ranged from 0 to 16. The mean score was higher in patients with CH than in non-CH patients (12.9 vs. 3.4, p 8 points, the CHSQ had a sensitivity, specificity, positive predictive value, and negative predictive value of 95.2%, 96%, 76.9%, and 99.3%, respectively. CONCLUSIONS: The CHSQ is a reliable screening tool for the rapid identification of CH.

Differences in Characteristics and Comorbidity of Cluster Headache According to the Presence of Migraine

BACKGROUND AND PURPOSE: Cluster headache (CH) can present with migrainous symptoms such as nausea, photophobia, and phonophobia. In addition, an overlap between CH and migraine has been reported. This study aimed to determine the differences in the characteristics of CH according to the presence of comorbid migraine. METHODS: This study was performed using data from a prospective multicenter registry study of CH involving 16 headache clinics. CH and migraine were diagnosed by headache specialists at each hospital based on third edition of the International Classification of Headache Disorders (ICHD-3). We interviewed patients with comorbid migraine to obtain detailed information about migraine. The characteristics and psychological comorbidities of CH were compared between patients with and without comorbid migraine. RESULTS: Thirty (15.6%) of 192 patients with CH had comorbid migraine, comprising 18 with migraine without aura, 1 with migraine with aura, 3 with chronic migraine, and 8 with probable migraine. Compared to patients with CH without migraine, patients with CH with comorbid migraine had a shorter duration of CH after the first episode [5.4±7.4 vs. 9.0±8.2 years (mean±standard deviation), p=0.008], a lower frequency of episodic CH (50.0% vs. 73.5%, p=0.010), and a higher frequency of chronic CH (13.3% vs. 3.7%, p=0.033). Psychiatric comorbidities did not differ between patients with and without comorbid migraine. The headaches experienced by patients could be distinguished based on their trigeminal autonomic symptoms, pulsating character, severity, and pain location. CONCLUSIONS: Distinct characteristics of CH remained unchanged in patients with comorbid migraine with the exception of an increased frequency of chronic CH. The most appropriate management of CH requires clinicians to check the history of preceding migraine, particularly in cases of chronic CH.

Clinical Features of Cluster Headache Patients in Korea

Cluster headache (CH) is a rare underdiagnosed primary headache disorder with very severe unilateral pain and autonomic symptoms. Clinical characteristics of Korean patients with CH have not yet been reported. We analyzed the clinical features of CH patients from 11 university hospitals in Korea. Among a total of 200 patients with CH, only 1 patient had chronic CH. The average age of CH patients was 38.1 ± 8.9 years (range 19–60 years) and the average age of onset was 30.7 ± 10.3 years (range 10–57 years). The male-to-female ratio was 7:1 (2.9:1 among teen-onset and 11.7:1 among twenties-onset). Pain was very severe at 9.3 ± 1.0 on the visual analogue scale. The average duration of each attack was 100.6 ± 55.6 minutes and a bout of CH lasted 6.5 ± 4.5 weeks. Autonomic symptoms were present in 93.5% and restlessness or agitation was present in 43.5% of patients. Patients suffered 3.0 ± 3.5 (range 1–25) bouts over 7.3 ± 6.7 (range 1–30) years. Diurnal periodicity and season propensity were present in 68.5% and 44.0% of patients, respectively. There were no sex differences in associated symptoms or diurnal and seasonal periodicity. Korean CH patients had a high male-to-female ratio, relatively short bout duration, and low proportion of chronic CH, unlike CH patients in Western countries.

Hypercoagulability and Mortality of Patients with Stroke and Active Cancer: The OASIS-CANCER Study / 대한뇌졸중학회지

BACKGROUND AND PURPOSE: Patients with active cancer are at an increased risk for stroke. Hypercoagulability plays an important role in cancer-related stroke. We aimed to test whether 1) hypercoagulability is a predictor of survival, and 2) correction of the hypercoagulable state leads to better survival in patients with stroke and active cancer. METHODS: We recruited consecutive patients with acute ischemic stroke and active systemic cancer between January 2006 and July 2015. Hypercoagulability was assessed using plasma D-dimer levels before and after 7 days of anticoagulation treatment. The study outcomes included overall and 1-year survival. Plasma D-dimer levels before and after treatment were tested in univariate and multivariate Cox regression models. We controlled for systemic metastasis, stroke mechanism, age, stroke severity, primary cancer type, histology, and atrial fibrillation using the forward stepwise method. RESULTS: A total of 268 patients were included in the analysis. Patients with high (3rd–4th quartiles) pre-treatment plasma D-dimer levels showed decreased overall and 1-year survival (adjusted HR, 2.19 [95% CI, 1.46–3.31] and 2.70 [1.68–4.35], respectively). After anticoagulation treatment, post-treatment D-dimer level was significantly reduced and independently associated with poor 1-year survival (adjusted HR, 1.03 [95% CI, 1.01–1.05] per 1 μg/mL increase, P=0.015). The successful correction of hypercoagulability was a protective factor for 1-year survival (adjusted HR 0.26 [CI 0.10–0.68], P=0.006). CONCLUSIONS: Hypercoagulability is associated with poor survival after stroke in patients with active cancer. Effective correction of hypercoagulability may play a protective role for survival in these patients.

Impact of Slow Blood Filling via Collaterals on Infarct Growth: Comparison of Mismatch and Collateral Status / 대한뇌졸중학회지

BACKGROUND AND PURPOSE: Perfusion-diffusion mismatch has been evaluated to determine whether the presence of a target mismatch helps to identify patients who respond favorably to recanalization therapies. We compared the impact on infarct growth of collateral status and the presence of a penumbra, using magnetic resonance perfusion (MRP) techniques. METHODS: Consecutive patients who were candidates for recanalization therapy and underwent serial diffusion-weighted imaging (DWI) and MRP were enrolled. A collateral flow map derived from MRP source data was generated by automatic post-processing. The impact of a target mismatch (Tmax>6 s/apparent diffusion coefficient (ADC) volume≥1.8, ADC volume10 s for ADC volume<100 mL) on infarct growth was compared with MR-based collateral grading on day 7 DWI, using multivariate linear regression analysis. RESULTS: Among 73 patients, 55 (75%) showed a target mismatch, whereas collaterals were poor in 14 (19.2%), intermediate in 36 (49.3%), and good in 23 (31.5%) patients. After adjusting for initial severity of stroke, early recanalization (P<0.001) and the MR-based collateral grading (P=0.001), but not the presence of a target mismatch, were independently associated with infarct growth. Even in patients with a target mismatch and successful recanalization, the degree of infarct growth depended on the collateral status. Perfusion status at later Tmax time points (beyond the arterial phase) was more closely correlated with collateral status. CONCLUSIONS: Patients with good collaterals show a favorable outcome in terms of infarct growth, regardless of the presence of a target mismatch pattern. The presence of slow blood filling predicts collateral status and infarct growth.

The Migraine-Stroke Connection / 대한뇌졸중학회지

Migraine and stroke are common neurovascular disorders which share underlying physiological processes. Increased risks of ischemic stroke, hemorrhagic stroke, and subclinical ischemic lesions have been consistently found in migraineurs. Three possible associations are suggested. One is that underlying pathophysiology of migraine can lead to ischemic stroke. Second, common comorbidities between migraine and stroke can be present. Lastly, some syndromes can manifest with both migraine-like headache and cerebrovascular disease. Future studies should be targeted on bidirectional influence of migraine on different stroke mechanisms and optimal prevention of stroke in migraine patients.

Update of the Korean Clinical Practice Guidelines for Endovascular Recanalization Therapy in Patients with Acute Ischemic Stroke

Patients with severe stroke due to acute large cerebral artery occlusion are likely to be severely disabled or die if reperfusion is not achieved in a timely manner. Intravenous tissue plasminogen activator (IV-TPA) administered within 4.5 hours after stroke onset was previously the only proven therapy, but IV-TPA alone does not sufficiently improve the outcome of patients with acute large artery occlusion. With the introduction of the advanced endovascular therapy that enables faster and more successful recanalization, recent randomized trials consecutively and consistently demonstrated the benefit of adding endovascular recanalization therapy (ERT) to IV-TPA. Accordingly, to update the recommendations, we assembled members of a writing committee appointed by the Korean Stroke Society, the Korean Society of Interventional Neuroradiology, and the Society of Korean Endovascular Neurosurgeons. The writing committee revised recommendations based on a review of the accumulated evidence, and a formal consensus was achieved by convening a panel of 34 experts from the participating academic societies. The current guideline provides evidence-based recommendations for ERT in patients with acute large cerebral artery occlusion regarding patient selection, treatment modalities, neuroimaging evaluation, and system organization.

Update of the Korean Clinical Practice Guidelines for Endovascular Recanalization Therapy in Patients with Acute Ischemic Stroke / 대한뇌졸중학회지

Patients with severe stroke due to acute large cerebral artery occlusion are likely to be severely disabled or dead without timely reperfusion. Previously, intravenous tissue plasminogen activator (IV-TPA) within 4.5 hours after stroke onset was the only proven therapy, but IV-TPA alone does not sufficiently improve the outcome of patients with acute large artery occlusion. With the introduction of the advanced endovascular therapy, which enables more fast and more successful recanalization, recent randomized trials consecutively and consistently demonstrated the benefit of endovascular recanalization therapy (ERT) when added to IV-TPA. Accordingly, to update the recommendations, we assembled members of the writing committee appointed by the Korean Stroke Society, the Korean Society of Interventional Neuroradiology, and the Society of Korean Endovascular Neurosurgeons. Reviewing the evidences that have been accumulated, the writing members revised recommendations, for which formal consensus was achieved by convening a panel composed of 34 experts from the participating academic societies. The current guideline provides the evidence-based recommendations for ERT in patients with acute large cerebral artery occlusion regarding patient selection, treatment modalities, neuroimaging evaluation, and system organization.

Update of the Korean Clinical Practice Guidelines for Endovascular Recanalization Therapy in Patients with Acute Ischemic Stroke / 대한뇌졸중학회지

Patients with severe stroke due to acute large cerebral artery occlusion are likely to be severely disabled or dead without timely reperfusion. Previously, intravenous tissue plasminogen activator (IV-TPA) within 4.5 hours after stroke onset was the only proven therapy, but IV-TPA alone does not sufficiently improve the outcome of patients with acute large artery occlusion. With the introduction of the advanced endovascular therapy, which enables more fast and more successful recanalization, recent randomized trials consecutively and consistently demonstrated the benefit of endovascular recanalization therapy (ERT) when added to IV-TPA. Accordingly, to update the recommendations, we assembled members of the writing committee appointed by the Korean Stroke Society, the Korean Society of Interventional Neuroradiology, and the Society of Korean Endovascular Neurosurgeons. Reviewing the evidences that have been accumulated, the writing members revised recommendations, for which formal consensus was achieved by convening a panel composed of 34 experts from the participating academic societies. The current guideline provides the evidence-based recommendations for ERT in patients with acute large cerebral artery occlusion regarding patient selection, treatment modalities, neuroimaging evaluation, and system organization.

Association of Left Atrial Enlargement with Cortical Infarction in Subjects with Patent Foramen Ovale / 대한뇌졸중학회지

BACKGROUND AND PURPOSE: Left atrial dysfunction has been reported in patients with patent foramen ovale (PFO). Here we investigated the role of left atrial dysfunction in the development of embolic stroke in patients with PFO. METHODS: We identified consecutive patients with embolic stroke of undetermined sources except for PFO (PFO+ESUS). Healthy subjects with PFO served as controls (PFO+control). A stratified analysis by 10-year age group and an age- and sex- matching analysis were performed to compare echocardiographic markers between groups. In the PFO+ESUS group, infarct patterns of PFO-related stroke were determined (cortical vs. cortico-subcortical) and analyzed in correlation with left atrial function parameters. RESULTS: A total of 118 patients and 231 controls were included. The left atrial volume indices (LAVIs) of the PFO+ESUS patients were higher than those of the PFO+controls in age groups of 40–49, 50–59, and 60–69 years (P28 mL/m2) LAVI was more associated with the cortical infarct pattern (P=0.043 for an acute infarction and P=0.024 for a chronic infarction, both adjusted for age and shunt amount). The degree of right-to-left shunting was not associated with infarct patterns, but with the posterior location of acute infarcts (P=0.028). CONCLUSIONS: Left atrial enlargement was associated with embolic stroke in subjects with PFO. Left atrial physiology might contribute to the development of PFO-related stroke and need to be taken into consideration for optimal prevention of PFO-related stroke.

Stroke System of Care: A Policy Statement from the Korean Stroke Society

No abstract available.

Current Status and Problems of Stroke Units in Korea: Results of a Nationwide Acute Care Hospital Survey by the Korean Stroke Society

BACKGROUND: The patients who received organized inpatient care are more likely to survive and to be independent. The benefit is most apparent in units based in a discrete ward, stroke unit (SU). The observed benefit is sufficiently large to warrant efforts of widespread implementation of SU care. The Korean Stroke Society surveyed acute stroke care hospitals to know the density and the distribution of SU in Korea. METHODS: One hundred-sixty one acute care hospitals were selected among those included in the 5th Quality Audit in 2014 by the Health Insurance Review and Assessment Service of Korea. A senior director of stroke service in each hospital was chosen and asked about the current status of acute stroke care including SU and major obstacles to establish SU in each hospital. RESULTS: The results of the questionnaire revealed the shortage of a total SU number and markedly uneven distribution of SU between rural and urban area. Most hospitals indicated the absence of the insurance reimbursement for medical service in SU, which served as the fundamental cause of lack of skilled manpower for establishing SU. CONCLUSIONS: The state-of-the-art SU, which is properly certified or designated, should be spread out more evenly in Korea for the optimal treatment of public regardless of a residential district. Government should encourage and support for the establishment of SU, which is an important first step toward making it reality.

Current Status and Problems of Stroke Units in Korea: Results of a Nationwide Acute Care Hospital Survey by the Korean Stroke Society

BACKGROUND: The patients who received organized inpatient care are more likely to survive and to be independent. The benefit is most apparent in units based in a discrete ward, stroke unit (SU). The observed benefit is sufficiently large to warrant efforts of widespread implementation of SU care. The Korean Stroke Society surveyed acute stroke care hospitals to know the density and the distribution of SU in Korea. METHODS: One hundred-sixty one acute care hospitals were selected among those included in the 5th Quality Audit in 2014 by the Health Insurance Review and Assessment Service of Korea. A senior director of stroke service in each hospital was chosen and asked about the current status of acute stroke care including SU and major obstacles to establish SU in each hospital. RESULTS: The results of the questionnaire revealed the shortage of a total SU number and markedly uneven distribution of SU between rural and urban area. Most hospitals indicated the absence of the insurance reimbursement for medical service in SU, which served as the fundamental cause of lack of skilled manpower for establishing SU. CONCLUSIONS: The state-of-the-art SU, which is properly certified or designated, should be spread out more evenly in Korea for the optimal treatment of public regardless of a residential district. Government should encourage and support for the establishment of SU, which is an important first step toward making it reality.

Primary Angiitis of the Central Nervous System Diagnosed by High-Resolution Vessel Wall MRI

Primary angiitis of the central nervous system (PACNS) is a poorly understood form of vascular inflammatory disease that is restricted to the brain and spinal cord. A 38-year-old woman presented with severe headache and transient aphasia. Her cerebrospinal fluid exhibited aseptic meningitis, and high-resolution vessel-wall MRI (HRVW-MRI) revealed narrowing of multiple intracranial vessels with concentric wall thickening and diffuse enhancement, suggestive of PACNS. High-dose steroid and azathioprine therapy resulted in a significant improvement in vessel wall thickening, and enhancement was observed on the follow-up HRVW-MRI.

Clinical Predictors for Migraine in Patients Presenting With Nausea and/or Vomiting

BACKGROUND/AIMS: Many migraine patients develop nausea and/or vomiting (N/V) and are referred to gastroenterologists. This can lead to an inappropriate treatment and a delay of the correct diagnosis. We therefore aimed to identify predictors for migraine in patients presenting with N/V as well as headache. METHODS: A total of 407 patients who were first diagnosed with migraine at Samsung Medical Center, Seoul, Korea, in 2009 were analyzed. Among them, 261 patients had N/V (migraine with N/V group) and 146 did not (migraine without N/V group). Each patient was evaluated using a structured questionnaire. RESULTS: Migraine with N/V group was younger, comprised of more females, had more abnormal body mass index, less alcohol intake, more family history of migraine, higher attack severity, more stress association, more aggravation by physical activity, more abdominal pain, and more photophobia/phonophobia than migraine without N/V group. Multivariate analysis revealed that young age (age or = 40 years, odds ratio (OR), 2.128; 95% confidence interval (CI), 1.206-3.756; P = 0.009), female (OR, 2.703; 95% CI, 1.492-4.896; P = 0.001), family history of migraine (OR, 2.080; 95% CI, 1.169-3.700; P = 0.013), abdominal pain (OR, 4.452; 95% CI, 1.263-15.693; P = 0.020), and photophobia/phonophobia (OR, 2.296; 95% CI, 1.308-4.030; P = 0.004) were independent predictive factors associated with migraine in patients with N/V. CONCLUSIONS: Because young age, female, family history of migraine, abdominal pain, and photophobia/phonophobia are associated with migraine in patients presenting with N/V as well as headache, physicians should have a high index of suspicion for migraine in N/V patients who belong to these categories.

Ischemic Stroke in Takayasu's Arteritis: Lesion Patterns and Possible Mechanisms

BACKGROUND AND PURPOSE: The purpose of the present study was to use brain magnetic resonance imaging (MRI) and magnetic resonance angiography (MRA) to identify the mechanism of stroke in patients with Takayasu's arteritis (TA). METHODS: Among a retrospective cohort of 190 TA patients, 21 (3 males and 18 females) with a mean age of 39.9 years (range 15-68 years) who had acute cerebral infarctions were included in lesion pattern analyses. The patients' characteristics were reviewed, and infarction patterns and the degree of cerebral artery stenosis were evaluated. Ischemic lesions were categorized into five subgroups: cortical border-zone, internal border-zone, large lobar, large deep, and small subcortical infarctions. RESULTS: In total, 21 ischemic stroke events with relevant ischemic lesions on MRI were observed. The frequencies of the lesion types were as follows: large lobar (n=7, 33.3%), cortical border zone (n=6, 28.6%), internal border zone (n=1, 4.8%), small cortical (n=0, 0%), and large deep (n=7, 33.3%). MRA revealed that 11 patients had intracranial artery stenosis. CONCLUSIONS: Hemodynamic compromise in large-artery stenosis and thromboembolic mechanisms play significant roles in ischemic stroke associated with TA.

2011 Update of Scientific Statement for the Primary Prevention of Stroke: Dyslipidemia and Inflammation

BACKGROUND: This scientific statement is intended to provide a systematic review of new evidences in dyslipidemia and inflammation for primary stroke prevention. METHODS: Using a structured literature search, we identified major observational studies, clinical trials, meta-analyses, and updated major guidelines published between July 2007 and November 2010. In addition to the brief summary of earlier evidences employed in the first edition of Korean clinical practice guideline for primary prevention of stroke, we summarized the newly identified evidences. RESULTS: For dyslipidemia, observational studies further support a strong association between ischemic stroke and high total and low-density lipoprotein cholesterol and low high-density lipoprotein cholesterol. Two clinical trials and 6 meta-analyses confirm statin efficacy for primary prevention of stroke in high risk patients. Efficacy of other lipid-lowering agents is not established. For inflammation, inflammatory markers might help to identify patients having high risk for stroke or cardiovascular event and to decide whether statin therapy is indicated, but its usefulness for broad population needs to be confirmed. CONCLUSIONS: Writing committee will continue to keep an eye on upcoming evidences to timely update the guideline for primary stroke prevention in dyslipidemia and inflammation.