Moderate-Intensity Rosuvastatin Plus Ezetimibe Versus High-Intensity Rosuvastatin for Target Low-Density Lipoprotein Cholesterol Goal Achievement in Patients With Recent Ischemic Stroke: A Randomized Controlled Trial / 대한뇌졸중학회지

Background@#and Purpose Moderate-intensity statin plus ezetimibe versus high-intensity statin alone may provide a greater low-density lipoprotein cholesterol (LDL-C) reduction in patients with recent ischemic stroke. @*Methods@#This randomized, open-label, controlled trial assigned patients with recent ischemic stroke <90 days to rosuvastatin/ezetimibe 10/10 mg once daily (ROS10/EZT10) or to rosuvastatin 20 mg once daily (ROS20). The primary endpoint was LDL-C reduction ≥50% from baseline at 90 days. Key secondary endpoints were LDL-C <70 mg/dL and multiple lipid goal achievement, and composite of major vascular events. @*Results@#Of 584 randomized, 530 were included in the modified intention-to-treat analysis. The baseline LDL-C level was 130.2±34.7 mg/dL in the ROS10/EZT10 group and 131.0±33.9 mg/dL in the ROS20 group. The primary endpoint was achieved in 198 patients (72.5%) in the ROS10/EZT10 group and 148 (57.6%) in the ROS20 group (odds ratio [95% confidence interval], 1.944 [1.352–2.795]; P= 0.0003). LDL-C level <70 mg/dL was achieved in 80.2% and 65.4% in the ROS10/EZT10 and ROS20 groups (P=0.0001). Multiple lipid goal achievement rate was 71.1% and 53.7% in the ROS10/EZT10 and ROS20 groups (P<0.0001). Major vascular events occurred in 1 patient in the ROS10/EZT10 group and 9 in the ROS20 group (P=0.0091). The adverse event rates did not differ between the two groups. @*Conclusion@#Moderate-intensity rosuvastatin plus ezetimibe was superior to high-intensity rosuvastatin alone for intensive LDL-C reduction in patients with recent ischemic stroke. With the combination therapy, more than 70% of patients achieved LDL-C reduction ≥50% and 80% had an LDL-C <70 mg/dL at 90 days.

Quality of Acute Stroke Care within Emergency Medical Service System in Korea: Proposal for Severe Emergency Medical Center

Background@#Korea recently established 70 emergency medical service areas. However, there are many concerns that medical resources for stroke could not be evenly distributed through the country. We aimed to compare the treatment quality and outcomes of acute stroke among the emergency medical service areas. @*Methods@#This study analyzed the data of 28,800 patients admitted in 248 hospitals which participated in the 8th acute stroke quality assessment by Health Insurance Review and Assessment Service. Individual hospitals were regrouped into emergency service areas according to the address of the location. Assessment indicators and fatality were compared by the service areas. We defined the appropriate hospital by the performance of intravenous thrombolysis. @*Results@#In seven service areas, there were no hospitals which received more than 10 stroke patients for 6 months. In nine service areas, there were no patients who underwent intravenous thrombolysis (IVT). Among 167 designated emergency medical centers, 50 hospitals (29.9%) responded that IVT was impossible 24 hours a day. There are 97 (39.1%) hospitals that meet the definitions of appropriate hospital. In 23 service areas (32.9%) had no appropriate or feasible hospitals. The fatality of service areas with stroke centers were 6.9% within 30 days and 15.6% within 1 year from stroke onset than those without stroke centers (7.7%, 16.9%, respectively). @*Conclusions@#There was a wide regional gap in the medical resource and the quality of treatments for acute stroke among emergency medical service areas in Korea. The poststroke fatality rate of the service areas which have stroke centers or appropriate hospitals were significantly low.

Invasive Aspergillosis Complicated by Occlusion of Internal Carotid Artery and Cerebral Infarction

Invasive aspergillosis is one of rare causes of mortality for the immune-compromised patients. We present a case of invasive aspergillosis complicated by the occlusion of the internal carotid artery and cerebral infarction in a patient with diabetes mellitus. Although initial biopsy did not find the pathogen, the repeated attempts of sampling showed aspergillosis. Combination of surgical removal of necrotic tissue and voriconazole medication improved symptoms and reduced the burden of infection.

Sex differences in large artery atherosclerotic stroke, a Korean study

Background & Objective: Sex differences in cerebral atherosclerosis and subsequent stroke have not been thoroughly investigated and conflicting data exist. The aim of this study was to investigate sex differences in the risk factors and distribution of large artery atherosclerotic stroke in a Korean population. Methods: We included consecutive acute ischemic stroke patients with symptomatic extracranial atherosclerosis (ECAS) or intracranial atherosclerosis (ICAS) based on brain and vascular imaging who presented at our hospital between January 2011 and December 2015. We then compared risk factor profiles and the proportion of symptomatic ECAS and ICAS between men and women. Results: Eight hundred and forty four patients were enrolled during the study period. The proportion of ECAS in men was notably higher than in women (19.4% in men vs. 9.3% in women; p < 0.001). A multiple regression analysis showed that male gender was a factor favoring ECAS (vs. ICAS, odds ratio [OR], 3.554; 95% confidence interval [CI], 2.175-5.808; p < 0.001). Age (OR, 1.051; 95% CI, 1.031-1.072; p = 0.001) and hyperlipidemia (OR, 2.330; 95% CI, 1.538-3.529; p < 0.001) were also factors favoring ECAS. However, after stratification by sex, the association was only significant in men. Conclusions: There is a sex difference in the distribution of atherosclerotic stroke. Sex may be an effect modifier of the association between atherosclerotic risk factors and atherosclerotic distribution.

Hemichorea following Temporo-Parietal Infarction

Hemichorea after cortical infarction has rarely been reported. We report a female patient in which hemichorea of the right extremities developed following a left temporo-parietal infarction. An acute infarction in the territory of the inferior division of the left middle cerebral artery was evident in diffusion-weighted imaging, but the basal ganglia, thalamus, and brainstem appeared normal. Her choreic movement gradually improved after administering haloperidol, and the hemichorea disappeared after 4 days.

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.

The Clinico-Oncologic Outcomes of Elderly Patients with Glioblastoma after Surgical Resection Followed by Concomitant Chemo-Radiotherapy

BACKGROUND: There have been controversies in the treatment of elderly patients with glioblastoma. We introduce the outcome of the treatment of elderly patients with glioblastoma comparing with younger patients. METHODS: The author's hospital database was used to identify patients with histologically confirmed glioblastoma after surgery between January 2006 and December 2013. Forty-eight patients (control group) were under age 65 and 16 patients (elderly group) were aged 65 years or over at the time of surgery. RESULTS: The median age of the elderly group was 71 years and control group was 50 years. Mean number of medical comorbidities was 1.8 in the elderly group vs. 0.5 in the control group. The median progression free survival (PFS) was 5.6 months and the median overall survival (OS) was 19.9 months in all patients. The elderly group had a median PFS of 4.2 months vs. 8 months for the control group (log-rank test, p=0.762). Median OS was 8.2 months in the elderly group vs. 20.9 months in the control group (log-rank test, p=0.457). Major complications occurred in 5 cases (7.8%) for all patients. The ratio of completion of concomitant chemo-radiotherapy (CCRT) was 81.3% and was the same between the two groups. In multivariable analysis, extent of resection (p=0.034) and completion of CCRT (p=0.023) were statistically significant, independent prognostic factors only for PFS in all patients by Cox proportional hazards model. Age was not an independent prognostic factor. As for OS, there was no significant factor. CONCLUSION: Surgical resection and CCRT were well tolerated in elderly patients with glioblastoma, and maximal safe resection followed by timely CCRT could improve clinic-oncologic outcomes.

Pre-Procedural Evaluation and Peri-Procedural Management in Carotid Artery Stenting

Carotid-artery stenting (CAS) is as an alternative to surgical endarterectomy for severe carotid-artery stenosis. CAS is advantageous over carotid endarterectomy in that it is less invasive and could shorten the hospital stay. A preprocedural evaluation is necessary to assess the patient's anatomic status or clinical risk factors to determine whether they are a good candidate for CAS. Proper evaluation and management can reduce CAS-associated complications such as embolism and cerebral hyperperfusion syndrome. The frequent use of statins appears to improve the outcome of CAS. Using the appropriate stent type and a protection device could also reduce the complication rate. Given the changes in cerebral hemodynamics following CAS, adequately controlling the blood pressure in individual patients can enhance the efficacy of this treatment. However, there is currently limited data regarding the preprocedural evaluation and periprocedural management for CAS. The evidence and the clinical status related to the preprocedural evaluation and periprocedural management of CAS are presented herein.

Endovascular Management of Great Vessel Injury Following Lumbar Microdiscectomy

Great vessel injury is a rare but well-known complication of lumbar disc surgery, which may result in acute or fatal outcomes of delayed diagnosis. Thus, early detection and proper management is vital. The authors report a case of retroperitoneal hemorrhage with arteriovenous fistula and pseudoaneurysm after lumbar microdiscectomy. The patient was successfully managed by endovascular intervention using a stent graft. Endovascular repair is a minimally invasive and efficient treatment modality with considerably low morbidity and mortality.

Familial Hemiplegic Migraine with Prolonged Coma and Cerebellar Atrophy: CACNA1A T666M Mutation in a Korean Family

We report the first Korean patient with familial hemiplegic migraine type 1, with clinical and multimodal imaging findings. A 43-yr-old man was admitted for right hemianopia and aphasia, followed by coma. MRI showed only cerebellar atrophy. CT angiography showed mild vasodilation of intracranial blood vessels and increased vascularity in the left hemisphere and perfusion-weighted imaging showed elevated cerebral blood flow. Gene analysis of the patient and his mother led to the identification of a heterozygous point mutation (1997C-->T, T666M) in exon 16 of the CACNA1A gene. Familial hemiplegic migraine should be considered in patients with episodic neurological dysfunction with cerebellar atrophy.

Focused Update of Korean Clinical Practice Guidelines for the Thrombolysis in Acute Stroke Management / 대한뇌졸중학회지

Since the release of first Korean Clinical Practice Guideline of Stroke in 2009, many important new evidences have emerged in the field of thrombolytic therapy. Among the recent developments are the extended therapeutic time window of intravenous (IV) tissue plasminogen activator (tPA) up to 4.5 hours after onset, and the efforts for the wider application of IV thrombolysis to patients with minor stroke and elderly patients over 80 years old. Debates about the optimal dose of IV tPA according to the ethnic population is still ongoing. Further evidences for the efficacy of intra-arterial thrombolysis have also accumulated, including the application of various novel mechanical devices with promising results. Thus update of guideline became necessary and we revise the acute stroke management guideline, focusing on the thrombolytic therapy.

Difference in Infarct Volume and Initial Clinical Severity between Stroke Patient with Patent Foramen Ovale and Atrial Fibrillation / 대한뇌졸중학회지

BACKGROUND: Atrial fibrillation (AF) and patent foramen ovale (PFO) are established sources of cardioembolism. We investigated differences in stroke outcome and patterns between PFO and AF. METHODS: We performed a retrospective review of the medical records and brain MR images of patients with AF or PFO from the prospective acute stroke and transient ischemic attack registry. Infarct pattern and volume on diffusion-weighted imaging, and the national institutes of health stroke scale (NIHSS) on admission were compared between patients with AF and PFO. RESULTS: From June 2005 to July 2008, a total of 289 subjects were enrolled (AF group, n=156; PFO group, n=133). Infarct pattern analyzed with MR images revealed that multiple vascular territorial infarction was more prevalent in AF group than in PFO group (26.9% vs. 8.3%, P<0.01). A probable cardiac embolism, radiologically defined as territorial infarction without symptomatic steno-occlusion of the corresponding artery, was more frequently documented in AF group than in PFO group (71.8% vs. 41.4%, P<0.01) The infarct volume of PFO was smaller than that of AF. Compared to AF, PFO was associated with the mild neurologic deficit (NIHSS< or =3) after adjusting age, sex and previous stroke history. CONCLUSION: These results suggested that AF and PFO had different characteristics such as infarct patterns and initial clinical severity although both are classified as cardioembolism.

Cerebral Venous Thrombosis Presenting as Isolated Subarachnoid Hemorrhage / 대한뇌졸중학회지

Cerebral venous thrombosis (CVT) rarely presents with cortical subarachnoid hemorrhage. A 54 year-old woman complained of intractable headache. Brain MR scan showed subarachnoid hemorrhage in the right parietal sulci on Fluid-Attenuated Inversion Recovery image. The venous phase of digital subtraction angiography demonstrated the thrombus and venous congestion in superior sagittal sinus and vein of Trolad. After 3 days of anticoagulation therapy, the symptoms disappeared.

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.

Cerebral Venous Thrombosis in the Inferior Sagittal Sinus

No abstract available.

Increased Circulating Endothelial Microparticles and Carotid Atherosclerosis in Obstructive Sleep Apnea

BACKGROUND AND PURPOSE: Endothelial impairment is a linking mechanism between obstructive sleep apnea (OSA) and cardiovascular diseases. Profiles of endothelial microparticles (EMPs) and endothelial progenitor cells (EPCs) reflect the degree of endothelial impairment. The aims of this study were to measure the levels of EMPs and progenitor cells in OSA, determine the correlations between these factors and OSA severity and the degree of atherosclerosis, and document any changes in these factors after therapy. METHODS: Subjects with (n=82) and without (n=22) OSA were recruited prospectively. We measured the number of colony-forming units (CFU) in cell culture as the endothelial progenitor cell index, and the number of EMPs using flow cytometry with CD31 [platelet endothelial cell adhesion molecule (PECAM)], CD42 (platelet glycoprotein), annexin V, and CD62E (E-selectin) antibodies at baseline and after 4-6 weeks of continuous positive airway pressure (CPAP) therapy. Carotid intima-media thickness (IMT) was regarded as a marker of atherosclerosis. RESULTS: The levels of PECAM+CD42- (p<0.001), PECAM+annexin V+ (p<0.001), and E-selectin+ microparticles (p=0.001) were higher in OSA subjects than in non-OSA subjects. The number of CFU did not differ between the two groups. OSA severity independently predicted the levels of PECAM+CD42- (p=0.02) and PECAM+annexin V+ (p=0.004). Carotid IMT was correlated with OSA severity (p<0.001), PECAM+CD42- (p=0.03), and PECAM+annexin V+ (p=0.01). Neither OSA severity nor carotid IMT was correlated with either the number of CFU or E-selectin+. CPAP therapy decreased the occurrence of E-selectin+ (p<0.001) in 21 of the OSA subjects, but had no effect on the other microparticles of the number of CFU. CONCLUSIONS: OSA led to the overproduction of EMPs, which moderately correlated with OSA severity and the degree of atherosclerosis, and partly responded to therapy. The endothelial impairment might contribute to future cardiovascular events.

Stroke Mimicking Encephalopathy as an Initial Manifestation of Diffuse Large B-Cell Lymphoma

BACKGROUND: Systemic lymphoma can be difficult to recognize due to its diverse manifestations. Paraneoplastic leukoencephalopathy has rarely been reported in the context of lymphoma. CASE REPORT: We report a 45-year-old man with systemic lymphoma whose initial manifestation was sudden-onset leukoencephalopathy, mimicking stroke. This patient, who was eventually diagnosed with diffuse large B-cell lymphoma, initially presented with sudden cognitive impairment and gait disturbance. Radiological studies suggested a paraneoplastic leukoencephalopathy. Chemotherapy for lymphoma resulted in clinical and radiological improvement. CONCLUSIONS: The presented case indicates that diffuse large B-cell lymphoma may initially appear as a treatable leukoencephalopathy.

Vancomycin-Resistant Enterococcus Meningitis

The incidence of vancomycin-resistant enterococcus (VRE) meningitis is increasing. We present a 56-year-old man who suffered from VRE meningitis after cerebellar hemorrhage and intraventricular catheter insertion. The patient recovered completely after treatment with linezolid for 6 weeks. This is the first report on effectiveness of linezolid in treating VRE meningitis in Korea.