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The coronavirus disease-19 (COVID-19) pandemic leaded to inevitable expeditious vaccine rollout without sufficient safety profile. Especially, severe acute respiratory syndrome coronavirus 2 infection has known to induce overreacted immune responses such as releasing of proteinase-3 and myeloperoxidase (MPO) by neutrophil. This overreacted immune response leads to the concern of the development of autoimmune diseases after COVID-19 vaccination. We report the case of de novo MPO-associated systemic vasculitis involving central nervous system following heterogeneous mRNA1273 COVID-19 booster vaccination.
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Objective@#We aimed to evaluate the efficacy of EmboTrap II in terms of first-pass recanalization and to determine whether it could yield favorable outcomes. @*Materials and Methods@#In this multicenter, prospective study, we consecutively enrolled patients who underwent mechanical thrombectomy using EmboTrap II as a front-line device. The primary outcome was the first pass effect (FPE) rate defined by modified Thrombolysis In Cerebral Infarction (mTICI) grade 2c or 3 by the first pass of EmboTrap II. In addition, modified FPE (mFPE; mTICI grade 2b–3 by the first pass of EmboTrap II), successful recanalization (final mTICI grade 2b–3), and clinical outcomes were assessed. We also analyzed the effect of FPE on a modified Rankin Scale (mRS) score of 0–2 at 3 months. @*Results@#Two hundred-ten patients (mean age ± standard deviation, 73.3 ± 11.4 years; male, 55.7%) were included. Ninetynine patients (47.1%) had FPE, and mFPE was achieved in 150 (71.4%) patients. Successful recanalization was achieved in 191 (91.0%) patients. Among them, 164 (85.9%) patients underwent successful recanalization by exclusively using EmboTrap II. The time from groin puncture to FPE was 25.0 minutes (interquartile range, 17.0–35.0 minutes). Procedure-related complications were observed in seven (3.3%) patients. Symptomatic intracranial hemorrhage developed in 14 (6.7%) patients. One hundred twenty-three (58.9% of 209 completely followed) patients had an mRS score of 0–2. Sixteen (7.7% of 209) patients died during the follow-up period. Patients who had successful recanalization with FPE were four times more likely to have an mRS score of 0–2 than those who had successful recanalization without FPE (adjusted odds ratio, 4.13;95% confidence interval, 1.59–10.8; p = 0.004). @*Conclusion@#Mechanical thrombectomy using the front-line EmboTrap II is effective and safe. In particular, FPE rates were high. Achieving FPE was important for an mRS score of 0–2, even in patients with successful recanalization.
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Atrial fibrillation (AF) is associated with an increased incidence of ischemic stroke and transient ischemic attack. A confluence of various factors such as blood stasis, endothelial dysfunction, and prothrombotic state could be contributing to the thrombogenesis in AF. Anticoagulation is the first-line therapy for the prevention of thromboembolism by AF. In current days, non-vitamin K dependent oral anticoagulants (NOAC) are considered as the preferred choice of anticoagulants to prevent ischemic stroke in patients with AF. NOACs have comparable good efficacy and better safety with a predictable anticoagulant effect without the routine coagulation monitoring compared to vitamin K dependent oral anticoagulant. However, the proper use of NOACs needs a careful approach to many practical aspects for balancing the preventing thromboembolic events and bleeding risk. Thus, understanding the drug metabolism and indication of NOAC for a specific situation is essential. In this article, we review major clinical trials, the mechanism, and the use of NOACs in the actual clinical setting of managing ischemic stroke patients.
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Background@#Intravenous recombinant tissue plasminogen activator (IV rtPA) is the mainstay of treatment for acute ischemic stroke to recanalize thrombosed intracranial vessels within 4.5 hours. Emergency carotid artery stenting for the treatment of acute stroke due to stenoocclusion of the proximal internal carotid artery (ICA) can improve symptoms, prevent neurological deterioration, and reduce recurrent stroke risk. The feasibility and safety of the combination therapy of IV rtPA and urgent carotid artery stenting have not been established. @*Methods@#From November 2005 to October 2020, we retrospectively assessed patients who had undergone emergent carotid artery stenting after IV rtPA for hyperacute ischemic stroke due to steno-occlusive proximal ICA lesion. Hemorrhagic transformation, successful recanalization, modified Rankin Scale (mRS) score at 90 days, and stent patency at 3 and 12 months or longer were evaluated. Favorable outcome was defined as a 90-days mRS score of ≤ 2. @*Results@#Nineteen patients with hyperacute stroke had undergone emergent carotid artery stenting after IV rtPA therapy. Their median age was 70 (67.5–73.5) years (94.7% men).Among 15 patients with an additional intracranial occlusion after flow restoration in the proximal ICA, a modified TICI grade ≥ 2b was achieved in 11 patients (73.3%). Hemorrhagic transformation occurred in five patients (26.3%); mortality rate was 5.7%. Eleven patients (57.9%) had favorable outcomes at 90 days. Stent patients (94.1%) maintained stent patency for ≥ 12 months. @*Conclusion@#We showed that emergent carotid artery stenting after IV rtPA therapy for hyperacute stroke caused by atherosclerotic proximal ICA steno-occlusion was feasible and safe.
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Objective@#Variable treatment strategies and protocols have been applied to reduce time durations in the process of acute stroke management. The aim of this study is to investigate the effectiveness of our intra-arterial thrombectomy (IAT) protocol for decreasing door-to-recanalization time duration and improve successful recanalization. @*Methods@#A systemic and endovascular protocol included door-to-image, image-to-puncture and puncture-to-recanalization. We retrospectively analyzed the patients of pre- (Sep 2012–Apr 2014) and post-IAT protocol (May 2014–Jul 2018). Univariate analysis was used for the statistical significance according to variable factors (age, gender, the location of occluded vessel, successful recanalization TICI 2b-3). Independent t-test was used to compare the time duration. @*Results@#Among all 267 patients with acute stroke of anterior circulation, there were 50 and 217 patients with pre- and post-IAT protocol. Age, gender, and the location of occluded vessel have no statistical significance (p＞0.05). In pre- and post-IAT group, successful recanalization was 39 of 50 (78.0%) and 185/217 (85.3%), respectively (p＜0.05). Post-IAT (48.8%, 106/217) group had a higher tendency of good outcome than pre-IAT group (36.0%, 18/50) (p＞0.05). Pre- and post-IAT group showed 61.7±21.4 vs. 25±16.0 (p＜0.05), 102.0±29.8 vs. 82.7±30.4 (min) (p＜0.05), and 79.1±47.5 vs. 58.4±75.3 (p＜0.05) in three steps, respectively. @*Conclusions@#We suggest that the application of systemic and endovascular IAT protocols showed a significant time reduction for faster recanalization in patients with LVO. To build-up the well-designed IAT protocol through puncture-to-recanalization can be needed to decrease time duration and improve clinical outcome in recanalization therapy in acute stroke patients.
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Background@#and Purpose We aimed to develop a model predicting early recanalization after intravenous tissue plasminogen activator (t-PA) treatment in large-vessel occlusion. @*Methods@#Using data from two different multicenter prospective cohorts, we determined the factors associated with early recanalization immediately after t-PA in stroke patients with large-vessel occlusion, and developed and validated a prediction model for early recanalization. Clot volume was semiautomatically measured on thin-section computed tomography using software, and the degree of collaterals was determined using the Tan score. Follow-up angiographic studies were performed immediately after t-PA treatment to assess early recanalization. @*Results@#Early recanalization, assessed 61.0±44.7 minutes after t-PA bolus, was achieved in 15.5% (15/97) in the derivation cohort and in 10.5% (8/76) in the validation cohort. Clot volume (odds ratio [OR], 0.979; 95% confidence interval [CI], 0.961 to 0.997; P=0.020) and good collaterals (OR, 6.129; 95% CI, 1.592 to 23.594; P=0.008) were significant factors associated with early recanalization. The area under the curve (AUC) of the model including clot volume was 0.819 (95% CI, 0.720 to 0.917) and 0.842 (95% CI, 0.746 to 0.938) in the derivation and validation cohorts, respectively. The AUC improved when good collaterals were added (derivation cohort: AUC, 0.876; 95% CI, 0.802 to 0.950; P=0.164; validation cohort: AUC, 0.949; 95% CI, 0.886 to 1.000; P=0.036). The integrated discrimination improvement also showed significantly improved prediction (0.097; 95% CI, 0.009 to 0.185; P=0.032). @*Conclusions@#The model using clot volume and collaterals predicted early recanalization after intravenous t-PA and had a high performance. This model may aid in determining the recanalization treatment strategy in stroke patients with large-vessel occlusion.
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Background@#and Purpose We aimed to develop a model predicting early recanalization after intravenous tissue plasminogen activator (t-PA) treatment in large-vessel occlusion. @*Methods@#Using data from two different multicenter prospective cohorts, we determined the factors associated with early recanalization immediately after t-PA in stroke patients with large-vessel occlusion, and developed and validated a prediction model for early recanalization. Clot volume was semiautomatically measured on thin-section computed tomography using software, and the degree of collaterals was determined using the Tan score. Follow-up angiographic studies were performed immediately after t-PA treatment to assess early recanalization. @*Results@#Early recanalization, assessed 61.0±44.7 minutes after t-PA bolus, was achieved in 15.5% (15/97) in the derivation cohort and in 10.5% (8/76) in the validation cohort. Clot volume (odds ratio [OR], 0.979; 95% confidence interval [CI], 0.961 to 0.997; P=0.020) and good collaterals (OR, 6.129; 95% CI, 1.592 to 23.594; P=0.008) were significant factors associated with early recanalization. The area under the curve (AUC) of the model including clot volume was 0.819 (95% CI, 0.720 to 0.917) and 0.842 (95% CI, 0.746 to 0.938) in the derivation and validation cohorts, respectively. The AUC improved when good collaterals were added (derivation cohort: AUC, 0.876; 95% CI, 0.802 to 0.950; P=0.164; validation cohort: AUC, 0.949; 95% CI, 0.886 to 1.000; P=0.036). The integrated discrimination improvement also showed significantly improved prediction (0.097; 95% CI, 0.009 to 0.185; P=0.032). @*Conclusions@#The model using clot volume and collaterals predicted early recanalization after intravenous t-PA and had a high performance. This model may aid in determining the recanalization treatment strategy in stroke patients with large-vessel occlusion.
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Background@#and Purpose We aimed to determine whether the care process and outcomes in patients with acute stroke who received recanalization therapy changed during the outbreak of coronavirus disease 2019 (COVID-19) in South Korea. @*Methods@#We used data from a prospective multicenter reperfusion therapy registry to compare the care process including the time from symptom onset to treatment, number of treated patients, and discharge disposition and treatment outcomes between before and during the COVID-19 outbreak in South Korea. @*Results@#Upon the COVID-19 outbreak in South Korea, the number of patients receiving endovascular treatment to decrease temporarily but considerably. The use of emergency medical services by stroke patients increased from 91.5% before to 100.0% during the COVID-19 outbreak (p=0.025), as did the median time from symptom onset to hospital visit [median (interquartile range), 91.0 minutes (39.8–277.0) vs. 176.0 minutes (56.0–391.5), p=0.029]. Furthermore, more functionally dependent patients with disabilities were discharged home (59.5% vs. 26.1%, p=0.020) rather than staying in a regional or rehabilitation hospital. In contrast, there were no COVID-19-related changes in the times from the hospital visit to brain imaging and treatment or in the functional outcome, successful recanalization rate, or rate of symptomatic intracerebral hemorrhage. @*Conclusions@#These findings suggest that a prehospital delay occurred during the COVID-19 outbreak, and that patients with acute stroke might have been reluctant to visit and stay in hospitals. Our findings indicate that attention should be paid to prehospital care and the behavior of patients with acute stroke during the COVID-19 outbreak.
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Background@#and Purpose Nonbacterial thrombotic endocarditis (NBTE) is a cause of stroke in cancer. However, clinical characteristics and outcomes in stroke patients with cancer-associated NBTE are not well known. @*Methods@#We included consecutive patients with stroke and active cancer over a 9-year period who underwent echocardiography. We retrospectively compared clinical characteristics and presence of metastasis between patients with NBTE, those with cryptogenic etiologies, and those with determined etiologies. We also investigated mortality and stroke events during the 6-month follow-up. @*Results@#Among the 245 patients, 20 had NBTE, 96 had cryptogenic etiologies, and 129 had determined etiologies. Metastasis was seen in all 20 patients (100%) with NBTE, 69.8% in patients with cryptogenic etiology, and 48.8% in patients with or determined etiology. During the 6-month follow-up, 127 patients (51.8%) developed stroke and/or died (death in 110 [44.9%] and stroke events in 55 [22.4%]). Patients with NBTE showed significantly higher mortality (80%) and stroke occurrence (50%) than those with cryptogenic etiologies (mortality 54.2%, stroke 25.0%, log-rank P=0.006) and determined etiologies (mortality 32.6%, stroke 16.3%, log-rank P @*Conclusions@#NBTE should be suspected as a potential cause of stroke in patients with metastatic cancer. Patients with NBTE have a high risk of recurrent stroke and mortality. Future studies are necessary to determine strategies to reduce stroke recurrence in patients with NBTE.
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Objective@#Endovascular thrombectomy (EVT) fails in approximately 20% of anterior circulation large vessel occlusion (ACLVO).Nonetheless, the factors that affect clinical outcomes of non-recanalized AC-LVO despite EVT are less studied. Thepurpose of this study was to identify the factors affecting clinical outcomes in non-recanalized AC-LVO patients despite EVT. @*Materials and Methods@#This was a retrospective analysis of clinical and imaging data from 136 consecutive patients whodemonstrated recanalization failure (modified thrombolysis in cerebral ischemia [mTICI], 0–2a) despite EVT for AC-LVO. Datawere collected in prospectively maintained registries at 16 stroke centers. Collateral status was categorized into good or poorbased on the CT angiogram, and the mTICI was categorized as 0–1 or 2a on the final angiogram. Patients with good (modifiedRankin Scale [mRS], 0–2) and poor outcomes (mRS, 3–6) were compared in multivariate analysis to evaluate the factorsassociated with a good outcome. @*Results@#Thirty-five patients (25.7%) had good outcomes. The good outcome group was younger (odds ratio [OR], 0.962;95% confidence interval [CI], 0.932–0.992; p = 0.015), had a lower incidence of hypertension (OR, 0.380; 95% CI, 0.173–0.839; p = 0.017) and distal internal carotid artery involvement (OR, 0.149; 95% CI, 0.043–0.520; p = 0.003), lower initialNational Institute of Health Stroke Scale (NIHSS) (OR, 0.789; 95% CI, 0.713–0.873; p < 0.001) and good collateral status(OR, 13.818; 95% CI, 3.971–48.090; p < 0.001). In multivariate analysis, the initial NIHSS (OR, 0.760; 95% CI, 0.638–0.905; p = 0.002), good collateral status (OR, 14.130; 95% CI, 2.264–88.212; p = 0.005) and mTICI 2a recanalization (OR,5.636; 95% CI, 1.216–26.119; p = 0.027) remained as independent factors with good outcome in non-recanalized patients. @*Conclusion@#Baseline NIHSS score, good collateral status, and mTICI 2a recanalization remained independently associatedwith clinical outcome in non-recanalized patients. mTICI 2a recanalization would benefit patients with good collaterals innon-recanalized AC-LVO patients despite EVT.
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Coronavirus disease 2019 (COVID-19) is an ongoing pandemic infection associated with high morbidity and mortality. The Korean city of Daegu endured the first large COVID-19 outbreak outside of China. Since the report of the first confirmed case in Daegu on February 18, 2020, a total of 6,880 patients have been reported until May 29, 2020. We experienced five patients with ischemic stroke and COVID-19 during this period in four tertiary hospitals in Daegu. The D-dimer levels were high in all three patients in whom D-dimer blood testing was performed.Multiple embolic infarctions were observed in three patients and suspected in one. The mean time from stroke symptom onset to emergency room arrival was 22 hours. As a result, acute treatment for ischemic stroke was delayed. The present case series report raises the possibility that the coronavirus responsible for COVID-19 causes or worsens stroke, perhaps by inducing inflammation. The control of COVID-19 is very important; however, early and proper management of stroke should not be neglected during the epidemic.
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@#Background: Aortic calcification (AC), a predictor of generalized atherosclerosis, may precedes cerebral white matter lesions. Cerebral white matter changes (WMCs) are associated with cognitive decline and future dementia. The aim of study was to evaluate the usefulness of aortic calcification (AC) detection by chest radiograph for cueing early intervention in possible WMCs to prevent stroke and dementia in community-dwelling healthy people. Methods: We assessed the relationship between AC in chest radiography and vascular risk factors and severity of WMCs in 543 middle-aged and elderly individuals with no history of stroke or dementia. Results: The mean age of the subjects was 61.6 ± 7.4 years. Of these, AC was observed in 39 (7.2%) subjects. AC combined with grade 1 WMC (mild), 2 (moderate), and 3 (severe) were seen in 8 (25.8%), 7 (23.3%) subjects, and 3 (30.0%) subjects, respectively. After adjustment for age and vascular risk factors, diabetes (odds ratio [OR], 1.92, 95% confidence interval (CI) 1.01–3.65, p<0.05) and hypertension (OR, 1.86, 95% CI, 1.03-3.35, p<0.05), aortic knob width (OR, 1.07, 95% CI, 1.01–1.13, p<0.05) and aortic calcification (OR, 2.93, 95% CI, 1.36-6.33, p<0.05) were significantly associated with the severity of WMCs. Conclusion: There is an association between the presence of AC in chest radiography and WMC. It may be useful in providing important information about development of WMCs for prevention of future vascular-related cognitive impairments or ischemic stroke
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Herpes simplex virus type 2 (HSV2) meningitis primarily develops during or following a primary genital HSV2 infection that was acquired from sexual contact or through the birth canal during delivery from mother. We describe a 15 year old virgin without history of previous herpes simplex infection who developed 2 episodes of HSV2 meningitis. Although recurrent meningitis due to HSV is primarily seen in young or sexually active adults. HSV2 meningitis should be in the differential diagnosis of recurrent meningitis in adolescent patients.
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Adolescent , Adult , Female , Humans , Diagnosis, Differential , Herpes Simplex , Herpesvirus 2, Human , Meningitis , Mothers , Parturition , SimplexvirusABSTRACT
OBJECTIVES: The aim of study was to examine the prevalence of night eating syndrome(NES) and its correlates in schizophrenic outpatients. METHODS: The 14 items of self-reported night eating questionnaire(NEQ) was administered to 201 schizophrenic patients in psychiatric outpatient clinic. We examined demographic and clinical characteristics, body mass index(BMI), subjective measures of mood, sleep, binge eating, and weight-related quality of life using Beck's Depression Inventory(BDI), Pittsburgh Sleep Quality Index(PSQI), Binge Eating Scale(BES) and Korean version of Obesity-Related Quality of Life Scale(KOQoL), respectively. RESULTS: The prevalence of night eaters in schizophrenic outpatients was 10.4%(21 of 201). Comparisons between NES group and non-NES group revealed no significant differences in sociodemographic characteristics, clinical status and BMI. Compared to non-NES, patients with NES reported significantly greater depressed mood and sleep disturbance, more binge eating pattern, and decreased weight-related quality of life. While 'morning anorexia' and 'delayed morning meal'(2 of 5 NES core components in NEQ) were not differed between groups, 'nocturnal ingestions', 'evening hyperphagia', and 'mood/sleep' were more impaired in NES group. CONCLUSION: These findings are the first to describe the prevalence and its correlates of night eaters in schizophrenic outpatients. These results suggest that NES has negative mental health implications, although it was not associated with obesity. Further study to generalize these results is required.
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Humans , Ambulatory Care Facilities , Bulimia , Depression , Eating , Mental Health , Obesity , Outpatients , Prevalence , Quality of LifeABSTRACT
BACKGROUND AND PURPOSE: Aortic knob calcification (AC) is associated with increased risks of cardiovascular and cerebrovascular events. We evaluated the clinical importance of AC in ischemic stroke patients with intracranial (IC) stenosis using simple, non-invasive and routine chest radiography. METHODS: The presence of AC was assessed in a chest posteroanterior view in 307 acute ischemic stroke patients admitted from May 2009 to April 2010, and who underwent magnetic resonance angiography or distal subtraction angiography. The association of AC with IC stenosis was analyzed. RESULTS: Patient age (68.3+/-8.7 vs. 65.9+/-8.27 years, P=0.04), and the prevalence of IC stenosis (70.7 vs. 41.3%, P<0.01) were higher in patients with AC than in patients without calcification. After adjusting for age, gender and vascular risk factors, logistic regression analysis showed that AC (Odds ratio, 3.54; 95% confidence interval, 1.90 to 6.61, P<0.01) and age (Odds ratio, 1.79; 95% confidence interval, 1.01 to 3.19; P=0.04) were independent factors affecting IC stenosis. CONCLUSIONS: AC appears to be a reliable predictor for IC stenosis, an important mechanism of ischemic stroke.