Erratum: Stroke Epidemiology in South, East, and South-East Asia: A Review / 대한뇌졸중학회지

On page 287, “The lowest rates are observed in Japan (43.4/1,000,000 person-years and Singapore (47.9/100,000 person-years), followed by Bangladesh, Papua New Guinea, and Bhutan.” sentence should be corrected.

Stroke thrombolysis in the Philippines

Background & Objective: Currentlythere is limitedintervention for acute ischemic stroke. Recombinant tissue plasminogen activator (rTPA) has been approved for immediate recanalization after a steno-occlusive lesion of cerebral vessels. rTPA has shown its efficacy and safety from several clinical trials. The present study reports our experience with intravenous rTPA from several centers in the Philippines.Method:This is a retrospective cohort study consisting of 157 patients who qualified to receive rTPA following the NINDS trial inclusion and exclusion criteria. The primary outcome is in-hospital and 3-months mortality. Other outcome measures were determined: intracranial hemorrhage secondary to hemorrhagic conversion and functional outcome as measured by modified Rankin Scale. Additionally, standard dose (0.9mg/kg) was compared to low dose (0.6mg/kg) of rTPA in terms of mortality, intracranial bleeding and functional outcome.Results:The in-hospital mortality was seen in 23 (14.6%) and total death within 3 months was 18.3%. Independent patient (mRS 0-2) was seen in 69 (51.1%) at discharge and 95 (73.1%) at 3 months. Intracranial bleeding due to asymptomatic hemorrhagic transformation occurred in 39 (24.8%) and symptomatic hemorrhagic transformation was seen in 19 (12.1%).Conclusion: Comparing our results with SITS-MOST and Cochrane collaborations, our data showed that we have more independent patients however death and intracranial bleeding was noted to be high in our cohort of patients. Additionally, the study showed more independent patients in the low dose group.

Stroke Epidemiology in South, East, and South-East Asia: A Review / 대한뇌졸중학회지

Asia, which holds 60% of the world’s population, comprises some developing countries which are in economic transition. This paper reviews the epidemiology of stroke in South, East and South-East Asia. Data on the epidemiology of stroke in South, East, and South-East Asia were derived from the Global Burden of Disease study (mortality, disability-adjusted life-years [DALYs] lost because of stroke), World Health Organization (vascular risk factors in the community), and publications in PubMed (incidence, prevalence, subtypes, vascular risk factors among hospitalized stroke patients). Age- and sex-standardized mortality is the lowest in Japan, and highest in Mongolia. Community-based incidence data of only a few countries are available, with the lowest rates being observed in Malaysia, and the highest in Japan and Taiwan. The availability of prevalence data is higher than incidence data, but different study methods were used for case-finding, with different age bands. For DALYs, Japan has the lowest rates, and Mongolia the highest. For community, a high prevalence of hypertension is seen in Mongolia and Pakistan; diabetes mellitus in Papua New Guinea, Pakistan, and Mongolia; hypercholesterolemia in Japan, Singapore, and Brunei; inactivity in Malaysia; obesity in Brunei, Papua New Guinea, and Mongolia; tobacco smoking in Indonesia. Hypertension is the most frequent risk factor, followed by diabetes mellitus and smoking. Ischemic stroke occurs more frequently than hemorrhagic stroke, and subarachnoid hemorrhages are uncommon. There are variations in the stroke epidemiology between countries in South, East, and South-East Asia. Further research on stroke burden is required.

Clinical profile, risk factors and aetiology of young ischaemic stroke patients in Asia: A prospective, multicentre, observational, hospital-based study in eight cities

Background and Objective: There is a lack of international collaborative studies on young adults with ischaemic stroke in Asia. The aim of this study was to investigate risk factors, aetiology and outcome at hospital discharge of these patients across 8 participating countries in Asia. Methods: This was a prospective, observational, multicentre, hospital based cohort study. Consecutive young stroke patients with confirmed cerebral infarction between the ages of 18-49 were recruited from December 2011 to May 2012. Data was collected for patient demography, risk factors, investigations, clinical profile and TOAST classification. Outcome measures were death and independence (modified Rankin score≤ 2) at hospital discharge. Results: Two hundred and eighteen patients with the mean age was 40.8±6.7 years were recruited. There was a larger proportion of male patients with a ratio of 1.9:1. Traditional risk factors observed were hypertension (n=103; 47.3%), dyslipidaemia (n=93; 42.4%), smoking (n=85; 38.8%), diabetes (n=53; 24.3%), alcohol use (n=33; 15.0%), a previous history of stroke and transient ischaemic attacks (6.4%), family history (n=12; 5.5%), migraine (n=6;2.8%), pregnancy related (n=5; 2.3%) and numerous cardiac risk factors (0.9-5.5%). The majority suffered arterial infarction; n=216 (99.4%) while n=2 (0.6%) had venous strokes. The predominant stroke subtypes were large artery atherosclerosis (LAA); 29.8% and small vessel occlusion (SVO); 20.2%. LAA and SVO accounted for 37.5% of all stroke subtypes in the ≤36 year age-group. Cardioembolism (15.1%) and stroke of determined aetiology (14.7%) contributed to the other categories of identified stroke subtypes. Mortality on hospital discharge was 3.1% while 65.1% of patients were independent on discharge. Conclusion: This study demonstrated the substantial presence of premature atherosclerosis and conventional risk factors in young ischaemic stroke patients from 8 Asian cities. Venous infarction from cerebral venous thrombosis was rare in this study. Outcome on hospital discharge was poorer compared to Western studies. Detection of vascular risk factors and primary prevention measures should be initiated during late adolescence or early adulthood in urban Asia.

Complication of acute stroke: A study in ten Asian countries

Background and Objective: There is a paucity of studies looking into the frequency of complications after stroke among Asians. We sought to determine the frequency and rate of complications among Asians after acute stroke. Methods: Consecutive patients with acute stroke among 10 participating Asian countries were included in the study. The frequency and timing of pre-determined complications, and their relation to area of admission were noted. Results: Of the 1,153 patients included in the study, 423 (41.9%) developed complications within the first 2 weeks of stroke. Recurrent stroke, chest infections and urinary tract infections were most commonly encountered, and were most frequent within the first week of stroke onset. A lower rate of complications was noted among patients admitted at an organized stroke unit. Conclusion: There is a similar rate of frequency and timing of complications after acute stroke among Asians as compared with other populations.

Aspirin resistance among patients with recurrent non-cardioembolic stroke detected by rapid platelet function analyzer

Background and Objective: The prevalence of aspirin resistance amongst patients with cardiovascular disease and in the healthy population has been reported to range from 5% to 45%. Lately, rapid platelet function analyzer (RPFA) a point-of-care determination of platelet aggregability has been introduced for rapid determination of aspirin resistant patients. The purpose of this paper is to report the prevalence of aspirin resistance among patients with recurrent non cardioembolic ischemic stroke as detected by RPFA (Ultegra®). Methods: Seventy-seven patients with mean age of 61.2 + 10.4 (range 33-87 years) who developed recurrent non-cardioembolic ischemic stroke were consecutively included in the study. Fifty-seven (74%) were males. Aspirin resistance was determined using the RPFA (Ultegra®) machine. Patients with an aspirin reaction unit (ARU) value above 550 were identified as aspirin resistant. Results: Following this method, the prevalence of aspirin resistance was determined to be 10.4% (95% CI: 1% to17%). Comparison of baseline characteristics between aspirin resistant and aspirin responsive patients did not show any significant difference. Conclusion: The prevalence of aspirin resistance in this study was 10.4% amongst patients with recurrent non-cardioembolic ischemic stroke. The study has shown the feasibility of utilizing RPFA (Ultegra®) machine in detecting aspirin resistance.

A proposed scoring system to screen for vasospasm following aneurysmal subarachnoid hemorrhage

Vasospasm has been known to cause permanent morbidity in 40-70% of survivors who suffered from subarachnoid hemorrhage (SAH). Early recognition of vasospasm is the key to better outcome of SAH. Cerebral angiography is expensive and impractical as a monitoring tool. Transcranial Doppler is operator dependent, and not readily available. The objective of this study is to devise a non invasive tool to screen for cerebral vasospasm following SAH. The proposed vasospasm score was based on clinical and cranial CT scan features. The features are hypertension, admission World Federation of Neurosurgeons Score (WFNS), amount of blood in the cisterns and subarachnoid space, intraventricular hemorrhage and hydrocephalus. Thirty six patients with aneurismal SAH were assessed retrospectively and correlated with the angiogram for vasospasm. The patients’ vasospasm score and their corresponding sensitivity and specificity were: 1 (100%, 0%), 2 (100%, 8%), 3 (100%, 8%), 4 (100%, 8%), 5 (91%, 46%), 6 (74%, 85%), 7 (48%, 85%), 8 (26%, 23%), 9 (3%, 100%), 10 (4%, 100%). A receiver operator characteristic curve was constructed that yielded a cut-off score of 6. The score of 6 was a good trade-off between sensitivity (74%) and specificity (85%). A clinical vasospasm score was proposed to screen for vasospasm after SAH. A score of 4 to 6 was found to correlate with angiographic vasospasm. Prospective study is required to validate the scoring system.