Risk of Subsequent Events in Patients With Minor Ischemic Stroke or HighRisk Transient Ischemic Attack

This study aimed to present the prognosis after minor acute ischemic stroke (AIS) or transient ischemic attack (TIA), using a definition of subsequent stroke in accordance with recent clinical trials. In total, 9,506 patients with minor AIS (National Institutes of Health Stroke Scale ≤ 5) or high-risk TIA (acute lesions or ≥ 50% cerebral artery steno-occlusion) admitted between November 2010 and October 2013 were included. The primary outcome was the composite of stroke (progression of initial event or a subsequent event) and all-cause mortality. The cumulative incidence of stroke or death was 11.2% at 1 month, 13.3% at 3 months and 16.7% at 1 year. Incidence rate of stroke or death in the first month was 12.5 per 100 person-months: highest in patients with large artery atherosclerosis (17.0). The risk of subsequent events shortly after a minor AIS or high-risk TIA was substantial, particularly in patients with large artery atherosclerosis.

Hyperintense Vessel Sign in Large-Vessel Occlusion Stroke of Mild-to-Moderate Severity Ineligible for Recanalization

Background@#and PurposeThe impact of fluid-attenuated inversion recovery hyperintense vessels (FHVs) on outcomes in patients ineligible for recanalization therapy with large-vessel occlusion (LVO) is unclear. We investigated the impact of FHVs determined using the FHV– Alberta Stroke Program Early CT Score (ASPECTS) on clinical outcomes in patients with LVO stroke of mild-to-moderate severity ineligible for recanalization therapy. @*Methods@#Sixty-eight consecutive patients with M1-middle cerebral artery occlusion who underwent magnetic resonance imaging within 24 hours of symptom onset and were ineligible for recanalization were included. Patients were dichotomized into a severe-FHV group (FHV-ASPECTS ≤4; n=33) and a mild-FHV group (FHV-ASPECTS >4; n=35), and multiple logistic regression analysis was used to examine the relationships of FHV scores with early neurological deterioration (END) and an unfavorable 3-month outcome (modified Rankin Scale score ≥3). @*Results@#Mean age was 66.2±13.5 years (mean±SD), and 30 (44%) were female. The severe-FHV group had a larger infarct volume (median, 5.5 mL vs. 3 mL) and more frequently exhibited the susceptibility vessel sign (30% vs. 3%) than the mild-FHV group. Ipsilateral old nonlacunar infarct was more frequent in the mild-FHV group than in the severe-FHV group (37% vs. 15%). The severe-FHV group had a fivefold higher risk of END (odds ratio [OR] 5.02, 95% confidence interval [CI] 1.36–18.45) and unfavorable outcome (OR 5.97, 95% CI 1.18–33.31, p=0.03) compared with the mild-FHV group. @*Conclusions@#Greater FHV extent was associated with higher risk of END and unfavorable outcome in patients with LVO stroke of mild-to-moderate severity.

Hyperintense Vessel Sign in Large-Vessel Occlusion Stroke of Mild-to-Moderate Severity Ineligible for Recanalization

Background@#and PurposeThe impact of fluid-attenuated inversion recovery hyperintense vessels (FHVs) on outcomes in patients ineligible for recanalization therapy with large-vessel occlusion (LVO) is unclear. We investigated the impact of FHVs determined using the FHV– Alberta Stroke Program Early CT Score (ASPECTS) on clinical outcomes in patients with LVO stroke of mild-to-moderate severity ineligible for recanalization therapy. @*Methods@#Sixty-eight consecutive patients with M1-middle cerebral artery occlusion who underwent magnetic resonance imaging within 24 hours of symptom onset and were ineligible for recanalization were included. Patients were dichotomized into a severe-FHV group (FHV-ASPECTS ≤4; n=33) and a mild-FHV group (FHV-ASPECTS >4; n=35), and multiple logistic regression analysis was used to examine the relationships of FHV scores with early neurological deterioration (END) and an unfavorable 3-month outcome (modified Rankin Scale score ≥3). @*Results@#Mean age was 66.2±13.5 years (mean±SD), and 30 (44%) were female. The severe-FHV group had a larger infarct volume (median, 5.5 mL vs. 3 mL) and more frequently exhibited the susceptibility vessel sign (30% vs. 3%) than the mild-FHV group. Ipsilateral old nonlacunar infarct was more frequent in the mild-FHV group than in the severe-FHV group (37% vs. 15%). The severe-FHV group had a fivefold higher risk of END (odds ratio [OR] 5.02, 95% confidence interval [CI] 1.36–18.45) and unfavorable outcome (OR 5.97, 95% CI 1.18–33.31, p=0.03) compared with the mild-FHV group. @*Conclusions@#Greater FHV extent was associated with higher risk of END and unfavorable outcome in patients with LVO stroke of mild-to-moderate severity.

Development and Testing of Thrombolytics in Stroke / 대한뇌졸중학회지

Despite recent advances in recanalization therapy, mechanical thrombectomy will never be a treatment for every ischemic stroke because access to mechanical thrombectomy is still limited in many countries. Moreover, many ischemic strokes are caused by occlusion of cerebral arteries that cannot be reached by intra-arterial catheters. Reperfusion using thrombolytic agents will therefore remain an important therapy for hyperacute ischemic stroke. However, thrombolytic drugs have shown limited efficacy and notable hemorrhagic complication rates, leaving room for improvement. A comprehensive understanding of basic and clinical research pipelines as well as the current status of thrombolytic therapy will help facilitate the development of new thrombolytics. Compared with alteplase, an ideal thrombolytic agent is expected to provide faster reperfusion in more patients; prevent re-occlusions; have higher fibrin specificity for selective activation of clot-bound plasminogen to decrease bleeding complications; be retained in the blood for a longer time to minimize dosage and allow administration as a single bolus; be more resistant to inhibitors; and be less antigenic for repetitive usage. Here, we review the currently available thrombolytics, strategies for the development of new clot-dissolving substances, and the assessment of thrombolytic efficacies in vitro and in vivo.

Platelet-Derived Growth Factor Is Associated with Progression of Symptomatic Intracranial Atherosclerotic Stenosis

Background@#and Purpose We aimed to determine the relationships of 33 biomarkers of inflammation, oxidation, and adipokines with the risk of progression of symptomatic intracranial atherosclerotic stenosis (ICAS). @*Methods@#Fifty-two of 409 patients who participated in the TOSS-2 (Trial of Cilostazol in Symptomatic Intracranial Stenosis-2) showed progression of symptomatic ICAS in magnetic resonance angiography at 7 months after an index stroke. We randomly selected 20 patients with progression as well as 40 age- and sex-matched control patients. We serially collected blood samples at baseline, 1 month, and 7 months after an index stroke. Multiplex analysis of biomarkers was then performed. @*Results@#Demographic features and risk factors such as hypertension, diabetes, and smoking history were comparable between the two groups. Univariate analyses revealed that the levels of platelet-derived growth factor (PDGF)-AA [median (interquartile range)=1.64 (0.76–4.57) vs. 0.77 (0.51–1.71) ng/mL], PDGF-AB/BB [10.31 (2.60–25.90) vs. 2.35 (0.74–6.70) ng/mL], and myeloperoxidase [10.5 (7.5–22.3) vs. 7.8 (5.5–12.2) ng/mL] at 7 months were higher in the progression group. In the multivariate analysis using logistic regression, the PDGF AB/BB level at 7 months was independently associated with the progression of ICAS (p=0.02). @*Conclusions@#The PDGF-AB/BB level is associated with the progression of ICAS, and so may play a significant role in the progression of human ICAS.

Estimation of Acute Infarct Volume with Reference Maps: A Simple Visual Tool for Decision Making in Thrombectomy Cases / 대한뇌졸중학회지

BACKGROUND AND PURPOSE: Thrombectomy within 24 hours can improve outcomes in selected patients with a clinical-infarct mismatch. We devised an easy-to-use visual estimation tool that allows infarct volume estimation in centers with limited resources. METHODS: We identified 1,031 patients with cardioembolic or large-artery atherosclerosis infarction on diffusion-weighted images (DWIs) obtained before recanalization therapy and within 24 hours of onset, and occlusion of the internal carotid or middle cerebral artery. Acute DWIs were mapped onto a standard template and used to create visual reference maps with known lesion volumes, which were then used in a validation study (with 130 cases) against software estimates of infarct volume. RESULTS: The DWI reference map chart comprises 144 maps corresponding to 12 different infarct volumes (0.5, 1, 2, 3, 5, 7, 9, 11, 13, 15, 17, and 19 mL) in each of 12 template slices (Montreal Neurological Institute z-axis –15 to 51 mm). Infarct volume in a patient is estimated by selecting a slice with a similar infarct size at the corresponding z-axis level on the reference maps and then adding up over all slices. The method yielded good correlations to software volumetrics and was easily learned by both experienced and junior physicians, with approximately 1 to 2 minutes spent per case. The sensitivity, specificity, and accuracy for detecting threshold infarct volumes ( 90%). CONCLUSIONS: We developed easy-to-use reference maps that allow prompt and reliable visual estimation of infarct volumes for triaging patients to thrombectomy in acute stroke.

Nationwide Estimation of Eligibility for Endovascular Thrombectomy Based on the DAWN Trial / 대한뇌졸중학회지

No abstract available.

Ventriculitis Associated with Extended Spectrum Beta-Lactamase Producing Klebsiella pneumoniae after Acupuncture

BACKGROUND: Ventriculitis is a rare and critical infection of the central nervous system. Here, we report a case of ventriculitis by extended spectrum beta-lactamase (ESBL) producing Klebsiella pneumoniae , after acupuncture at the low back. CASE REPORT: A 72-year-old woman visited our center with fever, headache, and decreased mental status, after undergoing low back acupuncture. Brain imaging showed the fluid-debris level in the lateral ventricle, suggesting ventriculitis. ESBL producing Klebsiella pneumoniae were cultured from the cerebrospinal fluid. After the administration of antibiotics, although the ventriculitis was treated, the quadriplegia remained. CONCLUSIONS: This case stresses the importance of aseptic techniques during acupuncture.

Simple Estimates of Symptomatic Intracranial Hemorrhage Risk and Outcome after Intravenous Thrombolysis Using Age and Stroke Severity / 대한뇌졸중학회지

No abstract available.

Adipokines, Superoxide Dismutases and Progression of Symptomatic Intracranial Atherosclerotic Stenosis

OBJECTIVE: We aimed to investigate the relationship between adipokines and antioxidation enzyme and the risk of progression of symptomatic intracranial atherosclerotic stenosis (ICAS). METHODS: Of 409 patients who participated in the TOSS-2 (trial of cilostazol in symptomatic intracranial stenosis-2) study, 52 patients showed progression of symptomatic ICAS on magnetic resonance angiography at seven months after an index stroke. We randomly selected 20 patients with progression and 20 age- and sex-matched control patients. We serially collected blood sample initially, one month, and seven months after an index stroke. Then, multiplex analysis of biomarkers was performed for adiponectin, resistin, leptin, and superoxide dismutase-1, 2, 3. RESULTS: Demographic features and risk factors such as hypertension, diabetes, and smoking history were comparable between the two groups. Control group showed higher adiponectin levels at 7 months than progression group (P=0.05) and a significant in-creasing trend (P for trend=0.01). Resistin, leptin, and superoxide dismutase-1, 2, 3 levels were not different between the progression and control group initially, one month, and seven months after an index stroke. CONCLUSION: Increase of adiponectin level showed protective effect in the progression of ICAS. Resistin, leptin, and superoxide dismutase-1, 2, 3 levels are not different between the groups. Further large numbers of patients with longer follow-up studies are needed.

Prestroke Antiplatelet Effect on Symptomatic Intracranial Hemorrhage and Functional Outcome in Intravenous Thrombolysis / 대한뇌졸중학회지

BACKGROUND AND PURPOSE: About 30%-40% of stroke patients are taking antiplatelet at the time of their strokes, which might increase the risk of symptomatic intracranial hemorrhage (SICH) with intravenous tissue plasminogen activator (IV-TPA) therapy. We aimed to assess the effect of prestroke antiplatelet on the SICH risk and functional outcome in Koreans treated with IV-TPA. METHODS: From a prospective stroke registry, we identified patients treated with IV-TPA between October 2009 and November 2014. Prestroke antiplatelet use was defined as taking antiplatelet within 7 days before the stroke onset. The primary outcome was SICH. Secondary outcomes were discharge modified Rankin Scale (mRS) score and in-hospital mortality. RESULTS: Of 1,715 patients treated with IV-TPA, 441 (25.7%) were on prestroke antiplatelet. Prestroke antiplatelet users versus non-users were more likely to be older, to have multiple vascular risk factors. Prestroke antiplatelet use was associated with an increased risk of SICH (5.9% vs. 3.0%; adjusted odds ratio [OR] 1.79 [1.05-3.04]). However, at discharge, the two groups did not differ in mRS distribution (adjusted OR 0.90 [0.72-1.14]), mRS 0-1 outcome (34.2% vs. 33.7%; adjusted OR 1.27 [0.94-1.72), mRS 0-2 outcome (52.4% vs. 52.9%; adjusted OR 1.21 [0.90-1.63]), and in-hospital mortality (6.1% vs. 4.2%; adjusted OR 1.19 [0.71-2.01]). CONCLUSIONS: Despite an increased risk of SICH, prestroke antiplatelet users compared to non-users had comparable functional outcomes and in-hospital mortality with IV-TPA therapy. Our results support the use of IV-TPA in eligible patients taking antiplatelet therapy before their stroke onset.

Reversible Cerebral Vasoconstriction Syndrome Complicated with Cerebral Infarct after Inhaling Ethylene Oxide Gas

Reversible cerebral vasoconstriction syndrome (RCVS) is characterized by thunderclap headache and multiple reversible intracranial vasoconstrictions. Here we report a case of RCVS after exposure to ethylene oxide (EO) gas, which is a widely used sterilant. A 34-year-old woman presented with aphasia, right-arm weakness, and severe headache after inhaling EO gas. Brain imaging revealed multiple infarcts and multiple intracranial stenoses. The stenotic lesions completely regressed on follow-up CT angiography. This is the first report of RCVS after exposure to EO gas.

Intravenous Tissue Plasminogen Activator Improves the Outcome in Very Elderly Korean Patients with Acute Ischemic Stroke / 대한뇌졸중학회지

BACKGROUND AND PURPOSE: In a recent pooled analysis of randomized clinical trials (RCTs), intravenous tissue plasminogen activator (TPA) improves the outcome in patients aged > or =80 years. However, it is uncertain whether the findings are applicable to clinical practice in Asian populations. METHODS: From a multicenter stroke registry database of Korea, we identified patients with acute ischemic stroke who were aged > or = 80 years. Using multivariable analysis and propensity score (PS)-matched analyses, we assessed the effectiveness and safety of intravenous TPA within 4.5 hours. RESULTS: Among 2,334 patients who met the eligible criteria, 236 were treated with intravenous TPA (mean age, 83+/-5; median NIHSS, 13 [IQR, 8-17]). At discharge, the TPA group compared to the no-TPA group had a favorable shift on the modified Rankin Scale (mRS) score (multivariable analysis, OR [95% CI], 1.51 [1.17-1.96], P=0.002; PS-matched analysis, 1.54 [1.17-2.04], P=0.002) and was more likely to achieve mRS 0-1 outcome (multivariable analysis, 2.00 [1.32-3.03], P=0.001; PS-matched analysis, 1.59 [1.04-2.42], P=0.032). TPA treatment was associated with an increased risk of symptomatic intracranial hemorrhage (multivariable analysis, 5.45 [2.80-10.59], P<0.001; PS-matched analysis, 4.52 [2.24-9.13], P<0.001), but did not increase the in-hospital mortality (multivariable analysis, 0.86 [0.50-1.48], P=0.58; PS-matched analysis, 0.88 [0.52-1.47], P=0.61). CONCLUSIONS: In the setting of clinical practice, intravenous TPA within 4.5 hours improved the functional outcome despite an increased risk of symptomatic intracranial hemorrhage in very elderly Korean patients. The findings, consistent with those from pooled analysis of RCTs, strongly support the use of TPA for this population.

Case Characteristics, Hyperacute Treatment, and Outcome Information from the Clinical Research Center for Stroke-Fifth Division Registry in South Korea / 대한뇌졸중학회지

Characteristics of stroke cases, acute stroke care, and outcomes after stroke differ according to geographical and cultural background. To provide epidemiological and clinical data on stroke care in South Korea, we analyzed a prospective multicenter clinical stroke registry, the Clinical Research Center for Stroke-Fifth Division (CRCS-5). Patients were 58% male with a mean age of 67.2+/-12.9 years and median National Institutes of Health Stroke Scale score of 3 [1-8] points. Over the 6 years of operation, temporal trends were documented including increasing utilization of recanalization treatment with shorter onset-to-arrival delay and decremental length of stay. Acute recanalization treatment was performed in 12.7% of cases with endovascular treatment utilized in 36%, but the proportion of endovascular recanalization varied across centers. Door-to-IV alteplase delay had a median of 45 [33-68] min. The rate of symptomatic hemorrhagic transformation (HT) was 7%, and that of any HT was 27% among recanalization-treated cases. Early neurological deterioration occurred in 15% of cases and were associated with longer length of stay and poorer 3-month outcomes. The proportion of mRS scores of 0-1 was 42% on discharge, 50% at 3 months, and 55% at 1 year after the index stroke. Recurrent stroke up to 1 year occurred in 4.5% of patients; the rate was higher among older individuals and those with neurologically severe deficits. The above findings will be compared with other Asian and US registry data in this article.

Elevated Calcium after Acute Ischemic Stroke: Association with a Poor Short-Term Outcome and Long-Term Mortality / 대한뇌졸중학회지

BACKGROUND AND PURPOSE: An elevated intracellular calcium level is known to be a major initiator and activator of ischemic cell death pathway; however, in recent studies, elevated serum calcium levels have been associated with better clinical outcomes and smaller cerebral infarct volumes. The pathophysiological role played by calcium in ischemic stroke is largely unknown. METHODS: Acute stroke patients from a prospective stroke registry, consecutively admitted during October 2002-September 2008, were included. Significant associations between the modified Rankin scale distribution at discharge and serum calcium or albumin-corrected calcium were identified using ordinal logistic regression analysis. Cox proportional hazard models were used for survival analysis. RESULTS: Mean serum calcium and albumin-corrected calcium levels of the 1,915 participants on admission were 8.97+/-0.58 mg/dL and 9.07+/-0.49 mg/dL, respectively. Second [adjusted odds ratio 1.32 (95% confidence interval 1.07-1.61)] and third [1.24 (1.01-1.53)] tertiles of serum calcium level and the third [1.24 (1.01-1.53)] tertile of albumin-corrected calcium level were found to be independent risk factors for a poor discharge outcome. Significant relationships were observed with serum calcium [1.19 (1.03-1.38)] and albumin-corrected calcium [1.21(1.01-1.44)] as linear variables. However, only albumin-corrected calcium was associated with long-term mortality, third tertile [adjusted hazard ratio 1.40 (1.07-1.83)], and increase by 1 mg/dL [1.46 (1.16-1.84)]. CONCLUSIONS: Elevated albumin-corrected serum calcium levels are associated with a poorer short-term outcome and greater risk of long-term mortality after acute ischemic stroke.

ERRATUM: Table Correction. Case Characteristics, Hyperacute Treatment, and Outcome Information from the Clinical Research Center for Stroke-Fifth Division Registry in South Korea / 대한뇌졸중학회지

On page 47, the definition of stroke progression was erroneously described in the previous version of article.

Impact of CHADS2 Score on Neurological Severity and Long-Term Outcome in Atrial Fibrillation-Related Ischemic Stroke

BACKGROUND AND PURPOSE: The CHADS2 (an acronym for congestive heart failure, hypertension, age > or =75 years, diabetes mellitus, and prior stroke or transient ischemic attack or thromboembolism) score is a widely used system for estimating the risk of stroke in patients with atrial fibrillation. However, how the CHADS2 score is related to stroke severity and outcome in patients with strokes due to atrial fibrillation has not yet been elucidated. METHODS: We enrolled patients with atrial fibrillation who visited our stroke center within 7 days after the onset of acute ischemic stroke between October 2002 and September 2008. CHADS2 scores were categorized into three groups: 0 points, low risk; 1 or 2 points, intermediate risk; and 3-6 points, high risk. Poor neurological state was defined as follows: a National Institutes of Health Stroke Scale (NIHSS) score of > or =2, and a modified Rankin Scale (mRS) score of > or =3 at discharge. Mortality information was ascertained as at December 2008. RESULTS: A cohort of 298 patients with atrial-fibrillation-related stroke was included in this study. A high-risk CHADS2 score at admission was a powerful predictor of poor neurological outcome [for NIHSS: odds ratio (OR), 4.17; 95% confidence interval (CI), 1.76-9.87; for mRS: OR, 2.97; 95% CI, 1.23-7.16] after controlling for all possible confounders. In addition, a high-risk CHADS2 score was an independent predictor of all causes of death during the follow-up [hazard ratio (HR), 3.01; 95% CI, 1.18-7.65] and vascular death (HR, 12.25; 95% CI, 1.50-99.90). CONCLUSIONS: Although the CHADS2 score was originally designed to distinguish patients with a future risk of stroke, our study shows that it may also be used to predict poor neurological outcome after atrial-fibrillation-related stroke.

A Quantitative Comparison of the Vertebral Artery and Transverse Foramen Using CT Angiography

BACKGROUND AND PURPOSE: The vertebral artery (VA) is important for the development of the transverse foramen (TF). Most studies of these structures have focused on anatomical anomalies. Therefore, we investigated quantitatively the association between the relative sizes of the TF and VA. METHODS: We recruited a consecutive series of subjects who underwent CT angiography to estimate the relative sizes of the VA and TF in axial source images. Two neurologists independently reviewed the axial CT images of 208 patients who had no history of transient ischemic attack or stroke. Averaged areas of the VA and TF were defined by the sum of the areas at each level from C3 to C6, divided by 4. Correlation analyses were adjusted for age, sex, and vascular risk factors. RESULTS: The mean age of the subjects was 53 years. The interobserver and intraobserver reliabilities of TF size were good. There was a linear relationship between the sizes of the VA and TF on each side (right side: r2=0.58, p<0.001; left side: r2=0.62, p<0.001). The area of the VA was significantly associated with that of the TF after adjusting for vascular risk factors. CONCLUSIONS: The size of the VA is strongly and linearly correlated with the size of the TF. These findings suggest that measurement of the TF and VA with CT angiography is a reliable method for evaluating VA diseases, and may provide new insight into the differentiation between VA hypoplasia and atherosclerosis of the VA.

Emergency Superficial Temporal Middle Cerebral Artery Bypass Surgery for Acute Symptomatic Middle Cerebral Artery Occlusion With Hemodynamic Disturbance

The role of surgical revascularization for patients with ischemic stroke remains controversial. During acute phase of large artery occlusive ischemic stroke, extracranial?intracranial (EC-IC) bypass, such as superficial temporal-middle cerebral aretery (STA-MCA) bypass sugery, has been rarely performed. We report a case of successful emergency STA-MCA bypass surgery to stop the neurologic deterioration and improve the hemodynamic compromise in a patient with acute symptomatic MCA occlusion associated with hypoperfusion.

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.