Delayed Lesions on Diffusion-Weighted Imaging in Initially Lesion-Negative Stroke Patients / 대한뇌졸중학회지

Background@#and Purpose Lesions on diffusion-weighted imaging (DWI) occasionally appear on follow-up magnetic resonance imaging (MRI) among initially DWI-negative but clinically suspicious stroke patients. We established the prevalence of positive conversion in DWI-negative stroke and determined the clinical factors associated with it. @*Methods@#This retrospective, observational, single-center study included 5,271 patients hospitalized due to stroke/transient ischemic attack (TIA) in a single university hospital during 2010 to 2017. Patients without initial DWI lesions underwent follow-up DWI imaging as a routine practice. Adjusted hazard ratios (aHRs) for recurrent stroke risk according to positive conversion were determined using Cox proportional hazard regression. Adjusted odds ratios (aORs) and 95% confidence intervals (CIs) for positive conversion among initially DWI-negative patients were estimated. @*Results@#In total, 694 (13.2%) patients (mean±standard deviation age, 62.9±13.7 years; male, 404 [58.2%]) were initially DWI-negative. Among them, 22.5% had positive-conversion on follow-up DWI. Positive conversion was associated with a higher risk of recurrent stroke (aHR, 3.12; 95% CI, 1.56 to 6.26). Early neurologic deterioration (aOR, 15.1; 95% CI, 5.71 to 47.66), atrial fibrillation (aOR, 6.17; 95% CI, 3.23 to 12.01), smoking (aOR, 3.76; 95% CI, 2.19 to 6.63), pre-stroke dependency (aOR, 1.62; 95% CI, 1.15 to 2.27), objective hemiparesis (aOR, 4.39; 95% CI, 1.90 to 10.32), longer symptom duration (aOR, 2.17; 95% CI, 1.57 to 3.08), high cholesterol (aOR, 4.70; 95% CI, 1.78 to 12.77), National Institutes of Health Stroke Scale score (aOR, 1.44; 95% CI, 1.08 to 1.91), and high systolic blood pressure (aOR, 1.01; 95% CI, 1.00 to 1.02) were associated with a higher incidence of lesions with delayed appearance. Regarding the location of lesions on follow-up DWI, 34.6% and 21.2% were in the cortex and brainstem, respectively. @*Conclusions@#In DWI-negative stroke/TIA, positive conversion is associated with a higher risk of recurrent stroke. DWI-negative stroke with factors related to positive conversion may require follow-up MRI for a definitive diagnosis.

CT Angiography of Collateral Vessels and Outcomes in Endovascular-Treated Acute Ischemic Stroke Patients

BACKGROUND AND PURPOSE: Measuring the extent of the collateral blood vessels using computed tomography (CT) angiography source images may promote tissue survival and functional gain in acute ischemic stroke patients who are candidates for endovascular recanalization treatment. METHODS: Of 5,558 acute stroke patients registered in a prospective clinical stroke registry, 104 met the selection criteria of endovascular recanalization treatment for internal cerebral artery or middle cerebral artery main-stem (M1) occlusions and presented for treatment ≤4 hours after the event. Using CT angiography source images, two independent and blinded reviewers measured the extent of collateral circulations at four regions, with good interrater reliability. The functional recovery at 3 months after stroke was used as an outcome variable. RESULTS: Cases with a sufficient collateral circulation at the Sylvian fissure showed significantly increased likelihood of having a modified Rankin Scale score of ≤2 at 3 months after stroke (adjusted odds ratio=3.03, 95% confidence interval=1.19–7.73, p=0.02), but the association became nonsignificant after adding the infarct volume to the model (p=0.65). The association between leptomeningeal convexity collaterals and functional recovery was no longer significant after adjusting for the infarct volume (p=0.28). The natural indirect effect of infarct volume on functional recovery was significant for both the Sylvian fissure (p=0.03) and leptomeningeal convexity (p=0.02) collaterals. CONCLUSIONS: The extent of collateral circulation at the Sylvian fissure was significantly associated with functional recovery, which may be mediated via the volume of the final infarction.

Early Statins after Intravenous or Endovascular Recanalization Is Beneficial Regardless of Timing, Intensity, and Stroke Mechanism / 대한뇌졸중학회지

No abstract available.

Left Ventricular Diastolic Dysfunction in Ischemic Stroke: Functional and Vascular Outcomes / 대한뇌졸중학회지

BACKGROUND AND PURPOSE: Left ventricular (LV) diastolic dysfunction, developed in relation to myocardial dysfunction and remodeling, is documented in 15%-25% of the population. However, its role in functional recovery and recurrent vascular events after acute ischemic stroke has not been thoroughly investigated. METHODS: In this retrospective observational study, we identified 2,827 ischemic stroke cases with adequate echocardiographic evaluations to assess LV diastolic dysfunction within 1 month after the index stroke. The peak transmitral filling velocity/mean mitral annular velocity during early diastole (E/e') was used to estimate LV diastolic dysfunction. We divided patients into 3 groups according to E/e' as follows: <8, 8-15, and ≥15. Recurrent vascular events and functional recovery were prospectively collected at 3 months and 1 year. RESULTS: Among included patients, E/e' was 10.6±6.4: E/e' <8 in 993 (35%), 8-15 in 1,444 (51%), and ≥15 in 378 (13%) cases. Functional dependency or death (modified Rankin Scale score ≥2) and composite vascular events were documented in 1,298 (46%) and 187 (7%) patients, respectively, at 3 months. In multivariable analyses, ischemic stroke cases with E/e' ≥15 had increased odds of functional dependence or death at 3 months (adjusted OR [95% CI]: 1.73 [1.27-2.35]) or 1 year (1.47 [1.06-2.06]) and vascular events within 1 year (1.65 [1.08-2.51]). Subgroups with normal ejection fraction or sinus rhythm exhibited a similar overall pattern and direction. CONCLUSIONS: LV diastolic dysfunction was associated with poor functional outcomes and composite vascular events up to 1 year.

Effectiveness and Safety of Thrombolysis in Ischemic Stroke Patients Aged 80 Years or Older / 대한뇌졸중학회지

BACKGROUND: Thrombolysis becomes an emerging therapeutic option for acute ischemic stroke. However, few reports exist on its use in the very elderly. We investigated whether there is a difference in the effectiveness and safety of intravenous (IV) and/or intra-arterial (IA) thrombolysis between patients aged > or =80 years and those aged or =80 years, 21% of patients received IV or IA or combined thrombolysis while 23% of 980 patients or =80 years, and 1.71 (1.05-2.78) in those or =80 years versus <80 years.

Association of 3 Stigmas of Cerebral Microangiopathy With Early Neurological Deterioration in Lacunar Infarction

BACKGROUND: Neurological deterioration following acute lacunar infarction is not uncommon. Its association with poor clinical outcome is well-known, but little is known about what causes it. This study aimed to elucidate whether 3 stigmas of cerebral microangiopathy, a pathogenesis of lacunar infarction, are associated with neurological deterioration in patients with acute lacunar infarction. METHODS: Patients with acute lacunar infarction who were admitted within 24 hours of onset were identified using a prospective stroke registry. Patients who presented neurological deterioration within 7 days of hospitalization (progressive lacune group) were matched to 4 controls (non-progressive lacune group) for 'onset to arrival time'. Three stigmas of cerebral microangiopathy (leukoaraiosis, cerebral microbleeds, and silent lacunes) were measured using initial brain MRI, and their associations with neurological deterioration were analyzed. RESULTS: During 45 months, a total of 23 patients were identified and matched to 80 controls. Simple comparison of 2 groups showed that those 3 stigmas of cerebral microangiopathy were not significantly associated with neurological deterioration. Hyperlipidemia (p=0.18), history of transient ischemic attack or stroke (p=0.01), initial NIH stroke scale (p=0.07), white blood cell counts (p=0.16), and lesion volume (p=0.03) were possibly different (p's0.5). CONCLUSIONS: This study did not find a relationship between cerebral microangiopathy and neurological deterioration following acute lacunar infarction. The possibility of inadequate power should be noted.

Burden of Ischemic Stroke in Korea: Analysis of Disability-Adjusted Life Years Lost

BACKGROUND AND PURPOSE: Disability-adjusted life years (DALY), incorporating both disability and mortality, has been widely employed to measure regional and global burdens of stroke. Thus far, the DALY lost to stroke in a population has been estimated using only the crude population-level data; no previous study has incorporated refined data from stroke registries. The aim of this study was to integrate the stroke registry data and the population-level incidence data to project the nationwide DALY lost to ischemic stroke. METHODS: From the data of two large ischemic stroke registries, we derived an average DALY lost due to ischemic stroke for each of the following age groups: or =85 years. The nationwide ischemic stroke incidence for each age group was extracted from a cardiovascular and cerebrovascular surveillance study that analyzed the 2004 Korean Health Insurance database. RESULTS: The average DALY lost due to ischemic stroke for the age groups or =85 years was 5.07, 4.63, 4.35, 3.88, 2.88, and 1.73, respectively. By multiplying the incidence and the average DALY lost, the nationwide DALY lost was determined to be 9,952 for those or =85 years, respectively. The projected nationwide DALY lost due to 64,688 ischemic strokes in 2004 was 234,399 (121,482 for men and 113,244 for women), and the DALY lost per 100,000 person-years was 483 (500 for men and 469 for women). CONCLUSIONS: Incidence data from a population study and DALY values derived from stroke registries can be integrated to provide a more refined projection of the nationwide burden of ischemic stroke. In Korea, more than 230,000 years of healthy life are being lost annually due to ischemic stroke, and hence prompt action is imperative.

Prestroke Medication Adherence and its Clinical Significance in Patients With Ischemic Stroke: Single Hospital-Based Study

BACKGROUND: Medication adherence (MA) is poor among patients with chronic illnesses, such as those involving the risk factors of stroke. However, the impacts of poor MA on the modifiable risk factors of stroke are not well known. METHODS: We evaluated the MA for the control of hypertension, diabetes, hyperlipidemia, and previous ischemic stroke among consecutive patients with ischemic stroke within 7 days of symptom onset. Nonadherence was defined as taking doctor-prescribed medications for less than 3 weeks during the previous month. Demographic data, risk factor profile, stroke mechanism, and baseline score on the National Institutes of Health Stroke Scale (NIHSS) were compared among patients with nonadherence and those without. RESULTS: Among 1133 patients with at least one medicated risk factor, the rates of nonadherence in hypertension, diabetes, hyperlipidemia, and previous ischemic stroke were 18.5%, 15.3%, 30.3%, and 28.1%, respectively. Overall, 27.4% of patients with more than one risk factor presented nonadherence, with a predilection toward being male (male, 63.9% vs. female, 56.1%, p=0.02) and younger (mean age 64.9 years vs. 66.4 years, p=0.01). Stroke severity according to MA did not differ using either crude analysis (NIHSS score: 5.5+/-5.9 vs. 5.4+/-5.5, p=0.71) or multivariable analysis after log transformation. The prevalence of nonadherence was low for large-artery disease and small-vessel occlusion, and high for cardioembolism. CONCLUSIONS: Prestroke poor MA for the major risk factors was common among patients with chronic illnesses, and was more frequent in younger male patients. Stroke severity was not affected by MA during the month preceding stroke.

Can Early Ischemic Lesion Recurrence on Diffusion-Weighted MRI Affect Functional Outcome after Acute Ischemic Stroke?

BACKGROUND AND PURPOSE: Ischemic lesion recurrence on diffusion-weighted imaging (DWI-LR) is a frequently observed phenomenon after acute ischemic stroke. However, no study has elucidated the impact of DWI-LR on functional outcome. METHODS: Among a consecutive series of patients who presented with focal symptoms or signs compatible with stroke within 48 hours from the onset over a 50-month period, those who had relevant ischemic lesions on initial DWI and underwent follow-up DWI within 14 days after the onset were enrolled in this study. As outcome variables, the scores on the modified Rankin Disability Scale (mRDS) at 3 months and 1 year were measured prospectively and dichotomized into good (0-2) vs. poor (3-6). When calculating odds ratios (ORs), adjustment was performed for age, previous stroke, initial score on the NIH Stroke Scale, stroke subtype, and IV thrombolysis. RESULTS: Among those 786 patients finally enrolled in this study, 221 (28.1%) had DWI-LR. For a poor outcome at 3 months, the crude ORs of any, symptomatic, and asymptomatic DWI-LR were 2.70 [95% confidence interval (CI), 1.96 to 3.72], 10.03 (95% CI, 4.39 to 22.96), and 2.04 (95% CI, 1.44 to 2.88), respectively. With adjustment, the OR of symptomatic DWI-LR was 6.44 (95% CI, 2.50 to 16.57), whereas those of any and asymptomatic DWI-LR lost their statistical significance: 1.44 (95% CI, 0.94 to 2.20) and 1.04 (95% CI, 0.65 to 1.65), respectively. Analyzing with the 1-year outcome produced similar results. CONCLUSIONS: This study shows that symptomatic early lesion recurrence can affect functional outcome after acute ischemic stroke, whereas an asymptomatic one may not.

Long-term Prognosis of Patients With Acute Intracranial Large Artery Occlusion and its Determining Factors

BACKGROUND: Acute intracranial large-artery occlusions (AILAOs) are detected frequently and cause severe neurological disabilities. Most studies in this field do not focus on the natural history of AILAOs, but on the individual prognosis for each intervention. The aim of this study was to elucidate the clinical profiles and outcomes of AILAOs. METHODS: A consecutive series of patients hospitalized between January 2004 and October 2007 due to AILAO within 24 hours from onset were recruited. Based on a prospective stroke registry, their clinical profiles were collected. AILAO was defined as an intracranial internal carotid artery (ICA), middle cerebral artery (MCA), or basilar artery (BA) occlusion that could be confirmed by angiography, with relevant lesions on diffusion-weighted imaging (DWI). The modified Rankin Scale (MRS) score at 3 months and the recanalization rate within 14 days were recorded as outcomes. RESULTS: Among 1,047 patients with acute ischemic stroke who were examined within 24 hours of onset, 189 [18.1%; 101 men, 88 women; age 68.6+/-13.0 years (mean+/-SD); median National Institutes of Health Stroke Scale (NIHSS) score=11]. Occlusion sites were MCA M1, MCA M2, distal ICA, and BA in 99 (52.4%), 50 (26.5%), 20 (10.6%), and 20 (10.6%) of cases,respectively. Embolic sources were found in 103 (54.5%) cases. MRS scores were available for 184 (97.4%) of the patients, of which 78 had a favorable outcome (MRS: 0.2). Follow-up angiography was performed in 122 (64.6%) cases, with recanalization observed in 88 (72.1%) of these. Thrombolysis, occlusion site, presence of an embolic source, and initial glucose level were predictors of early recanalization (p<0.001). Recanalization status and initial NIHSS score were strongly correlated with a favorable outcome (p<0.005). CONCLUSIONS: This is the first report of the clinical profiles, outcomes, and their predictors in a cohort of Korean patients with AILAO.

The Long-term Incidence of Recurrent Stroke: Single Hospital-based Cohort Study

BACKGROUND: Recurrent stroke is a major cause of morbidity and mortality among stroke survivors. However, studies of the long-term prognosis after acute stroke are very rare, especially in Asia. This study aimed to provide estimates of recurrent stroke rates by age, gender, and subtype of stroke in an unselected cohort of patients hospitalized to a community-based general hospital due to acute stroke. METHODS: Based on a prospective stroke registry, acute stroke patients were enrolled within 7 days of symptom onset and followed retrospectively or prospectively for up to 3 years. Information was gathered about stroke recurrence and other vascular events. The cumulative risk of recurrent stroke was calculated using the Kaplan-Meier method. RESULTS: Two-thousand and sixty-eight patients were enrolled in this study. The cumulative risks of stroke recurrence were 2.3%, 5.5%, 8.6%, and 10.0% at 90 days and 1, 2, and 3 years, respectively. The prevalence of stroke recurrence increased with age and the presence of previous stroke history (p<0.001), but not with gender or stroke subtype. CONCLUSIONS: To the best of our knowledge, this is the first cohort study of stroke recurrence in Korea. Its limitation of being a single hospital-based study warrants community- or multicenter-based cohort studies to identify high-risk groups for stroke recurrence.

A Clinical Observation of Newborns of Unmarried Mothers

PURPOSE: The purpose of this study was to assess the importance of prenatal care of the unmarried mothers. METHODS: Clinical characteristics of 131 newborn babies of unmarried mothers who were hospitalized at National Medical Center from April, 1998 to August, 1999 were compared to 131 newborn babies of married mothers who were also hospitalized at National Medical Center from June, 1999 to August, 1999 by reviewing their medical records retrospectively. RESULTS: Average age of mothers were 20.1+/-4.0 years in unmarried group and 28.8+/-4.4 years in married group, which was statistically significant. In unmarried group, the highest rate of maternal age (55.8%) was below 20 years of age, which showed increased tendency compared to previous report. In cesarean section rate, there was significant difference; 11.4% in unmarried group and 48.1% in married group. In the birth order, the first baby was most frequent in both groups. The sex ratio showed 1.78 : 1 with male preponderance in unmarried group and 1 : 1.02 with slight female preponderance in married group. In average gestational age, birth weight, height, head circumference, chest circumference, 5 minutes Apgar score, and admission rate, there was no significant difference. The unmarried group had more babies in postmaturity and meconium-stained condition. CONCLUSION: There was no significant difference in growth and morbidity rate between newborn babies from unmarried mothers who had prenatal care and those from married mothers.

A Study of the Survival Rate of Childhood Cancer in Korea / Journal of the Korean Cancer Association, 대한암학회지

PURPOSE: It is known that the prognosis of childhood cancer is relatively good, however actual representative nationwide data on childhood cancer, particularly of survival rate, are rare. In this study we attempted to establish the overall survival rate of major childhood cancer. MATERIALS AND METHODS: The primary source of data of childhood cancer under 15 years of age were the registry files of the Central Cancer Registry Report (Ministry of Health & Welfare) from 1993 to 1997. The above data was compared to death case data files of the same period obtained from the Korea National Statistical Office using the personal identification code. We calculated the 1, 3, and 5 year survival rates using the life table of SPSS and Kaplan-Meier method and compared the survival rate of disease according to prognostic factors. RESULTS: A total of 6,720 cases of pediatric cancer from the Central Cancer Registry files were computerized and sorted by personal identification (ID) code to extract duplicated cases as well as cases with incomplete data. The final number of cases entered in this study was 4,983. 1) The number of confirmed death cases was 1,448 (29.1%). 2) The disease distribution showed that the most common pediatric cancer was leukemia (1,468/4,983, 29%), followed by brain tumors (503/4,983, 10%), lymphoma (315/4,983, 6%), Wilms tumor (165/4,983, 3%), etc. in order by number of patients. 3) The 5 year survival rate of disease was as follows: overall 62%, acute lymphocytic leukemia 61%, acute non-lymphocytic leukemia 32%, malignant lymphoma 72%, neuroblastoma 47%, medulloblastoma 51%, Astrocytoma 66%, Wilms tumor 83%, etc. CONCLUSION: We analyzed and report the 5 year survival rate of overall childhood cancer and of each of the twelve major childhood cancers from in Korea 1993 to 1997 to provide basic data on childhood cancer statistics.