Safety and Efficacy of Intravenous Thrombolysis in the 3- to 4.5-hour Window in Acute Ischemic Stroke Patients Who Have Both Diabetes Mellitus and History of Prior Stroke

Background@#For acute ischemic stroke (AIS) patients with history of prior stroke (PS) and diabetes mellitus (DM), intravenous recombinant tissue plasminogen activator (IV-tPA) therapy in the 3- to 4.5-hour window is off-label in Korea. This study aimed to assess the safety and efficacy of IV-tPA in these patients. @*Methods@#Using data from a prospective multicenter stroke registry between January 2009 and March 2021, we identified AIS patients who received IV-tPA in the 3- to 4.5-hour window, and compared the outcomes of symptomatic intracranial hemorrhage (SICH), 3-month mortality, 3-month modified Rankin Scale (mRS) score 0-1 and 3-month mRS distribution between patients with both PS and DM (PS/DM, n=56) versus those with neither PS nor DM, or with only one (non-PS/DM, n=927). @*Results@#The PS/DM group versus the non-PS/DM group was more likely to have a prior disability, hypertension, hyperlipidemia, coronary heart disease and less likely to have atrial fibrillation. The PS/DM and the non-PS/DM groups had comparable rates of SICH (0% vs. 1.7%; p>0.999) and 3-month mortality (10.7% vs. 10.2%; p=0.9112). The rate of 3-month mRS 0-1 was non-significantly lower in the PS/DM group than in the non-PS/DM group (30.4% vs. 40.7%; adjusted odds ratio [95% confidence interval], 0.81 [0.41-1.59]). @*Conclusions@#In the 3- to 4.5-hour window, AIS patients with PS/DM, as compared to those with non-PS/DM, might benefit less from IV-tPA. However, given the similar risks of SICH and mortality, IV-tPA in the late time window could be considered in patients with both PS and DM.

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.

Cerebral Infarction Caused by Painless Aortic Dissection

No abstract available.

A Case of Early Onset Alzheimer's Disease Diagnosed by ¹⁸F Flutemetamol PET Image

No abstract available.

Bilateral Sudden Hearing Difficulty Caused by Bilateral Thalamic Infarction

No abstract available.

Neurological Complications during Treatment of Middle East Respiratory Syndrome

BACKGROUND AND PURPOSE: Middle East respiratory syndrome (MERS) has a high mortality rate and pandemic potential. However, the neurological manifestations of MERS have rarely been reported since it first emerged in 2012. METHODS: We evaluated four patients with laboratory-confirmed MERS coronavirus (CoV) infections who showed neurological complications during MERS treatment. These 4 patients were from a cohort of 23 patients who were treated at a single designated hospital during the 2015 outbreak in the Republic of Korea. The clinical presentations, laboratory findings, and prognoses are described. RESULTS: Four of the 23 admitted MERS patients reported neurological symptoms during or after MERS-CoV treatment. The potential diagnoses in these four cases included Bickerstaff's encephalitis overlapping with Guillain-Barré syndrome, intensive-care-unit-acquired weakness, or other toxic or infectious neuropathies. Neurological complications did not appear concomitantly with respiratory symptoms, instead being delayed by 2–3 weeks. CONCLUSIONS: Neuromuscular complications are not rare during MERS treatment, and they may have previously been underdiagnosed. Understanding the neurological manifestations is important in an infectious disease such as MERS, because these symptoms are rarely evaluated thoroughly during treatment, and they may interfere with the prognosis or require treatment modification.

Development of a Swine Benign Biliary Stricture Model Using Endoscopic Biliary Radiofrequency Ablation

The large animal model with benign biliary stricture (BBS) is essential to undergo experiment on developing new devices and endoscopic treatment. This study conducted to establish a clinically relevant porcine BBS model by means of endobiliary radiofrequency ablation (RFA). Endoscopic retrograde cholangiography (ERC) was performed on 12 swine. The animals were allocated to three groups (60, 80, and 100 W) according to the electrical power level of RFA electrode. Endobiliary RFA was applied to the common bile duct for 60 seconds using an RFA catheter that was endoscopically inserted. ERC was repeated two and four weeks, respectively, after the RFA to identify BBS. After the strictures were identified, histologic evaluations were performed. On the follow-up ERC two weeks after the procedure, a segmental bile duct stricture was observed in all animals. On microscopic examination, severe periductal fibrosis and luminal obliteration with transmural inflammation were demonstrated. Bile duct perforations occurred in two pigs (100 W, n = 1; 80 W, n = 1) but there were no major complications in the 60 W group. The application of endobiliary RFA with 60 W electrical power resulted in a safe and reproducible swine model of BBS.

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.

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.

Euthyroid Graves' Ophthalmopathy with Negative Autoantibodies

Graves' ophthalmopathy occurs in 25-50% of patients with Graves' disease. Although patients with Graves' ophthalmopathy mostly present with hyperthyroidism, a minority of patients have euthyroid or hypothyroid characteristics, which may delay a correct diagnosis. Here, we report a case of euthyroid Graves' ophthalmopathy that was initially negative for thyroid autoantibodies, but later changed to positivity.

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.

MRI-based Algorithm for Acute Ischemic Stroke Subtype Classification / 대한뇌졸중학회지

BACKGROUND AND PURPOSE: In order to improve inter-rater reliability and minimize diagnosis of undetermined etiology for stroke subtype classification, using a stroke registry, we developed and implemented a magnetic resonance imaging (MRI)-based algorithm for acute ischemic stroke subtype classification (MAGIC). METHODS: We enrolled patients who experienced an acute ischemic stroke, were hospitalized in the 14 participating centers within 7 days of onset, and had relevant lesions on MR-diffusion weighted imaging (DWI). MAGIC was designed to reflect recent advances in stroke imaging and thrombolytic therapy. The inter-rater reliability was compared with and without MAGIC to classify the Trial of Org 10172 in Acute Stroke Treatment (TOAST) of each stroke patient. MAGIC was then applied to all stroke patients hospitalized since July 2011, and information about stroke subtypes, other clinical characteristics, and stroke recurrence was collected via a web-based registry database. RESULTS: The overall intra-class correlation coefficient (ICC) value was 0.43 (95% CI, 0.31-0.57) for MAGIC and 0.28 (95% CI, 0.18-0.42) for TOAST. Large artery atherosclerosis (LAA) was the most common cause of acute ischemic stroke (38.3%), followed by cardioembolism (CE, 22.8%), undetermined cause (UD, 22.2%), and small-vessel occlusion (SVO, 14.6%). One-year stroke recurrence rates were the highest for two or more UDs (11.80%), followed by LAA (7.30%), CE (5.60%), and SVO (2.50%). CONCLUSIONS: Despite several limitations, this study shows that the MAGIC system is feasible and may be helpful to classify stroke subtype in the clinic.

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.

Simultaneous Non-transcolumellar Incisioned Rhinoplasty in Nasal Bone Fracture : Analysis of 121 Cases

The traditional treatment of nasal bone fracture is closed manual reduction. Disadvantage of the method arises from frequent recurrence and inaccurate correction because open method is nonused in anatomical result. In addition, since the interest about cosmetic problems rapidly rises, people who want aesthetic correction during reduction surgery are increasing. From June 2007 to June 2009, This study includes 121 patients who had been performed by correction of nasal bone fracture in our center. 98 out of 121 patients, were undergone with nasal tip plasty, septoplasty was done in 51 patients. Cartilage graft for augmentation rhinoplasty was performed in 36 patients. Average period of follow-up was 6 months and existence of complications such as nasal deviation, nasal obstruction, infection and etc were investigated. Reoperation was done in one patient who showed nasal obstruction, and patients who complained about other complications, such as nasal deviation, were observed. There is the need of more accurate reduction method than traditional non-invasive reduction maneuver, in order to reduce the occurrence of secondary deformation after nasal bone fracture. Hence the authors operated precise reduction by extended endonasal approach without columellar scar, and aesthetic correction rather than anatomical correction was done with variable cartilage if needed.

Ventricular Tachycardia in Rhinoplasty: A Report of Two Cases

Local infiltration(lidocain and epinephrine) has been used to control bleeding in local or general anesthesia in plastic surgery field. However epinephrine also has various side effects, such as tarchycardia, arrhythmia, pulmonary edema, cardiac arrest, etc. We experienced two cases of ventricular tachycardia after local infiltration in rhinoplasty. The first case was a 21 year-old female and the second case was a 40 year-old male. None of them had previous history of cardiac disease. We performed cardiac massage and cardioversion several times immediately after ECG changed to Ventricular tachycardia in operation room until ECG turned to normal sinus rhythm. Patients were transferred to intensive care unit. The condition of patients improved rapidly in a few days and additional complications were not detected except pulmonary edema following cardiac massage. Conclusion: We experienced ventricular tachycardia unexpectedly after local infiltration during the surgical procedure. We report these cases with literature.

The study of fractural behavior of repaired composite / 대한치과보존학회지

OBJECTIVES: This study evaluated microtensile bond strength (microTBS) and short-rod fracture toughness to explain fractural behavior of repaired composite restorations according to different surface treatments. MATERIALS AND METHODS: Thirty composite blocks for microTBS test and sixty short-rod specimens for fracture toughness test were fabricated and were allocated to 3 groups according to the combination of surface treatment (none-treated, sand blasting, bur roughening). Each group was repaired immediately and 2 weeks later. Twenty-four hours later from repair, microTBS and fracture toughness test were conducted. Mean values analyzed with two-way ANOVA / Tukey's B test (alpha = 0.05) and correlation analysis was done between microTBS and fracture toughness. FE-SEM was employed on fractured surface to examine the crack propagation. RESULTS: The fresh composite resin showed higher microTBS than the aged composite resin (p < 0.001). Mechanically treated groups showed higher bond strength than non-mechanically treated groups except none-treated fresh group in microTBS (p < 0.05). The fracture toughness value of mechanically treated surface was higher than that of non-mechanically treated surface (p < 0.05). There was no correlation between fracture toughness and microtensile bond strength values. Specimens having high KIC showed toughening mechanism including crack deviation, microcracks and crack bridging in FE-SEM. CONCLUSIONS: Surface treatment by mechanical interlock is more important for effective composite repair, and the fracture toughness test could be used as an appropriate tool to examine the fractural behavior of the repaired composite with microtensile bond strength.

Easy Reproducible Tie-over Dressing using Silastic(R) Drainage

PURPOSE: Tie-over dressing is widely used to secure skin grafting on face, body, or extremities. It can be a rather complicated task and is not easy to make compressive dressing again if performed in a conventional method. So, we hereby introduce an easy reproducible tie over dressing method. METHODS: After completing the skin graft, Cut the silastic drainage longitudinally in half and spread to the grafted skin margin. Drainage is fixed by using the stapes or sutures. A fluffy gauze bolus dressing is placed over a furacin impregnated gauze and wrapped around. After suturing the distal margin of silastics with opposite side using the silk thread either 5-0 or 3-0, knot of suturing, which is pressed down against the dressing while the threads are tightened, is made into center of each sides. RESULTS: It can make dressing again after observing the grafted skin, and it can also make pressure on the grafted area evenly until the grafted skin is taken. CONCLUSION: This dressing method makes the surgeons and patients comfortable. To surgeons, it provides more rapid and easier way to do dressing, and to patients, it eliminates pain caused by redressing.

Correction of Problems after Eyelid Surgery using Various Techniques

Many techniques for prevention and correction of complication after blepharoplasty have been developed, however, satisfactory method has not yet been documented. The purpose of this article is to review common unfavorable complications after Asian cosmetic eyelid surgery, and to propose several methods of treatment for effective correction. From 1988 to 2008, authors reviewed 364 cases(480 eyes) of complications after cosmetic eyelid surgery. Follow-up period ranged from 6 months to 16 years. The results of treatments were classified into excellent, good, fair and unsatisfactory by operating surgeons, other surgeons, and by patients. About 40% of complications requiring revisional surgeries were treated early within 2 weeks after first operation. Other 60% of complications were treated by late reoperations, at least 6 months after first surgery. Majority of patients were satisfied with the results. However, a few patients reported unsatisfactory outcomes which required additional revisional procedures. The correction of complications following cosmetic eyelid surgery remains a difficult task. The strategies for successful Asian upper blepharoplasty include not only careful preoperative evaluation and delicate operative technique, but also, proper postoperative interventions such as early secondary blepharoplasty.

Distally Based Anterolateral thigh Pedicled Flap in the Reconstruction of Defect Around Knee

PURPOSE: As the soft tissue defect around the knee is difficult to reconstruct, local flap or free flap is used. Distally based anterolateral thigh pedicled flap introduced by Zhang uses sufficient reverse flow supplied from the vascular network around the knee. We report successful reconstruction of defect around knee by this method. METHODS: Four patients with skin & soft tissue defect around knee have been treated for reconstruction using the distally based anterolateral thigh pedicled flap. First, the doppler was used to check the perforator flap of the descending branch of the lateral circumflex femoral artery and to draw and dissect the perforator flap as much as needed. After the dissection, the proximal of the descending branch was clamped and checked for sufficient supply of blood flow from the reverse flow and then ligated. It was dissected along the descending branch and in order to prevent damage to the joined parts of the descending branch and the lateral superior geniculate artery, a more careful ligation was done starting from 10 cm superior to the knee. The defect was reconstructed after securing enough vascular pedicle to cover all the damaged parts. RESULTS: Not all patients suffered from flap necrosis. In case of the patient with chronic osteomyelitis, slight venous congestion was observed right after the surgery but it disappeared the following day. All three patients had no occurences of additional complications. CONCLUSION: Distally based anterolateral thigh pedicled flap was enough to provide large flap for knee reconstruction. It had sufficient blood flow and vascular pedicle. It also had taken short operation time compared to the free flap operation. The distally based anterolateral thigh pedicled flap used by the authors is a very useful way of reconstructing the area around knee.

Guillain-Barre Syndrome With anti-GM1 and GD1b Antibodies Following Acute Hepatitis A

Guillain-Barre syndrome (GBS) rarely develops following acute viral hepatitis, and there has been no report on the association with anti-ganglioside antibodies. Herein, we report a 36-year-old man who presented with rapidly progressive areflexic quadriparesis following acute viral hepatitis A. The results of nerve conduction study were consistent with demyelinating motor polyneuropathy, and IgG anti-GM1 and anti-GD1b antibodies were positive. Immune responses towards gangliosides may also be important mediators in acute hepatitis A-associated GBS.