Improving the Prognosis of Patients With Acute Ischemic Stroke Treated in the Late Time Window After the Introduction of Advanced Imaging Software: Benefits From Thrombectomy in the Extended Time Window

Background@#Mechanical thrombectomy (MT) of ischemic stroke was recommended as a clinical guideline in 2015, and the indication for time was expanded in 2018 based on two clinical studies. We aimed to compare and analyze the prognosis of patients treated under the extended time indication before and after the introduction of advanced software. @*Methods@#We obtained data from medical records between 2016 to 2020. From 2016 to 2017, patients who did not receive MT who visited the hospital within 24 hours from the last normal time (LNT) were classified as standard medical treatment (SMT) group. Among patients who underwent MT between 2019 and 2020, patients who visited the hospital between 6-24 hours from the LNT were classified into the extended MT (EMT) group. Good outcome was defined as 3-months modified rankin scale (mRS) ≤ 2, and a poor outcome as mRS ≥ 4. @*Results@#From 2016 to 2017, 1,058 patients were hospitalized for ischemic stroke, of which 60 (5.7%) received MT, and 27 patients were classified into the SMT group. Among 1,019 patients between 2019 and 2020, 85 (8.3%) received MT, and 24 patients were in the EMT group. Among the SMT group, only 3 had a good prognosis, and 24 (88.9%) had a poor prognosis. However, in the EMT group, 10 (41.7%) had a good prognosis, and 9 (37.5%) had a poor prognosis. The SMT group had a 49.1 times higher risk of poor prognosis compared to the EMT group (P = 0.008). @*Conclusion@#The number of patients with ischemic stroke who receive MT has increased by using advanced imaging software. It was confirmed that patients treated based on the extended time indication also had a good prognosis.

Prediction of Early Recanalization after Intravenous Thrombolysis in Patients with Large-Vessel Occlusion / 대한뇌졸중학회지

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.

Prediction of Early Recanalization after Intravenous Thrombolysis in Patients with Large-Vessel Occlusion / 대한뇌졸중학회지

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.

Care Process of Recanalization Therapy for Acute Stroke during the COVID-19 Outbreak in South Korea

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.

Status Epilepticus in a Patient with Extrapontine Myelinolysis

Extrapontine myelinolysis is a demyelinating disorder usually caused by rapid correction of chronic hyponatremia. We present an 82-year-old female patient with general weakness, and severe hyponatremia (103 mEq/L) which was corrected 14 mEq/L during 21 hours. She was stuporous and presented status epilepticus. Brain T2-weighted image showed high signal intensities of bilateral thalami and electroencephalogram monitoring indicated right hemisphere lateralized periodic discharges, maximal in the right frontal region. This case shows that status epilepticus can occur in a patient of extrapontine myelinolysis involved bilateral thalami without pontine lesions.

Ischemic Sciatic Neuropathy in a Patient with Liposarcoma

BACKGROUND: Various etiologies are the causative agents for sciatic neuropathy. We present here a case of ischemic sciatic neuropathy in a patient with liposarcoma. CASE REPORT: A 55-year-old woman presented with severe pain and weakness of the left leg. She had a history of recurred retroperitoneal liposarcoma, and was being administered chemotherapy. Examination revealed weakness in ankle dorsiflexion, plantar flexion and hamstring. Complaints also included dysesthesia, and numbness in the sole and dorsum of the foot. Nerve conduction study showed low compound muscle action potentials and slow motor conduction velocity of left peroneal and tibial nerves, with indiscernible sensory nerve action potentials of the left superficial peroneal and sural nerves. Computed tomography angiography revealed occlusion of the left common iliac artery. Commencement of intravenous infusion of heparin resulted in skin color change and progression of the weakness. Hence, the patient underwent an emergency thrombectomy. CONCLUSIONS: Ischemia should be considered as a cause of sciatic neuropathy in cancer patients, which requires management with timely treatment.

Status Epilepticus after Catheter Drainage of Basal Ganglia Hemorrhage

No abstract available.

Cerebrospinal Biomarker Cut-off Methods Defined Only by Alzheimer's Disease Predict More Precisely Conversions of Mild Cognitive Impairment

BACKGROUND AND PURPOSE: The cerebrospinal fluid (CSF) biomarkers play an important supportive role as diagnostic and predictive indicators of Alzheimer's disease (AD). About 30% of controls in old age show abnormal values of CSF biomarkers and display a higher risk for AD compared with those showing normal values. The cut-off values are determined by their diagnostic accuracy. However, the current cut-off values may be less accurate, because controls include high-risk groups of AD. We sought to develop models of patients with AD, who are homogenous for CSF biomarkers. METHODS: We included participants who had CSF biomarker data in the Alzheimer's Disease Neuroimaging Initiative database. We investigated the factors related to CSF biomarkers in patients with AD using linear mixed models. Using the factors, we developed models corresponding to CSF biomarkers to classify patients with mild cognitive impairment (MCI) into high risk and low risk and analyzed the conversion from MCI to AD using the Cox proportional hazards model. RESULTS: APOE ε4 status and age were significantly related to CSF Aβ1-42. CSF t-tau, APOE ε2 status and sex were significant factors. The CSF p-tau181 was associated with age and frequency of diagnosis. Accordingly, we modeled the three CSF biomarkers of AD. In MCI without APOE ε4, our models were better predictors of conversion. CONCLUSIONS: We can interpret CSF biomarkers based on the models derived from the data obtained from patients with AD.

The Prevalence and Incidence of Parkinson's Disease in South Korea: A 10-Year Nationwide Population: Based Study

BACKGROUND: The prevalence and incidence of Parkinson's disease (PD) are important for supporting the better comprehension of disease aspects and helping public health planning. Our aim is to evaluate the prevalence and incidence in South Korea between 2004 and 2013. METHODS: This retrospective, nationwide, longitudinal population-based study used National Health Insurance Service-National Sample Cohort Database to define patients with PD from 2004 to 2013 based on having Korean Classification of Diseases code G20, which were assigned by neurologists, and being prescribed PD medication. Annual prevalence and incidence were calculated. RESULTS: The prevalence of PD per 100,000 of population was 41.4 in 2004 and 142.5 in 2013, and there was 13.2% yearly increase over the 10 years. However, the incidence of PD per 100,000 of population increased steadily from 20.2 in 2004 to 53.1 in 2013. The prevalence and incidence were higher in women than in men. CONCLUSIONS: Our data show that there was an increasing trend in the prevalence and incidence of PD from 2004 to 2013, particularly in 70 years and older.

Successful Intra-arterial Stent Thrombectomy in Acute Infarction Caused by Spontaneous Middle Cerebral Artery Dissection

Spontaneous dissection of the middle cerebral artery could result in thromboembolic stroke caused by the intramural hematoma. Dissection should be considered as a possible etiology in a young stroke patient, but it is not straightforward in an emergency situation. Moreover, the efficacy and safety of thrombolytic treatment in the acute stage are unknown. We applied intravenous and intra-arterial stent thrombectomy with the Solitaire device successfully in a patient with acute left middle cerebral artery occlusion due to spontaneous dissection.

Spot Sign on Initial Brain Computed Tomography Angiography Source Image to Predict Large Hemorrhagic Transformation after Middle Cerebral Artery Infarction

The spot sign refers to tiny enhanced foci within the hematoma on a brain computed tomography angiography image. A spot sign is usually considered to be associated with hematoma progression in patients with acute intracerebral hemorrhage. We describe a patient with infarction of the left middle cerebral artery where a spot sign was observed. A spot sign may also have significant predictive value for large hemorrhagic transformation in patients with ischemic stroke.

Analysis of Lumbar Puncture Test in 5 Patients with Good Prognosis of Shunt Operation for Normal Pressure Hydrocephalus

Five patients with favorable outcomes after a shunt operation in normal pressure hydrocephalus were analyzed with the aim of identifying consistent findings in a lumbar puncture (LP) test. The cases commonly showed improvement in at least one cognition and two gait LP parameters. We suggest that when judging the effects of LP on a shunt operation, the gait parameters need to be tailored to the gait status and the analyzed LP parameters should be evaluated at least twice at different times.

Factors Associated with Ischemic Stroke on Therapeutic Anticoagulation in Patients with Nonvalvular Atrial Fibrillation

PURPOSE: In this study, we investigated the stroke mechanism and the factors associated with ischemic stroke in patients with nonvalvular atrial fibrillation (NVAF) who were on optimal oral anticoagulation with warfarin. MATERIALS AND METHODS: This was a multicenter case-control study. The cases were consecutive patients with NVAF who developed cerebral infarction or transient ischemic attack (TIA) while on warfarin therapy with an international normalized ratio (INR) > or =2 between January 2007 and December 2011. The controls were patients with NVAF without ischemic stroke who were on warfarin therapy for more than 1 year with a mean INR > or =2 during the same time period. We also determined etiologic mechanisms of stroke in cases. RESULTS: Among 3569 consecutive patients with cerebral infarction or TIA who had NVAF, 55 (1.5%) patients had INR > or =2 at admission. The most common stroke mechanism was cardioembolism (76.0%). Multivariate analysis demonstrated that smoking and history of previous ischemic stroke were independently associated with cases. High CHADS2 score (> or =3) or CHA2DS2-VASc score (> or =5), in particular, with previous ischemic stroke along with > or =1 point of other components of CHADS2 score or > or =3 points of other components of CHA2DS2-VASc score was a significant predictor for development of ischemic stroke. CONCLUSION: NVAF patients with high CHADS2/CHA2DS2-VASc scores and a previous ischemic stroke or smoking history are at high risk of stroke despite optimal warfarin treatment. Some other measures to reduce the risk of stroke would be necessary in those specific groups of patients.

Factors Associated with Ischemic Stroke on Therapeutic Anticoagulation in Patients with Nonvalvular Atrial Fibrillation

PURPOSE: In this study, we investigated the stroke mechanism and the factors associated with ischemic stroke in patients with nonvalvular atrial fibrillation (NVAF) who were on optimal oral anticoagulation with warfarin. MATERIALS AND METHODS: This was a multicenter case-control study. The cases were consecutive patients with NVAF who developed cerebral infarction or transient ischemic attack (TIA) while on warfarin therapy with an international normalized ratio (INR) > or =2 between January 2007 and December 2011. The controls were patients with NVAF without ischemic stroke who were on warfarin therapy for more than 1 year with a mean INR > or =2 during the same time period. We also determined etiologic mechanisms of stroke in cases. RESULTS: Among 3569 consecutive patients with cerebral infarction or TIA who had NVAF, 55 (1.5%) patients had INR > or =2 at admission. The most common stroke mechanism was cardioembolism (76.0%). Multivariate analysis demonstrated that smoking and history of previous ischemic stroke were independently associated with cases. High CHADS2 score (> or =3) or CHA2DS2-VASc score (> or =5), in particular, with previous ischemic stroke along with > or =1 point of other components of CHADS2 score or > or =3 points of other components of CHA2DS2-VASc score was a significant predictor for development of ischemic stroke. CONCLUSION: NVAF patients with high CHADS2/CHA2DS2-VASc scores and a previous ischemic stroke or smoking history are at high risk of stroke despite optimal warfarin treatment. Some other measures to reduce the risk of stroke would be necessary in those specific groups of patients.

Takotsubo Cardiomyopathy Associated With Status Epilepticus

Takotsubo cardiomyopathy is a reversible cardiac syndrome that occurs subsequently to other medical illnesses such as cerebral hemorrhage, shock, or seizure disorders that are presumed to disturb autonomic regulation. This syndrome is characterized by chest pain, dyspnea, and electrocardiographic changes mimicking an acute coronary syndrome. Mild elevation of cardiac enzymes and transient wall-motion abnormalities of apical akinesia can appear. However, takotsubo cardiomyopathy following epilepsy is not well recognized. We report two cases of takotsubo-cardiomyopathy-related idiopathic status epilepticus presenting with cardiogenic shock.

Lacunar Infarctions and the Cognitive Decline in Patients with Parkinson's Disease

BACKGROUND: The cause of dementia in Parkinson's disease (PD) remains incompletely understood. Cerebrovascular lesions (CVLs) are frequently found in the aging brain and may coexist with PD pathology. We hypothesized that lacunar infarction, which is one type of CVL, impacts on cognitive decline in patients with PD. METHODS: The Mini Mental Status Examination (MMSE) and Clinical Dementia Rating (CDR) tools were applied to PD patients with lacunar infarction (<1.5 cm on brain MRI; PD-S) and PD patients with normal brain MRI (PD-NS). RESULTS: Totals of 19 PD-S patients (9 males and 10 females) and 59 PD-NS patients (16 males and 43 females) took part in this study. Univariate analysis revealed that the gender distribution did not differ between the PD-S and PD-NS groups (p=0.1731), whereas age did differ significantly [79.1+/-5.0 years vs 73.0+/-7.8 years (mean+/-SD), respectively; p=0.0002]. There was no difference between the PD-S and PD-NS patients in either PD disease duration (6.9+/-3.2 vs 5.6+/-3.8 years, respectively; p=0.1790) or education duration (5.3+/-5.4 vs 6.4+/-5.3 years, respectively; p=0.4168). After adjustment for age in ANCOVA analysis, the MMSE score was significantly lower (p=0.0128) and the CDR score was significantly higher (p=0.0426) in the PD-S group than in the PD-NS group. Ten of the PD-S patients had a single lesion. The lacunar infarctions appeared in various locations in these patients, but they were most common in the basal ganglia, thalamus, and periventricular white matter. CONCLUSIONS: Lacunar infarction appears to be associated with cognitive decline in patients with PD even after adjustment for age. Analysis of larger age-matched cases for PD-S and PD-NS is required in order to validate these results.

Two Cases of Intracranial Vertebral Artery Dissecting Aneurysm Improved by Antiplatelets Therapy

The clinical course and management of aneurysm by intracranial arterial dissection are not well known. Since intracranial dissecting aneurysm has a higher bleeding risk than an extracranial one, the optimal choice of treatment is controversial. We report two patients who presented with a dissecting aneurysm in the intracranial vertebral artery without subarachnoid hemorrhage. They showed successful responses to antiplatelet treatment without any surgical interventions.

A Case of Rhabdomyolysis Associated with Phenytoin Loading

No abstract available.

A Case of Rhabdomyolysis Associated with Phenytoin Loading

No abstract available.

Two Cases of Atopic Myelitis

Myelitis is caused by various infectious organisms or an autoimmune mechanism. We report two cases of myelitis with increased serum total IgE and mite antigen specific IgE. The patients had paresthesia and Lhermitte's signs without weakness nor bladder dysfunctions. A spine MRI revealed a T2-high signal lesion with focal enhancement in the upper cervical cord. The patients showed favorable responses to steroid treatment. Atopic myelitis should be considered as a form of myelitis.