Systemic immune-inflammation index as a predictor of early stroke progression/recurrence in acute atherosclerotic ischemic stroke.

OBJECTIVES: Although the systemic immune-inflammatory index (SII) has recently been correlated with stroke severity and functional outcome, the underlying pathogenesis remains largely unknown. The objective of this study was to explore whether SII could predict early neurologic deterioration (END) in different etiologies of acute ischemic stroke. MATERIALS AND METHODS: From January 2019 to December 2021, a total of 697 consecutive patients with acute ischemic stroke, admitted within 72 hours from stroke onset, were prospectively enrolled. The patients were categorized into 4 groups based on quartiles of SII, calculated as platelets multiplied by neutrophils divided by lymphocytes. END and stroke progression/recurrence were assessed during the first 7 days after stroke onset using predetermined definitions. Logistic regression analysis was conducted to evaluate the association between SII and END, while considering the variation in association across stroke etiologies. RESULTS: END occurred in 135 patients: 24 (3.4%) for Group I, 25 (3.6%) for Group II, 33 (4.7%) for Group III, and 53 (7.6%) for Group IV. Among the END subtypes, stroke progression/recurrence stroke was the most prevalent. In the logistic regression model, the adjusted odds ratios (ORs) of END and stroke progression/recurrence for group IV were 2.51 (95% CI, 1.27-4.95) and 1.98 (95% CI, 1.03-3.89), respectively. Among the stroke etiologies, group IV showed a significant increase in END (OR 4.24; 95% CI, 1.42-12.64) and stroke progression/recurrence (OR 4.13; 95% CI, 1.39-12.27) specifically in case of large artery atherosclerosis. CONCLUSIONS: SII independently predicts early stroke progression/recurrence in patients with acute atherosclerotic ischemic stroke.

A case of acute disseminated encephalomyelitis following human papillomavirus quadrivalent vaccination.

Acute disseminated encephalomyelitis is a rare autoimmune demyelinating disease associated with preceding infection or vaccination. Herein, we report a case of refractory fulminant acute disseminated encephalomyelitis that occurred 25 days after Gardasil vaccination (Merck).

Recent glycemic control can predict the progressive motor deficits of acute subcortical infarction with diabetes or prediabetes.

BACKGROUND AND PURPOSE: The predictors of progressive motor deficits in acute subcortical infarctions are still controversial. It is not known whether glycemic control influences on stroke progression. METHODS: A total of 268 consecutive patients with diabetes or prediabetes who had acute (< 24 h) subcortical infarction were enrolled. (1) All patients were divided into 4 groups by quartile of glycated hemoglobin (HbA1c). (2) Only the patients with diabetes were divided by effective glycemic control. Progressive motor deficits were prospectively captured and defined as an increase of motor score ≥ 1 on the upper or lower limb items of the National Institute of Health Stroke Scale within 72 h from stroke onset. RESULTS: Progressive motor deficits occur in 8/78 (10.3%) for ≤ 5.9, 15/61 (24.6%) for 6.0-6.4, 16/62 (25.8%) for 6.5-7.4, and 30/67 (44.8%) for ≥ 7.5. In diabetic patients alone, those occur in 5/37 (13.5%) for ≤ 6.5, 10/42 (23.8%) for 6.6-7.0, 12/42 (28.6%) for 7.1-8.0, and 24/50 (48.0%) for ≥ 8.1. An adjusted OR of progressive motor deficits was 2.61 (95% confidence interval [CI] 0.98-7.00, P = .056) for 6.0-6.4, 3.42 (95% CI 1.27-9.18, P = .015) for 6.5-7.4, and 6.65 (95% CI 2.38-18.62, P < .001) for ≥ 7.5. In diabetic patients alone, those were 3.15 (95% CI 0.89-11.15, P = .075) for 6.6-7.0, 2.90 (95% CI 0.79-10.61, P = .107) for 7.1-8.0, and 4.17 (95% CI 1.07-16.25, P = .038) for ≥ 8.1. The optimal cutoff value of HbA1c was 6.65% in discriminating progressive motor deficits. CONCLUSION: Increased HbA1c was associated with higher incidence of progressive motor deficits in acute subcortical infarction with diabetes and prediabetes.

A Case Report of Wall-Eyed Bilateral Internuclear Ophthalmoplegia with Bilateral Facial Palsy.

Case reports of bilateral facial palsy with horizontal gaze restriction are rare. A 62-year-old woman experienced sudden onset of bilateral adduction deficits, bilateral abducting nystagmus accompanied with facial diplegia. We confirmed acute ischemic stroke in the midline dorsal pons, where medial longitudinal fasciculus (MLF) and facial nerve fascicles are located. This can be explained by vascular variation of pontine perforating arteries.

Dizziness in patients with early stages of Parkinson's disease: Prevalence, clinical characteristics and implications.

AIM: The clinical features and implications of dizziness in patients with Parkinson's disease (PD) remain little known. This study aimed to investigate the clinical characteristics of dizziness, and the association of dizziness with motor and non-motor symptoms in early stages of PD. METHODS: Demographics and clinical characteristics of patients with early PD (disease duration ≤5 years) were retrospectively assessed. The characteristics of dizziness were surveyed in each parkinsonian patient according to existence, frequency, duration and nature. Not only motor symptoms, but also non-motor scales for global cognition, anxiety, depression and fatigue were evaluated to identify risk factors of dizziness. RESULTS: Of a total of 80 patients with early PD, 37 (46.3%) had dizziness. The characteristics of dizziness included short duration (seconds to minutes) and frequent occurrence (several times in a day or a week). The most common type of dizziness was orthostatic (40.5%), followed by non-specific and disequilibrium type. Among many scales for motor and non-motor symptoms, dizzy patients with early PD showed lower scores of Montreal Cognitive representing global cognition than non-dizzy people. A lower Montreal Cognitive Assessment score was the only factor significantly related to dizziness in patients with early PD. CONCLUSIONS: We found that dizziness frequently occurs in early parkinsonian patients. It is highly linked to low Montreal Cognitive Assessment scores in patients with early PD, inferring that dizziness might be a potential non-motor symptom associated with cognitive decline in PD. Geriatr Gerontol Int 2020; 20: 443-447.

Lack of association between dopamine transporter loss and non-motor symptoms in patients with Parkinson's disease: a detailed PET analysis of 12 striatal subregions.

INTRODUCTION: Patients with Parkinson's disease (PD) present a variety of non-motor symptoms. However, it remains unclear whether dopamine depletion is related to non-motor symptoms, and which non-motor symptoms are significantly dependent on dopaminergic deficit. METHODS: Forty-one patients with PD who underwent positron emission tomography imaging of dopamine transporters (DATs) were recruited for this study. The striatum was divided into 12 subregions, and DAT activity, as striatal dopaminergic concentration, was calculated in each subregion. In addition to measuring motor symptoms using the Unified Parkinson's Disease Rating Scale-part III (UPDRS-III), various non-motor symptoms were assessed using the Montreal cognitive assessment, frontal assessment battery, Beck depression inventory (BDI), Beck anxiety inventory, PD sleep scale (PDSS), PD fatigue scale, and non-motor symptoms scale (NMSS) for PD. RESULTS: For simple linear regression analyses, dopaminergic depletion in all striatal subregions was negatively correlated with the UPDRS-III score. The most relevant non-motor symptom assessment related to dopaminergic loss in the 12 subregions was NMSS, followed by BDI and PDSS. However, following multiple linear regression analyses, dopaminergic depletion in the 12 striatal subregions was not related with any of the non-motor symptoms. Conversely, dopaminergic deficit in the right anterior and posterior putamen was associated with the UPDRS-III score. CONCLUSIONS: Striatal dopaminergic depletion was not significantly correlated with any of the various non-motor symptoms in PD. Our findings suggest that non-dopaminergic systems are significantly implicated in the pathogenesis of non-motor symptoms in patients with PD.

Left Ventricular Ejection Fraction Predicts Poststroke Cardiovascular Events and Mortality in Patients without Atrial Fibrillation and Coronary Heart Disease.

BACKGROUND AND OBJECTIVES: It is controversial that decreased left ventricular function could predict poststroke outcomes. The purpose of this study is to elucidate whether left ventricular ejection fraction (LVEF) can predict cardiovascular events and mortality in acute ischemic stroke (AIS) without atrial fibrillation (AF) and coronary heart disease (CHD). METHODS: Transthoracic echocardiography was conducted consecutively in patients with AIS or transient ischemic attack at Soonchunhyang University Hospital between January 2008 and July 2016. The clinical data and echocardiographic LVEF of 1,465 patients were reviewed after excluding AF and CHD. Poststroke disability, major adverse cardiac events (MACE; nonfatal stroke, nonfatal myocardial infarction, and cardiovascular death) and all-cause mortality during 1 year after index stroke were prospectively captured. Cox proportional hazards regressions analysis were applied adjusting traditional risk factors and potential determinants. RESULTS: The mean follow-up time was 259.9±148.8 days with a total of 29 non-fatal strokes, 3 myocardial infarctions, 33 cardiovascular deaths, and 53 all-cause mortality. The cumulative incidence of MACE and all-cause mortality were significantly higher in the lowest LVEF (<55) group compared with the others (p=0.022 and 0.009). In prediction models, LVEF (per 10%) had hazards ratios of 0.54 (95% confidence interval [CI], 0.36-0.80, p=0.002) for MACE and 0.61 (95% CI, 0.39-0.97, p=0.037) for all-cause mortality. CONCLUSIONS: LVEF could be an independent predictor of cardiovascular events and mortality after AIS in the absence of AF and CHD.

Recently Uncontrolled Glycemia in Diabetic Patients Is Associated with the Severity of Intracranial Atherosclerosis.

BACKGROUND AND PURPOSE: Diabetes mellitus is a specific risk factor for intracranial atherosclerosis (ICAS) regardless of race. However, it is largely unknown whether poor glycemic control is associated with the severity of ICAS in diabetic patients. METHODS: We selected diabetic patients with acute ischemic stroke who were prospectively registered between March 2005 and December 2015. The patients who had a high-risk source of cardiogenic embolism were excluded. ICAS was graded from 0 to 3 by the number of significant (≥50%) stenoses on intracranial magnetic resonance angiography, and was divided into 4 types: unilateral anterior, bilateral anterior, posterior, and anterior plus posterior. Ordinal and multinomial regression tests were applied for the factors influencing the number and types of ICAS. RESULTS: A total of 774 patients with noncardioembolic acute ischemic stroke with diabetes were enrolled. The multiplicity of ICAS was independently associated with age (odds ratio [OR], 1.035 per 1 year, 1.018-1.052; P < .001), hypertension (OR, 1.992, 1.336-2.965; P = .001), and glycated hemoglobin (HbA1c; OR, 1.207 per 1%, 1.089-1.338; P < .001) in the ordinal regression model. In multinomial regression, bilateral anterior stenosis tended to be correlated with age (OR, 1.042, 1.008-1.077; P = .016) and HbA1c (OR, 1.201 per 1%, .991-1.520; P = .057). Both anterior and posterior stenoses were significantly associated with age (OR, 1.056, 1.029-1.084; P < .001), hypertension (OR, 2.584, 1.404-4.762; P = .002), and HbA1c (OR, 1.272, 1.070-1.511; P = .006). CONCLUSIONS: Age, concomitant hypertension, and HbA1c were factors associated with multiple intracranial stenoses. Further study is warranted to elucidate whether poor glycemic control facilitates ICAS in diabetic patients.

Poststroke glycemic variability increased recurrent cardiovascular events in diabetic patients.

BACKGROUND AND PURPOSE: The association between blood glucose fluctuation and poststroke cardiovascular outcome has been largely unknown. This study attempted to evaluate whether initial glycemic variability increases cardiovascular events and mortality in diabetic patients with acute ischemic stroke. METHODS: We recruited consecutive patients with acute ischemic stroke or transient ischemic attack from March 2005 to December 2014. A total of 674 patients with diabetes within 72 hours from stroke onset were included. The serum glucose levels were checked 4 times per day during the initial 3 hospital days. J-index, coefficients of variation and standard deviation were calculated for glycemic variability. Composite outcome (nonfatal stroke, nonfatal myocardial infarction, cardiovascular death) and all-cause mortality at 3 months were prospectively captured. Multivariable logistic regression analyses were done adjusting for covariates which can influence on cardiovascular outcomes. RESULTS: Cardiovascular composite outcomes at 3 months were identified in 71 (10.5%): 11 (6.5%), 15 (8.9%), 18 (10.7%) and 27 (16.0%) in each J-index quartiles (P = .035). The highest quartile of J-index had significantly higher cardiovascular death (4.2%, 3.6%, 6.5% and 11.8%; P = .008). In multivariable logistic regression, age (odds ratio [OR] 1.045; 95% confidence interval [CI] 1.006-1.084), P = .021), NIH stroke scale (OR 1.078; 95% CI 1.024-1.134, P = .004), and the highest J-index (OR 12.058; 95% 1.890-76.912, P = .008) were significantly associated with 3-month cardiovascular composite outcome. Increased cardiovascular outcomes in highest J-index quartile were similar in both euglycemic and hyperglycemic groups. CONCLUSION: The initial glycemic variability might increase cardiovascular events in acute ischemic stroke patients with diabetes.

Numbers of Stroke Patients and Stroke Subtypes According to Highest and Lowest Daily Temperatures in Seoul.

BACKGROUND AND PURPOSE: There is conflicting evidence for whether or not the incidence of stroke is influenced by the daily temperature. The association between daily temperature and incidence of stroke is largely unknown in Korea. This study attempted to evaluate whether the maximum or minimum daily temperature is associated with increased numbers of strokes and stroke subtypes among Seoul residents. METHODS: We obtained the maximum and minimum daily temperatures in Seoul from the Korean Meteorological Administration between January 2005 and December 2014. Consecutive patients with acute stroke were registered who visited the emergency room or outpatient clinic in Soonchunhyang University Hospital, Seoul. The residential addresses of cases were restricted to within a 2-kilometer radius of this hospital. The stroke events were prospectively recorded with onset time, and were classified by subtypes. The categories of daily temperature were divided by 10℃ from the mean temperature. The mean daily number of strokes was calculated during the study period. One-way analysis of variance and Duncan's post-hoc test were applied to compare the number of strokes among the temperature groups. RESULTS: In total, 2,313 acute strokes were identified during the period: 1,643 ischemic strokes and 670 hemorrhagic strokes. The number of cases was significantly higher when the maximum daily temperature was >32℃ or ≤3℃ (p=0.048) or the minimum daily temperature was ≤-11.0℃ (p=0.020). The lowest maximum daily temperature was associated with increased instances of intracerebral hemorrhage (p=0.029) and small-vessel occlusion (p=0.013), while the highest maximum daily temperature was associated with an increased instance of large-artery atherosclerosis (p=0.045). CONCLUSIONS: The daily temperature had measurable and different associations with the number of strokes and strokes subtypes in Seoul, Korea.

Uremic parkinsonism with atypical phenotypes and radiologic features.

Uremic encephalopathy with bilateral basal ganglia lesions has been reported as an acute neurometabolic disease which shows reversible clinical course and brain imaging features. The exact nature and pathophysiology have not been well established. We encountered two patients who showed a relapsing and aggravating course and an atypical phenotype including parkinsonism with paroxysmal dystonic head tremor and acute onset monoparesis of the lower extremity. They also showed unusual radiological findings which revealed combined lesions in the basal ganglia and cortex, persistent hemorrhagic transformation, and focal ischemic lesion in the internal capsule. Herein, we present the unusual phenomenology with atypical radiologic findings and suggest the possible multifactorial pathogenesis of uremic encephalopathy.

The Association between Motor Laterality and Cognitive Impairment in Parkinson's Disease.

BACKGROUND AND PURPOSE: The relationship between the side of motor symptoms and cognitive impairment has rarely been reported in Parkinson's disease (PD). We aimed to estimate the influence of motor laterality on cognition in PD patients. METHODS: We enrolled 67 patients with PD, and they were divided into two groups according to side of symptom onset or predominant motor symptom presentation (right and left). Right-sided PD (RPD, 40) and left-sided PD (LPD, 27) patients underwent a neuropsychological battery exploring memory, attention/working memory, frontal/executive, visuospatial, and language functions. Student's t-test and Chi-square test have been carried out to compare the clinical and neuropsychological data between two groups. RESULTS: There were no significant differences in any neuropsychological test between the RPD and LPD groups, except for digit forward span test. RPD patients scored lower on the digit forward span test than LPD patients (5.43±9.49 vs. 6.15±1.38, p=0.045). CONCLUSIONS: RPD patients seem to experience more difficulties in attention and working memory than did LPD patients. The laterality of motor symptoms is not a major determinant for cognitive impairment in PD patients but, we should consider differences of cognitive deficits depending on the side of motor symptoms to treat patients with PD.

Association between Hypertriglyceridemia and Lacunar Infarction in Type 2 Diabetes Mellitus.

BACKGROUND: Although recent studies have shown that the elevation of serum triglyceride (TG) is related to the increased incidence of ischemic stroke, the relationship between hypertriglyceridemia and subtypes of ischemic stroke is largely unknown. This study attempted to evaluate whether hypertriglyceridemia is associated with lacunar stroke in diabetes mellitus (DM). METHODS: A total of 2141 consecutive patients with acute ischemic stroke were enrolled from March 2005 to April 2014, excluding the subjects with undetermined/other determined etiology or no lipid data. We compared the lipid profiles among stroke subtypes. The estimated serum TG levels and the interaction between DM and stroke subtypes were determined by analysis of covariance (ANCOVA) and Tukey's multiple comparison. RESULTS: In ANCOVA test, the difference of estimated TG between DM and non-DM patients was largest in small-vessel occlusion (SVO; 159.7 [95% confidence interval {CI}, 143.2-176.2] versus 122.4 [95% CI, 106.1-138.7]), and a significant interaction was observed between DM and stroke subtypes for TG levels (P = .013) but not for total cholesterol (P = .363), low-density lipoprotein cholesterol (P = .171), or high-density lipoprotein cholesterol (P = .231). By Tukey's multiple comparison, SVO was consistently associated with DM for serum TG levels (P < .001). CONCLUSIONS: In acute ischemic stroke with DM, serum TG level was significantly associated with lacunar infarction adjusting for other lipid profiles and vascular risk factors. Further studies are warranted to reveal the pathophysiologic implication of hypertriglyceridemia for lacunar infarction in type 2 DM.

Association between insufficient medication of antihypertensives and the severity of acute ischemic stroke.

BACKGROUND: Although recent studies have suggested that adherence to antihypertensive treatment reduced stroke incidence, the relationship of adherence to antihypertensives with stroke severity has not been studied. This study attempted to know whether nonadherence before stroke is associated with initial severity of acute ischemic stroke. METHODS: Consecutive patients with acute ischemic stroke were identified in Soonchunhyang University Hospital from Mar 2005 to Aug 2014, excluding the cases without hypertension or information of antihypertensive adherence. We compared the mean of National Institute of Health Stroke Scale (NIHSS) score between adherence groups and insufficient medication group, and additionally in each stroke subtype. Multiple linear regression model was established for initial NIHSS score adjusting alleged factors linked to stroke severity. RESULTS: Initial NIHSS score were higher in insufficient medication group than adherence group (6.5 ± 7.2 VS 5.4 ± 5.7, P = .11). In large artery atherosclerosis (LAA) and small vessel occlusion (SVO), initial NIHSS score were significantly higher in insufficient medication group (6.1 ± 6.5 VS 4.4 ± 4.4, P = .004 for LAA; 3.8 ± 3.5 VS 2.7 ± 1.8, P = .014 for SVO). In multiple linear regression model, insufficient medication to antihypertensives had a significant effect on NIHSS score (t = 3.417, P = .001) after adjusting covariates. CONCLUSION: Insufficient medication of antihypertensives before stroke was independently associated with the severity of acute ischemic stroke. Further studies with prospective designs are warranted to evaluate clinical implication of adherence to antihypertensives for ischemic stroke.

Implication of left ventricular diastolic dysfunction in cryptogenic ischemic stroke.

BACKGROUND AND PURPOSE: Left ventricular diastolic dysfunction (LVDD) is a predictor for atrial fibrillation (AF). This study was aimed to investigate whether LVDD in cryptogenic ischemic stroke (CS) could be a clue to stroke mechanism. METHODS: The clinical and echocardiographic findings of 1589 consecutive patients with acute ischemic stroke or transient ischemic attack between 2004 and 2013 were reviewed. LVDDs among stroke subtypes were graded by transthoracic echocardiography into 4 groups by severity: normal, abnormal relaxation (grade I), pseudonormal (grade II), and restrictive diastolic filling (grade III), whereas severe LVDD was defined as grade III. We classified the lesion pattern of CS into cardioembolism-mimic or non-cardioembolism-mimic and determined whether cardioembolism-mimic lesions were associated with severe LVDD. RESULTS: The fraction of severe LVDD in CS was not different from that of stroke with AF (27.3% versus 37.1%; P=0.173) but was significantly higher than that of stroke without AF (27.3% versus 13.4%; P=0.008). Cardioembolism-mimic CS had more severe LVDD than non-cardioembolism-mimic CS (41.4% versus 11.5%; P=0.013). LVDD of grade II (odds ratio, 4.37; 95% confidence interval, 2.99-6.41) and grade III (odds ratio, 5.60; 95% confidence interval, 3.42-9.17) were independently related to stroke with AF after adjusting covariates. CONCLUSIONS: The severe LVDD could be a predictor of stroke with AF, and its frequency was similar between CS and stroke with AF. Cardioembolism-mimic CS had significantly more severe LVDD than non-cardioembolism-mimic CS. LVDD could be helpful to discriminate the stroke mechanism in the patients with acute CS.

Intracranial arterial calcification can predict early vascular events after acute ischemic stroke.

BACKGROUND: Intracranial arterial calcification (IAC) is an evidence of advanced atherosclerosis. This study was aimed to investigate whether IAC predicts early vascular events (EVEs) during acute period of ischemic stroke. METHODS: We prospectively enrolled consecutive patients with acute ischemic stroke and transient ischemic attack within 48 hours from January 2005 to October 2012. Three IAC categories were defined according to the total IAC score as follows: no IAC (0 point), mild IAC (1-2 points), and severe IAC (≥3 points). EVEs included early progression/recurrence of stroke, coronary events, and vascular deaths within 2 weeks from stroke onset. We used multivariable Cox regression analyses to determine the effect of IAC on EVE. RESULTS: In the trend analysis of 1017 total patients, there were significant trends of increased IAC toward higher total EVEs (10.5% versus 13.8% versus 21.2%, P < .001). Severe IAC was related to increased rate of early progression/recurrence (hazard ratio [HR] 2.00; 95% confidence interval [CI] 1.07-3.71, P = .029) and coronary events (HR 3.51; 95% CI 1.00-12.31, P = .050) but did not show an association for mortality (HR .54; 95% CI .19-1.53, P = .224). Increased IAC was also related to a poor functional outcome after 3 months (odds ratio 2.23; 95% CI 1.38-3.59). CONCLUSIONS: IAC was significantly associated with increased early progression/recurrence of stroke and coronary events during acute period of ischemic stroke. IAC on the initial brain computed tomography would be used as a predictor for recurrent vascular events after acute ischemic stroke before further angiographic evaluation.