Measuring patient acuity and nursing care needs in South Korea: application of a new patient classification system.

BACKGROUND: An accurate and reliable patient classification system (PCS) can help inform decisions regarding adequate assignments for nurse staffing. This study aimed to evaluate the criterion validity of the Asan Patient Classification System (APCS), a new tertiary hospital-specific PCS, by comparing its rating and total scores with those of KPCS-1 and KPCS-GW for measuring patient activity and nursing needs. METHODS: We performed a retrospective analysis of the medical records of 50,314 inpatients admitted to the general wards of a tertiary teaching hospital in Seoul, South Korea in March, June, September, and December 2019. Spearman's correlation and Kappa statistics according to quartiles were calculated to examine the criterion validity of the APCS compared with the KPCS-1 and KPCS-GW. RESULTS: The average patient classification score was 28.3 points for APCS, 25.7 points for KPCS-1, and 21.6 points for KPCS-GW. The kappa value between APCS and KPCS-1 was 0.91 (95% CI:0.9072, 0.9119) and that between APCS and KPCS-GW was 0.88 (95% CI:0.8757, 0.8810). Additionally, Spearman's correlation coefficients among APCS, KPCS-1, and KPCS-GW showed a very strong correlation. However, 10.8% of the participants' results were inconsistent, and KPCS-1 tended to classify patients into groups with lower nursing needs compared to APCS. CONCLUSION: This study showed that electronic health record-generated APCS can provide useful information on patients' severity and nursing activities to measure workload estimation. Additional research is needed to develop and implement a real-world EHR-based PCS system to accommodate for direct and indirect nursing care while considering diverse population and dynamic healthcare system.

[Willingness to Use and Appropriate Payable Cost for Visiting Nurse Service for the Elderly in the Community].

PURPOSE: This study aimed to measure willingness to use (WTU) and appropriate payable cost of visiting nurse service for the elderly and explore their impact factors. METHODS: The study included 752 participants selected from data that were completed in 2017 for the elderly aged over 60 nationwide. Logit and Tobit regression analysis were performed to confirm the influencing factors. RESULTS: The study found that 39.1% of the elderly in the community were WTU the visiting nurse service, and they reported that the cost per visit was 12,650 Korean Won. The factors influencing WTU were having less than moderate subjective health status (OR = 1.63, p = .011), being part of a social participating groups (OR = 1.50, p = .046), or participation in senior health promotion programs (SHPPs) (OR = 1.96, p =.003). The cost was also influenced by less than moderate subjective health status (ß = 4.37, p = .021), being part of a social participating groups (ß = 4.41, p = .028), or participation in SHPPs (ß = 4.87, p = .023). Additionally, elderly people living alone who were used as covariates were highly WTU (OR = 2.20, p = .029). CONCLUSION: This study provides evidence to predict demand for visiting nurse service and reflects consumer value in setting the service cost. This is the first study to derive cost from consumers' perspective regarding the service for the elderly. As it is the result of an open-ended survey, follow-up studies are needed to estimate more reliable and reasonable results.

Polymer Stereocomplexation as a Scalable Platform for Nanoparticle Assembly.

DNA-mediated assembly of inorganic particles has demonstrated to be a powerful approach for preparing nanomaterials with a range of interesting optical and electrical properties. Building on this inspiration, we describe a generalizable gram-scale method to assemble nanoparticles through the formation of poly(methyl methacrylate) (PMMA) triple-helices. In this work, alkene-terminated syndiotactic (st-) and isotactic (it-) PMMA polymers were prepared and subsequently functionalized to afford nanoparticle ligands. Nanoparticles with complementary st- and it-PMMA ligands could then be spontaneously assembled upon mixing at room temperature. This process was robust and fully reversible through multiple heating and cooling cycles. The versatility of PMMA stereocomplexation was highlighted by assembling hybrid structures composed of nanoparticles of different compositions (e.g., Au and quantum dots) and shapes (e.g., spheres and rods). These initial demonstrations of nanoparticle self-assembly from inexpensive PMMA-based materials present an attractive alternative to DNA-based nanomaterials.

Designing with Light: Advanced 2D, 3D, and 4D Materials.

Recent achievements and future opportunities for the design of 2D, 3D, and 4D materials using photochemical reactions are summarized. Light is an attractive stimulus for material design due to its outstanding spatiotemporal control, and its ability to mediate rapid polymerization under moderate reaction temperatures. These features have been significantly enhanced by major advances in light generation/manipulation with light-emitting diodes and optical fiber technologies which now allows for a broad range of cost-effective fabrication protocols. This combination is driving the preparation of sophisticated 2D, 3D, and 4D materials at the nano-, micro-, and macrosize scales. Looking ahead, future challenges and opportunities that will significantly impact the field and help shape the future of light as a versatile and tunable design tool are highlighted.

The Importance of Salt-Enhanced Electrostatic Repulsion in Colloidal Crystal Engineering with DNA.

Realizing functional colloidal single crystals requires precise control over nanoparticles in three dimensions across multiple size regimes. In this regard, colloidal crystallization with programmable atom equivalents (PAEs) composed of DNA-modified nanoparticles allows one to program in a sequence-specific manner crystal symmetry, lattice parameter, and, in certain cases, crystal habit. Here, we explore how salt and the electrostatic properties of DNA regulate the attachment kinetics between PAEs. Counterintuitively, simulations and theory show that at high salt concentrations (1 M NaCl), the energy barrier for crystal growth increases by over an order of magnitude compared to low concentration (0.3 M), resulting in a transition from interface-limited to diffusion-limited crystal growth at larger crystal sizes. Remarkably, at elevated salt concentrations, well-formed rhombic dodecahedron-shaped microcrystals up to 21 µm in size grow, whereas at low salt concentration, the crystal size typically does not exceed 2 µm. Simulations show an increased barrier to hybridization between complementary PAEs at elevated salt concentrations. Therefore, although one might intuitively conclude that higher salt concentration would lead to less electrostatic repulsion and faster PAE-to-PAE hybridization kinetics, the opposite is the case, especially at larger inter-PAE distances. These observations provide important insight into how solution ionic strength can be used to control the attachment kinetics of nanoparticles coated with charged polymeric materials in general and DNA in particular.

Non-equilibrium anisotropic colloidal single crystal growth with DNA.

Anisotropic colloidal crystals are materials with novel optical and electronic properties. However, experimental observations of colloidal single crystals have been limited to relatively isotropic habits. Here, we show DNA-mediated crystallization of two types of nanoparticles with different hydrodynamic radii that form highly anisotropic, hexagonal prism microcrystals with AB2 crystallographic symmetry. The DNA directs the nanoparticles to assemble into a non-equilibrium crystal shape that is enclosed by the highest surface energy facets (AB2(10[Formula: see text]0) and AB2(0001)). Simulations and theoretical arguments show that this observation is a consequence of large energy barriers between different terminations of the AB2(10[Formula: see text]0) facet, which results in a significant deceleration of the (10[Formula: see text]0) facet growth rate. In addition to reporting a hexagonal colloidal crystal habit, this work introduces a potentially general plane multiplicity mechanism for growing non-equilibrium crystal shapes, an advance that will be useful for designing colloidal crystal habits with important applications in both optics and photocatalysis.

Lattice Mismatch in Crystalline Nanoparticle Thin Films.

For atomic thin films, lattice mismatch during heteroepitaxy leads to an accumulation of strain energy, generally causing the films to irreversibly deform and generate defects. In contrast, more elastically malleable building blocks should be better able to accommodate this mismatch and the resulting strain. Herein, that hypothesis is tested by utilizing DNA-modified nanoparticles as "soft," programmable atom equivalents to grow a heteroepitaxial colloidal thin film. Calculations of interaction potentials, small-angle X-ray scattering data, and electron microscopy images show that the oligomer corona surrounding a particle core can deform and rearrange to store elastic strain up to ±7.7% lattice mismatch, substantially exceeding the ±1% mismatch tolerated by atomic thin films. Importantly, these DNA-coated particles dissipate strain both elastically through a gradual and coherent relaxation/broadening of the mismatched lattice parameter and plastically (irreversibly) through the formation of dislocations or vacancies. These data also suggest that the DNA cannot be extended as readily as compressed, and thus the thin films exhibit distinctly different relaxation behavior in the positive and negative lattice mismatch regimes. These observations provide a more general understanding of how utilizing rigid building blocks coated with soft compressible polymeric materials can be used to control nano- and microstructure.

The Role of Repulsion in Colloidal Crystal Engineering with DNA.

Hybridization interactions between DNA-functionalized nanoparticles (DNA-NPs) can be used to program the crystallization behavior of superlattices, yielding access to complex three-dimensional structures with more than 30 different lattice symmetries. The first superlattice structures using DNA-NPs as building blocks were identified almost a decade ago, yet the role of repulsive interactions in guiding structure formation is still largely unexplored. Here, a comprehensive approach is taken to study the role of repulsion in the assembly behavior of DNA-NPs, enabling the calculation of interparticle interaction potentials based on experimental results. In this work, we used two different means to assemble DNA-NPs-Watson-Crick base-pairing interactions and depletion interactions-and systematically varied the salt concentration to study the effective interactions in DNA-NP superlattices. A comparison between the two systems allows us to decouple the repulsive forces from the attractive hybridization interactions that are sensitive to the ionic environment. We find that the gap distance between adjacent DNA-NPs follows a simple power law dependence on solution ionic strength regardless of the type of attractive forces present. This result suggests that the observed trend is driven by repulsive interactions. To better understand such behavior, we propose a mean-field model that provides a mathematical description for the observed trend. This model shows that the trend is due to the variation in the effective cross-sectional diameter of DNA duplex and the thickness of DNA shell.

Altering DNA-Programmable Colloidal Crystallization Paths by Modulating Particle Repulsion.

Colloidal crystal engineering with DNA can be used to realize precise control over nanoparticle (NP) arrangement. Here, we investigate a case of DNA-based assembly where the properties of DNA as a polyelectrolyte brush are employed to alter a hybridization-driven NP crystallization pathway. Using the coassembly of DNA-conjugated proteins and spherical gold nanoparticles (AuNPs) as a model system, we explore how steric repulsion between noncomplementary, neighboring NPs due to overlapping DNA shells can influence their ligand-directed behavior. Specifically, our experimental data coupled with coarse-grained molecular dynamics (MD) simulations reveal that, by changing factors related to NP repulsion, two structurally distinct outcomes can be achieved. When steric repulsion between DNA-AuNPs is significantly greater than that between DNA-proteins, a lower packing density crystal lattice is favored over the structure that is predicted by design rules based on DNA hybridization considerations alone. This is enabled by the large difference in DNA density on AuNPs versus proteins and can be tuned by modulating the flexibility, and thus conformational entropy, of the DNA on the constituent particles. At intermediate ligand flexibility, the crystallization pathways are energetically similar, and the structural outcome can be adjusted using the density of DNA duplexes on DNA-AuNPs and by screening the Coulomb potential between them. Such lattices are shown to undergo dynamic reorganization upon changing the salt concentration. These data help elucidate the structural considerations necessary for understanding repulsive forces in DNA-mediated assembly and lay the groundwork for using them to increase architectural diversity in engineering colloidal crystals.

Epitaxy: Programmable Atom Equivalents Versus Atoms.

The programmability of DNA makes it an attractive structure-directing ligand for the assembly of nanoparticle (NP) superlattices in a manner that mimics many aspects of atomic crystallization. However, the synthesis of multilayer single crystals of defined size remains a challenge. Though previous studies considered lattice mismatch as the major limiting factor for multilayer assembly, thin film growth depends on many interlinked variables. Here, a more comprehensive approach is taken to study fundamental elements, such as the growth temperature and the thermodynamics of interfacial energetics, to achieve epitaxial growth of NP thin films. Both surface morphology and internal thin film structure are examined to provide an understanding of particle attachment and reorganization during growth. Under equilibrium conditions, single crystalline, multilayer thin films can be synthesized over 500 × 500 µm2 areas on lithographically patterned templates, whereas deposition under kinetic conditions leads to the rapid growth of glassy films. Importantly, these superlattices follow the same patterns of crystal growth demonstrated in atomic thin film deposition, allowing these processes to be understood in the context of well-studied atomic epitaxy and enabling a nanoscale model to study fundamental crystallization processes. Through understanding the role of epitaxy as a driving force for NP assembly, we are able to realize 3D architectures of arbitrary domain geometry and size.

Cancer-specific incidence rates of tuberculosis: A 5-year nationwide population-based study in a country with an intermediate tuberculosis burden.

Population-based studies of the incidence of tuberculosis in cancer patients according to the type of cancer are limited. We investigated the cancer-specific incidence of tuberculosis in a nationwide population-based cohort in a country with an intermediate burden of tuberculosis.We used mandatory National Health Insurance claims data to construct a cancer cohort of adults (aged 20-99 years) with newly diagnosed malignancies other than lung cancer, from January 2008 to December 2012. Patients who developed tuberculosis in this period were identified in the cancer cohort and the general population. Standardized incidence ratios (SIRs) of tuberculosis in the cancer cohort according to type of cancer and time after cancer diagnosis were calculated by comparing the observed incidence rates with those inferred from the age- and gender-specific incidence rates in the general population.A total of 855,382 cancer patients and 1589,876 person-years (py) were observed. A total of 5745 patients developed tuberculosis; the mean incidence rate was 361.3 per 100,000 py, and the SIR was 2.22 (95% confidence interval [CI], 2.17-2.27). The incidence rate was highest for hematologic malignancy and lowest for thyroid cancer. It was also highest as 650.1 per 100,000 py, with SIR of 3.70 (CI, 3.57-3.83) for the first 6 months after diagnosis of malignancy and then declined. However, it still remained higher than that of the general population after 24 months (SIR = 1.43, CI, 1.36-1.51).The incidence of tuberculosis increases after diagnosis in patients with malignancies. The risk of tuberculosis differs according to the type of cancer and remains elevated even 24 months after cancer diagnosis. Tuberculosis should be considered an important comorbidity in patients with malignancies.

Modulating the Bond Strength of DNA-Nanoparticle Superlattices.

A method is introduced for modulating the bond strength in DNA-programmable nanoparticle (NP) superlattice crystals. This method utilizes noncovalent interactions between a family of [Ru(dipyrido[2,3-a:3',2'-c]phenazine)(N-N)2](2+)-based small molecule intercalators and DNA duplexes to postsynthetically modify DNA-NP superlattices. This dramatically increases the strength of the DNA bonds that hold the nanoparticles together, thereby making the superlattices more resistant to thermal degradation. In this work, we systematically investigate the relationship between the structure of the intercalator and its binding affinity for DNA duplexes and determine how this translates to the increased thermal stability of the intercalated superlattices. We find that intercalator charge and steric profile serve as handles that give us a wide range of tunability and control over DNA-NP bond strength, with the resulting crystal lattices retaining their structure at temperatures more than 50 °C above what nonintercalated structures can withstand. This allows us to subject DNA-NP superlattice crystals to conditions under which they would normally melt, enabling the construction of a core-shell (gold NP-quantum dot NP) superlattice crystal.

Duplex-selective ruthenium-based DNA intercalators.

We report the design and synthesis of small molecules that exhibit enhanced luminescence in the presence of duplex rather than single-stranded DNA. The local environment presented by a well-known [Ru(dipyrido[3,2-a:2',3'-c]phenazine)L2 ](2+) -based DNA intercalator was modified by functionalizing the bipyridine ligands with esters and carboxylic acids. By systematically varying the number and charge of the pendant groups, it was determined that decreasing the electrostatic interaction between the intercalator and the anionic DNA backbone reduced single-strand interactions and translated to better duplex specificity. In studying this class of complexes, a single Ru(II) complex emerged that selectively luminesces in the presence of duplex DNA with little to no background from interacting with single-stranded DNA. This complex shows promise as a new dye capable of selectively staining double- versus single-stranded DNA in gel electrophoresis, which cannot be done with conventional SYBR dyes.

Naloxone induces endoplasmic reticulum stress in PC12 cells.

Naloxone is an opioid inverse agonist used in the treatment of opiate overdose, with well known pharmacology. In the present study, we determined the effects of naloxone on the unfolded protein response (UPR) in PC12 cells. Data from a 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide (MTT) assay indicated that naloxone may accelerate PC12 cell apoptosis in a dose-dependent manner. We also demonstrated that naloxone upregulated gene expression of endoplasmic reticulum (ER) chaperones, including binding immunoglobulin protein (Bip), calnexin, ER protein 29 (ERp29) and protein disulfide isomerase (PDI), and ER stress sensors, including activating transcription factor 6 (ATF6), inositol-requiring enzyme 1 (IRE1) and protein kinase-like ER kinase (PERK). In addition, naloxone also induced typical ER stress phenomena, including ART6 proteolytic cleavage, eIF2α phosphorylation and XBP1 mRNA splicing. Furthermore, naloxone upregulated gene expression of ER chaperones and ER stress sensors in in vivo experiments. To the best of our knowledge, these results are the first to indicate that naloxone induces ER stress in vitro and in vivo.

Biofeedback therapy for female patients with constipation caused by radical hysterectomy or vaginal delivery.

BACKGROUND AND AIM: Chronic constipation is frequently seen in women who have undergone hysterectomy or delivery. However, reports regarding anorectal physiologic features in those patients are rare. Patients with constipation associated with either radical hysterectomy or vaginal delivery were analyzed in order to clarify the anorectal physiologic features and the effectiveness of biofeedback therapy. METHODS: Of the constipated patients, a hysterectomy group (n = 40), delivery group (n = 41), and a control group (n = 89), who had no history of either surgery or delivery before developing functional constipation were included. Their anorectal physiological tests and the effectiveness of biofeedback therapy were investigated. RESULTS: The volume of desire to defecate was greater in the hysterectomy group than in the control group (86.5 ± 55.0 mL vs 62.9 ± 33.7 mL; P = 0.03), and more than 240 mL of maximal volume of toleration was more frequently noted in the hysterectomy group (32.5%) than in the delivery group (14.6%) and control group (13.5%) (P = 0.02).The failure of balloon expulsion was more frequently noted in the delivery group (44.0%) than in the hysterectomy group (15.0%) and control group (25.0%) (P = 0.01). The defecation satisfaction score was significantly increased after biofeedback therapy in the hysterectomy group (2.0 ± 2.7 vs 7.8 ± 1.5, P < 0.001), the delivery group (1.6 ± 2.1 vs 6.7 ± 2.0, P < 0.001), and the control group (2.5 ± 2.7 vs 6.9 ± 2.1, P < 0.001). CONCLUSIONS: Rectal hyposensitivity could have been the characteristic mechanism in the hysterectomy group, whereas dyssynergic defecation could have been the cause in the delivery group. Biofeedback therapy was effective for both groups.

Pulmonary thromboembolism in a patient with myotonic dystrophy type 1.

Thromboembolism is a rare complication in patients with myotonic dystrophy. While immobilization of patients with advanced disease predisposes to high risk for venous thromboembolism, hypercoagulability could account for venous thromboembolism in patients without impaired mobilization. We report a patient with myotonic dystrophy type 1 who developed pulmonary thromboembolism unrelated to immobilization.

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: <45, 45-54, 55-64, 65-74, 75-84, and ≥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 <45, 45-54, 55-64, 65-74, 75-84, and ≥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 <45 years, 24,608 for 45-54 years, 50,682 for 55-64 years, 88,875 for 65-74 years, 52,089 for 75-84 years, and 8,192 for ≥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.

Mutations at codons 178, 200-129, and 232 contributed to the inherited prion diseases in Korean patients.

BACKGROUND: Polymorphisms of the human prion protein gene (PRNP) contribute to the genetic determinants of Creutzfeldt-Jakob disease (CJD). Numerous polymorphisms in the promoter regions as well as the open reading frame of PRNP were investigated. Greater than 90% of Korean, Chinese, and Japanese carry the homozygote 129 MM codon. In Korea, polymorphisms have not been comprehensively studied, except codons 129 and 219 in PRNP among Korean CJD cases. Although polymorphisms at codons 129 and 219 play an important role in susceptibility to sporadic CJD, patients with other polymorphisms in PRNP exhibited critical distinctions of clinical symptoms. METHODS: The genetic analyses of PRNP were carried out among probable CJD patients in comparison with the results from magnetic resonance imaging (MRI) and electroencephalogram (EEG). RESULTS: The molecular analyses revealed that three mutations at codons D178N, E200K, and M232R in heterozygosity. Patients with the D178N and M232R mutations had a 129MM codon, whereas the patient with the E200K mutation showed 129MV heterozygosity. They all revealed strong 14-3-3 positive signals. The 67-year-old patient with the D178N-129M mutation showed progressive gait disturbance and dysarthria was in progress. The 58-year-old patient with the E200K mutation coupled to the 129MV codon had gait disturbance, dysarthria, agitation, and ataxic gait, and progressed rapidly to death 3 months from the first onset of symptoms. The 65-year-old patient with the M232R mutation showed rapidly progressive memory decline and gait disturbance, and died within 16 months after onset of symptoms. CONCLUSION: Despite differences in ethnicity, the clinical and pathological outcomes were similar to the respective mutations around the world, except absence of insomnia in D178N-129M subject.

Nonmotor symptoms in de novo Parkinson disease before and after dopaminergic treatment.

BACKGROUND: Nonmotor symptoms (NMSs) are common in patients with Parkinson disease (PD), but little is known about the burden of the full range of NMSs in de novo PD patients. OBJECTIVES: NMSs in untreated de novo PD patients were evaluated both quantitatively and qualitatively using the Non-Motor Symptoms Assessment Scale (NMSS); the findings were compared to those of control subjects. The effects of dopaminergic treatment on NMSs were also determined. METHODS: NMSs were evaluated in 23 patients with untreated de novo PD and 23 healthy controls. The motor section of the Unified Parkinson Disease Rating Scale (mUPDRS) and the Hoehn and Yahr (HY) stage were also checked in the PD patients. The number of NMSs and the NMSS scores of the PD patients were compared with those of the controls. Three months after the start of dopaminergic medication, 16 PD patients were reevaluated with respect to the NMSS and mUPDRS, and the HY stage. RESULTS: The number of NMSs and the NMSS scores were significantly higher in the PD patients than in the controls. The three most prevalent NMSs among the PD patients were 'nocturia,' 'forget things or events,' and 'restless legs.' In the PD group, the number of NMSs was correlated with the HY stage but not with age, disease duration, or mUPDRS score. Follow-up of 16 patients at 3months after commencing PD medication revealed no changes in either the number of NMSs or the NMSS score, despite improvement in motor symptoms. CONCLUSIONS: Untreated de novo PD patients have more nonmotor problems than controls, and these NMSs are not ameliorated by dopaminergic medication.

Intravenous recombinant tissue plasminogen activator thrombolysis in a patient with acute ischemic stroke secondary to aortic dissection.

BACKGROUND: Acute ischemic stroke secondary to aortic dissection (AoD) is challenging in the era of thrombolysis owing to the diagnostic difficulty within a narrow time window and the high risk of complications. CASE REPORT: A 64-year-old woman with middle cerebral artery occlusion syndrome admitted to the emergency room within intravenous recombinant tissue plasminogen activator (rt-PA) time window. Her neurological symptoms improved during thrombolysis, but chest and abdominal pain developed. Repeated history-taking, physical examination, and imaging studies led to the timely diagnosis and surgical treatment of AoD, which produced a successful outcome. CONCLUSIONS: Clinical suspicion is invaluable for the diagnosis of this rare cause of stroke. Considering the stroke mechanism and complications, the risks of thrombolysis might outweigh its benefits.