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Background and Purpose: The purpose of the present study was to test the hypothesis that plasma brain natriuretic peptide (BNP) is associated with short-term mortality after intracerebral hemorrhage (ICH). Methods: We prospectively enrolled 271 patients (median age 72 years; 109 females) who were admitted within 24 h of ICH onset between April 2007 and July 2011 and in whom plasma BNP levels were measured upon admission. The patients were assigned to two groups according to survival within 1 month of ICH. Factors associated with mortality were determined by multivariate logistic regression analysis. Results: Within 1 month of ICH, 48 (17.7%) of the 271 enrolled patients died. The median (interquartile range) level of plasma BNP was significantly higher in the group of non-survivors than in the group of survivors [102.5 (48.7-205.0) vs. 32.4 (17.3-85.0) pg/ml; p < 0.001]. A cutoff BNP level of 60.0 pg/ml could predict death within 1 month of ICH. Multivariate logistic regression analysis showed that a plasma BNP of >60.0 pg/ml (OR 4.7; 95% CI 1.43-15.63; p = 0.011) was independently associated with mortality within 1 month after ICH. Conclusions: A high BNP level upon admission is associated with mortality within 1 month after ICH.

Background and Purpose: We investigated whether brain natriuretic peptide (BNP) can serve as a biological marker of long-term mortality in ischemic stroke survivors. Methods: Consecutive patients with ischemic stroke within 24 h of onset from April 2007 to December 2010 were prospectively enrolled, and admission plasma BNP levels were measured. Survivors were followed up until 1 year after stroke onset. Patients were divided into two groups: the deceased group and the surviving group. The factors associated with long-term mortality were investigated by multiple logistic regression analysis. Results: A total of 736 patients who were alive at hospital discharge were included; 130 (17.7%) patients died. On multivariate analysis, age >75 years (odds ratio, OR, 2.83; 95% CI, 1.74-4.60, p = 0.0001), dialysis-dependent chronic renal failure (OR, 5.99; 95% CI, 2.18-16.47, p = 0.0005), modified Rankin Scale score >3 at discharge (OR, 4.41; 95% CI, 2.76-7.05, p < 0.0001), and plasma BNP >100.0 pg/ml (OR, 3.94; 95% CI, 2.31-6.73, p < 0.0001) were found to be independently associated with long-term mortality. We developed a risk score from 4 variables (each variable: 1 point, total score: 0-4 points). The mortality rates were 2% with a score of 0, 9% with a score of 1, 27% with a score of 2 and 50% with a score ≥3. Conclusions: The risk score, composed of clinical parameters and BNP, may predict long-term mortality in ischemic stroke survivors.

Background and Purpose: Our previous retrospective study demonstrated that a brain natriuretic peptide (BNP) level of >140 pg/ml on admission was useful to distinguish cardioembolism (CE) from non-CE. The aim of the present study was to prospectively investigate the utility of this predefined threshold. Method: Two hundred and twenty-one consecutive patients were prospectively enrolled. On admission, the BNP levels of the patients were measured and classified according to low BNP (≤140.0 pg/ml) or high BNP (>140.0 pg/ml) levels. Final diagnosis of stroke subtype on discharge was made using the TOAST criteria. Measured parameters included the sensitivity, specificity, positive predictive value, and negative predictive value for CE in the high BNP group. Results: There were 81 patients in the high BNP group and 140 patients in the low BNP group. A total of 76 (34.4%) patients were diagnosed with CE, including 59 (72.8%) patients in the high BNP group and 17 (12.1%) patients in the low BNP group (p < 0.001). A BNP level >140.0 pg/ml corresponded to a sensitivity of 77.6%, specificity of 84.8%, positive predictive value of 72.8%, and negative predictive value of 87.9% for a diagnosis of CE. Conclusion: A BNP level of >140.0 pg/ml on admission in patients with acute ischemic stroke is a strong biochemical predictor for CE.

Background: The aim of the present study was to clarify the effect of glucose profiles after stroke, which was assessed by a continuous glucose monitoring (CGM) device. Methods: Acute ischemic stroke patients within 24 h of onset were prospectively studied. CGM was performed for 72 h after admission. CGM parameters were evaluated as follows: (1) mean glucose level, (2) area under the curve (AUC) for glucose level >140 mg/dl and (3) SD of the glucose level. Infarct volume was measured at admission and 24 and 72 h after admission using diffusion-weighted imaging. CGM data and infarct volume growth were compared at 24 and 72 h. Results: Seventy-eight patients were enrolled in the present study. Spearman's rank correlation coefficients showed that both the mean glucose level (r = 0.433, p < 0.001 for 24 h; r = 0.308, p = 0.006 for 72 h) and AUC >140 mg/dl (r = 0.417, p < 0.001 for 24 h; r = 0.277, p = 0.014 for 72 h) were significantly correlated with acute infarct volume growth. The SD of the glucose level was associated with infarct volume growth at 24 h (r = 0.303, p = 0.007), but not 72 h (r = 0.195, p = 0.088). Conclusion: Post-stroke hyperglycemia was associated with infarct volume growth during the acute phase of ischemic stroke.

Background and Purpose: The present study aimed to devise a simple scale to predict very poor outcome after tissue plasminogen activator (t-PA) therapy using clinical and MRI factors. Methods: Consecutive stroke patients treated with t-PA within 3 h of onset were studied prospectively. Clinical factors and MRI findings independently associated with very poor outcome (modified Rankin Scale score 4–6) at 3 months after t-PA therapy were assessed. Results: The subjects were 117 patients. Multivariate logistic regression analysis revealed the following independent factors associated with very poor outcome: time from stroke onset to treatment ≧140 min (OR 2.790, 95% CI 1.082–7.193; p = 0.0337), baseline National Institutes of Health Stroke Scale score ≧20 (OR 3.794, 95% CI 1.199–12.009; p = 0.0233), glucose ≧180 mg/dl (OR 3.288, 95% CI 1.126–9.600; p = 0.0295), internal carotid artery occlusion (OR 6.187, 95% CI 5.090–18.354; p = 0.0129) and M1 susceptibility vessel sign (OR 6.379, 95% CI 1.194–34.074; p = 0.030). Those 5 variables were selected in the scale, with each factor as 1 point. Frequencies of patients with a very poor outcome for each score were as follows: score 0, 26.3%; score 1, 30.6%; score 2, 70.0%, and score 3–5, 100%. Conclusion: A clinical scale using clinical and MRI factors can predict very poor outcome in t-PA patients.

Background and Purpose: The aim of this study was to devise a new ischemic stroke (IS)/hemorrhagic stroke (HS) stroke score to distinguish IS from HS for emergency medical services (EMS). Materials and Methods: We studied patients with IS and HS who were admitted within 6 h of onset and transferred by the EMS. We compared characteristics of IS and HS to devise a new IS/HS score. Results: A total of 227 patients (median age, 71 years; 139 males; IS, 127 patients; HS, 100 patients) were included in the study. On multivariate analysis following univariate analysis, presence of atrial fibrillation, diastolic blood pressure Conclusion: KP3S is useful for distinguishing IS from HS and for the evaluation of stroke patients by EMS.

Background/Aim: Early recanalization after tissue plasminogen activator (t-PA) infusion greatly improves outcome in stroke patients. However, the time threshold of early recanalization for a favorable outcome remains unclear. The aim of this study was to assess patient outcome 3 months after t-PA therapy among patients with early, delayed and without recanalization. Methods: Consecutive patients with major brain artery occlusion on magnetic resonance angiography (MRA) before t-PA infusion were enrolled. We divided the patients into 3 groups according to the findings of follow-up MRA 1 and 24 h after t-PA: the early group who had recanalization within 1 h after t-PA; the delayed group who had recanalization between 1 and 24 h, and the no recanalization group. We then assessed the outcomes (modified Rankin score 0–1) 3 months after t-PA therapy among the 3 groups. Results: A total of 92 patients (53 men, mean age 75.8 ± 10.3 years) were enrolled. A favorable outcome was most frequently observed in the early group (n = 39, 40.6%), followed by the delayed group (n = 25, 18.2%), and the no recanalization group (n = 28, 10.5%; p = 0.037). After adjusting for age, atrial fibrillation and NIHSS score, the adjusted OR for early recanalization when compared with no recanalization was 7.11 (95% CI 1.177–43.063; p = 0.032) for a favorable outcome, while the adjusted OR for delayed recanalization was 1.75 (95% CI 0.104–29.356; p = 0.698). Conclusion: Early recanalization within 1 h after intravenous t-PA is associated with a favorable outcome in stroke patients.

Purpose: The present study investigated the factors related to neurological deterioration in pontine infarction. Methods: Consecutive patients with acute pontine infarction without basilar artery (BA) occlusion were enrolled. Patients were classified into two groups (D, group with neurological deterioration; ND, group without neurological deterioration). After magnetic resonance angiography was performed to identify the diameters of internal carotid artery (ICA) and BA, the BA diameter/ICA diameter (BA/ICA) ratio was calculated. When the ischemic lesion on diffusion-weighted magnetic resonance imaging extended to the ventral basal pial surface, it was diagnosed as branch atheromatous disease (BAD). Results: Neurological deterioration occurred in 16 (31%) of 51 patients. BAD was found in 13 (81%) of 16 patients of the D group and 14 (40%) of 35 in the ND group (p = 0.008). The BA/ICA ratio was 0.73 (0.59–0.84) in the D group and 0.64 (0.55–0.71) in the ND group (p = 0.049). Multivariate regression analysis demonstrated that BAD (OR 15.62, 95% CI 2.37–103.13, p = 0.004) and a BA/ICA ratio of ≧0.70 (OR 7.76, 95% CI 1.55–38.88, p = 0.013) were independent factors associated with neurological deterioration. Conclusion: The BA diameter may be associated with neurological deterioration in acute pontine infarction.

to be elevated in patients with acute ischemic stroke [2–6] , in particular, those with atrial fibrillation [2–4, 6] , and associated with neurological severity [3–5] . Furthermore, we demonstrated that high BNP level is associated with in-hospital mortality [5] or long-term mortality [2] after ischemic stroke. Recently, a rapid (approx. 15 min) and easy assay for the measurement of BNP was developed [6] . Therefore, we propose regular BNP meaDear Sir, We appreciate the interest of Dr. Kapoor in our article recently published in European Neurology [1] . Brain natriuretic peptide (BNP) is a cardiac neurohormone specifically secreted from the ventricles in response to ventricular volume expansion and pressure overload. Previous studies have shown that the BNP level is related to cardiac function, and it has been used as a biochemical marker of congestive heart failure. BNP levels have also been shown Received: December 3, 2013 Accepted: January 8, 2014 Published online: June 4, 2014

Background/Aims: The main predictors of intracerebral hemorrhage (ICH) are clinical stroke severity and large ischemic lesions. Therefore, ICA occlusion as severe stroke is thought to frequently have ICH after tissue plasminogen activator (t-PA) therapy. The aim of this study was to investigate whether ICA occlusion more frequently had ICH after t-PA therapy compared with other occluded arteries. Subjects andMethods: We prospectively studied consecutive stroke patients treated with t-PA within 3 h of onset. We investigated the frequency of ICH after t-PA therapy for each occluded artery. Results: 165 patients were enrolled. Initial MRA demonstrated ICA occlusion in 38 patients, M1 in 48, M2 in 28, and BA and PCA in 12. At 24 h after t-PA infusion, 113 (68.5%) patients (non-HT group) did not have hemorrhagic transformation, 37 (22.4%; HI group) had hemorrhagic cerebral infarction and 15 (9.1%; ICH group) had ICH. The ICH group most frequently had M2 occlusion, NIHSS ≧15, and ≧1/3 of the MCA territory among the three groups. The frequency of ICH was 2.6% in no occlusion, 10.5% in ICA occlusion, 6.3% in M1, 21.4% in M2, and 8.3% in PCA and BA (p = 0.1016). Conclusion: Patients with ICA occlusion did not have ICH more frequently after t-PA therapy in comparison to other occluded arteries.

Background: It is not clear whether tissue plasminogen activator (t-PA) thrombolysis in patients without major arterial occlusion is effective or safe. Methods: Consecutive anterior circulation stroke patients treated with t-PA within 3 h of onset were studied. The patients were divided into three groups according to magnetic resonance angiography findings before t-PA infusion: ICA group, ICA occlusion; MCA group, M1 and M2 occlusion, and no occlusion group. Clinical characteristics, the presence of hemorrhagic transformation on T2* at 24 h after t-PA thrombolysis, and outcome at 3 months were compared among the three groups. Results: 112 patients were enrolled. The no occlusion group had 21 (18.8%) patients, the ICA group had 29 (25.9%), and the MCA group had 62 (55.4%). The frequency of hemorrhagic transformation was only 4.8% in the no occlusion group (31.0% for the ICA group, and 48.4% for the MCA group, p = 0.0012). At 3 months after t-PA therapy, 61.5% of the no occlusion group had a favorable outcome (modified Rankin score 0–1), which was the highest among the three groups (15.0% for the ICA group, and 41.5% for the MCA group, p = 0.0203). Conclusion: Intravenous t-PA therapy in acute stroke patients without major artery occlusion seems to be safe and effective.

Purpose: The present study investigated early recanalization rate of major occluded arteries after tissue plasminogen activator (t-PA) infusion using serial magnetic resonance angiography (MRA) studies. Methods: Consecutive stroke patients treated with t-PA within 3 h of onset were prospectively studied. Four serial MRA studies were conducted: before, immediately, 24 h and 5–7 days after t-PA infusion. Results: Initial MRA demonstrated occluded brain arteries in 64 patients: M1 occlusion, 30 patients; M2, 12, and internal carotid artery (ICA), 22. Combining M1 and M2 occlusion, the recanalization rates (complete and partial) were 52.3% (19.0 and 33.3%) within 1 h, 80.9% (47.6 and 33.3%) at 24 h and 87.8% (73.2 and 14.6%) 7 days after t-PA infusion. However, the recanalization rate of ICA occlusion was 31.8% (4.5 and 27.3%) within 1 h, 51.1% (14.3 and 47.6%) at 24 h and 66.7% (38.9 and 27.8%) 7 days after t-PA infusion. Complete recanalization rate at 24 h and 7 days was lower in ICA occlusion than M1 and M2 occlusion (p = 0.014 and p = 0.016). Conclusion: Within 1 h after t-PA infusion, approximately half the patients with major arteries occlusion had early recanalization. ICA occlusion is resistant to intravenous t-PA therapy compared with middle cerebral artery occlusion.