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Abstract: Isolated middle cerebral artery dissection (MCAD) has rarely been encountered clinically and few have reviewed it systemically. The etiologies, clinical manifestations, natural clinical course and prognosis of MCAD remain poorly understood. From 1995 to 2004, there were 5 cases diagnosed clinically and angiographically to have MCAD (isolated MCAD in 1, ICAD-MCAD in 4) from a medical center in Taiwan. MEDLINE (1966–2003) was searched for published articles in English that concerned the diagnosis of MCAD. Clinical presentations, stroke types, angiographic findings, etiologies, treatment strategies and outcomes were compared between cases with isolated MCAD or ICAD-MCAD. There were 23 cases (male, 46%; mean age, 22.9±19.5 years) with 24 events of isolated MCAD and 31 cases (male, 47%; mean age, 22.2±12.9 years) with 35 events of ICAD-MCAD. The types of stroke in isolated MCAD group included subarachnoid hemorrhage (12%) and cerebral infarction (88%); and in ICAD-MCAD group were subarachnoid hemorrhage (6%) and cerebral infarction (94%). The presenting symptoms were similar between both groups. Fluctuating course was more often in isolated MCAD than in ICAD-MCAD (17% vs. 3%, p =0.061). Recurrence of dissection events in both groups was infrequent (4% vs. 9%, p =0.56). Both groups had high case-fatality rates (MCAD, 48%; ICAD-MCAD, 58%). The cause of dissection in both groups was idiopathic in the majority. Congenital vessel wall defects were found in 26% of ICAD-MCAD, but in only 4% of isolated MCAD (p =0.066). In contrast, preceded trauma was more often found in isolated MCAD than ICAD-MCAD (35% vs. 19%, p =0.085). Arteritis was noted in 16% of ICAD-MCAD patients, but none in isolated MCAD. Angiography revealed segmental stenosis in 72% of isolated MCAD and 96% of ICAD-MCAD. Aneurysmal dilatation of the involved cerebral arteries was noted in 28% of isolated MCAD, but none in MCAD-ICAD. Both isolated MCAD and ICAD-MCAD can cause vascular events with high mortality rates. Several aspects differed between 2 groups, including clinical course, underlying etiologies and angiographic findings. [Copyright &y& Elsevier]

Pregnancy may increase the risk of stroke. However, few studies have compared strokes in women of reproductive age that occur in pregnancy or the puerperium (pregnancy-related stroke, PRS) with those unrelated to pregnancy. This study assesses risk factors and etiologies of stroke in these women based on relationship to pregnancy. From 1984 to 2002, all female patients 15 through 40 years of age with a first-ever stroke at National Taiwan University Hospital were included in this study. PRS was defined as patients who had stroke occurrence during pregnancy or within 6 weeks postpartum. Stroke was categorized as cerebral infarction (CI), cerebral hemorrhage (CH), or subarachnoid hemorrhage (SAH) and divided into subtype according to etiology. Risk factors and etiologies were compared for patients with PRS and stroke unrelated to pregnancy. We identified 49 patients with PRS, and 353 patients with stroke unrelated to pregnancy. There was no statistically significant difference in distribution of CI subtypes. Cerebral venous thrombosis (CVT) was more common in PRS than stroke unrelated to pregnancy (39% vs. 7%, P<0.001), and 73% of these cases occurred postpartum. Preeclampsia–eclampsia was an important cause of peripartum CH (37%), but not CI (4%). Among PRS cases, postpartum cerebral venous thrombosis and preeclampsia–eclampsia were the major causes of CI and CH, respectively. [Copyright &y& Elsevier]

Abstract: Dysphagia increases the risk of pneumonia in stroke patients. This study aimed to evaluate bedside swallowing screening for prevention of stroke-associated pneumonia (SAP) in acute stroke patients admitted to the intensive care unit (ICU). Consecutive acute stroke patients admitted to the stroke ICU from May 2006 to March 2007 were included. Patients were excluded if they were intubated on the first day of admission or had a transient ischemic attack. A 3-Step Swallowing Screen was introduced since October 2006 and therefore patients were divided into pre-screen and post-screen groups. A binary logistic regression model was used to determine independent risk factors for SAP and in-hospital death. There were 74 and 102 patients included in the pre- and post-screen groups, respectively. Pneumonia was associated with higher National Institutes of Health Stroke Scale (NIHSS) score, older age, nasogastric and endotracheal tube placement. After adjusting for age, gender, NIHSS score and nasogastric and endotracheal tube insertion, dysphagia screening was associated with a borderline decrease in SAP in all stroke patients (odds ratio, 0.42; 95% CI, 0.18–1.00; p =0.05). However, dysphagia screening was not associated with reduction of in-hospital deaths. Systematic bedside swallowing screening is helpful for prevention of SAP in acute stroke patients admitted to the ICU. [Copyright &y& Elsevier]

Abstract: Stroke centers and intravenous tissue plasminogen activators (tPA) are effective management for acute ischemic stroke. This study aimed to analyze stroke center characteristics on the administration of thrombolytic therapy. A national survey of stroke centers in academic medical centers and regional teaching hospitals in Taiwan was conducted. The survey questions included the number of tPA or other thrombolytic therapies, presence of stroke intensive care units and wards, initiation of rehabilitation, and 15 criteria for establishment of stroke centers adopted from the Brain Attack Coalition''s recommendation. Factors influencing administration of thrombolytic therapy were analyzed. Intravenous tPA increased from 135 cases in 2004 to 246 cases in 2006, accounting for approximately 0.4% and 0.8% of all acute ischemic stroke patients in Taiwan, respectively. The frequency of thrombolytic therapy administration significantly correlated with stroke center criteria (Spearman''s rho=0.731, P <0.001). Multivariate analysis showed routine intravenous tPA protocol in the emergency room (odds ratio=4.6, P =0.042) and supervision by the stroke center director (odds ratio=3.7, P =0.031) significantly influenced the administration of thrombolytic therapy. Well-organized stroke centers, routine use of thrombolytic therapy protocols in the emergency room, and guidance by a stroke center director are important for enhancing thrombolytic therapy in patients with acute ischemic stroke. [Copyright &y& Elsevier]

Abstract: Multivariate models have not been widely used to predict the outcome of acute stroke patients admitted to the intensive care unit (ICU). The purpose of this study was to determine potential measures observed in the first 12 h post-stroke that predict early mortality and functional outcomes in ICU-admitted stroke patients. Eight hundred and fifty acute stroke patients (ischemic stroke, 508; intracerebral hemorrhage, 342) were included in this analysis between November 2002 and December 2006. Measures of interest were obtained in the first 12 h after onset of stroke were analyzed for three types of outcome: 3-month mortality, 3-month mortality or institutional care, and poor functional outcomes at discharge. Poor functional outcomes were defined as a Barthel index <80 or a Rankin scale >2. Multivariate regression models were used to determine the predictive value of the observed measures. After 3 months, 17% of patients had died; 21% were alive but being cared for in institutional settings; and 62% were alive and living at home. Functional status at discharge indicated 16% of patients had died, poor function in 50%, and good function in 34% of patients. Initial stroke severity, measured by National Institute of Health Stroke Scale, and dependence on a ventilator predicts 3-month mortality and poor outcome in all stroke patients. In addition, old age, previous stroke, and total anterior circulatory infarct were associated with poor outcome in ischemic stroke patients; old age, low body mass index and the presence of intraventricular hemorrhage were associated with poor outcomes in intracerebral hemorrhage patients. In conclusion, early stroke mortality and outcome at discharge can be predicted in the first few hours following an acute stroke for moderate to severe ICU-admitted stroke patients. [Copyright &y& Elsevier]

Abstract: The phenotype and genotype of cerebral autosomal dominant arteriopathy and subcortical infarcts and leukoencephalopathy (CADASIL) in Caucasians have been well characterized, but CADASIL is less recognized in Asian populations. Here we investigated the first known Taiwanese family affected by CADASIL and identified an uncommon NOTCH3 mutation. The family had clinical manifestations in affected members including recurrent strokes, early dementia, and depression, but not migraine. A skin biopsy in the proband patient showed characteristic pathological findings of CADASIL on electron microscopy. Afterward, genetic analysis found an Arg332Cys mutation at exon 6 of NOTCH3. Neuropsychological evaluation showed vascular dementia in two of four affected people. Head MRI showed multiple infarcts in bilateral basal ganglia, thalami, periventricular white matter, external capsules, and brainstem, but involvement of the anterior temporal pole was found only in two people with milder symptoms. To our knowledge, the Arg332Cys NOTCH3 mutation at exon 6, which was identified in the studied family, has not been reported in Asian populations. Our findings emphasize the importance of genetic analysis of NOTCH3 for Asians with a phenotype typical of CADASIL. [Copyright &y& Elsevier]

Abstract: Vascular lesions are infrequently recognized as manifestations of neurofibromatosis 1 (NF1), but they can produce serious complications and contribute to mortality at younger ages. Here we report the case of a young female patient with NF1 who suffered from a fatal middle cerebral artery (MCA) infarct. In addition to the MCA infarct, head MRI also disclosed old infarcts at bilateral cerebella and multiple intracranial arterial steno-occlusions. Stroke related to NF1 cerebral vasculopathy was highly suggested after other diseases were excluded. Additionally, genetic analysis of the patient identified a novel mutation at the splicing donor site, c. 2409+2T>G that resulted in a splicing aberration. [Copyright &y& Elsevier]