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急性缺血性腦中風(Acute Ischemic Stroke)發作8小時內接受機械取栓術(Endovascular Thrombectomy, EVT)治療，可提升病人預後、降低殘疾嚴重程度，分析2018年1月1日至2019年4月30日共計55位個案，其中7位案例合併其他原因、急性疾病故排除，因此由急診檢傷至抵達血管攝影室接受穿刺止之個案數共計48名。參考文獻後，將檢傷至穿刺時間(Door-to-Puncture Time)之目標值設定為120分鐘。48名個案從入急診到接受EVT時間平均值為173分鐘，達成率僅10.4%，平均住院日為36.8天。參考國際文獻及標竿北市醫中後，發現仍有改善空間，即成立跨領域照護團隊，分析延遲原因為人員對檢查流程備物生疏、傳呼不到傳送員、資訊系統不完備、訊息傳遞異常等，團隊共同制定跨單位機械取栓護理交班單、搶救急性中風衛教單、創意研發固定帶、增設計時器及EVT Bundle包、修訂腦中風暨機械取栓標準流程及傳送員管理辦法後，接受EVT病人平均時間由173分鐘降至112.6分鐘、120分鐘內完成EVT比率由10.4%提升至68.8%。由品管圈的執行，不但優化了各單位作業流程、縮短治療時間，更提供病人即時且優質的照護。 Multiple studies have indicated that receiving an endovascular thrombectomy (EVT) within 8 hours from the onset of acute ischemic stroke substantially improves the patient’s prognosis and reduces the likelihood of disability. In this study, we analyzed 55 patients with acute ischemic stroke who underwent an EVT between January 1, 2018, and April 30, 2019, at Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan. From these patients, 48 were included in the final analysis and 7 were excluded for other reasons, such as having concomitant acute illnesses. According to a literature review, we set our optimum door-to-puncture (D2P) time to within 120 minutes, starting from the arrival at the emergency department to the time of arterial puncture for EVT. The average D2P time for the 48 patients was 173 minutes, and only 10.4% of the patients had a D2P time that was less than 120 minutes (our target), with an average hospital stay of 36.8 days. Room for improvement remained, as indicated by comparisons with data from international studies and from other medical centers in Taipei. Therefore, we formed a multidisciplinary team and identified the causes of the delays, including staff unfamiliarity with the clinical protocol, insufficient manpower for transportation, lack of information technology support, and ineffective communication among different departments. The team then worked together and formulated a nursing staff sign-off checklist for EVT, published educational pamphlets advocating timely interventions for acute stroke for the general public, and invented a head immobilization hood for patients with stroke. A timer was also placed at the triage desk to assist with adherence to the protocol. In addition, an institutional protocol including porter management was established as part of our EVT bundle. After the implementation of such an EVT bundle strategy, 68.8% of our patients had a D2P time of less than 120 minutes (up from 10.4%) and the average D2P time decreased from 173 to 112.6 minutes. In conclusion, by establishing a quality control circle, we not only streamlined the workflow among different departments but also optimized the treatment cycle and provided our patients with the best care possible. &nbsp

BACKGROUND AND PURPOSE The CHA2 DS2 -VASc score has immense prognostic value in patients with embolic stroke of undetermined source (ESUS). We aimed to determine the usefulness of advanced renal dysfunction and its addition to the CHA2 DS2 -VASc score in improving predictive accuracy. METHODS In total, 3775 ESUS patients were enrolled from a nationwide hospital-based prospective study. Advanced renal dysfunction was defined as estimated glomerular filtration rate 2 at first-, third-, and sixth-month post-stroke. The renal (R)-CHA2 DS2 -VASc score was derived by including advanced renal dysfunction in the CHA2 DS2 -VASc score. Risk stratification improvement after including advanced renal dysfunction was assessed using C statistic, integrated discrimination improvement (IDI), and category-free net reclassification index (NRI). RESULTS After adjusting for confounding factors and CHA2 DS2 -VASc score, advanced renal dysfunction showed significant associations with all-cause mortality (HR: 2.88, 95% CI: 1.92-4.34) and poor functional outcome at third- (OR: 2.69, 95% CI: 1.47-4.94) and sixth-month post-stroke (OR: 2.67, 95% CI: 1.47-4.83). IDI and NRI showed that incorporating advanced renal dysfunction significantly improved risk discrimination over the original CHA2 DS2 -VASc score. R-CHA2 DS2 -VASc score ≥2 increased risk by 1.94-fold (95% CI: 1.15-3.27) for all-cause mortality, and ≥4 increased risk by 1.62-fold (95% CI: 1.05-2.50) of poor functional outcome at third-month post-stroke and by 1.81-fold (95% CI: 1.19-2.75) at sixth-month post-stroke. CONCLUSIONS Advanced renal dysfunction was significantly associated with clinical and functional outcomes in ESUS patients and may improve prognostic impact of the CHA2 DS2 -VASc score.

The CHAIn total, 3775 ESUS patients were enrolled from a nationwide hospital-based prospective study. Advanced renal dysfunction was defined as estimated glomerular filtration rate30 ml/min per 1.73 mAfter adjusting for confounding factors and CHAAdvanced renal dysfunction was significantly associated with clinical and functional outcomes in ESUS patients and may improve prognostic impact of the CHA

Objective Features of cerebral autosomal dominant arteriopathy with subcortical infarct and leukoencephalopathy ( CADASIL) caused by NOTCH3 mutations vary between ethnicities and regions. In Taiwan, more than 70% of CADASIL patients carry the mutation hot spot of p.R544C. We investigated the prevalence of NOTCH3 p.R544C mutation in stroke patients in Taiwan. Methods This prospective, multicenter study recruited acute stroke patients within 10 days of symptom onset. The p.R544C mutation was identified by polymerase chain reaction with confronting two‐pair primers and sequencing. Clinical parameters, vascular risk factors, stroke subtypes, and stroke outcomes were analyzed. Results Of the 1970 stroke patients (mean age 61.1 ± 13.6 years, male 69.5%) included, 1705 (86.5%) had ischemic stroke and 265 (13.5%) had intracerebral hemorrhage. The prevalence of p.R544C in the study population was 2.8% (95% confidence interval [CI] = 2.1–3.5%). The prevalence was highest in patients with small vessel occlusion type of ischemic stroke (5.6%), followed by intracerebral hemorrhage (5.3%), and infarct of undetermined etiology (2.7%), and was low in patients with cardioembolism (0.8%) and large artery atherosclerosis (0.7%). All p.R544C patients with intracerebral hemorrhage were nonlobar hemorrhage. Sibling history of stroke (odds ratio [OR] = 4.50, 95% CI = 1.67–12.14 in ischemic stroke; OR = 6.03, 95% CI = 1.03–35.47 in intracerebral hemorrhage, respectively) and small vessel occlusion (OR, 4.03, 95% CI, 1.26–12.92) were significantly associated with p.R544C. Interpretation p.R544C NOTCH3 mutation is underdiagnosed in stroke patients in Taiwan, especially in those with small vessel occlusion and sibling history of stroke.

Background and aims Renal dysfunction is a potent risk factor for cardiovascular diseases, including stroke. This study aimed to evaluate the impact of admission estimated glomerular filtration rate (eGFR) levels on short-term (1-month) and long-term (1-year) mortality in patients with acute ischemic stroke. Methods From the Taiwan Stroke Registry data, we classified ischemic stroke patients, identified from April 2006 to December 2015, into 5 groups by eGFR at admission: ≥ 90, 60–89, 30–59, 15–29, and Results Among 52,732 ischemic stroke patients, 1480 died within one month. The 1-month mortality rate was over 5-fold greater in patients with eGFR Conclusions After acute ischemic stroke, patients with reduced eGFR are at elevated risks of short-term and long-term deaths in a graded relationship.

We investigated the impact of serum cholesterol levels on 30-day mortality after ischemic stroke in dialysis patients.From the Taiwan Stroke Registry data, we identified 46,770 ischemic stroke cases, including 1101 dialysis patients and 45,669 nondialysis patients from 2006 to 2013.Overall, the 30-day mortality was 1.46-fold greater in the dialysis group than in the nondialysis group (1.75 versus 1.20 per 1000 person-days). The mortality rates were 1.64, .62, 2.82, and 2.23 per 1000 person-days in dialysis patients with serum total cholesterol levels of 120 mg/dL, 120-159 mg/dL, 160-199 mg/dL, and ≥200 mg/dL, respectively. Compared to dialysis patients with serum total cholesterol levels of 120-159 mg/dL, the corresponding adjusted hazard ratios of mortality were 4.20 (95% confidence interval [CI] = 1.01-17.4), 8.06 (95% CI = 2.02-32.2), and 6.89 (95% CI = 1.59-29.8) for those with cholesterol levels of 120 mg/dL, 160-199 mg/dL, and ≥200 mg/dL, respectively.Dialysis patients with serum total cholesterol levels of ≥160 mg/dL or 120 mg/dL on admission are at an elevated hazard of 30-day mortality after ischemic stroke.

A 61-year-old man with myasthenia gravis who previously underwent post-thymectomy radiotherapy for a metastatic thymoma presented with altered mental status. Examination revealed papilledema and frontoexecutive dysfunction.

Cerebral autosomal dominant arteriopathy with subcortical infarct and leukoencephalopathy (CADASIL) caused by mutations of the 33-exon NOTCH3 gene is the most common single gene disorder of stroke.1 To date, more than 200 different NOTCH3 mutations have been reported worldwide, while R544C in exon 11 was the most prevalent hot spot mutation in East Asia and accounted for more than 70% of the patients in their CADASIL cohorts.2 3 Patients with CADASIL may suffer from ischaemic stroke (IS) and intracerebral haemorrhage (ICH), especially among Asians. Therefore, we aimed to compare the clinical features of acute ICH vs IS events in patients with CADASIL and focused on the effects of ICH on stroke recurrence and long-term outcome. The patients enrolled in this study were prospectively recruited from a multicentre stroke registry established since 2006 with at least 12 hospitals in Taiwan. We screened R544C mutation from participants who provided their blood sample and those whose harbouring R544C mutation were then included in the present study. Preadmission, inpatient and discharge data were collected by trained personnel. The responsible neurologist on each study site will examine the medical record or interview the patients to acquire follow-up information. All patients received at least one neuroimaging examination to document the locations of acute stroke. Abnormal white matter hyperintensity (WMH) lesion was scored by the Fazekas scale. The number and …

Background Cumulative evidence has shown that low mitochondrial DNA (mt DNA ) content is related to elevated oxidative stress and atherosclerosis, which play important roles in ischemic stroke. The objective of this study was to explore the association between mt DNA content in peripheral blood leukocytes and ischemic stroke. Methods and Results A total of 350 patients with first‐ever ischemic stroke and 350 healthy controls were recruited in this case‐control study. The mt DNA content in peripheral blood leukocytes was determined by quantitative real‐time polymerase chain reaction. The levels of oxidized glutathione, reduced glutathione, and 8‐hydroxy‐2′‐deoxyguanosine were measured by ELISA kits. Multivariate logistic regression models were used to analyze the relationship between mt DNA content in peripheral blood leukocytes and ischemic stroke. Our results show that mt DNA content of patients with ischemic stroke was notably lower compared with controls. A significant association was found between low mt DNA content and ischemic stroke. Furthermore, significant interactions were identified between low mt DNA and proven risk factors in patients with ischemic stroke. The levels of oxidized glutathione and 8‐hydroxy‐2′‐deoxyguanosine were significantly greater in patients with ischemic stroke compared with controls. Conclusions Our results demonstrate that low mt DNA content in peripheral blood leukocytes is associated with ischemic stroke. The relationship of low mt DNA content and ischemic stroke was particularly notable in individuals who had low mt DNA content combined with diabetes mellitus, metabolic syndrome, or cigarette smoking. Oxidative stress may be one of the contributory factors to decreased mt DNA content in patients with ischemic stroke.

Hypoperfusion on single-photon emission computed tomography (SPECT) of the stroke-like lesion (SLL) at the hyperacute stage of mitochondrial encephalopathy with lactic acidosis and stroke-like episodes (MELAS) is considered to be a supportive evidence of the mitochondrial angiopathy theory. Our objectives were to examine whether other neuroimages, especially transcranial color-coded sonography (TCCS), done at the hyperacute stage of stroke-like episode (SLE) is consistent with hypoperfusion of the SLL. We reviewed the magnetic resonance imaging (MRI), SPECT, cerebral angiography, and TCCS of a patient with MELAS syndrome, all of which were performed at the hyperacute stage of one SLE. MRI on the 1st day post SLE showed right temporoparietal lesion with vasogenic edema. SPECT on the 2nd day showed focal decreased uptake of technetium-99m hexamethylpropyleneamine oxime ((99m)Tc-HMPAO) in the same region, but cerebral angiography and TCCS on the 3rd day showed increased regional cerebral blood flow (rCBF) and distal arteriole dilation in the same region. TCCS can delineate increased rCBF of the SLL at the hyperacute stage of SLE. We propose that the discrepancy between the decreased (99m)Tc-HMPAO uptake and increased rCBF might be caused by mitochondrial dysfunction. The phenomenon of "hypoperfusion" on SPECT might be caused by cell dysfunction but not decreased rCBF. We suggest that SPECT can be complemented by angiography and TCCS in future studies to delineate the perfusion status of SLLs.

Rhino-orbito-cerebral mucormycosis is a fatal infection in immunocompromised hosts. Prompt recognition of this clinical condition is essential for early diagnosis to avoid a delay of treatment. The presence of black eschar, usually in the nasal cavity, is the most alerting sign to the diagnosis. We present a patient with extremely fulminant ROCM in which the disease might be acquired via an orbital infection without nasal or paranasal involvement. With black eschars appearing at the bilateral canthi as the first alarm to extensive vascular involvement, the lethal infection rapidly evolved to occlusion of the bilateral ophthalmic arteries and eventually major intracranial arteries.