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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.

BACKGROUND Recent studies have shown that ingestion of glucose water lowers blood pressure (BP) in patients with perturbed autonomic control and more modestly lowers BP in elderly normal subjects. Whether glucose water affects cardiovascular control during orthostatic stress in normal young healthy subjects is unknown. We hypothesized that glucose water ingestion will reduce orthostatic tolerance in young healthy volunteers. METHODS In a randomized, controlled, within-subject study, 15 healthy male subjects (21-28 years of age) ingested water or 10% glucose water 5 min before tilt-table testing. We measured finger BP, brachial BP, heart rate, and peripheral vascular resistance. Orthostatic tolerance was measured as the time to presyncope during a 70 degrees head-up tilt, in which the head was tilted for 45 min or until presyncopal symptoms were observed. RESULTS During the first 45 min of tilt, 8 of 15 subjects who ingested 10% glucose water experienced presyncope, but only 2 of 15 who ingested water (P = 0.029) experienced presyncope. Ingestion of 10% glucose water increased the heart rate significantly more than pure water during head-up tilt (P = 0.026). Ingestion of water increased the peripheral vascular resistance significantly >10% glucose water during the head-up tilt test (P = 0.013). CONCLUSIONS Ingestion of 10% glucose water impairs head-up tilt tolerance relative to water ingestion. The contrasting effect of 10% glucose water vs. pure water on orthostatic tolerance is associated with increased heart rate and attenuation of the increase in peripheral vascular resistance in head-up tilt testing.

Hereditary protein C deficiency is inherited primarily as an autosomal dominant trait with incomplete penetrance. Arterial thrombosis, especially of the intracranial arteries, due to this deficiency is relatively rare. A 31-year-old man was admitted to our department because of sudden onset of neurological symptoms. Magnetic resonance imaging of the brain disclosed an acute ischemic infarction of the area supplied by the left middle cerebral artery. Protein C antigen was 40.7% (77-129%) and protein C activity was 46.3% (70-140%). No other possible associated causes of stroke were present. A survey of his relatives for protein C deficiency showed this deficiency in his mother, brother, sister and nephews. Protein C concentrations should be determined in cases of ischemic stroke in all young patients with no other major risk factors. Once protein C deficiency is detected, a search for protein C deficiency in the patient's relatives should be performed to prevent the occurrence of ischemic strokes.

Background Intracranial stenosis (ICS) is a major determinant of ischemic stroke in Asians. We determined the clinical significance of different risk factors and the role of ICS in Taiwanese patients with varied distributions of cervicocerebral stenosis. Methods and Results Presence of extracranial carotid stenosis (ECS, ≥70%) and ICS (>50%) was examined in 13 539 patients using ultrasonography and magnetic resonance angiography, respectively. Seven hundred thirty‐three patients with non‐ECS/ICS (n=372), isolated ICS (n=112), isolated ECS (n=121), or combined ECS/ICS (CEIS, n=128) were selected. Prevalence of ischemic stroke in each group was compared, and risk factors for stenosis were determined. The area under the receiver operating characteristic curve for each risk factor was calculated. Prevalence of ischemic stroke was highest in patients with CEIS (odds ratio 15.86; P P P =0.011), and non‐ECS/ICS. Multivariate logistic regression analysis revealed that hypertension, coronary artery disease, and smoking were risk factors for isolated ECS; hypertension, diabetes mellitus, coronary artery disease, and smoking were risk factors for isolated ICS; and diabetes mellitus, coronary artery disease, and smoking were risk factors for CEIS. Smoking, diabetes mellitus, and coronary artery disease were the greatest contributors to CEIS, isolated ICS, and isolated ECS, respectively. Conclusions CEIS was associated with higher odds of ischemic stroke compared with isolated ICS and isolated ECS. Smoking and diabetes mellitus, major determinants of CEIS and isolated ICS, should be targeted in therapeutic strategies to reduce the risk of ischemic stroke.

Background Intractable hiccups are occasionally encountered in the presence of stroke but are usually difficult to manage. Methods We describe two stroke patients with intractable hiccups that were refractory to pharmacological treatment but were well resolved by application to relevant acupoints with the modality linear polarized near-infrared ray equipment on PC 6 (Nei Guan), ST 36 (Zu San Li), and DU 9 (Chih Yang), which are the empirical acupoints aimed at regulating gastrointestinal mobility and function of the thoracic organ. Results The first patient who received the treatment for only one time came out with a dramatic termination of intractable hiccups 3 hours later and with no recurrence thereafter. We applied the same treatment on the second patient once a day for 8 consecutive days, which led to progressive amelioration of intractable hiccups. Conclusions This is the first report about the complete resolution of intractable hiccups due to stroke using near-infrared irradiation to acupoints, rather than using conventional pharmacologic therapy, traditional acupuncture, or moxibustion. Consequently, these findings suggest that linear polarized near-infrared ray irradiation, with its noninvasive properties, might be an alternative treatment for intractable hiccups after stroke.

Nigral dopaminergic projections to the striatum are targeted in Parkinson's disease (PD). The extent of the degeneration of the dopaminergic system in PD can be visualised by dopamine transporter imaging using single-photon emission tomography (SPET). In this study in 188 patients with PD, we analysed the image patterns and compared them with the clinical features in order to verify the usefulness of technetium-99m TRODAT-1 brain SPET in the evaluation of patients with PD. Two independent readers visually assessed SPET slices from three brain axes according to a "fine" visual scale; results were also grouped according to a "rough" visual scale. Results of both visual and semi-quantitative analyses were compared among patients with different stages of PD and healthy controls. There was good agreement between the readers in the interpretation of the image patterns [kappa statistic (kappa)=0.85 for the presence of PD; kappa=0.88 for the rough scale and 0.81 for the fine scale]. Good concordance was obtained when visual interpretation was used to evaluate the presence of PD (sensitivity = 98%, specificity = 86%, kappa = 0.85). Semi-quantitative analyses revealed significant negative correlations between both striatal and putaminal uptake and disease severity as assessed using the Hoehn and Yahr scale (rho = -0.89 and -0.93 respectively). An apparent decrease in striatal uptake in early PD, hardly discernible from the uptake level in advanced PD, was commonly found in visual analyses. The results suggest that both visual and semi-quantitative analyses of 99mTc-TRODAT-1 SPET images reflect neurodegeneration in PD, and that 99mTc-TRODAT-1 SPET represents an adequate means for evaluation of the status of patients with PD.

Background Discharge disposition planning is vital for poststroke patients. We investigated clinical factors associated with discharging patients to nursing homes, using the Taiwan Stroke Registry data collected from 39 major hospitals. Methods We randomly assigned 21,575 stroke inpatients registered from 2006 to 2008 into derivation and validation groups at a 3-to-1 ratio. We used the derivation group to develop a prediction model by measuring cumulative risk scores associated with potential predictors: age, sex, hypertension, diabetes mellitus, heart diseases, stroke history, snoring, main caregivers, stroke types, and National Institutes of Health Stroke Scale (NIHSS). Probability of nursing home care and odds ratio (OR) of nursing home care relative to home care by cumulative risk scores were measured for the prediction. The area under the receiver operating characteristic curve (AUROC) was used to assess the model discrimination against the validation group. Results Except for hypertension, all remaining potential predictors were significant independent predictors associated with stroke patient disposition to nursing home care after discharge from hospitals. The risk sharply increased with age and NIHSS. Patients with a cumulative risk score of 15 or more had an OR of 86.4 for the nursing home disposition. The AUROC plots showed similar areas under curves for the derivation group (.86, 95% confidence interval [CI], .85-.87) and for the validation group (.84, 95% CI, .83-.86). Conclusions The cumulative risk score is an easy-to-estimate tool for preparing stroke patients and their family for disposition on discharge.

In 24 patients with vascular dementia of Binswanger's type (VDBT) and 14 age-matched neurologically normal volunteers, we investigated the relationship between clinical features, white matter lesions (leuco-araiosis) and cerebral atrophy on computed tomographic (CT) scan, and regional cerebral blood flow. All subjects underwent the Mini-Mental State Examination of Taiwan, version 1 (MMSE-T1), for assessing the severity of cognitive impairment. The patients were subdivided into two groups, one with mild to moderate (group I, MMSE-T1 scores: 11-24, n=11), and the other with severe dementia (group II, MMSE-T1 scores: below 10, n=13). White matter degeneration was evaluated with densitometric methods. Loss of brain parenchyma was estimated with seven linear measurements (Evan's ratio, third ventricle ratio, width of temporal horn tip, anterior-posterior length of temporal horn, anterior-posterior length of Sylvian fissure and width of frontal interhemispheric fissure) by CT scans. Regional cerebral blood flow was determined with technetium-99m hexamethylpropylene amine oxime (HMPAO) single-photon emission tomography (SPET). In neuroimaging studies, subcortical leuco-araiosis was localized at the frontal region in group I patients and scattered diffusely in group II patients. 99mTc-HMPAO SPET analysis revealed reduction of regional cerebral blood flow in the frontal lobe in group I patients and widespread reduction of regional cerebral blood flow in group II patients. A correlation between frontal leuco-araiosis and perfusion defect of the frontal pole was demonstrated in group I patients, showing findings typical of subcortical dementia. There was no difference in frontal atrophic measurements between group I patients and controls. Ratios of volumes of lost brain parenchyma and leuco-araiosis were significantly higher in group II patients than in the age-matched controls, corresponding to a diffuse cerebral perfusion defect. These results suggest that patients with VDBT have early frontal lobe involvement with posterior progression. Patients with mild VDBT are more likely to show reduction of frontal cerebral blood flow and leuco-araiosis, while those with severe VDBT are more likely to have diffuse leuco-araiosis, cerebral hypoperfusion and brain atrophy.

The purpose of this study was to evaluate molecular evidence of nigrostriatal pathway involvement in Japanese encephalitis (JE) survivors with movement complications.Three JE patients were recruited. All had cranial magnetic resonance imaging (MRI) and single-photon emission computed tomography (SPECT) studies with (99m)Tc-TRODAT-1 and (123)I-IBZM.Cranial MRI revealed involvement of bilateral thalami, substantia nigra, and medial temporal lobes in all three patients, but only case 1 had additional bilateral basal ganglia involvement. The (99m)Tc-TRODAT-1 SPECT for presynaptic dopamine transporter imaging disclosed asymmetrical decreases in bilateral striatal uptake in all three patients. However, the (123)I-IBZM SPECT imaging for postsynaptic D2 dopamine receptors (D2Rs) revealed inconsistent abnormalities including asymmetrical bilateral decreases (case 1), unilateral decrease (case 2), and bilateral increases (case 3) in striatal uptakes.Data have suggested that presynaptic dopaminergic neurons in JE patients are more susceptible to JE virus than postsynaptic striatal neurons. The degree of movement impairment was more closely correlated to the degree of D2Rs disruption seen in (123)I-IBZM SPECT imaging.

BACKGROUND Neuropsychiatric symptoms as the initial presentation of dural arteriovenous fistula (DAVF) are unusual. Anticoagulation therapy may be warranted for prevention of further thromboembolism if an underlying thrombophilia condition is diagnosed. CASE REPORT We present a 70-year-old woman with sensory aphasia, who was diagnosed with a DAVF, Cognard type II a + b, by cerebral angiography. Her stroke-like syndrome resolved after transarterial embolization of the left occipital and middle meningeal arteries. Meanwhile, hypercoagulability was found because of hyperhomocysteinemia and the presence of a lupus anticoagulant. One month later, she suffered an acute pulmonary embolism and was started on anticoagulation therapy before stereotactic radiosurgery. CONCLUSION Sensory aphasia may be the initial manifestation of a transverse-sigmoid sinus DAVF even if there are no symptoms such as headache or tinnitus. We postulate that early anticoagulation therapy is indicated for preventing thromboembolism in DAVF patients with thrombophilia because the possibility of intracranial bleeding has been reduced by embolization.

Background: Epidemiological evidence suggests that heavy alcohol consumption increases the risk for either stroke or liver disease. The goal of this study was to determine whether heavy drinkers with mild liver disorder (MLD) are at risk of hemorrhagic stroke. Methods:All of the 524 patients recruited were males with a first-ever acute stroke and were consecutively admitted to the Tri-Service General Hospital between January 2000 and December 2001. The risk factors, liver function, stroke subtypes, and hemostatic factors were assessed among 68 patients defined as heavy drinker stroke (HDS) and 456 patients as nonheavy drinker stroke (NHDS). Results: HDS patients had a significantly higher incidence of hemorrhagic stroke than NHDS patients. HDS patients were also associated with significantly higher occurrence of cigarette smoking, hyperuricemia, liver dysfunction, and significantly lower platelet counts. HDS patients with MLD were more likely to have hemorrhagic stroke (76.5%) than HDS patients without MLD (33.3%) and NHDS patients with (40.3%) or without (26.7%) MLD. HDS patients with MLD also exhibited a significantly higher glutamic oxaloacetic transaminase/glutamic pyruvic transaminase ratio (2.0 ± 1.2) and lower platelet number (185,000 ± 85,000 per µl) when compared with HDS patients without MLD (1.4 ± 0.5; 206,000 ± 59,000 per µl) and NHDS patients with (1.1 ± 1.0; 256,000 ± 97,000 per µl) or without (1.4 ± 0.7; 216,000 ± 68,000 per µl) MLD. Conclusions: HDS patients with MLD are at higher risk for hemorrhagic stroke in part due to the changes in hemostatic factors, although other factors may also contribute to hemorrhagic stroke.

The purpose of this study was to examine depression and the related factors in elderly stroke patients. Purposive sampling was used to recruit 106 par tic i pants from the out patients department (OPD) of a teaching hospital in Taipei. The major findings of this study were: (1) Twenty-nine stroke survivors (27.4%) and eight stroke survivors (7.5%) were classifled as having mild depression and mod e r ate to severe depression, respectively. (2) There was no significant difference or correlation between the depression score and demo graphic character is tics, chronicillness condition, or disease character is tics. The depression scores in “worrying about nothing” were significantly lower than the depression scores in “worrying about disease” (t(subscript _)=-4.03, p(subscript _)=.03). (3) There was no significant correlation between the depression score and the Mini-Mental State Examination score, or the Barthel Index score. (4) Social sup port and depression were negatively correlated (?(subscript _)=-.306, p(subscript _)=.001). (5) Multiple regression anal y sis revealed that “worrying about disease,”“ worrying about family,” and informational sup port from family, relatives and friends accounted for 22.1% of the variance in depression. The implications for clinical practice and further studies are suggested.

BACKGROUND Cranial nerve palsy is a rare complication after patients with nasopharyngeal carcinoma (NPC) receive radiotherapy using a technique that delivers 180–200 centigrays (cGy) per day. Cranial neuropathy is of particular clinical interest in terms of making a differential diagnosis, because it is also a common presenting manifestation in patients with NPC. Cranial neuropathy may lead to distressing signs and symptoms in these patients, and their treatment has not been addressed in previous reports. This article presents the authors' experience with radiotherapy-related cranial nerve palsy in patients with NPC. METHODS Nineteen patients were diagnosed with radiation-related neuropathy. Patients with recurrent tumors or with a suspicion of persistent or recurrent tumors were excluded. Most patients were treated using 180 cGy or 200 cGy per fraction per day. The total dose was 7000–13,000 cGy to the nasopharynx and 5000–9000 cGy to the neck. Unilateral vocal cord paralysis alone and hearing loss were not included in the analysis. RESULTS There were 15 male patients and 4 female patients. The latency before palsy occurred was 12–240 months. Single nerve palsy developed in four patients, including two patients with hypoglossal palsy and two patients with recurrent laryngeal palsy. Two patients had three nerve palsies each. The other 13 patients presented with 2 nerve palsies each. Vagus and hypoglossal palsy appeared to be a frequent combination and occurred in 11 patients. Overall, there were 17 patients with hypoglossal palsy (7 bilateral, 8 left-sided, and 2 right-sided), 11 patients with vagus palsy (2 bilateral, 7 left-sided, and 2 right-sided), 6 patients with recurrent laryngeal nerve palsy (5 bilateral), and 2 patients with accessory palsies (all bilateral). Marked neck fibrosis was present in 12 patients. Patients who had vocal cord paralysis suffered from easy choking and hoarseness. Severe respiratory difficulty occurred in two patients who had bilateral vocal cord palsy. Surgical procedures included laryngoplasty, tracheostomy, and gastrostomy. Quality of life improved considerably after patients underwent surgery. CONCLUSIONS Radiotherapy-related cranial nerve palsy may occur in patients with NPC after they receive conventional radiotherapy. Hypoglossal nerve palsy was found the most frequently in this series, followed by vagus nerve palsy and recurrent laryngeal nerve palsy. Neck fibrosis and the course of the three nerves through the neck may be important risk factors for the development of palsy. The diagnosis must be made only after the possibilities of tumor-induced palsy and idiopathic palsy are excluded. Surgery is helpful in improving the quality of life in many patients. Cancer 2002;95:404–9. © 2002 American Cancer Society. DOI 10.1002/cncr.10668

We report on a healthy female with a unique relapsing transverse myelitis accompanied by herpes simplex virus type 1 (HSV-1) infection. Magnetic resonance imaging showed cord enlargement and increased signal intensity on T1-weighted image with gadolinium enhancement from T-4 to T-10 during the first attack and from C-1 to C-2 during the second episode. She was not diagnosed during the first attack. During the second episode, laboratory studies disclosed IgM and IgG antibodies to HSV at the outset with greater than fourfold increases in antibody levels in the serum and cerebrospinal fluid (CSF). Cells cultured from the CSF were positive for HSV-1 according to the immunofluorescence method. The presence of HVS-1 DNA in CSF was documented by polymerase chain reaction (PCR) technique. Acyclovir was given with a partial recovery. We anticipate that PCR assay of CSF will assist early diagnosis of herpetic central nervous system disorders.

Cerebral venous sinus thrombosis is a rare neurologic manifestation of antiphospholipid syndrome. We report a case of a 49-year-old woman who presented to the emergency department with recurrent episodes of transient clumsiness of the left upper extremity. The results of unenhanced brain computed tomography and electroencephalography were unremarkable. Serial neuroimages revealed superior sagittal sinus thrombosis. Thrombophilia screen disclosed positive lupus anticoagulant. In this case report, we aim to emphasize the significance of recognizing an unusual presentation of antiphospholipid syndrome.

We present serial magnetic resonance imaging (MRI) scans on a biopsy-verified case of Creutzfeldt-Jakob disease (CJD). The initial MRI scan demonstrated increased T2 signal-intensity within the basal ganglia and thalami. Subsequent MRI scans demonstrated a thin cortex, increased T2 signals diffusely within the white matter including U-fibers, and hypointense T2 signals within the basal ganglia, and thalami. Proton magnetic resonance spectroscopy (1H-MRS) study showed an absence of creatine, choline and N-acetylaspartate signals. By these characteristic findings, serial MRI and MRS studies may be helpful in differentiating CJD from other dementing illnesses.

Ten recruited soldiers developed acute left wrist drop and numbness on the back of the thumb after a three hour military shooting training. Neurological examination disclosed decreased muscle power (0-2/5) of left wrist dorsiflexion, hypalgesia and hypaesthesia on the radial side of the left hand, and diminished brachioradialis reflex. Electrophysiological studies showed prolonged distal latency, reduced amplitude and slowness of left radial nerve motor conduction velocity between the axilla and elbow. Electromyography (EMG) revealed fibrillation potentials at rest, polyphasic motor unit and an incomplete interference pattern at volition over the extensor digitorum communis and brachioradialis. Nine patients recovered completely clinically and electrophysiologically between nine and 12 weeks after the onset of the palsy. Sensation recovered faster than the weakness. One patient failed to recover after three months, possibly because of the longer duration of nerve compression. Longer nerve compression time and sustained, decreased muscle power with signs of active denervation in EMG are indicators of poor prognosis.