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Shinn-Kuang Lin,1,2 Pei-Ya Chen,1,2 Guei-Chiuan Chen,1 Po-Jen Hsu,1 Cheng-Lun Hsiao,1 Fu-Yi Yang,1 Chih-Yang Liu,1 Adam Tsou1 1Stroke Center and Department of Neurology, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei City, Taiwan; 2School of Medicine, Tzu Chi University, Hualien, TaiwanCorrespondence: Shinn-Kuang LinStroke Center and Department of Neurology, Taipei Tzu Chi Hospital, No. 289, Jian Guo Road, 231, Sindian District, New Taipei City, TaiwanTel +886-2-66289779 ext 3129Fax +886-2-66289009Email stuartlin0428@gmail.comPurpose: Immune–inflammatory processes are involved in all the stages of stroke. This study investigated the association of the neutrophil-to-lymphocyte ratio (NLR) with the hyperdense artery sign (HAS) observed on brain computed tomography (CT) and with clinical features in patients with acute ischemic stroke.Methods: We retrospectively enrolled 2903 inpatients with acute ischemic stroke from May 2010 to May 2019. Data collected included imaging studies, risk factors, laboratory parameters, and clinical features during hospitalization.Results: The HAS was identified in 6% of the 2903 patients and 66% of the 236 patients with acute middle cerebral artery occlusion. Patients with the HAS had a higher NLR. HAS prevalence was higher in men and patients with cardioembolism. The NLR exhibited positive linear correlations with age, glucose and creatinine levels, length of hospital stay, initial National Institutes of Health Stroke Scale (NIHSS) scores, and mRS scores at discharge. The NLR was significantly higher in patients with large-artery atherosclerosis and cardioembolism and was the highest in patients with other determined etiology. Multivariate analysis revealed that an initial NIHSS score of ≥ 10 and an NLR of > 3.5 were significant positive factors, whereas diabetes mellitus and age > 72 years were significant negative factors for the HAS, with a predictive performance of 0.893. An initial NIHSS score of ≥ 5, positive HAS, age > 75 years, diabetes mellitus, an NLR of > 3.5, female sex, a white blood cell count of > 8 × 103/mL, and elevated troponin I were significant predictors of unfavorable outcomes, with a predictive performance of 0.886.Conclusion: An NLR of > 3.5 enabled an efficient prediction of CT HAS. In addition to conventional risk factors and laboratory parameters, both an NLR of > 3.5 and CT HAS enabled improved prediction of unfavorable stroke outcomes.Keywords: acute ischemic stroke, hyperdense artery sign, neutrophil-to-lymphocyte ratio, NIHSS, unfavorable outcome

Background Atherosclerosis is a chronic inflammatory process that occurs in the arterial wall. This immuno-inflammatory process plays a role throughout all stages of stroke. Neutrophils, lymphocytes, and platelets are crucial blood cells for innate and adaptive immunity. This study investigated the associations of four types of immuno-inflammatory markers, namely the systemic immune-inflammation index (SII), neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), and neutrophil count (NC), with clinical outcomes in patients with acute ischemic stroke. Methods In this retrospective study, we enrolled 2903 inpatients with acute ischemic stroke from May 2010 to May 2019. Data included risk factors, laboratory parameters, and clinical features during hospitalization. The National Institutes of Health Stroke Scale (NIHSS), and modified Rankin Scale (mRS) were used to assess stroke severity and outcomes. Results All four immuno-inflammatory markers exhibited positive linear correlations with age, glucose, creatinine, length of hospital stay, NIHSS score on admission, and mRS score at discharge. The levels of the four immuno-inflammatory markers were significantly higher in patients with large-artery atherosclerosis and cardioembolism and were highest in patients with other determined etiology. Patients with levels of immuno-inflammatory markers higher than their cutoff values for unfavorable outcomes also exhibited higher rates of cancer history (except for SII and NC), uremia (except for NC), elevated troponin I, and in-hospital complications. Multivariate analysis including SII revealed that admission NIHSS score ≥ 5, age > 75 years, SII > 724, diabetes mellitus, female sex, elevated troponin I, heart disease, and prior stroke were significant predictors for unfavorable outcomes. These significant predictors were retained after replacing SII > 724 with NLR > 143, PLR > 3.5, or NC > 6 × 10 3 /mL, except for prior stroke. For a basic model comprising seven significant predictors of unfavorable outcomes, the C-statistic was 0.860. The addition of SII, NLR, and PLR to the basic model resulted in a significant improvement in the prediction performance to 0.864, 0.863, and 0.863, respectively. Conclusions Immuno-inflammatory markers provide more useful information than conventional risk factors and other laboratory parameters for the prediction of stroke outcomes. SII > 724 is the most appropriate marker when combined with other predictors.

Background: Efficacy of thrombolytic therapy decreases with time elapsed from symptom onset. We sought to identify the impact of code stroke on the thrombolytic therapy. Methods: Code stroke is activated by the emergency physician when a patient is eligible for thrombolytic therapy. We retrospectively reviewed patients with acute ischemic stroke between January 2011 and December 2014. Results: In total, 1809 patients were enrolled. Code stroke was activated in 233 of 351 patients arriving at the emergency room (ER) within 3 h of symptom onset, and in 21 patients arriving >3 h. The sensitivity, specificity, and positive and negative predictive values of code stroke were 76%, 46%, 72%, and 51%, respectively. Thrombolytic therapy was provided to 58 patients, accounting for 3.4% of all cerebral infarcts. Code stroke was activated in 40 of these patients. The most common reasons for excluding thrombolytic therapy were: National Institute of Health Stroke Scale (NIHSS) 80 years. Mean liaison-to-neurological evaluation time was only 6 min. Code stroke activation significantly reduced all the intervals, except for the onset-to-ER and door-to-order times. During the 4-year study period, there were significant reductions of the door-to-neurology liaison time by 28 min and door-to-laboratory time by 22 min. The proportion of door-to-needle time within 60 min improved from 33% in 2011 to 67% in 2014. Improved NIHSS scores during hospitalization were most prominent in tPA-treated patients. Symptomatic ICH occurred in 3.6% patients arriving within 3 h. Death occurred in 50% of patients received tPA treatment on family's request, and only 13% of those patients had favorable outcome. Conclusion: Code stroke is effective in reducing in-hospital delays. The accuracy of code stroke activation has acceptable sensitivity but low specificity. Rapid patient assessment by neurologists increases the number of patients eligible for thrombolytic therapy. Keywords: Acute stroke, Brain infarction, Code stroke, In-hospital delays, Thrombolytic therapy

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.

Background: Stroke and dementia represent frequent causes of psychophysical and socioeconomic burdens. We conducted a vascular, cognitive, and psychomental survey involving elderly volunteers at community-based recycling stations in Northern Taiwan.Methods: Recycling volunteers aged ≥60 years were surveyed. We recorded seven parameters, namely (1) body mass index (BMI), (2) fasting glucose, (3) fasting cholesterol, (4) ankle-brachial index (ABI), (5) carotid duplex sonography, (6) five-item Brief Symptom Rating Scale (BSRS-5) score, and (7) eight-item Interview to Differentiate Aging and Dementia (AD8). During the carotid duplex study, we measured the carotid intima-media thickness (CIMT) and the carotid total plaque score (CTPS) of the common and internal carotid arteries.Results: In total, 985 subjects (mean age: 70.8 years) participated in this study. Among these, 81% were women, and 52% were vegetarians. The average ABI, CIMT, and CTPS were higher in men, whereas women had higher cholesterol levels and BSRS-5 scores. Obesity, hypertension, hyperglycemia, and hyperlipidemia were present in 21, 38, 9, and 27% of all subjects, respectively. Carotid plaques with mild (CTPS 1–5), moderate (CTPS 5.1–10), and severe (CTPS > 10) atherosclerosis were detected in 45, 16, and 7% of the subjects, respectively. Mild cognitive impairment (AD8 > 2) was observed in 13% of the subjects, whereas moderate mood disorder (BSRS-5≧10) was observed in only 1% of subjects. Vegetarians had a lower BMI, systolic blood pressure (SBP), cholesterol, CIMT, and CTPS than did non-vegetarians. Substantial predictors of severe atherosclerosis were advanced age (>70 years), male sex, history of heart disease, hyperlipidemia, and currently elevated SBP and cholesterol levels. Predictors of mild cognitive impairment were illiteracy, history of hypertension, hyperlipidemia, and moderate mood disorder.Conclusions: Subclinical carotid atherosclerosis was common in elderly recycling volunteers, with 23% having moderate to severe stenosis. Vegetarians had a reduced risk of atherosclerosis. The low incidence of moderate mood disorder might indicate that recycling work enhances psychomental health. In addition, a healthier lifestyle, better mood condition, and vegetarian diet might contribute to lower incidence of mild cognitive impairment.

BACKGROUND AND PURPOSE The requirement for neurology liaison is increasing in accordance with the growing health care demands associated with aging populations. The aim of this study was to characterize the nature of neurological inpatient liaisons (NILs) to help plan for the appropriate use of neurology resources. METHODS This was a retrospective cross-sectional study of NILs in a secondary referral hospital over a 12-month period. RESULTS There were 853 neurological consultations with a liaison rate of 3% per admission case. Chest medicine, gastroenterology, and infectious disease were the three most frequent specialties requesting liaison, and altered consciousness, seizure, and stroke were the three most frequent disorders for which a NIL was requested. Infection was the most common cause of altered consciousness. Epilepsy, infection, and previous stroke were common causes of seizure disorders. Acute stroke accounted for 44% of all stroke disorders. Electroencephalography was the most recommended study, and was also the most frequently performed. Ninety-five percent of emergency consultations were completed within 2 hours, and 85% of regular consultations were completed within 24 hours. The consult-to-visit times for emergency and regular consultations were 44±47 minutes (mean±standard deviation) and 730±768 minutes, respectively, and were shorter for regular consultations at intensive care units (p=0.0151) and for seizure and stroke disorders (p=0.0032). CONCLUSIONS Altered consciousness, seizure, and stroke were the most common reasons for NILs. Half of the patients had acute neurological diseases warranting immediate diagnosis and treatment by the consulting neurologists. Balancing increasing neurologist workloads and appropriate health-care resources remains a challenge.

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.