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Although it is not recognized as essential to test for antiphospholipid antibody (aPL) in stroke of unknown cause, aPL-related stroke may account for a considerable number of cryptogenic strokes. We aimed to assess the current status and diagnostic value of aPL testing in cryptogenic stroke patients.Consecutive patients admitted with acute ischemic stroke were examined to confirm the factors associated with performing aPL testing and with positive aPL test results in real-world practice. Cryptogenic stroke patients were separately examined in the same manner. The antibody profiles of cryptogenic stroke patients with aPL positivity were compared by age.Among 2947 patients, 606 (20.6%) were tested for aPLs and 129 (21.3%) were positive. Physicians tended to perform aPL testing in patients aged50 years and in cryptogenic stroke patients. Cryptogenic stroke was a strong predictor of positive aPL results (adjusted odds ratio 3.70, 95% confidence interval 2.38-5.76). However, aPL positivity did not differ by age in stroke patients. Among 283 cryptogenic stroke patients, 136 (48.1%) were tested for aPLs and 56 (41.2%) were positive. aPL tests were performed predominantly in patients aged50 years rather than in older patients, even among cryptogenic stroke patients. The two age groups had similar positivity rates of40% (50 years: 43.2%; ≥50 years: 40.4%; p = 0.92) and their antibody profiles were similar.A significant number of patients with cryptogenic stroke had positive aPL results regardless of age. aPL testing may offer additional diagnostic opportunities in cryptogenic stroke patients, and thus may reduce the incidence of cryptogenic stroke.

Introduction: The coronavirus disease 2019 (COVID-19) pandemic has led to changes in stroke patients’ healthcare use. This study evaluated changes in Korean stroke patients’ health-seeking behaviors and stroke care services using data from the Korean Stroke Registry (KSR). Methods: We reviewed data from patients with acute stroke and transient ischemic attack (TIA) during 2019 (before COVID-19 period) and 2020 (COVID-19 period). Outcomes included patient characteristics, time from stroke onset to hospital arrival, and in-hospital stroke pathways. Subgroup analyses were performed for an epidemic region (Daegu city and Gyeongsangbuk-do region, the D-G region). Results: The study included 1,792 patients from the pre-COVID-19 period and 1,555 patients from the COVID-19 period who visited hospitals that contribute to the KSR. During the COVID-19 period, the D-G region had two-thirds the number of cases (vs. the pre-CO­VID-19 period) and a significant decrease in the proportion of patients with TIA (9.97%–2.91%). Unlike other regions, the median onset-to-door time increased significantly in the D-G region (361 min vs. 526.5 min, p = 0.016), and longer onset-to-door times were common for patients with mild symptoms and who were in their 60s or 70s. The number of patients who underwent intravenous thrombolysis also decreased during the COVID-19 period, although the treatment times were not significantly different between the 2 periods. Discussion/Conclusion: Korean stroke patients in a CO­VID-19 epidemic region exhibited distinct changes in health-seeking behaviors. Appropriate triage system and public education regarding the importance of early treatment are needed during the COVID-19 pandemic.

Background The research about the influence of triglyceride-glucose index on early prognosis in stroke is lacking. Aims In this study, we evaluated the association between triglyceride-glucose index and early neurological deterioration in patients with single subcortical infarctions. Methods Consecutive patients with single subcortical infarctions within 72 h of symptom onset between 2011 and 2015. Early neurological deterioration was defined as an increase of ≥2 in the total NIHSS score or ≥1 in the motor NIHSS score. The triglyceride-glucose index was calculated using the log scale of fasting triglyceride (mg/dL) × fasting glucose (mg/dL)/2. Results A total of 305 patients with single subcortical infarctions were evaluated. In multivariable analysis, the triglyceride-glucose index (adjusted odds ratio [aOR] = 2.94, 95% confidence interval [CI] = 1.58–5.45) and age (aOR = 1.05, 95% CI = 1.01–1.09) were associated with early neurological deterioration. In subgroup analysis according to the type of single subcortical infarctions, only patients with proximal single subcortical infarctions showed a significant association between the triglyceride-glucose index and early neurological deterioration (aOR = 2.92, 95% CI = 1.35–6.29). On the other hand, there was no statistical significance in patients with distal single subcortical infarctions. Patients with untreated diabetes also showed the close association between the triglyceride-glucose index and early neurological deterioration (aOR = 3.94, 95% CI = 1.47–10.52). Conclusions The triglyceride-glucose index was associated with early neurological deterioration in single subcortical infarctions. This association differed depending on the location of lesion and the presence of untreated diabetes.

Background and Purpose: Renal dysfunction is known to affect vasculature and lead to systemic arterial stiffness. It also independently increases the risk of cerebral small vessel disease (cSVD) and stroke. We aimed to examine the effect of renal dysfunction on cerebral hemodynamics and the burden of cSVD. Methods: Of the 412 patients admitted to Seoul National University Hospital, between May 2015 and 2019, with lacunar infarction and no major intracranial arterial stenosis observed on magnetic resonance angiography, we included 283 patients who had undergone a transcranial Doppler (TCD) ultrasound after 72 h of stroke onset. The patients were divided into renal dysfunction (estimated glomerular filtration rate [eGFR] 2 at admission) and control (eGFR ≥60 mL/min/1.73 m2) groups. We investigated the correlations between renal function, the pulsatility index (PI), and the total MRI burden of cSVD. Furthermore, multivariate analysis was performed to assess the association between renal dysfunction and the PI of the middle cerebral artery (MCA) measured through TCD ultrasound. Results: Among the total patients, 74 (26.1%) had renal dysfunction (eGFR 2 at admission). Patients with renal dysfunction were significantly older, showed higher pulse pressure, and had a higher prevalence of hypertension, diabetes mellitus, and coronary artery disease. Renal dysfunction was significantly associated with higher distal cerebrovascular flow resistance (median PI 1.12, interquartile range [IQR]: 0.85–1.57 vs. controls 0.84, IQR: 0.54–1.22; p < 0.001). Also, patients with renal dysfunction had a significantly higher total MRI burden of cSVD (median cSVD score 2, IQR: 1–3 vs. controls median score 1, IQR: 0–2; p < 0.001). There was an inverse proportional relationship between the PI and eGFR. Finally, multivariate analysis showed renal dysfunction (adjusted odds ratio: 4.516, 95% confidence interval: 1.051–20.292) and older age (adjusted odds ratio: 1.076, 95% confidence interval: 1.038–1.114) as independent predictors of a high PI. Conclusions: Renal dysfunction is independently associated with a high PI of MCA. Renal dysfunction leads to systemic arterial stiffness including stiffness in cerebral arteries, thus increasing the burden of cSVD. Therefore, noninvasive screening for high PI by TCD in kidney failure patients might be helpful.

Background We tried to evaluate the prevalence of premature discontinuation of antiplatelets and its affecting factors after ischemic stroke using large-sized representative national claims data. Methods Patients aged 20 years or older with newly confirmed ischemic stroke who started aspirin or clopidogrel for the first time were selected from 2003 to 2010 National Health Insurance Service-National Sample Cohort (NHIS-NSC) of South Korea (n = 4621), a randomly collected sample which accounts for 2.2% (n = 1,017,468) of total population (n = 46,605,433). The prevalence of discontinuation of antiplatelets was measured every 6 months until the 24 months since the first prescription. Then we classified the participants into 2 groups according to the discontinuation status at 12 months and assessed the factors influencing premature discontinuation of antiplatelets within 12 months. Results Among total participants, 35.5% (n = 1640) discontinued antiplatelets within 12 months and 58.5% (n = 2704) discontinued them within 24 months. The remaining 41.5% (n = 1917) continued them for 24 months or more. In the multivariate logistic regression analysis, initiating treatment with aspirin monotherapy [adjusted OR (aOR), 2.66, 95% CI 2.17–3.25] was the most prominent determinant of premature discontinuation within 12 months followed by CCI score ≥ 6 (aOR 1.50, 95% CI 1.31–1.98), and beginning treatment with clopidogrel monotherapy (aOR 1.41, 95% CI 1.15–1.72). Rural residency (aOR 1.36, 95% CI 1.14–1.62), Conclusions The prevalence of premature discontinuation of antiplatelets after ischemic stroke was quite high. Thus, by understanding factors associated with premature discontinuation, a more strategic approach is required for the physicians to improve persistence with antiplatelets.

Few studies have examined the influenza vaccination rates among stroke survivors despite the importance of vaccines in preventing influenza- and stroke-related complications. Thus, we investigated the vaccination rates and the associated factors among stroke survivors using the representative Korea National Health and Nutrition Examination Survey 2014–2018. We measured and compared the vaccination rates of 591 stroke survivors and 17,997 non-stroke survivors. Multivariate logistic regression analyses of all stroke survivors and age subgroups (&lt, 65 and ≥65 years) were performed to identify the factors influencing vaccination. The overall vaccination rate was significantly higher in the stroke survivors (64.8%) than in the non-stroke survivors (41.1%), but it was low compared to global standards. Among stroke survivors aged &lt, 65 years, the rate was low (37.5%), but it improved in those aged ≥ 65 years (85.6%). Age ≥ 65 years, the eligible age for the national free vaccination program was the most prominent predictor of vaccination for all stroke survivors, while smoking was a negative predictor. No significant factors were found in the subgroup analyses according to age (&lt, 65 and ≥65 years). Therefore, implementing strategic public health policies, such as expanding the free vaccination program to stroke survivors aged &lt, 65 years, may improve vaccine coverage.

Purpose: There are many differences between in hospital ischemic stroke(IHS) and community onset ischemic stroke(COS), and there are several comparative studies. Although the importance of mechanical thrombectomy(MT) in the treatment of acute ischemic stroke is becoming increasingly important, there are not many studies on the effectiveness of MT in IHS. We aimed to compare the clinical features and outcomes between IHS and COS patients who received MT. Methods: We analyzed cases of mechanical thrombectomy performed at Seoul National University Hospital from January 2012 to June 2020. We selected patients with previous mRS(modified Rankin Scale) 0-1 and then divided them into two groups: IHS and COS, and compared successful recanalization, discharge mRS, 3month mRS, and 3month functional independence (mRS 0-2). Results: A total of 41 patients with IHS and 213 patients with COS were included. The baseline characteristics(age, sex, underlying disease, occlusion site) of the two groups were similar, but malignancy tended to be more common in IHS than COS(19.5% vs 7.5%). The median/mean LNT(last normal time)-to-puncture time was 341min/399min in IHS and 370min/461min in COS. The percentages of successful recanalization (92% vs 89%), discharge mRS (mean, 2.19 vs 2.97), 3 month mRS (mean, 2.05 vs 2.56), 3 month functional independence (61% vs 49%) were comparable between the two groups. In the multivariable analysis of the 3 month functional independence, initial NIHSS and successful recanalization were the most important predictors. In addition, a multivariable analysis was performed on successful recanalization, and LNT to puncture time was the most important predictor. Conclusions: The importance of MT is still high even in the in hospital stroke. In addition, IHS has more factors that can reduce the onset to puncture time compared to COS such as well designed on-call system and patient transfer system, well arrangement of nursing manpower. Therefore, more attention is needed for MT in IHS.

Background and Purpose: Chronic kidney disease (CKD) is known to have affected the systemic vasculature and its remodeling, which eventually led to the systemic arterial stiffness. However, the relationship between cerebral circulation and impaired renal function is poorly understood. To evaluate the effect of renal dysfunction to increase systemic and intracranial arterial stiffness, we assessed the relation between renal resistive index (RRI) and pulsatility index (PI) of the middle cerebral artery (MCA). Methods: We included patients with acute lacunar infarction. Demographic and clinical data were collected by retrospective chart review. Bilateral transcranial Doppler ultrasound (TCD) examination of the MCAs was performed using the ST3 Ultrasound system (Spencer Technologies) and PI were calculated. RRI was obtained through kidney Doppler sonography. Subjects with occlusion or significant stenosis of MCA, atrial fibrillation, bilaterally absent transtemporal sonographic windows were excluded. Results: Of the 283 included subjects (mean age 67.8 ± 10.2), 74 patients had renal dysfunction (glomerular filtration rate < 60ml/min/1.73m2 at admission) and 49 patients underwent kidney Doppler ultrasound within 1 year since their acute stroke. Renal dysfunction was significantly associated with higher arterial stiffness (median PI 1.12, IQR 0.85 to 1.57 vs. controls PI 0.84, IQR 0.54 to 1.22 [pr =0.65, p Conclusions: In patients with lacunar infarction, renal impairment is an independent determinant of increased arterial stiffness in cerebral circulations. In addition, PI is significantly associated with RRI.

BackgroundFamily history (FH) is one of important risk factors for cardiovascular disease (CVD). However, little is known about its impact on dyslipidemia prevalence and management status. Thus, we aimed to investigate the impact of FH of CVD on dyslipidemia prevalence, awareness, treatment, control, and healthy behaviors in Korean adults.MethodsWe conducted a cross-sectional study using representative data from the Korea National Health and Nutrition Examination Survey (KNHANES) 2014–2018. A total of 22,024 participants aged ≥ 19 years without histories of CVDs were classified into two groups according to the presence of FH of CVD (with FH, n = 3,778; without FH, n = 18,246). FH of CVD was defined as having a first-degree relative with ischemic heart disease or stroke. Multivariate logistic regression analyses were performed to evaluate the association between FH of CVD and dyslipidemia prevalence, awareness, treatment, control, and healthy behaviors (weight control, non-smoking, non-risky drinking, sufficient physical activity, and undergoing health screening).ResultsFH of CVD was significantly associated with a higher dyslipidemia prevalence (adjusted odds ratio [aOR] 1.34, 95% confidence interval [CI] 1.18–1.51), better awareness (aOR 1.54, 95%CI 1.19–2.00), and treatment rates (aOR 1.34, 95%CI 1.12–1.60), but not control. Having an FH of CVD was not predictive of any healthy behaviors in dyslipidemia patients. For non-dyslipidemia patients, FH of CVD even showed significant association with smoking (aOR 1.18, 95%CI 1.02–1.36), and risky drinking (aOR 1.20, 95%CI 1.03–1.40) while it was predictive of receiving health screening (aOR 1.14, 95% CI 1.02–1.27).ConclusionsHaving an FH of CVD might positively trigger dyslipidemia patients to start pharmacological intervention, but not non-pharmacological interventions. Therefore, physicians should make more efforts to educate and promote the importance of non-pharmacological behavioral modification in dyslipidemia patients with an FH of CVD.

We report a case of acute middle cerebral territory ischemic infarction caused by left ventricular thrombus (LVT) in a doxorubicin cardiomyopathy patient. A major adverse effect of doxorubicin is cardiotoxicity. In doxorubicin cardiomyopathy, as the ventricular contractility decreases, LVT can occur and lead to systemic embolic events such as stroke.

Background The effectiveness of mechanical thrombectomy (MT) in cancer-related stroke (CRS) is largely unknown. This study aims to investigate the clinical and radiological outcomes of MT in CRS patients. We also explored the factors that independently affect functional outcomes of patients with CRS after MT. Methods We retrospectively reviewed 341 patients who underwent MT after acute ischemic stroke onset between May 2014 and May 2020. We classified the patients into CRS (n = 34) and control (n = 307) groups and compared their clinical details. Among CRS patients, we analyzed the groups with and without good outcomes (3-months modified Rankin scale [mRS] score 0, 1, 2). Multivariate analysis was performed to investigate the independent predictors of unfavorable outcomes in patients with CRS after MT. Results A total of 341 acute ischemic stroke patients received MT, of whom 34 (9.9%) had CRS. Although the baseline National institute of health stroke scale (NIHSS) score and the rate of successful recanalization was not significantly different between CRS patients and control group, CRS patients showed more any cerebral hemorrhage after MT (41.2% vs. controls 23.8%, p = 0.037) and unfavorable functional outcome at 3 months (CRS patients median 3-month mRS score 4, interquartile range [IQR] 2 to 5.25 vs. controls median 3-month mRS score 3, IQR 1 to 4, [p = 0.026]). In the patients with CRS, elevated serum D-dimer level and higher baseline NIHSS score were independently associated with unfavorable functional outcome at 3 months (adjusted odds ratio [aOR]: 1.524, 95% confidence interval [CI]: 1.043–2.226; aOR: 1.264, 95% CI: 1.010–1.582, respectively). Conclusions MT is an appropriate therapeutic treatment for revascularization in CRS patients. However, elevated serum D-dimer levels and higher baseline NIHSS scores were independent predictors of unfavorable outcome. Further research is warranted to evaluate the significance of these predictors.

Background: There is evidence that smoking increases stroke risk. However, the impact of smoking status on age at onset of ischemic stroke has not been studied. The aim of this study is to explore the effect of smoking status on the age at onset of first-ever ischemic stroke using the Korean Stroke Registry(KSR), the nation-wide, multicenter, hospital-based stroke registry in Republic of Korea. Methods: This study used individual data of first-ever ischemic stroke patients from the KSR, between 2014 and 2018. We divided the patients into four groups according to their smoking status; current smokers, past-smokers - quit in recent 5 years, past smokers - quit over than 5 years, and never-smokers. Results: A total of 27,942 patients were included in the analysis. The mean age at onset of the first-ever stroke were 60.0±11.9 in current smokers, 65.9±11.9 past-smokers - quit in recent 5 years, 70.1±10.8 in past smoker - quit over than 5 years, and 70.5±12.8 in never-smokers (p Conclusions: The smoking status of patients was associated with an earlier onset age of the first-ever stroke. The onset age tends to be delayed with the longer duration of cessation period.

Introduction: Temperature affects human health. It is widely known that mean ambient temperature with both short-term and cumulative lagged effect, is the exposure measure for ischemic stroke. Recently, not only mean temperature, larger diurnal temperature range (DTR, difference between high- and low-daily temperature) was associated with coronary heart disease mortality and ischemic stroke hospitalizations. We hypothesized that a larger DTR results in environmental stress to the human cardiovascular system, thereby increasing the risk for acute ischemic stroke severity. Methods: We used both time-series and case-crossover approaches to assess the relation between DTR and ischemic stroke severity between summer of 2016 and 2018 in Korea. Data were obtained from Korean Stroke Registry and Korean Meteorological Administration. We used exposures averaged over periods varying from 1 to 14 days to assess the effects of DTR on stroke severity. We estimated the relation between DTR and ischemic stroke severity after adjustment for classical stroke risk factor and weather conditions of stroke index day. Results: A 9,249 patients were included in both time-series and case-crossover analyses. The results showed that DTR was significantly associated with stroke severity. The lag effect of DTR was stabilized at about 3-4 days. A 5 °C increase of three-day moving average of DTR corresponded to a 1.67 (95% Confidential Interval, CI 1.64-1.70, p Discussion: The current study supported our hypothesis that diurnal temperature variation could be a new severity factor for acute ischemic stroke. Moreover, the two different methods we used provided relatively similar results, suggesting that the association between DTR and stroke severity was reasonably robust. Our data added additional evidence that exposure to large DTR was associated with increased burden of stroke. This findings would contribute public health program to prevent unstable thermal environments.

Background: There is growing interest in the use of new biomarkers such as glycated albumin (GA), but data are limited in acute ischemic stroke. We explored the impact of GA on short-term functional outcomes as measured using the modified Rankin Scale (mRS) at 3 months compared to glycated hemoglobin (HbA1c). Methods: A total of 1163 AIS patients from two hospitals between 2016 and 2019 were included. Patients were divided into two groups according to GA levels (GA &lt, 16% versus GA ≥ 16%). Results: A total of 518 patients (44.5%) were included in the GA ≥ 16% group. After adjusting for multiple covariates, the higher GA group (GA ≥ 16%) had a 1.4-fold risk of having unfavorable mRS (95% CI 1.02–1.847). However, HbA1c was not significantly associated with 3-month mRS. In addition, GA ≥ 16% was independently associated with unfavorable short-term outcomes only in patients without diabetes. Conclusions: In light of these results, GA level might be a novel prognostic biomarker compared to HbA1c for short-term stroke outcome. Although the impact of GA is undervalued in the current stroke guidelines, GA monitoring should be considered in addition to HbA1c monitoring.

Background and Objectives: Atrial fibrillation (AF) is well-established risk factor for cardioembolic stroke. Epidemiological evidence indicates that there is increased risk of AF with chronic kidney disease (CKD) and impaired renal function. Cystatin C (Cys-C) is now considered as a specific marker for detection of renal impairment. However, there are no data about the potential association of Cys-C with AF and cardioembolic stroke in the subjects without evident CKD. We investigated whether serum Cys-C level is associated with development of cardioembolic stroke in patients with AF. Methods: Consecutive data were collected retrospectively at the Seoul National University Hospital (SNUH). Patients with ischemic stroke with subtypes of large artery atherosclerosis, small vessel occlusion and cardioembolism who admitted at the SNUH between November 2014 and November 2017 were screened. We excluded the patient who have a history of secondary hypertension, CKD (estimated glomerular filtration rate < 60 mL/min/1.73 m 2 ), valvular heart disease, congenital heart disease, dilated or hypertrophy cardiomyopathy and thyroid disease. Results: Among the total 627 patients, 61.8% were male, with a mean age of 67.9 years. Compared to the other stroke mechanisms, a stepwise logistic regression analysis showed that AF was independently associated with size of left atrium (OR, 1.196, 95% CI: 1.160-1.266), initial stroke severity (NIH Stroke Scale) (OR, 1.126, 95% CI: 1.083-1.189), and Cys-C (OR, 2.472, 95% CI: 1.255-15.129), but not with eGFR (OR 0.993, 95% CI: 0.977-1.009). Conclusion: Cys-C is a superior predictor for cardioembolic stroke due to AF in patients without evident CKD.

Patients with hereditary hemorrhagic telangiectasia (HHT) are at risk of developing pulmonary arteriovenous malformations (pAVMs). Paradoxical embolism may occur through pAVMs or patent foramen ovale (PFO) and lead to cerebral infarction. We present a case of cerebral infarction with both pAVM associated with HHT and PFO. Evidence of a right-to-left shunt can suggest other treatment options for stroke prevention, and patients without evidence of conventional stroke etiologies require a thorough evaluation. J Korean Neurol Assoc 33(3):217-220, 2015