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Background Intravenous tissue plasminogen activator (tPA) (0.9 mg/kg, maximum 90 mg) with a bolus of 10% of the total dose given within 1-2 mins is the standard therapy for patients receiving thrombolytic therapy. Low-dose (0.6 mg/kg) tPA is also approved for thrombolytic therapy for ischemic stroke patients. Low-dose tPA is associated with a low bolus dose. It is unknown whether increasing the bolus dose in patients receiving low-dose tPA thrombolysis may improve outcomes or increase the risk of hemorrhagic transformation (HT). Aim This study investigated the impact of the bolus dose on the outcome in ischemic stroke patients receiving low-dose tPA thrombolytic therapy. Methods In this retrospective, observational study, we enrolled 214 ischemic stroke patients receiving low-dose tPA thrombolytic therapy. Of these 214 patients, 107 patients received 10% of the total dose as a bolus dose, and 107 patients received 15% of the total dose as a bolus dose. The National Institutes of Health Stroke Score (NIHSS) were evaluated before tPA infusion, 24 h after thrombolytic therapy, and at discharge. Stroke severity was categorized as mild (0-5), moderate (6-14), severe (15-24), or very severe (≥25). Neurological improvement (NI) was defined as an improvement of 6 or more points in the NIHSS, and no response (NR) was defined as an increase in the NIHSS of ≤4 points or a decrease ≤6 points. Neurological deterioration (ND) was defined as an increase in the NIHSS >4 points. A good outcome was defined as a modified Ranking Score (mRS) of 0 or 1. We compared the NI, NR, and ND rates at 24 hrs after thrombolytic therapy and discharge between the 15% and 10% bolus dose groups. Results In patients with mild and moderate stroke, there was no significant difference in the NI, NR, ND, and HT rates and 6-month outcomes between the 15% and 10% bolus groups. In patients with severe and very severe stroke, outcomes at 6 months were significantly better in the 15% bolus group than in the 10% bolus group. The factors affecting the outcomes of severe and very severe stroke patients are hypertension and bolus dose. Conclusion In severe and very severe stroke patients receiving low-dose tPA thrombolytic therapy, a bolus dose of 15% of the total dose can improve outcomes.

The risk factors for recurrence of hemorrhagic or ischemic stroke in patients with intracranial hemorrhage (ICH) are inconclusive. This study was designed to investigate the risk factors for stroke recurrence and the impact of antiplatelet on stroke recurrence in patients with ICH. This population-based case-cohort study analyzed the data obtained from a randomized sample of 2 million subjects in the Taiwan National Health Insurance Research Database. The survival of patients with hemorrhagic stroke from January 1, 2000, to December 31, 2013, was included in the study. During the 5-year follow-up period, the recurrence rate of stroke was 13.1% (7.01% hemorrhagic stroke, and 6.12% ischemic stroke). The recurrence rate of stroke was 13.3% in the without antiplatelet group and 12.6% in the antiplatelet group. The risk factor for hemorrhagic stroke was hypertension (OR 1.87). The risk factors for ischemic stroke were age (OR 2.99), diabetes mellitus (OR 1.28), hypertension (OR 2.68), atrial fibrillation (OR 1.97), cardiovascular disease (OR 1.42), and ischemic stroke history (OR 1.68). Antiplatelet may decrease risk of hemorrhagic stroke (OR 0.53). The risk of stroke recurrence is high in patients with ICH. Hypertension is a risk factor for ischemic and hemorrhagic stroke recurrence. Antiplatelet therapy does not decrease risk of ischemic stroke recurrence but may reduce recurrence of hemorrhagic stroke.

Background Studies on insomnia in patients with ischemic stroke, particularly in the acute phase, are limited. The proportion of patients with sleep disturbance during the acute stroke period who are likely to develop insomnia in subacute and chronic stages of stroke is unknown. This study aimed to investigate the risk factors for sleep disturbance and the clinical course of the disease in patients with acute ischemic stroke. Methods This prospective observational study included patients diagnosed with ischemic stroke between July 1, 2020, and October 31, 2021. The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) for insomnia and the eight-item Athens Insomnia Scale (CAIS-8) were used to diagnose insomnia. Beck Depression Inventory (BDI) was applied to evaluate the mood of patients. Patient reported their sleeping conditions, before stroke onset and during the acute (within 7 days) and chronic (3 months after presentation) stroke periods. Results In total, 195 patients with ischemic stroke were included in this study. Of these, 34.3% (67), 37.4% (73), and 29.7% (58) presented with sleep disturbance before stroke onset and during the acute and chronic stroke periods, respectively. Of the 128 patients without insomnia before stroke onset, 15.6% (20/128) presented with insomnia symptoms 3 months after stroke onset. Moreover, 13 (12.7%) of the 102 patients without sleep disturbance during the acute stroke period developed insomnia 3 months after stroke onset. Of the 67 patients with insomnia before stroke onset 29 (43.3%) did not develop the condition 3 months after stroke onset. A higher risk of sleep disturbance was associated with atrial fibrillation, hypertension, and mood disturbance in the acute stroke period, and a higher risk of insomnia was associated with low education and mood disturbance in the chronic stroke period. Conclusion The prevalence rates of sleep disturbance before and during the acute and chronic stroke periods were 34.3%, 37.4%, and 29.7%, respectively. The incidence of stroke-related insomnia was 15.6%. Patients with insomnia before stroke may recover after the stroke. Atrial fibrillation, hypertension, and mood disturbance were associated with a higher risk of sleep disturbance in the acute stroke period, whereas low education and mood disturbance were associated with insomnia in the chronic stroke period.

Introduction Carpal tunnel syndrome (CTS) is prevalent in workers who utilize hand-held vibration tools, engage in tasks involving repetitive wrist movements, and suffer from wrist overuse. Although electrical injuries involving the median nerve are a relatively rare but plausible cause of CTS, the related literature is limited. Here, we report a case of CTS in which the symptoms developed after an electrical injury, and review the related literature. Case summary The patient was a right-handed male electrician who often used hand tools but had no symptoms of CTS before the injury, with the left hand as the point of entry. Typical symptoms of CTS manifested after the electrical injury, and a nerve conduction velocity test confirmed the presence of severe CTS in the left hand. Therefore, we believe that the symptoms can be largely attributed to the electrical injury. Conclusions The available literature supports the occurrence of delayed compressive neuropathy caused by scarring from substantial cutaneous burns in patients with electrical injuries. This case shows that electrical injuries may cause CTS in the absence of severe scarring through other mechanisms such as direct injuries to the nerve. Therefore, patients with electrical burns should be routinely examined for peripheral nerve compression symptoms in follow-ups, even when there are minimal cutaneous burns.

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.

Background In real-world practice settings, there is insufficient evidence on the efficacy of antiplatelet drugs, including clopidogrel, aspirin, and ticlopidine, in stroke prevention. Purpose To compare the efficacies between aspirin and clopidogrel and aspirin and ticlopidine in stroke prevention. Methods This population-based case-cohort study utilized the data obtained from a randomized sample of one million subjects in the Taiwan National Health Insurance Research Database. Patients who were hospitalized owing to the primary diagnosis of ischemic stroke from January 1, 2000 to December 31, 2010 and treated with aspirin, ticlopidine, or clopidogrel were included in the study. Propensity score matching with a 1:4 ratio was performed to compare aspirin with ticlopidine and clopidogrel. The criteria for inclusion were the use of one of the three antiplatelet drugs for more than 14 days within the first month after the stroke and then continued use of the antiplatelet drugs until the study endpoint of recurrent stroke. Results During the 3-year follow-up period, the recurrent stroke rates were 1.62% (42/2585), 1.48% (3/203), and 2.55% (8/314) in the aspirin, ticlopidine, and clopidogrel groups, respectively. Compared with the patients treated with aspirin, those treated with clopidogrel and ticlopidine showed competing risk-adjusted hazard ratios of recurrent stroke of 2.27 (1.02–5.07) and 0.62 (0.08–4.86), respectively. Conclusion Compared with the patients treated with aspirin, those treated with clopidogrel were at a higher risk of recurrent stroke. For stroke prevention, aspirin was superior to clopidogrel whereas ticlopidine was not inferior to aspirin.

Cheung-Ter Ong,1,2 Yi-Sin Wong,3 Chi-Shun Wu,1 Yu-Hsiang Su1 1Department of Neurology, Chia-Yi Christian Hospital, 2Department of Nursing, Chung Jen Junior College of Nursing, Health Science and Management, 3Department of Family Medicine, Chia-Yi Christian Hospital, Chia-Yi, Taiwan Background and purpose: Intravenous recombinant tissue plasminogen activator (tPA) at a dose of 0.9mg/kg body weight is associated with a high hemorrhagic transformation (HT) rate. Low-dose tPA (0.6 mg/kg) may have a lower hemorrhage rate but the mortality and disability rates at 90 days cannot be confirmed as non-inferior to standard-dose tPA. Whether the doses 0.7and 0.8 mg/kg have better efficacy and safety needs further investigation. Therefore, this study is to compare the efficacy and safety of each dose of tPA (0.6, 0.7, 0.8, and 0.9 mg/kg body weight) and to investigate the factors affecting early neurological improvement (ENI) and earlyneurological deterioration (END).Methods: For this observational study, data were obtained from 274 patients who received tPA thrombolytic therapy in Chia-Yi Christian Hospital stroke unit. The tPA dose was given at the discretion of each physician. The definition of ENI was a >8 point improvement (compared with baseline) at 24h following thrombolytic therapy or an improvement in the National Institutes of Health Stroke Score (NIHSS) to 0 or 1 toward the end of tPA infusion. The definition of END was a >4 point increase in NIHSS (compared with baseline) within 24 h of tPA infusion. The primary objective was to investigate whether 0.7 and 0.8 mg/kg of tPA have higher ENI rate, lower END rate, and better outcome at 6 months. Poor outcome was defined as having a modified Rankin Scale of 3 to 6 (range, 0 [no symptoms] to 6 [death]). The secondary objective was to investigate whether low-dose tPA has a lower risk of intracerebral HT than that with standard-dose tPA. We also investigated the factors affecting ENI, END, HT, and 6-month outcome.Results: A total of 274 patients were included during the study period, of whom 260 were followed up for >6 months. There was a trend for the HT rate to increase as the dose increased (P=0.02). The symptomatic HT rate was not significantly different among the low-dose and standard-dose groups. The ENI and END (P=0.52) were not significantly different among the four dosage groups. The clinical functional outcome at 6 months after stroke onset was poorer in the standard-dose group (P=0.02). Stroke severity (P12), stroke type (cardioembolism and large artery atherosclerosis) and diabetes mellitus were associated with poor outcome at 6 months. Keywords: stroke, thrombolytic therapy, outcome, neurological deterioration, tissue plasminogen activator, thrombolysis

Myasthenia gravis (MG) is an autoimmune disease caused by antibodies to acetylcholine receptors of the skeletal muscle. Myasthenic crisis (MC) is a complication observed during both early and late stage MG cases. In this study, we examined current treatments and three years outcomes in patients with MG and MC. We also investigated the impact of thymectomy and systemic lupus erythematosus (SLE) in patients with MG and MC.In this retrospective study, we reviewed the medical records of all patients admitted to one teaching hospital between January 2006 and December 2014 and identified those for whom discharge diagnosis included the International Classification of Diseases, ninth revision (ICD-9) codes corresponding to MG (358.X, all extensions and all positions).We identified 29 patients and 49 hospitalizations. Among these patients, the cause for initial hospitalization was MG in 16 cases and MC in 13 cases. Six out of the 16 MG patients were readmitted within 3 years; with 2 of the cases due to MC. Eight of the initial 13 MC patients were readmitted within 3 years, and 6 of the cases due to MC. Among these 15 MC patients, 14 were admitted to the intensive care unit (ICU), and 8 were intubation and put on mechanical ventilators. The median ICU stay was 7 days (3-45). Both MG patients who were also diagnosed with SLE experienced MC. One patient died during the first-time hospitalization, and one patient died during re-hospitalization within 2 years.Plasma exchange (PE) is the main treatment modality of MC, and most patients in our cohort had a good response. Infection is the most common trigger of MC and a significant cause of death. Despite significant morbidity and mortality in patients with MC, a favorable long-term outcome is possible with intensive treatment. Key Words: myathenia gravis, myasthenic crisis, systemic lupus erythematosus, outcome.

Background and purpose Sex-related differences in the clinical presentation and outcomes of stroke patients are issues that have attracted increased interest from the scientific community. The present study aimed to investigate sex-related differences in the risk factors for in-hospital mortality and outcome in ischemic stroke patients. Methods A total of 4278 acute ischemic stroke patients admitted to a stroke unit between January 1, 2007 and December 31, 2014 were included in the study. We considered demographic characteristics, clinical characteristics, co-morbidities, and complications, among others, as factors that may affect clinical presentation and in-hospital mortality. Good and poor outcomes were defined as modified Ranking Score (mRS)≦2 and mRS>2. Neurological deterioration (ND) was defined as an increase of National Institutes of Health Stroke Score (NIHSS) ≥ 4 points. Hemorrhagic transformation (HT) was defined as signs of hemorrhage in cranial CT or MRI scans. Transtentorial herniation was defined by brain edema, as seen in cranial CT or MRI scans, associated with the onset of acute unilateral or bilateral papillary dilation, loss of reactivity to light, and decline of ≥ 2 points in the Glasgow coma scale score. Results Of 4278 ischemic stroke patients (women 1757, 41.1%), 269 (6.3%) received thrombolytic therapy. The in hospital mortality rate was 3.35% (139/4278) [4.45% (80/1757) for women and 2.34% (59/2521) for men, p < 0.01]. At discharge, 41.2% (1761/4278) of the patients showed good outcomes [35.4% (622/1757) for women and 45.2% (1139/2521) for men]. Six months after stroke, 56.1% (1813/3231) showed good outcomes [47.4% (629/1328) for women and 62.2% (1184/1903) for men, p < 0.01]. Atrial fibrillation (AF), diabetes mellitus, stroke history, and old age were factors contributing to poor outcomes in men and women. Hypertension was associated with poor outcomes in women but not in men in comparison with patients without hypertension. Stroke severity and increased intracranial pressure were associated with increased in-hospital mortality in men and women. AF was associated with increased in-hospital mortality in women but not in men compared with patients without AF. Conclusion The in-hospital mortality rate was not significantly different between women and men. Functional outcomes at discharge and six months after stroke were poorer in women than in men. Hypertension is an independent factor causing poorer outcomes in women than in men. AF is an independent factor affecting sex differences in hospital mortality in women.

Brain abscess (BA) is a severe neurological emergency, which remains a challenge for physicians despite medical advancements. The purpose of this study is to describe the epidemiology of BA in Taiwan and to investigate potential factors affecting the survival of patients with BA. By using the Taiwan National Health Insurance Research Database, we identified hospitalized patients with a discharge diagnosis of pyogenic BA (324.X) between 2000 and 2013. The incidence and in-hospital mortality of BA were calculated based on both age and sex. A total of 6027 BA cases were identified. The overall incidence of BA was 1.88 (95% CI: 1.83-1.93) per 100,000 person-years and increased with age, from 0.58 per 100,000 person-years in individuals aged 0-14 years to 4.67 per 100,000 person-years in those over 60 years of age. The male-to-female incidence ratio was 2.37 (95% CI: 2.24-2.50), with a mountain-shaped distribution across ages peaking at 40-44 years. The in-hospital mortality also increased with age, from 4.22% (95% CI: 2.54-6.97) at 0-14 years to 17.34% (95% CI: 15.79-19.02) in individuals over 60 years of age, without a gender difference (11.9% for males, 12.5% for females). Age, stroke, septicemia, pneumonia, meningitis, and hepatitis were associated with increased risk of in-hospital mortality. There was a male predominance for BA, and both the incidence and in-hospital mortality rates increased with age. Infection-related disease such as septicemia, pneumonia and meningitis were important factors associated with in-hospital mortality. In addition to the original treatment of BA, we suggest paying close attention to potential infections to improve the outcome of BA patients.

Cheung-Ter Ong,1,2 Yi-Sin Wong,3 Chi-Shun Wu,1 Yu-Hsiang Su1 1Department of Neurology, Chia-Yi Christian Hospital, 2Department of Nursing, Chung Jen Junior College of Nursing, Health Science and Management, Chiayi, 3Department of Family Medicine, Chia-Yi Christian Hospital, Chiayi, Taiwan, Republic ofChina Background/purpose: In-hospital mortality rate of acute ischemic stroke patients remains between 3% and 18%. For improving the quality of stroke care, we investigated the factors that contribute to the risk of in-hospital mortality in acute ischemic stroke patients.Materials and methods: Between January 1, 2007, and December 31, 2011, 2,556 acute ischemic stroke patients admitted to a stroke unit were included in this study. Factors such as demographic characteristics, clinical characteristics, comorbidities, and complications related to in-hospital mortality were assessed.Results: Of the 2,556 ischemic stroke patients, 157 received thrombolytic therapy. Eighty of the 2,556 patients (3.1%) died during hospitalization. Of the 157 patients who received thrombolytic therapy, 14 (8.9%) died during hospitalization. History of atrial fibrillation (AF, P

Serotonin syndrome is a potentially life-threatening complication of serotonergic agents. Although mirtazapine is a relatively safe antidepressant and has a comparatively low incidence of side effects, it still could induce serotonin syndrome.We described a 34-year-old man with schizophrenic disorder who presented with acute consciousness disturbance, extremely high fever, rigidity, and spontaneous clonus in lower limbs. Two days before entry, oral mirtazapine was added to his regular medication of olanzapine. The serotonin-related symptoms resolved soon after withdrawal of mirtazapine and olanzapine combined with treatment with intravenous benzodiazepine and oral cyproheptadine. However, the clinical course was complicated by rhabdomyolysis, acute renal failure, and acute pulmonary edema. After receiving mechanical ventilation, hemodialysis, and appropriate supportive treatment, his general condition recovered and he was discharged without any neurological sequelae.With the increasing use of serotonergic agents, awareness of serotonin syndrome is important. Early diagnosis and timely discontinuation of the offending agent(s) are imperative to prevent morbidity and mortality.

Background Carbamazepine, an anticonvulsant and a mood-stabilizing drug, is the main cause of the Stevens–Johnson syndrome (SJS) and its related disease, toxic epidermal necrolysis (TEN), in Southeast Asian countries. Carbamazepine-induced SJS–TEN is strongly associated with the HLA-B*1502 allele. We sought to prevent carbamazepine-induced SJS–TEN by using HLA-B*1502 screening to prospectively identify subjects at genetic risk for the condition. Methods From 23 hospitals in Taiwan, we recruited 4877 candidate subjects who had not taken carbamazepine. We genotyped DNA purified from the subjects' peripheral blood to determine whether they carried the HLA-B*1502 allele. Those testing positive for HLA-B*1502 (7.7% of the total) were advised not to take carbamazepine and were given an alternative medication or advised to continue taking their prestudy medication; those testing negative (92.3%) were advised to take carbamazepine. We interviewed the subjects by telephone once a week for 2 months to monitor them ...

Background/Purpose: Silent infarcts (SIs) are commonly found on brain computed tomography (CT) or magnetic resonance imaging (MRI) among elderly subjects, but their risk factors and impact on outcome in stroke patients are unknown. We evaluated the prevalence, risk factors and impact of SIs on the outcome of patients admitted with first-ever ischemic stroke or transient ischemic attack (TIA). Methods: A prospective study of 446 patients admitted consecutively to the neurology service with a diagnosis of TIA or stroke between July 2003 and June 2005, including 226 without any history of prior TIA or stroke. All patients underwent brain CT on the day of admission to the hospital. Risk factors analyzed included age, history of hypertension, diabetes mellitus, cardiovascular disease or stroke, smoking habit and alcohol use. Cholesterol and triglyceride levels were measured on the second day of admission. We monitored these patients for 24 months after stroke onset. Results: The frequency of SIs among the 226 patients with first-ever stroke or TIA was 20%. Most of the SIs were small and deep. Small-artery disease was more frequently observed in patients with SIs. Age, hypertension, diabetes mellitus, hypercholesterolemia, hypertriglyceridemia, alcohol use, smoking habits and atrial fibrillation did not significantly differ between patients with SIs and those without SIs. During the 24-month follow-up period, the frequency of recurrent stroke was higher in patients with SIs than those without SIs. The mortality rate was higher in patients without SIs than those with SIs. The interval from stroke onset to rehospitalization was shorter in patients without SIs than in those with SIs. Conclusion: The study showed a higher frequency of small artery disease in patients with SIs. First-ever stroke patients with SIs should be considered at high risk for recurrent stroke.

Abnormal course of the carotid artery (ABCA) is commonly identified during carotid sonography studies. Whether ABCA is related to the risk of stroke and stroke risk factors remains unclear. The purpose of the study is to investigate the prevalence of ABCA and the relationship with stroke and the risk factors of stroke.Color duplex ultrasound scanning of carotid arteries was performed on 615 subjects (between January 1, 2012 and March 31, 2012). ABCA and intimal thickness were recorded. Risk factors of stroke such as hypertension, diabetes mellitus, dyslipidemia, atherosclerosis, stroke history, and heart disease were recorded. The prevalence of ABCA was analyzed and its relationship with stroke and stroke risk factors was evaluated.ABCA was found in 4.1% (25/615) patients, 6.29% (19/302) in women, and 1.91% (6/313) in men. ABCA in 1 vessel was noted in 18 patients, 2 vessels in 3 patients, 3 vessels in 3 patients, and 4 vessels in 1 patient. The frequency of ABCA was significantly higher in women than in men (6.3% vs 1.9%, p = 0.01). There was no difference in the prevalence of ABCA between stroke patients and nonstroke subjects ( p = 0.60). ABCA was more frequent in patients older than 65 years. (5.91% (22/372) vs. 1.23% (3/243) p = 0.01). Logistic regression analysis did not reveal associations between ABCA and stroke risk factors (hypertension, diabetes mellitus, dyslipidemia, stroke history, heart disease and atherosclerosis). During 1 year follow-up, 2.88% (17/590) of non-ABCA patients and 4.0% (1/25) of ABCA patients had event of stroke or transient ischemic attack (TIA) ( p =0.08).The prevalence of ABCA in the present study is significantly lower than that in previous studies (Togay-Isikay et al., 24.6%, Del Corso et al., 58%). ABCA is more frequent in women and older patients. ABCA is not related to stroke and stroke risk factors. From our results, we suggest that patients with ABCA be placed under observation unless they exhibit neurological symptoms.

Purpose. Status epilepticus (SE) is an important neurological emergency. Early diagnosis could improve outcomes. Traditionally, SE is defined as seizures lasting at least 30 min or repeated seizures over 30 min without recovery of consciousness. Some specialists argued that the duration of seizures qualifying as SE should be shorter and the operational definition of SE was suggested. It is unclear whether physicians follow the operational definition. The objective of this study was to investigate whether the incidence of SE was underestimated and to investigate the underestimate rate.Methods. This retrospective study evaluates the difference in diagnosis of SE between operational definition and traditional definition of status epilepticus. Between July 1, 2012, and June 30, 2014, patients discharged with ICD-9 codes for epilepsy (345.X) in Chia-Yi Christian Hospital were included in the study. A seizure lasting at least 30 min or repeated seizures over 30 min without recovery of consciousness were considered SE according to the traditional definition of SE (TDSE). A seizure lasting between 5 and 30 min was considered SE according to the operational definition of SE (ODSE); it was defined as underestimated status epilepticus (UESE).Results. During a 2-year period, there were 256 episodes of seizures requiring hospital admission. Among the 256 episodes, 99 episodes lasted longer than 5 min, out of which 61 (61.6%) episodes persisted over 30 min (TDSE) and 38 (38.4%) episodes continued between 5 and 30 min (UESE). In the 38 episodes of seizure lasting 5 to 30 minutes, only one episode was previously discharged as SE (ICD-9-CM 345.3).Conclusion. We underestimated 37.4% of SE. Continuing education regarding the diagnosis and treatment of epilepsy is important for physicians.

Status epilepticus (SE) is a serious neurologic emergency associated with a significant mortality. The objective of this study is to investigate its epidemiology in terms of age- and sex-specific incidences and mortality. By using the Taiwan National Health Insurance Research Database during 2000 to 2011, we identified hospitalized patients with a discharged diagnosis of SE and calculated the incidence and in-hospital mortality of SE with respect to age and sex. The overall incidence of SE was 4.61 per 100,000 person-years, which displayed a “J-shaped” distribution by age with a little higher under the age of 5 and highest over 60 years. The male-to-female rate ratio was 1.57 and it demonstrated a “mountain-shape” across ages with the peak at 45 to 49 years old. The in-hospital mortality was significantly lower in males (7.38%) than in females (11.12%) with an odds ratio of 0.64 (95% CI 0.56-0.72). Notably, the in-hospital mortality for females increased rapidly after the age of 40 to 45 years. The multivariate analysis found males had a significantly lower risk of mortality than females after, but not before, 45 years of age with an odds ratio of 0.56 (95% CI 0.49-0.65). Sex and age are crucial factors associated with the incidence and in-hospital mortality of SE. The females over 45 years of age have a higher risk of occurrence and mortality from SE. The underlying mechanism deserves further study.

Objectives An ideal triage system used in the emergency department (ED) should identify patients who need urgent medical care. The purpose of this study was to validate the Taiwan Triage and Acuity Scale (TTAS) for stratifying patients according to their severity, need for thrombolysis, resource utilisation, and outcome. Methods The authors retrospectively reviewed all admitted patients with a discharge diagnosis of acute ischaemic stroke from January 2010 to September 2011. Presenting complaints, activation of code stroke protocol, eligibility of intravenous tissue plasminogen activator treatment, time from ED arrival to treatment, and outcome at discharge were compared by the five-level triage system. Results Of 706 enrolled patients (level 1, 55; level 2, 455; level 3, 192; level 4, 4; level 5, 0), there were 412 (58.4%) men and 294 women (41.6%), with a mean age of 69.4 years. The initial stroke severity, time from onset to arrival, time from arrival to imaging, proportion of patients for whom code stroke protocol was activated, length of hospital stay, and good functional outcome at discharge correlated with TTAS levels. A total of 84 patients were thrombolysis candidates, and 98.8% of them were designated as either level 1 or level 2. For those treated with thrombolytic therapy (n=47), the time from arrival to thrombolysis was not significantly different between TTAS level 1 and 2. Conclusion Acuity measured by the computerised TTAS demonstrated good validity in facilitating acute care of stroke patients with special regard to thrombolytic therapy.

Objective Atrial fibrillation (AF) is associated with poor outcome after intravenous thrombolysis probably due to greater pretreatment stroke severity. We conducted this retrospective study to determine whether AF is an independent predictor for clinical outcome in patients stratified by initial stroke severity. Methods A total of 143 acute ischemic stroke patients who received intravenous thrombolysis within 3 h after onset were enrolled. The patients were categorized according to the baseline stroke severity by National Institute of Health Stroke Scale (NIHSS) score (≤10 vs. >10) and the presence of AF or not. Favorable 90-day outcome was defined as a modified Rankin Scale (mRS) score Results Among the 100 patients with severe stroke (NIHSS > 10), those with AF (n = 52) had a higher proportion of favorable 90-day outcome than those without AF (31% vs. 8%, P = 0.005). After adjustment for age, baseline glucose level, and onset to treatment time, the difference remained significant (odds ratio 5.80, 95% confidence interval 1.63–20.68). In patients with mild stroke (NIHSS ≤ 10), no difference in clinical outcome was found between AF (n = 20) and non-AF (n = 23) groups. Conclusion Presence of AF was associated with favorable 90-day outcome following intravenous thrombolysis in patients with severe stroke at baseline, while the association did not exist in patients with mild stroke.

To improve and standardize stroke care, the establishment of primary stroke centers (PSCs) has been advised. Thrombolytic therapy has been proved to improve the outcome of acute ischemic stroke (AIS). We assessed the use of thrombolytic therapy before and after setting up a PSC at a community hospital.In November 2007, a PSC was established at our hospital. Following guidelines based on national recommendations, we administered intravenous tissue plasminogen activator (tPA) to patients who met the criteria. To study the effects of the establishment of the PSC on tPA treatment rates, we examined our database of stroke patients dating back to January 2004.Before the establishment of the PSC, there have been 2,420 patients admitted to our hospital diagnosed with AIS. Only 1.2% of these patients were treated with intravenous tPA. Following the establishment of the PSC, 2.8% of 1151 AIS patients were treated with tPA. Time of patient arrival to patient treatment was also diminished.The establishment of the PSC significantly increases the usage of tPA treatment. Furthermore, response time to patient cases was also quicker. However, for maximum effectiveness, the public still needs to be made more aware of the risks of stroke and the importance of seeking medical care at the first signs of stroke.

Introduction. Quick thrombolysis after stroke improved clinical outcomes. The study objective was to shorten door-to-needle time for thrombolysis.Methods. After identifying the sources of in-hospital delays, we developed a protocol with a parallel algorithm and recruited nurse practitioners into the acute stroke team. We applied the new protocol on stroke patients from October 2009 to September 2010. Patients from the previous two years were used for comparison.Results. For ischemic stroke patients within 3 hours of onset, the median time from arrival to computed tomography scanning was reduced from 29 to 20 minutes () and the median time from arrival to neurology evaluation decreased from 61 to 43 minutes (). For those patients who received thrombolysis, the median door-to-needle time was shortened from 68.5 to 58 minutes ().Conclusions. The parallel thrombolysis protocol successfully improved the median door-to-needle time to below the guideline-recommended 60 minutes.

To discuss the ethical challenge in thrombolytic therapy.Thrombolytic therapy with recombinant tissue-type plasminogen activator (rt-Pa) has been found to be beneficial to the outcome of patients who had a stroke. However, the ethic issue that is related to intravenous rt-Pa infusion has not been discussed.Four patients with a middle cerebral artery (MCA) infarct arrived at the emergency department (ER) of our hospital within 3 hours of stroke onset. All of them violated the guidelines of thrombolytic therapy for patients. The families of three patients insisted on the thrombolytic therapy. Two patients received rt-Pa infusion and two did not.Two patients who received rt-Pa infusion experienced hemorrhagic transformation. One died on the fifth day after stroke, and the other one had a poor outcome with a modified ranking scale (mRS) of 5. One of the two patients who did not receive rt-Pa infusion suffered from hemorrhagic transformation and died on the third day after stroke, and the other one had a poor outcome with mRS of 5.These 4 cases highlight the complexity of thrombolytic therapy in patients who violate the guidelines because the families insisted on thrombolytic therapy. No one is sure that the family's decision was the patient's wish. When a stroke patient violates the guidelines of thrombolytic therapy and the family of the patient insists on the thrombolytic therapy, a conversation between patients, patients' families and clinicians is necessary. Physician should tell patient and their families about the high risk of hemorrhagic transformation and mortality. If the family wants to make a decision, physician should request patient or patient's families to sign an against medical advice form and follow the patient's or their family's decision for the outcome.

Tissue plasminogen activator (tPA) is a standard therapy for acute ischemic stroke (AIS) but only limited data are noted in Taiwan. The purpose of this study was to assess the safety, feasibility, and efficacy of treatment in a community hospital setting.We retrospectively reviewed the medical records of all patients who had received intravenous tPA therapy from 1998 to 2007 in our hospital. We compared the characteristics, complications, and outcomes in our patients with those of patients in the National Institute of Neurological Disorders and Stroke (NINDS) trial.A total of 43 patients were reviewed with a mean age of 63 years and a male predominance (64%). The median pretreatment National Institutes of Health Stroke Scale score was 18. In our patients, cardioembolism was the leading course of the strokes. The mean time from stroke onset to treatment was 134 minutes, and the mean door-to-computed tomography-time was 34 minutes while the mean door-to-needle time was 93 minutes. Within 36 hours symptomatic intracerebral hemorrhage occurred in two patients (4.7%). Four patients (9.3%) developed brain herniation with fatality. At follow-up, fourteen patients (33%) had a favorable outcome on the modified Rankin Scale (0-1). Patient outcome was not significantly different from that in the NINDS trial.Although the number of patients with AIS receiving tPA in this study was small, thrombolytic therapy can be performed safely and effectively by physicians in the community hospital setting.

Silent infarcts (SIs) are commonly found in brain computed tomography (CT) or magnetic resonance imaging (MRI) of elderly subjects. However, the prevalence of this silent infarction (SI) and risk factors for this entity are not entirely known. This study was aimed to evaluate the prevalence of silent infarcts in brain CT and risk factors in patients admitted with first-ever ischemic stroke or transient ischemic attack (TIA).From July 2003 to May 2005, a prospective study was performed for 446 patients admitted to our neurology service with a diagnosis of TIA or stroke. Two hundred and twenty-six patients did not have a history of stroke or TIA prior to the event. All patients received a brain CT on the day when they arrived at the hospital. Risk factors that are monitored included age, history of hypertension, diabetes mellitus, cardiovascular disease, stroke, smoking and alcohol use. Cholesterol and triglyceride levels were measured on the second day of admission.The results showed that the frequency of SI among 226 patients with first-ever stroke or TIA was 20%. Most of the SIs were small and deep. Small-artery disease was more frequently observed in patients with silent infarction. Age, hypertension, diabetes mellitus, hypercholesterolemia, hypertriglyceridemia, alcohol habit, smoking and atrial fibrillation were not significantly different between patients with silent infarct and patients without silent infarct.The study shows small-artery disease is more frequent in patients with silent infarction. The clinical significance of silent infarct needs further study.

A study was conducted for 121 patients (55 female, 66 male; age 68.7 +/- 10.4 years) with first-ever ischemic stroke to investigate the frequency and risk factors of early neurological deterioration (ND). The initial evaluation was carried out within 24 hours of stroke onset. National Institutes of Health Stroke Scale score and Barthel index were used to evaluate patients for a period of 2 months. Thirty-eight patients (31.4%) showed early ND and 83 patients (68.6%) were stable or improved. Among the 38 patients with ND, 25 (65.8%) patients occurred within 48 hours after initial evaluation. In most patients, ND began on the first day and ceased on the third day after stroke onset. Neurological function started to improve after ND reaching the nadir. The mortality rate was 13.2% (5/38) for patients with ND and 1.2% (1/83) for patients without deterioration. At the end of the study, the functional ability and motility of patients were lower in the progressive group than in the non-progressive/stable group. Results of this study seem to indicate that an elevated C-reactive protein level and total anterior circulation infarction are risk factors for ND. The results also suggest that more aggressive and early treatments are needed for stroke patients to prevent disease progression.

A 77-year-old man presented with dizziness and ataxia after 7-day treatment of phenytoin 100 mg 3 times daily for prophylaxis of post-traumatic seizure. Thrombocytopenia and hematuria were found incipiently and supportive measures were employed. Owing to extremely slow metabolism of phenytoin in this patient, the period of exposure to phenytoin overdose was prolonged, resulting in delayed hypersensitivity syndrome. Neutropenia and fever developed and thus antibiotics and granulocyte-colony stimulating factor were administered. Although charcoal hemoperfusion is generally not applied in cases of phenytoin overdose, this method was successfully used to enhance the removal of phenytoin in our patient.

Division of Neurology, Department of Internal Medicine, Ditmanson Medical Foundation Chia-Yi Christian Hospital, Chiayi City, Taiwan Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Ditmanson Medical Foundation Chia-Yi Christian Hospital, Chiayi City, Taiwan Division of Cardiology, Department of Internal Medicine, Ditmanson Medical Foundation Chia-Yi Christian Hospital, Chiayi City, Taiwan