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Background and ObjectivesWhite matter hyperintensities (WMHs) are reportedly increased in moyamoya disease (MMD); however, their clinical importance is not well-established owing to their pathophysiologic heterogeneity by distribution. This study aimed to evaluate the burden and pattern of WMHs and its clinical implications in the MMD trajectory.MethodsAdult patients with MMD without significant structural lesions were 1:1 propensity score-matched with healthy controls for sex and vascular risk factors. The total, periventricular, and subcortical WMH volumes were segmented and quantified fully automatically. WMH volumes were detrended by age and compared between the 2 groups. MMD severity based on Suzuki stage and future ischemic events were assessed for their association with WMH volumes.ResultsA total of 161 pairs of patients with MMD and controls were analyzed. MMD significantly correlated with increased total WMH volume (B [standard error], 0.126 [0.030];p< 0.001), periventricular WMH volume (0.114 [0.027];p< 0.001), and periventricular-to-subcortical ratio (0.090 [0.034];p= 0.009). In the MMD subgroup (n = 187), advanced MMD had an independent association with the total WMH volume (0.120 [0.035];p< 0.001), periventricular WMH volume (0.110 [0.031];p< 0.001), and periventricular-to-subcortical ratio (0.139 [0.038];p< 0.001). Periventricular WMH volume (adjusted hazard ratio [95% confidence interval], 5.12 [1.26–20.79]) and periventricular-to-subcortical ratio (3.80 [1.51–9.56]) were associated with future ischemic events in patients with medically followed up MMD. However, no demonstrable association was found between subcortical WMH volume and MMD, MMD severity, or future ischemic events.DiscussionPeriventricular WMHs, but not subcortical WMHs, may represent the main pathophysiology of MMD. Periventricular WMHs may be used as a marker for ischemic vulnerability in patients with MMD.

Background: Korea recently established 70 emergency medical service areas. However, there are many concerns that medical resources for stroke could not be evenly distributed through the country. We aimed to compare the treatment quality and outcomes of acute stroke among the emergency medical service areas.Methods: This study analyzed the data of 28,800 patients admitted in 248 hospitals which participated in the 8th acute stroke quality assessment by Health Insurance Review and Assessment Service. Individual hospitals were regrouped into emergency service areas according to the address of the location. Assessment indicators and fatality were compared by the service areas. We defined the appropriate hospital by the performance of intravenous thrombolysis.Results: In seven service areas, there were no hospitals which received more than 10 stroke patients for 6 months. In nine service areas, there were no patients who underwent intravenous thrombolysis (IVT). Among 167 designated emergency medical centers, 50 hospitals (29.9%) responded that IVT was impossible 24 hours a day. There are 97 (39.1%) hospitals that meet the definitions of appropriate hospital. In 23 service areas (32.9%) had no appropriate or feasible hospitals. The fatality of service areas with stroke centers were 6.9% within 30 days and 15.6% within 1 year from stroke onset than those without stroke centers (7.7%, 16.9%, respectively).Conclusions: There was a wide regional gap in the medical resource and the quality of treatments for acute stroke among emergency medical service areas in Korea. The poststroke fatality rate of the service areas which have stroke centers or appropriate hospitals were significantly low.

BackgroundThe high prevalence of coronary stenosis in patients with stroke is well established. However, the association between coronary stenosis and cerebral small vessel diseases (cSVD) in asymptomatic populations remains unclear.MethodsAs a cross-sectional study, we evaluated South Korean adults who underwent a health checkup including brain magnetic resonance imaging and coronary computed tomography angiography between January 2010 and December 2013. The degree of coronary stenosis was classified into three groups: no stenosis (0%), non-significant stenosis (1–49%), and significant stenosis (≥50%). cSVD includes silent lacunar infarction (SLI), cerebral microbleeds (CMB), and white matter hyperintensity (WMH). We used binary logistic regression analyses for SLI and CMB, and linear regression analysis for WMH.ResultsA total of 1,571 participants were evaluated. The prevalence of non-significant and significant coronary stenosis was 369 (23.5%) and 95 (6.1%), respectively. The prevalence of SLI and CMB was 112 (7.1%) and 66 (4.2%), respectively. The mean WMH volume was 2.6 ± 6.1 mL. SLI was significantly associated with both non-significant (adjusted odds ratio [aOR] = 1.94;p= 0.004) and significant coronary stenosis (aOR = 2.37;p= 0.011), even showing dose-response relationship (pfor trend = 0.012). For WMH, only significant coronary stenosis was associated with WMH (β = 0.27;p= 0.013) and had a dose–response relationship (pfor trend = 0.012).ConclusionsThe presence and severity of coronary stenosis were significantly associated with SLI and WMH. Physicians who detects any of coronary stenosis or cSVD should pay attention to the possible coexistence of the other disease.

Introduction: Although the association between vertebral artery or posterior inferior cerebellar artery dissection and lateral medullary infarction (LMI) has been established, the actual prevalence of dissection among patients with LMI may still be underestimated. Methods: Consecutive patients with acute pure LMI admitted between 2010 and 2021 were included. High-resolution vessel wall MRI (VWMRI) and/or transfemoral cerebral angiography (TFCA) were performed in a part of patients and were regarded as gold standard tests for diagnosis of dissection. Factors associated with definite dissection based on VWMRI or TFCA findings were assessed. Risk scoring for dissection was created based on multivariate logistic regression and applied to estimate the number of possible dissection. Results: Eighty-seven LMI patients were eligible and 47 (54.0%) of them underwent VWMRI (n=43) and/or TFCA (n=7). Among these 47 cases, 24 were definite dissection. Three out of 40 patients without gold standard tests were diagnosed with definite dissection based on conventional MRI findings. Preceding headache and normal body weight were independently associated with dissection in LMI patients. A risk scoring which includes age, body mass index, and headache predicted dissection with 91.7% sensitivity and 69.6% specificity (area under the receiver operating characteristic curve, 0.889; 95% confidence intervals, 0.802-0.977) in our population. Additional nine out of 37 patients without gold standard tests nor diagnosis of definite dissection in conventional MRI could be considered as possible dissection based on the scoring. Definite and possible dissections together comprised 41.4% (n=36) of LMI in our study. Conclusions: Arterial dissection may be more prevalent among LMI patients than reported before. Thorough diagnostic effort for dissection is necessary based on scrutinizing risk stratification.

Introduction: White matter hyperintensities (WMH) are reportedly increased in moyamoya disease (MMD); however, their clinical importance is not well-established owing to their pathophysiological heterogeneity by distribution. This study aimed to evaluate the burden and pattern of WMH and its clinical implications in the MMD trajectory. Methods: Adult MMD patients without significant structural lesions were 1:1 propensity score-matched with healthy controls for sex and vascular risk factors. The total, periventricular, and subcortical WMH volumes were segmented and quantified fully automatically. WMH volumes were detrended by age and compared between the two groups. MMD severity based on Suzuki stage and future ischemic events were assessed for their association with WMH volumes. Results: A total of 190 pairs of patients with MMD and controls were analyzed. MMD significantly correlated with increased total (B, 0.086; standard error [SE], 0.027; p=0.002) and periventricular WMH volumes (B, 0.079; SE, 0.025; p=0.002). In the MMD subgroup, advanced MMD had an independent positive association with the total (B, 0.124; SE, 0.034; p Conclusions: Periventricular WMH, but not subcortical WMH, may represent the main pathophysiology of MMD. Periventricular WMH may be used as a marker for ischemic vulnerability in patients with MMD.

Introduction: Alteration of the gastrointestinal (GI) tract by resection or bypass surgery might affect the absorption of both warfarin and direct oral anticoagulants (DOACs). The clinical trials of DOACs excluded individuals with altered GI tract, hence there are limited pharmacokinetic data for them. Only several cases have been reported suggesting atrial fibrillation-related stroke due to reduced absorption of DOACs after GI surgery. We aimed to investigate the efficacy of warfarin and DOACs who underwent GI surgery using nationwide population-based data. Methods: This was a retrospective cohort study using claim-based national data from 2013 to 2020 from Korean Health Insurance Review and Assessment Service (HIRA). Patients with nonvalvular AF (NVAF) taking oral anticoagulants (OACs) were included. The patients taking OACs due to other indications than NVAF were excluded. Cox proportional hazard models with time-varying covariates were used to investigate the impact of GI surgery in patients taking warfarin and DOACs. Results: Of the 311,782 patients (mean age 72, male 56.7%) with NVAF, 3,807 underwent GI surgery. Warfarin and DOACs were prescribed in 14.3% and 85.7% of the patients, respectively. Overall, warfarin was associated with a higher risk of ischemic stroke compared with DOACs (hazard ratio [HR] 1.51, 95% confidence interval [CI] 1.44-1.59). In the GI surgery group, the hazard ratio for ischemic stroke for warfarin compared with DOACs was 2.70 (95% CI, 1.63-4.45, Figure). In the no GI surgery group, warfarin also had a higher risk of ischemic stroke compared with DOACs (HR 1.51, 95% CI 1.44-1.59). Among DOAC-treated patients, GI surgery was not associated with a risk of ischemic stroke (HR 0.87, 95% CI 0.67-1.12). Conclusions: DOACs were more effective for stroke prevention than warfarin in patients with NVAF whose GI tracts were altered due to previous surgery. GI surgery did not affect the risk of stroke in patients with NVAF taking DOAC.

Introduction: Clonal hematopoiesis of indeterminate potential (CHIP) has been linked with incident cardiovascular disease and its outcome. However, the association between CHIP and acute ischemic stroke is not yet fully elucidated. Methods: This retrospective, observational cohort study included 366 acute ischemic stroke patients from a single center prospective stroke registry and 4,628 general population control (age over 40 years old). We compared the prevalence of CHIP between stroke patients and control groups. A multivariable linear or logistic regression model was used to assess the association between CHIP and initial stroke severity, hemorrhagic transformation and functional disability at 90-day (modified Rankin scale score >1) after stroke. The contribution of individual CHIP driving genes was also evaluated. Results: When comparing the acute ischemic stroke patients (N=366) and the general population (N=4,628), the prevalence of CHIP was significantly higher in stroke patients than in the general population (32.0% vs. 13.9% with variant allele frequencies of 1.5%, p Conclusion: CHIP was obviously increased in ischemic stroke patients. Furthermore, CHIP was significantly associated with stroke severity, hemorrhagic transformation, and functional disability at 90 days.

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.

Biomarkers are needed to predict prognosis and disease activity in patients with Guillain-Barré syndrome (GBS). The complement system is a key player in the pathogenesis of GBS. This study aimed to assess the potential utility of serum complement proteins as novel biomarkers in GBS.We reviewed the medical records of 76 GBS patients with C3 and C4 measurements during hospitalization between 2010 and 2021. Clinical outcomes were correlated with baseline serum C3, C4, and seven additional predictors: four existing biomarkers (GM1, albumin, immunoglobulin G, neutrophil-lymphocyte ratio) and three clinical factors from the modified Erasmus GBS outcome score model. Five complement activation products (C3a, C4a, C5a, soluble C5b-9, factor Bb) were measured in 35 patients and were compared with C3 and C4 levels. Longitudinal changes in C3 and C4 levels were compared with the disease course in 12 patients.Higher C3, but not C4, was associated with poorer outcomes: lower Medical Research Council sum scores (MRCSS), higher GBS disability score (GBSDS), longer hospitalization, and more frequent treatment-related fluctuations. Age, MRCSS at admission, and baseline serum C3 were significant independent indicators of 1- and 3-month GBSDS. We found that C3 was positively correlated with C3a (r = 0.32) and C5a (r = 0.37), which indicates an activated complement cascade with high C3. Longitudinal change of C3 coincided with clinical severity of the disease course.This study highlights the use of serum C3 as a novel mechanistic biomarker in GBS. Larger prospective studies are needed to validate our findings.

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: Recent clinical evidence supports the early initiation of aspirin and clopidogrel combination for patients with minor stroke or high-risk transient ischemic attack (TIA) to prevent stroke recurrence. However, some of the patients still experience early neurological deterioration (END) despite optimal antithrombotic treatment. We investigated clinical and laboratory variables related to END after optimal antithrombotic treatment among the patients with non-cardioembolic stroke or TIA. Methods: The patients with minor neurological deficit who received aspirin and clopidogrel within 24 hours after symptom onset were selected from the prospective stroke registries of Seoul National University and Chung-Ang University Hospital, in Seoul, Korea. The END due to ischemic stroke (END_IS) was defined as two or more national institute health stroke scale increase within 5 days after stroke which us due to stroke progression or recurrence. Included patients were divided into two groups according to the presence of END_IS and demographic and laboratory variables were compared between the two groups. Multivariable logistic regression analysis was performed to assess the independent predictors of the END. Results: During the study period from January 2015 to January 2021, 33 (8.7%) out of 380 patients experienced END_IS. In multivariate analysis, independent predictors of END_IS were the presence of intracranial artery stenosis ≥ 50% (odds ratio [OR] 2.922, [95% CI, 1.342-6.364], p=0.007), higher initial NIHSS score, (OR 1.502 [95% CI 1.120-2.015], p=0.007), previous use of statin (OR 0.282 [95% CI 0.080-0.990], p=0.007) and higher serum D-dimer level (OR 1.408 [95% CI, 1.074-1.847], p=0.048). Conclusions: Intracranial artery stenosis, stroke severity, previous statin use, and D-dimer level were the independent predictors of END_IS after dual-antiplatelet treatment in patients with minor stroke. Future studies are necessary to develop an additional therapeutic strategy for the at-risk patient group.

Introduction: The coronavirus disease 2019 (COVID-19) pandemic has changed the medical use of stroke patients. This study evaluated the health-seeking behavior of stroke patients and changes in stroke care services at the time of three domestic COVID-19 outbreaks in Korea using the Korean Stroke Registry (KSR) data. Methods: We reviewed data from patients with acute stroke and transient ischemic attack (TIA) from Jan 2019 to May 2021. There were three domestic COVID-19 outbreaks (1st: Feb to Mar 2020, 2nd Aug to Sep 2020, 3rd Nov 2020 to Jan 2021). Outcomes included patient characteristics, times from stroke onset to hospital arrival, and in-hospital stroke pathways. Results: The study included 34,271 patients who visited hospitals that contribute to the KSR. In the first outbreak, in Daegu city (the main epicenter), the number of patients decreased by two-thirds compared to the pre-COVID period, and the number of TIA patients was particularly decreased (9.97% to 2.91%). Unlike other regions, the median onset-to-door time increased significantly in the epicenter (361 min vs. 526.5 min, p=0.016), and longer times were common for patients with mild symptoms and who were in their 60s or 70s. The median onset-to-door time increased in the epicenter during the second outbreak, but it was not statistically significant. At the third outbreak, the median onset-to-door time was reduced even in the epicenter compared to the previous one. The number of patients decreased with each outbreak compared to the previous one, but the decrease gradually became smaller. Conclusions: Korean stroke patients in a COVID-19 outbreak region showed clear changes in health-seeking behaviors and showed a pattern of adaptation to the COVID-19 environment. There is a need for continued attention to an appropriate triage system and public education on the importance of early treatment during the COVID-19 pandemic.

The code stroke system is designed to identify stroke patients who may benefit from reperfusion therapy. It is essential for emergency physicians to rapidly distinguish true strokes from stroke mimics to activate code stroke. This study aimed to investigate the clinical and neurological characteristics that can be used to differentiate between stroke and stroke mimics in the emergency department (ED).We conducted a retrospective observational study of code stroke patients in the ED from January to December 2019. The baseline characteristics and the clinical and neurological features of stroke mimics were compared with those of strokes.A total of 409 code stroke patients presented to the ED, and 125 (31%) were diagnosed with stroke mimics. The common stroke mimics were seizures (21.7%), drug toxicity (12.0%), metabolic disorders (11.2%), brain tumors (8.8%), and peripheral vertigo (7.2%). The independent predictors of stroke mimics were psychiatric disorders, dizziness, altered mental status, and seizure-like movements, while current smoking, elevated systolic blood pressure, atrial fibrillation on the initial electrocardiogram, hemiparesis as a symptom, and facial palsy as a sign suggested a stroke. In addition, the likelihood of a stroke in code stroke patients tended to increase as the number of accompanying deficits increased from the following set of seven focal neurological deficits: hemiparesis (or upper limb monoparesis), unilateral limb sensory change, facial palsy, dysarthria, aphasia (or neglect), visual field defect, and oculomotor disorder (Some clinical and neurological characteristics have been identified to help differentiate stroke mimics from true stroke. In particular, the likelihood of stroke tended to increase as the number of accompanying focal neurological deficits increased.

Although obesity has been proven as a risk factor of metabolic and cardiovascular diseases, there have been few studies addressing the association between obesity and cerebral white matter hyperintensity (WMH) volume with controversial findings. In this study, we evaluated the relationship between abdominal fat distribution and WMH volume in a neurologically healthy population. We performed an observational study in a consecutive series of subjects who were examined during voluntary health check-ups between January 2006 and December 2013. We directly measured both visceral adipose tissue (VAT) and subcutaneous adipose tissue (SAT) using abdominal computed tomography. The WMH volumes were also recorded quantitatively. A total of 2504 subjects were included in this study. In multivariate analysis, the relationship between SAT and WMH volume remained significant (β = −0.170, standard error [SE] = 0.065, P = .006) after adjusting for confounding factors. The protective effects of SAT on the WMH volume were more prominent in female participants (β = −0.295, SE = 0.138, P = .033) and in severely obese participants (β = −0.358, SE = 0.167, P = .033). Conclusively, we demonstrated a negative association between SAT and WMH volume in a healthy population.

Obesity without metabolic disorder [Ob(+)MD(−)] is a unique subcategory of obesity where individuals are protected from the obesity-related complications. Although conflicting clinical outcomes have been reported, there has been no study of the effects of Ob(+)MD(−) on cerebrovascular disease. In this study, we evaluated the association between the Ob(+)MD(−) phenotype and silent brain infarcts (SBI) in a neurologically healthy population. We evaluated a consecutive series of healthy volunteers recruited between January 2006 and December 2013. MD(−) status was assessed using five clinical markers: blood pressure, triglycerides, high-density lipoprotein, fasting plasma glucose, and waist circumference. Obesity was defined when body mass index ≥ 25 kg/m2. SBI was defined as asymptomatic, well-defined lesions with a diameter ≥ 3 mm with the same signal characteristics as the cerebrospinal fluid on T1- or T2-weighted images. A total of 3165 subjects were assessed, and 262 (8%) SBI cases were identified. In multivariate analyses, non-obesity with metabolic disorder [Ob(−)MD(+)] (adjusted odds ratio [aOR] = 1.65, 95% confidence interval [CI] = 1.07–2.56, P = 0.025) and obesity with metabolic disorder [Ob(+)MD(+)] (aOR = 1.75, 95% CI = 1.12–2.75, P = 0.014) were closely associated with SBI after adjustment for confounders. Meanwhile, Ob(+)MD(−) did not show any significant association with SBI (aOR = 0.85, 95% CI = 0.20–3.72, P = 0.832). These findings may indicate that metabolic abnormality, irrespective of obesity status, is a main risk factor of SBI. When we compared SBI burdens between the four metabolic phenotypes, the Ob(+)MD(+) and Ob(−)MD(+) groups had higher rates of multiple lesions than the Ob(+)MD(−) and non-obesity without metabolic disorder groups. The presence of metabolic abnormality, and not obesity per se, is independently associated with the prevalence of SBI in a healthy population.

Background and purpose: With the wide spread of coronavirus disease 2019 (COVID-19) around the world, not only patients with COVID-19, but also patients with other disease such as stroke have undergone many changes in their health-seeking behavior. Between late February and March 2020, COVID-19 was epidemic in the community of Daegu city and Gyeongsangbuk-do region (D-G region) in Korea. We aimed to clarify the changes in the health-seeking behaviors of stroke patients and stroke care services by region in Korea through analysis of data from Korean Stroke Registry (KSR). Methods: We retrospectively reviewed the data with acute stroke and transient ischemic attack (TIA) patients between 2019 and 2020. We compared the stroke onset to hospital arrival (onset-to-door) time of these patients in the D-G region and other regions in Korea during the epidemic period in 2020 (post-COVID-19: February 18-March 31, 2020) and the same period in 2019 (Pre-COVID-19). In addition, we investigated the in-hospital stroke pathways with the patients. Results: 1,792 patients in pre-COVID-19 and 1,555 patients in post-COVID-19 who visited KSR-registered hospitals were analyzed. Compared to pre-COVID-19, the number of patients registered in KSR decreased in most regions in post-COVID-19. In the D-G region, the number of registered patients decreased by two thirds, and the proportion of patients with TIA decreased significantly. (9.97% to 2.91%). Unlike other regions, the median onset-to-door time increased significantly in the D-G region (361 versus 526.5 minutes, p=0.0084). The proportion of patients with onset-to-door time within 3 hours also decreased significantly (36.45% versus 28.16%, p=0.0485). Patients in their 60s and 70s and mild symptoms (NIHSS score 0 to 3) came to the hospital later. As a result, the patients who underwent thrombectomy also decreased, but the treatment time did not differ between the two periods. Conclusion: During the epidemic of COVID-19, the patients residing in the epicenter showed distinct changes in health-seeking behavior. Appropriate public education about stroke is needed during the COVID-19 pandemic.

Supplemental material, sj-pdf-1-wso-10.1177_1747493020984069 for Triglyceride-glucose index is associated with early neurological deterioration in single subcortical infarction: Early prognosis in single subcortical infarctions by Ki-Woong Nam, Min K Kang, Han-Yeong Jeong, Tae J Kim, Eung-Joon Lee, Jeonghoon Bae, Kipyoung Jeon, Keun-Hwa Jung, Sang-Bae Ko and Byung-Woo Yoon in International Journal of 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.

Visceral adiposity index (VAI) has been associated with various cardio-metabolic diseases; however, there is limited information about its association with cerebrovascular diseases. In this study, we evaluated the relationship between VAI and silent brain infarct (SBI). We evaluated a consecutive series of healthy volunteers over the age of 40 between January 2006 and December 2013. SBI was defined as an asymptomatic, well-defined lesion with a diameter ≥ 3 mm with the same signal characteristics as the cerebrospinal fluid. VAI was calculated using sex-specific equations as described in previous studies. A total of 2596 subjects were evaluated, and SBI was found in 218 (8%) participants. In multivariable analysis, VAI (adjusted odds ratio [aOR] = 1.30; 95% confidence interval [CI] 1.03–1.66; P = 0.030) remained a significant predictor of SBI after adjustment for confounders. The close relationship between VAI and SBI was prominent only in females (aOR = 1.44; 95% CI 1.00–2.07; P = 0.048). In the evaluation between VAI and the burden of SBI, VAI showed a positive dose–response relationship with the number of SBI lesions (P for trend = 0.037). High VAI was associated with a higher prevalence and burden of SBI in a neurologically healthy population.

Background Visceral adiposity index (VAI) is a novel indicator of the mass and function of visceral adipose tissue, and it has been associated with metabolic disease, cardiovascular disease, and subclinical atherosclerosis; however, there is limited information about its association with cerebrovascular diseases, especially in subclinical pathology. In this study, we evaluated the relationship between VAI and silent brain infarct (SBI) in a healthy population. Methods We evaluated a consecutive series of healthy volunteers over the age of 40 between January 2006 and December 2013. SBI was defined as an asymptomatic, well-defined lesion with a diameter ≥ 3 mm with the same signal characteristics as the cerebrospinal fluid on T1- or T2 weighted images. VAI was calculated using sex-specific equations as described in previous studies, and was based on a number of parameters including waist circumference, triglycerides, high-density lipoprotein cholesterol, and body mass index. Results A total of 2,596 subjects were evaluated (mean age 56y, male sex: 54%), and SBI was found in 218 (8%) participants. In multivariable analysis, VAI (adjusted odds ratio [aOR] = 1.30; 95% confidence interval [CI] = 1.03–1.66; P = 0.030) remained a significant predictor of SBI after adjustment for confounders. On the other hand, visceral adipose tissue area on computed tomography did not show any statistical significance with SBI. The close relationship between VAI and SBI was prominent only in females (aOR = 1.44; 95% CI = 1.00-2.07; P = 0.048). In the evaluation between VAI and the burden of SBI, VAI showed a positive dose-response relationship with the number of SBI lesions (P for trend = 0.037). Conclusions High VAI was associated with a higher prevalence and burden of SBI in a neurologically healthy population, especially in females. Our findings indicate that VAI could be used as a simple and convenient predictor for SBI.

ObjectiveTo evaluate the relationship between serum total homocysteine (tHcy) levels and cerebral small vessel disease (cSVD) in a healthy population.MethodsWe included consecutive participants who visited our department for health checkups between 2006 and 2013. We rated white matter hyperintensity volumes using both the Fazekas score and semiautomated quantitative methods. We also evaluated lacunes, cerebral microbleeds, and enlarged perivascular spaces (EPVS), which are involved in cSVD. To assess the dose-dependent relationship between tHcy and cSVD parameters, we scored the burdens of each radiologic marker of cSVD.ResultsA total of 1,578 participants were included (age 55 ± 8 years, male sex 57%). In the multivariable analysis, tHcy remained an independent predictor of the white matter hyperintensity volume (B = 0.209; 95% confidence interval [CI] = 0.033–0.385, p = 0.020), presence of cerebral microbleeds (adjusted odds ratio = 2.800; 95% CI = 1.104–7.105, p = 0.030), and moderate to severe EPVS (adjusted odds ratio = 5.906; 95% CI = 3.523–9.901, p < 0.001) after adjusting for confounders. Furthermore, tHcy had positive associations with periventricular Fazekas score (p = 0.001, p for trend p = 0.003, p for trend = 0.005), and moderate to severe EPVS lesion burden (p < 0.001, p for trend ConclusionsSerum tHcy level is correlated with cSVD development in a dose-dependent manner. These findings provide us with clues for further studies of the pathophysiology of cSVD.

Prediction of outcome after stroke may help clinicians provide effective management and plan long-term care. We aimed to develop and validate a score for predicting good functional outcome available for hospitals after ischemic stroke using linked data. A total of 22,005 patients with acute ischemic stroke from the Clinical Research Center for Stroke Registry between July 2007 and December 2014 were included in the derivation group. We assessed functional outcomes using a modified Rankin scale (mRS) score at 3 months after ischemic stroke. We identified predictors related to good 3-month outcome (mRS score ≤ 2) and developed a score. External validations (geographic and temporal validations) of the developed model were performed. The prediction model performance was assessed using the area under the receiver operating characteristic curve (AUC) and the calibration test. Stroke severity, sex, stroke mechanism, age, pre-stroke mRS, and thrombolysis/thrombectomy treatment were identified as predictors for 3-month good functional outcomes in the S-SMART score (total 34 points). Patients with higher S-SMART scores had an increased likelihood of a good outcome. The AUC of the prediction score was 0.805 (0.798–0.811) in the derivation group and 0.812 (0.795–0.830) in the geographic validation group for good functional outcome. The AUC of the model was 0.812 (0.771–0.854) for the temporal validation group. Moreover, they had good calibration. The S-SMART score is a valid and useful tool to predict good functional outcome following ischemic stroke. This prediction model may assist in the estimation of outcomes to determine care plans after stroke.

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.

Cerebral white matter hyperintensity (WMH) is commonly found in ischemic stroke patients, especially when accompanied by intracranial atherosclerosis (ICAS). However, the relationship between WMH and ICAS in a healthy population has not been evaluated.A total of 3159 healthy subjects who underwent health checkups, including brain magnetic resonance imaging and angiography, were enrolled. ICAS was defined as an occlusion or more than 50% stenosis of intracranial vessels on magnetic resonance angiography. Volumes of WMH were quantitatively rated.Eighty-two (2.6%) subjects had ICAS. The mean age of the cohort was 56 years, and the median volume of WMH was 1.02 [0.20-2.60] mL. In a multivariate analysis, ICAS [β = 0.331, 95% confidence interval (CI) = 0.086 to 0.576, p = 0.008] was significantly associated with WMH volumes after adjusting confounders. Age (β = 0.046, 95% CI = 0.042 to 0.050, p 0.001), hypertension (β = 0.113, 95% CI = 0.017 to 0.210, p = 0.021), and diabetes (β = 0.154, 95% CI = 0.043 to 0.265, p = 0.006) were also significant, independently of ICAS. The ICAS (+) group had more frequent vascular risk factors including hypertension, diabetes, and statin use, than the ICAS (-) group, and these tendencies increased when WMH was accompanied by ICAS.ICAS is associated with larger WMH volume in a healthy population. Close observation of this group and strict control of vascular risk factors are needed.

High neutrophil to lymphocyte ratio (NLR) is correlated with the occurrence, morbidity and mortality of cerebrovascular disease as a marker of systemic inflammation. However, its effect on cerebral white matter hyperintensity (WMH) is unclear. We investigated high NLR burden as a surrogate marker of WMH volume in a healthy population. Healthy subjects with voluntary health check-ups between January 2006 and December 2013, including brain MRI and laboratory examination, were collected. WMH volumes were rated quantitatively. A total of 2875 subjects were enrolled, and the mean volume of WMH was 2.63±6.26mL. In multivariate linear regression analysis, NLR [β=0.191, 95% confidence interval (CI)=0.104 to 0.279, P0.001] remained significant after adjusting for confounders. Age (β=0.049, 95% CI=0.045 to 0.054, P0.001), hypertension (β=0.191, 95% CI=0.101 to 0.281, P0.001), diabetes (β=0.153, 95% CI=0.045 to 0.261, P=0.006), and extracranial atherosclerosis (β=0.348, 95% CI=0.007 to 0.688, P=0.045) were also significant independently from NLR. Additionally, the high NLR group (NLR≥1.52) was related to male sex, hypertension, diabetes, current smoking, extracranial atherosclerosis, silent brain infarct, and high WMH volumes. In conclusion, high NLR is associated with larger WMH volumes in a healthy population. Assessment of NLR may be helpful in detecting cerebral WMH burdens in high risk groups.