Search

Hereditary diffuse leukoencephalopathy with axonal spheroids (HDLS) is a rare autosomal dominant disorder that is caused by colony stimulating factor 1 receptor gene mutation degenerating the cerebral white matter. It is characterized by various symptoms such as progressive cognitive decline, personality changes, and motor disorders. Since these clinical features are not consistent, HDLS is often underdiagnosed or misdiagnosed. This case report presents a patient priorly diagnosed with cerebral infarction by clinical features, but eventually with HDLS by a genetic test.

Posterior reversible encephalopathy syndrome (PRES) and reversible cerebral vasoconstriction syndrome (RCVS) are relatively uncommon neurological disorders. These two independent syndromes can be concurrent as a part of a continuum process; however, the specific mechanism is not well known. Although the relationship between RCVS and PRES is currently unclear, they could share a common pathophysiology. This case report aimed to determine the pathophysiology underlying the co-occurrence of PRES and RCVS in a patient with an acute exacerbation of chronic obstructive pulmonary disease.

Immune checkpoint inhibitors (ICIs) have emerged as one of the most promising therapeutic options for advanced cancers. While ICIs have improved survival in multiple cancers, their increased use is restricted by various immune-related adverse events. In this report we describe a patient with renal cell carcinoma who received a combination of ICIs, nivolumab plus ipilimumab, and who developed lumbosacral polyradiculoneuropathy. Corticosteroid use was an effective treatment for this patient.

Purpose Although endovascular treatment is currently thought to only be suitable for patients who have pial arterial filling scores >3 as determined by multiphase computed tomography angiography (mpCTA), a cut-off score of 3 was determined by a study, including patients within 12 hours after symptom onset. We aimed to investigate whether a cut-off score of 3 for endovascular treatment within 6 hours of symptom onset is an appropriate predictor of good functional outcome at 3 months. Materials and Methods From April 2015 to January 2016, acute ischemic stroke patients treated with mechanical thrombectomy within 6 hours of symptom onset were enrolled into this study. Pial arterial filling scores were semi-quantitatively assessed using mpCTA, and clinical and radiological parameters were compared between patients with favorable and unfavorable outcomes. Multivariate logistic regression analysis was then performed to investigate the independent association between clinical outcome and pial collateral score, with the predictive power of the latter assessed using C-statistics. Results Of the 38 patients enrolled, 20 (52.6%) had a favorable outcome and 18 had an unfavorable outcome, with the latter group showing a lower mean pial arterial filling score (3.6±0.8 vs. 2.4±1.2, P=0.002). After adjusting for variables with a P-value of 2 vs. ≤2. Conclusion A pial arterial filling cut-off score of 2 as determined by mpCTA appears to be more suitable for predicting clinical outcomes following endovascular treatment within 6 hours of symptom onset than the cut-off of 3 that had been previously suggested.

BackgroundCentral retinal artery occlusion (CRAO) is an ischemic stroke of the eye. The atherosclerotic lesions in the intracranial segment of the carotid artery (CA) and the ophthalmic artery (OphA) are not well defined. We aimed to investigate the cerebral angiographic features of CRAO patients and assess the relationship between the angiographic features and outcomes after intra-arterial thrombolysis (IAT).MethodsWe included 101 acute non-arteritic CRAO patients treated with IAT. We analyzed the detailed angiographic features of the OphA and ipsilateral CA, visual acuity, fundus photography, and fluorescein angiography.ResultsOf the 101 patients, 38 patients (37.6%) had steno-occlusive lesions in the OphA, and 62 patients (61.4%) had atherosclerotic lesions in the ipsilateral CA. The patients with a higher degree of stenosis in the OphA showed a higher degree of stenosis (P=0.049) and a more severe morphology of plaque (P=0.000) in the ipsilateral CA. Additionally, although the visual outcome was not associated with these angiographic features, the lower degree of stenosis and less severe morphology of plaque in the ipsilateral CA resulted in a significant improvement in early reperfusion rate (P=0.018 and P=0.014, respectively) and arm-to-retina circulation (P=0.016 and P=0.002, respectively) of the eye after IAT.ConclusionsThere was a significant correlation in the severity of steno-occlusive lesions between the OphA and the ipsilateral CA in patients with CRAO. The patients with less severe angiographic features in the CA showed a more improved retinal reperfusion after IAT. The angiographic findings in the CA may serve as a predictive marker for the vessel integrity of the OphA and recanalization outcome after IAT.

Recanalization of a completely occluded vertebral artery, which involves ruptured vertebral dissecting aneurysm, to a normal configuration is rare. Here we report the case of a recanalized vertebral artery dissecting aneurysm in a 51-year-old woman that was treated using endovascular trapping and the right vertebral artery was completely occluded. Six months after the procedure, transfemoral cerebral artery angiography showed a normal configuration of the antegrade recanalized vertebral artery. We also suggest three possible mechanisms for the phenomenon of antegrade recanalization, of which we consider the water-hammer effect mechanism to be the most probable. Endovascular trapping, regardless of the presence of a true or false lumen, is capable of providing promising results and good prognosis through antegrade revascularization or complete occlusion. Keywords: Recanalization, Vertebral artery dissecting aneurysm, Endovascular trapping, Aneurysmal Subarachnoid Hemorrhage

Purpose Acute ischemic strokes caused by steno-occlusive lesion of the cervical internal carotid artery are associated with poor clinical outcome. We evaluated the clinical efficacy of emergent carotid artery stenting for the management of these lesions. We compared the clinical outcomes regarding the intracranial lesion, namely tandem occlusions versus isolated cervical internal carotid artery occlusion. Materials and methods We retrospectively reviewed patients with acute ischemic stroke who underwent carotid artery stenting for cervical internal carotid artery steno-occlusive lesion between 2011 and 2018. After dividing the patients into two groups according to the presence or absence of intracranial lesions (tandem group and isolated cervical group), we analyzed demographic data, angiographic findings, and clinical outcomes. A modified Rankin Scale score ≤2 was defined as a favorable clinical outcome. Results Of 75 patients, 46 patients (61.3%) had tandem lesions, and the remaining 29 had only cervical internal carotid artery steno-occlusive lesion. Successful stenting was performed in all patients with favorable clinical outcomes (64.0%). Successful reperfusion score (thrombolysis in cerebral infarction ≥2 b) was 84.0%; tandem group (76.1%) versus isolated cervical group (96.6%) of cases. Mean modified Rankin Scale score at 90-days was 2.09. The rate of favorable clinical outcome showed no statistically significant difference between the two groups ( p = 0.454). Conclusions Endovascular treatment in patients with acute ischemic stroke due to cervical internal carotid artery steno-occlusive lesion is a technically feasible and clinically effective intervention regardless of intracranial occlusion. Therefore, we recommend endovascular treatment regardless of the presence of concomitant intracranial artery occlusion for patients with acute ischemic stroke caused by cervical internal carotid artery steno-occlusive lesion.

We investigated the association between early recanalization degree after intravenous thrombolysis (IVT), occurrence of hemorrhagic transformation, and functional outcome. We also evaluated whether recombinant tissue plasminogen activator (rTPA) dosing error could influence the outcome. Patients with ischemic stroke with major vessel occlusion (n=256) who underwent IVT were included. Recanalization status (no recanalization, partial recanalization, and complete recanalization) was confirmed by subsequent magnetic resonance or conventional angiography. Association between early recanalization degree and favorable outcome (modified Rankin Scale score ≤2) was evaluated using logistic regression analysis. Early partial recanalization was achieved in 33 (12.9%), and complete recanalization in 7 (2.7%) patients. Patients with the highest quintile of rTPA dosage achieved complete recanalization more frequently than the lower four quintiles (8.0% vs 2.0%, P=0.03). Hemorrhagic transformation tended to occur more frequently in patients with complete recanalization as compared with patients with partial recanalization (57.1% vs 21.2%, P=0.15). The proportion of favorable outcome was significantly lower in patients with the highest quintile of rTPA dosage used as compared with the patients with lower four quintiles (40.8%, 57.0%, P=0.04). In multivariable analysis, partial recanalization was significantly associated with favorable outcome (adjusted odds ratio, 3.15; 95% CI, 1.06-9.35), but complete recanalization was not. Early partial recanalization after IVT may be an indicator of favorable outcome with low occurrence of any hemorrhagic transformation.

Summary Background and purpose To determine whether status of dominant vertebral artery could affect clinical outcome in patients with symptomatic basilar artery occlusion (BAO). Methods We reviewed patients with symptomatic BAO who underwent endovascular treatment at the institute between January 2007 and July 2014. Patients were categorized into 2 groups according to functional outcome and baseline characteristics, treatment related factors were compared. Variables including clinical and imaging parameters were also compared according to the dominant V1 lesion. Results Fifty-nine of 101 patients underwent endovascular treatment and 23 patients (39.0%) showed favorable outcome (modified Rankin score ≤3 at 3 month). Younger age, male sex, lower baseline NIHSS score, higher PC-ASPECTS, absence of hemorrhagic transformation, shorter procedure time, and complete recanalization were associated with favorable outcome. Procedure time tended to be longer in patients with dominant V1 lesion (130.0; range, 105.0–179.0 vs. 101.5; range, 48.0–138.0, P = 0.05). Among patients with large artery disease (LAD), higher initial NIHSS, and clinical manifestation of decreased mental status were significantly associated with dominant V1 lesion. Endovascular procedure time tended to be longer, distal basilar occlusion tended to be more frequent, and proportion of the patients with complete recanalization tended to be less in patient with dominant V1 lesion. Poor outcome tended to be more frequent in dominant V1 lesion with LAD (88.9% vs. 42.9%, P = 0.05). These findings were comparable in patients who underwent mechanical thrombectomy. Conclusion Dominant V1 steno-occlusion may be associated with poor functional outcome in patients with the symptomatic BAO. Status of dominant VA and various treatment strategy should be considered when performing endovascular treatment for recanalization in patients with symptomatic BAO.

Background Coil protrusion occasionally occurs during embolization and can lead to thromboembolic complications. We aimed to evaluate the efficacy of rescue stenting procedures with a low-profile stent system (LVIS Jr.) for treating ruptured intracranial aneurysms during complicated coil embolization. Methods We performed a retrospective review to identify patients who had subarachnoid hemorrhage and were treated with LVIS Jr. stent rescue therapy. We enrolled 15 patients with intracranial aneurysms and evaluated the technical success and immediate postprocedural clinical and angiographic outcomes. Results All 15 patients underwent successful rescue-stent treatment, and no thrombotic or hemorrhagic complications occurred. Immediate postprocedural angiography revealed complete aneurysm occlusion in 40% (6/15) of the patients, whereas 60% (9) of the patients had a residual neck. Among the 12 patients who underwent follow-up angiography, 10 (83.3%) patients had complete aneurysm occlusion, 1 (8.3%) had a residual neck, and 1 (8.3%) showed an increase in the filling status of the aneurysm. There were no thrombotic complications during the follow-up period. Conclusions Our findings indicate that LVIS Jr. stent rescue therapy is clinically useful for handling coil protrusion during the embolization of ruptured intracranial aneurysms.

Introduction: The aim of this study was to assess whether we could distinguish stroke subtype by analyzing the size, weight, shape, color and imaging characteristics of the retrieved thrombus. Methods: From October 2013 to January 2016, 28 thrombi were classified as cardioembolism (CE) and 16 were large artery atherosclerosis (LAD). The size, shape, and color characteristics of the thrombus were analyzed. The weight of total thrombi of each case was measured. The weight, length, and sectional area of the largest thrombus of each case was measured again. We compared the degree of circularity, roundness, aspect ratio, and solidity of the largest thrombus. The color image of the largest thrombus was analyzed by using RGB histograms. Retrieved thrombus was subjected to post-MRI under ex vivo conditions. Results: The probability of stroke due to CE increases as the RBC composition of thrombus increases, and the probability of stroke due to LAD increases as the fibrin composition of thrombus increases (p=0.018). The size of the cross-sectional area of the largest thrombus (22.38 ±21.48mm2 vs. 12.15±10.86mm2, p=0.043) is larger in the CE group. Also, the weight of total thrombi (140.00±231.39mg vs. 37.50± 30.31mg, p=0.049) and the weight of the largest thrombus (46.14±47.34mg vs. 17.94±16.89mg, p=0.013) is heavier in the CE group. Higher RGB values in the LAD group mean that the thrombus of the LAD group is brighter than the thrombus of the CE group. In multivariate logistic regression analysis, the mean Green value of RGB (OR 1.488, 95% CI 1.032-2.146; p= 0.033) was independently associated with LAD. Blooming artifacts of the post-MRI under ex vivo conditions well correlate with that of the pre-MRI (p=0.016), and blooming artifacts of the post-MRI under ex vivo conditions was associated with red blood cell composition of thrombus (p=0.005). Conclusions: The shape of the thrombus did not help to determine the stroke subtype. The weight, cross-sectional area, and color difference of the thrombus helped to distinguish CE and LAD, and the mean Green value of RGB was found to be the most significant predictor. And blooming artifacts of the post-MRI under ex vivo conditions was well correlated with that of the pre-MRI and red blood cell composition of thrombus.

Background The oculomotor nerve has two major fibers: the outer autonomic fiber innervates the ciliary muscles and sphincter pupillae involved in pupil constriction, and the inner somatic fiber innervates the levator palpebrae superioris in the eyelid and four extraocular muscles involved in oculomotor dysfunction. We present a rare case of oculomotor nerve palsy with internal carotid artery (ICA) dissection and discuss the vascular anatomical feature of interest to be considered during treatment. Case report A 56-year-old man presented with language impairment, right visual field loss, and right-sided facial sensory loss, weakness, and hypesthesia 30 hours after the last seen normal. CT perfusion imaging revealed a large left middle cerebral artery distribution and possible salvageable ischemic penumbra. Angiography showed occlusion of the communicating segment of the left ICA. We performed mechanical thrombectomy for left ICA occlusion that led to partial recanalization after several attempts. A control digital subtraction angiography showed dissection features in the communicating part of the left ICA. The recanalized ICA got blocked again within ten minutes. Angioplasty was performed and the flow improved. Five hours after thrombectomy, the patient developed complete left oculomotor palsy with ptosis, a fixed mydriatic pupil, and lateral and downwards eyeball deviation suggesting oculomotor nerve palsy. MRI on the 23rd day after symptom onset revealed enhancement of the left oculomotor nerve. Conclusions The clinical and imaging course described in this case shows an injury to the oculomotor nerve with compressive plus ischemic injury in a patient with ICA dissection who received endovascular treatment.

Although high uric acid levels have been reported to be a risk factor for cardiovascular disease and stroke, the relationship between serum uric acid (SUA) levels and cardioembolic stroke (CES) has not been fully elucidated. In this study, we sought to investigate the relationship between the risk of CES and SUA levels. We hypothesized that SUA concentrations are associated with CES.We retrospectively analyzed 2350 patients with acute ischemic stroke who were admitted to the Seoul National University Hospital between 2002 and 2010. The participants were stratified into five groups according to SUA levels obtained within 24h after stroke onset. The association between SUA levels and CES was evaluated using multivariable logistic regression models.Of the 2350 patients, 412 (27.7%) were classified with CES, and 1077 (72.3%) were classified with non-CES, including LAA (large artery atherosclerosis) and SVO (small vessel occlusion). Among the acute stroke patients, SUA levels were higher in those with atrial fibrillation and other cardiovascular risk factors. Compared with the non-CES patients, the CES patients were more likely to fall in the highest quintile of SUA level. Multivariate analysis revealed that the patients with SUA concentrations in the highest quintile were associated with CES (OR=2.59, 95% CI: 1.35-4.97), test for trend P0.001. Similar results were obtained for gender-based subgroups by (in men, OR=2.34, 95% CI: 1.06-5.15 and in women OR=3.41, 95% CI: 1.15-10.07), test for trend P0.01 and P0.001, respectively.SUA level is associated with the risk of CES in acute ischemic stroke patients of both sexes. Further prospective clinical trials of lowering SUA to prevent CES may be worth considering.

Fulminant hepatic failure (FHF) is often accompanied by a myriad of neurologic complications, which are associated with high morbid-ity and mortality. Although appropriate neuromonitoring is recommended for early diagnosis and to minimize secondary brain injury, individuals with FHF usually have a high chance of coagulopathy, which limits the ability to use invasive neuromonitoring. Jugular bulb venous oxygen saturation (JvO₂) monitoring is well known as a surrogate direct measures of global brain oxygen use. We report the case of a patient with increased intracranial pressure due to FHF, in which JvO₂ was used for appropriate brain oxygen monitoring.

Background and Purpose Recent advances in intra-arterial techniques and thrombectomy devices lead to high rate of recanalization. However, little is known regarding the effect of the evolvement of endovascular revascularization therapy (ERT) in acute basilar artery occlusion (BAO). We compared the outcome of endovascular mechanical thrombectomy (EMT) versus intra-arterial fibrinolysis (IAF)-based ERT in patients with acute BAO. Methods After retrospectively reviewed a registry of consecutive patients with acute ischemic stroke who underwent ERT from September 2003 to February 2015, 57 patients with acute BAO within 12 hours from stroke onset were enrolled. They were categorized as an IAF group (n=24) and EMT group (n=33) according to the primary technical option. We compared the procedural and clinical outcomes between the groups. Results The time from groin puncture to recanalization was significantly shorter in the EMT group than in the IAF group (48.5 [25.3 to 87.8] vs. 92 [44 to 179] minutes; P=0.02) The rate of complete recanalization was significantly higher in the EMT group than in the IAF group (87.9% vs 41.7%; P

Background Stroke unit care is associated with decrease in mortality and improvement in neurological outcome in patients with acute stroke. Heart rate is a commonly monitored variable in the stroke unit. However, little is known about tachycardia burden in the stroke unit and its association with outcome. Aims To investigate the effects of tachycardia burden in the stroke unit on functional outcome in patients with acute ischemic stroke. Methods We collected data from 246 patients with acute ischemic stroke admitted to our stroke unit between July 2013 and June 2014. Tachycardia burden was defined as duration of heart rate over 95 per minute divided by the total monitoring time, using the heart rate data sampled every 1 min. We divided the study population into quartiles of tachycardia burden and analyzed their association with poor three-month functional outcome (modified Rankin Scale score of ≥3). Results Among included patients (age, 67.4 ± 12.8; male, 53.7%), tachycardia burden was 0.7% (median, interquartile range [0.1–5.7%]). The patients with higher tachycardia burdens were older, more likely to have higher stroke severity, cardioembolic etiology, atrial fibrillation, fever, pneumonia, higher initial glucose level, and higher white blood cell count. As compared with the lowest quartile (Conclusions Patients with increased tachycardia burden during stroke unit stay have poor functional outcome. Countermeasures against worsening factors might be utilized for patients with increased tachycardia burden.

Supplemental material, Supplementary Tables for Procedural and clinical outcomes of endovascular recanalization therapy in patients with cancer-related stroke by Seunguk Jung, Cheolkyu Jung, Jae Hyoung Kim, Byung Se Choi, Yun Jung Bae, Leonard Sunwoo, Ho Geol Woo, Jun Young Chang, Beom Joon Kim, Moon-Ku Han and Hee-Joon Bae in Interventional Neuroradiology

Background Controversy exists regarding the question of whether weight change decreases or increases the risk of mortality. Aim The aim of this study was to evaluate the prognostic importance of weight change on short-term outcomes in acute ischemic stroke patients. Methods A total of 654 patients with acute ischemic stroke were enrolled in this study from March 2010 to May 2013. We assessed the weight change of each participant between admission and discharge from the Department of Neurology. Weight change was defined as change ≥0.05 kg/baseline body mass index unit. We evaluated the short-term outcomes using a modified Rankin Scale at three-months after the onset of a stroke. Results Among the 654 patients, 35.2% were included in the weight-change group. Weight loss occurred in 24.6% of the participants during the hospital stay following the stroke, which lasted an average of nine-days. Compared with the weight-stable group, the pronounced weight-loss group had a higher risk of unfavorable outcomes (odds ratio 2.43; 95% confidence interval 1.12-5.25). Conclusions Short-term weight loss after stroke appears to be more common than we expected, and our results suggest that it is associated with unfavorable functional outcomes. Therefore, clinical nutrition should be considered as a component of medical treatment and weight loss should be monitored as an indicator of malnutrition.

Not infrequently, intracranial aneurysms may be multifocal. However, strategies conferring open surgical access to opposite sides of the brain are limited. Given the recent advances in protection devices and coiling technique, a study of single-stage coil embolization in patients with multiple intracranial aneurysms was undertaken, assessing procedural safety and efficacy. Data prospectively accrued between January 2010 and September 2013 were systematically reviewed, assessing clinical and morphologic outcomes of single-stage coil embolization in 172 patients with multiple aneurysms (≥ 2 aneurysms each; total, 371 aneurysms). Internal carotid artery (n = 132) was the most common site, with progressively fewer aneurysms found elsewhere (middle cerebral artery, 103; anterior communicating artery, 41; posterior communicating artery, 38). In 26 patients, one-stage embolization of three or more aneurysms took place (25 patients with three each; 1 patient with four). Stents were applied in 109 aneurysms, and in 33 lesions, balloons were used. Occlusion was achieved in 326 aneurysms (87.9 %) through coil embolization, and attempted coiling rarely failed (3 of 371, 0.8 %). Mean procedural time was 111.5 ± 37.8 min. Although procedure-related adverse events included three instances of treatment failure, asymptomatic thrombi in four patients, and aneurysmal leakage in one patient, procedural morbidity was low (1 of 172, 0.6 %), and no procedure-related deaths occurred. Postembolization follow-up of 303 aneurysms at > 6 months (mean, 15.4 ± 9.8 months) showed complete occlusion in the vast majority (275 of 303, 90.8 %), with comparatively fewer instances of minor (19 of 303, 6.3 %) and major (9 of 303, 3.0 %) recanalization. Four patients experienced delayed cerebral infarction, but only one suffered permanent neurologic deficit (Glasgow outcome scale 4). Single-stage coil embolization of multiple unruptured intracranial aneurysms is technically feasible. The time required for such procedures and the rate of complications observed seem acceptable.

The presence of primary intraventricular hemorrhage (IVH) without vascular lesion is very rare. We experienced solitary IVH without subarachnoid hemorrhage due to aneurysmal rupture in a 58-year-old man treated with coil embolization, which contributed to his good prognosis. After 33 days of hospitalization, he had mild right hemiplegic symptoms remaining, and he was transferred to a rehabilitation institute for further treatment. In cases of primary IVH, computed tomography angiography seems worthwhile for making a differential diagnosis, although the possibility of IVH due to cerebral aneurysmal rupture is very low. Endovascular intervention is a good option for diagnosis and treatment.

Background and purpose Although abnormal sleep duration is positively associated with increased risk for cardiovascular disease and mortality, the specific impact on intracerebral haemorrhage (ICH) risk remains unclear. The relationship between sleep duration and the risk of ICH was investigated in our study. Methods A nationwide, multicentre matched case−control study was performed to investigate the risk factors for haemorrhagic stroke, using patients from 33 hospitals in Korea. In all, 490 patients with ICH and 980 age- and sex-matched controls were enrolled. Detailed information regarding sleep, sociodemographic factors, lifestyle and medical history before ICH onset was obtained using qualified structured questionnaires. Sleep duration was categorized and the adjusted odds ratios (ORs) and 95% confidence intervals (CIs) were estimated using a conditional logistic regression with 7 h as the reference duration. Results The number of subjects with long sleep duration, more than 8 h, was significantly greater in the ICH group than in the control group (≥8 h, 30.4% vs. 22.6%, P = 0.002). After controlling for relevant confounding factors, longer sleep duration was found to be independently associated with the risk of ICH in a dose−response manner (8 h, OR 1.57, 95% CI 1.00–2.47; ≥9 h, OR 5.00, 95% CI 2.18–11.47). Conclusions Our study suggested that long sleep duration is positively associated with an increased ICH risk in a dose-dependent manner. Further studies on the relationship linking long sleep duration with increased risk of ICH are required.

Background: Diastolic dysfunction has a significant impact on symptoms, functional outcomes, and prognosis in ischemic stroke patients. The ratio of peak early to late diastolic filling velocity (E/A) is the simplest and most commonly used index to assess diastolic dysfunction. Methods: One thousand seven hundred seven patients with acute ischemic stroke who had a transthoracic echocardiogram during admission were identified. We classified patients into 3 groups by E/A ratios based on the previous literature search. We conducted binary logistic regression analysis for death, vascular death, and stroke death. Results: Among a total of 1707 patients, 261 (15.3%) had E/A 1.5. All cause death was higher with E/A 1.5 compared to E/A 0.6-1.5 (25.7% and 16.9% versus 15.1%), as was vascular death (10.2% and 8.5% versus 5.8%). After adjusting for age, gender, previous stroke history, hypertension, diabetes, smoking, dyslipidemia, atrial fibrillation, stroke subtype, left ventricular end-diastolic diameter, LA/Ao ratio, mitral E deceleration time, relative wall motion abnormality, and initial stroke severities, the relative risk of all-cause death with E/A >1.5 was 2.24 (95% CI, 1.14-4.33; p= 0.02); the relative risk of vascular death with E/A>1.5 was 3.50 (95% CI, 1.39-8.80; p ); the relative risk of stroke death with E/A >1.5 was 3.42 (95% CI, 1.21-9.69; p=0.02 ). Conclusion: The E/A>1.5 is associated with 2-fold increased all-cause mortality and 3-fold vascular and stroke mortalities independent of covariates in ischemic stroke patients.

Background: In many cardioembolic (CE) strokes, the specific embolic source might be uncertain. Despite the high mortality of CE stroke, we do not pay attention enough for the potential CE sources. Although atrial fibrillation (Af) is the most common cause of embolic sources, more complex and dynamic multiplicity of the cardiac sources may influence CE stroke. The aim of this study was to evaluate the new echocardiographic indicators which have been underestimated as low-risk CE sources. Methods: One thousand eight hundred twelve patients with acute ischemic stroke who had a transthoracic echocardiogram during admission were identified. We classified patients into 2 groups of potential CE and non-CE. In patients with undetermined etiology, we excluded patients who had definite non-CE sources such as vasculopathy, hypercoagulable state, hematologic disorder and patients with incomplete evaluation. Thereafter, a stroke neurologist reviewed all of the magnetic resonance images. Results: Among a total of 1812 patients, 575 (31.7%) had potential CE infarctions. About half of the patients with CE etiology had Af. Patients with potential CE etiology were more likely to have larger left ventricular end-diastolic diameter, left ventricular end-systolic diameter, left atrial size, mitral ratio of peak early to late diastolic filling velocity (E/A) and smaller ejection fraction. After adjusting for multiple echocardiographic variables including Af, binary logistic regression demonstrated that E/A >2.0 had a significant predictive value for CE stroke (OR 3.45, 95% CI: 1.43-8.36, p Conclusion: Diastolic dysfunction might be a predominant embolic source. The E/A>2.0 is a significant predictor of CE stroke and provides prognostic information incremental to left ventricular systolic function.

Introduction: Antiplatelets are the most important drugs to prevent ischemic stroke. These drugs are prescribed for nearly life long period. However, few studies have elaborated on the significance of adherence with antiplatelet monotherapy in ischemic stroke. Methods: We enrolled 36,128 patients with ischemic stroke from Jan 2008 through Dec 2011 from 40 hospitals which were participated in a nationwide research project in Korea. The whole drug information was obtained from the Health Insurance Review and Assessment Service in Korea. Among them, 8,299 patients had taken antiplatelet monotherapy over 6 months with one of the most popular antiplatelet drugs (aspirin, clopidogrel or cilostazol). The adherence with antiplatelet monotherpay was defined as % adherence = (n of days’ supply) / (actual n of days to refill) х 100. Nonadherence was defined as < 80% adherence. The mortality and drug information were censored on 31 Dec 2012. Results: From 8,299 patients using a single antiplatelet drug over 6 months, 1056 (12.7%) patients were included in nonadherence group. The factors related to nonadherence were severe neurological deficits and the atherosclerotic stroke subtype. Compared with the good adherence group, the adjusted hazard ratio (HR) of the nonadherence group for all-cause mortality was 1.49 (95% CI, 1.28-1.73), after controlling age, stroke severity, stroke subtype, and the presence of hypertension, diabetes, hyperlipidemia, and smoking. In subgroup analyses, the adjusted HRs for mortality after ischemic stroke were increased in the aspirin or clopidogrel monotherapy group respectively, compared with good adherence group (HR and 95% CI in nonadherence with aspirin, 1.22 and 1.01-1.46; HR and 95% CI in nonadherence with clopidogrel, 2.07 and 1.53-2.82). Conclusion: Our study demonstrated that nonadherence with antiplatelet monotherapy is an independent predictor of all-cause death after ischemic stroke from nationwide multicenter follow-up study.

Background and purpose An obesity paradox in patients with stroke has been documented. However, although the initial neurological severity (INS) is generally the most important prognostic factor, the impact of this paradox has not been considered in most previous studies. We sought to investigate the impact of obesity on INS in patients with ischaemic stroke and to investigate whether it is a significant risk factor for short-term outcomes. Methods A total of 2670 patients from Seoul National University Hospital with ischaemic stroke were enrolled from October 2002 to May 2013. Baseline information, including body mass index (BMI) and INS, was collected at admission. Associations between obesity and INS were analysed. In addition, we evaluated the effect of BMI on modified Rankin Scale (mRS) 3 months after stroke onset. Results Among the 2670 patients, patients whose BMI levels were higher than the chosen reference level had reduced risks of moderate to severe INS (Q2: OR, 0.65; 95% CI 0.49 to 0.87; Q3: OR, 0.48; 95% CI 0.35 to 0.65; Q4: OR, 0.39; 95% CI 0.28 to 0.54; and Q5: 0.31; 95% CI 0.22 to 0.44). In addition, of the 703 patients with available 3-month mRS patients with higher BMI levels seem to have had more favourable outcomes. Such associations disappeared after adjusting for INS. Conclusions In our study, although obesity was associated with better short-term functional outcomes, INS might be a more important prognostic factor. Therefore, initial status should also be considered when considering an ‘obesity paradox’ in chronic diseases.

Background and purpose: Fimasartan is a novel angiotensin receptor blocker (ninth), and its safety and efficacy have been established as an antihypertensive drug. Anti-apoptotic or anti-inflammatory effects of angiotensin receptor blockers were reported. However, few studies have elaborated on the effects of long-term treatment with low-dose ARB on cerebral ischemia independent of blood pressure lowering. Methods: Noninvasive blood pressure monitoring was performed in Sprague-Dawley rats which 0.5 mg/kg of fimasartan or phosphate-buffered saline (PBS) were administered for 4 weeks. Fimasartan (0.5, 1 or 3 mg/kg) was administered intraorally for 4 weeks, and we induced ischemia-reperfusion injury in rats. Infarct volume and the number of TUNEL-positive apoptotic cells were measured at 7 days. Functional outcomes were evaluated by modified limb placing test. To identify the anti-inflammatory effect of fimasartan, the number of inflammatory cells (OX6-positive cells) was measured. To identify mediators, phospho-STAT3 and IkB proteins were measured via Western blot analyses at 48 hours. Results: Blood pressures were decreased after administration of 1 mg/kg or 3 mg/kg of fimasartan for 4 weeks, but were not decreased in 0.5 mg/kg group. All doses of fimasartan decrease infarct volumes, and low-dose fimasartan (0.5 mg/kg) maximally reduced infarct volume up to 70% of those of the control group ( p < 0.05). Quantitative analysis showed that the number of TUNEL-positive cells was remarkably decreased in the low-dose fimasartan group (622 ± 57 cell/mm 3 vs. 235 ± 48 cells/mm 3 ; p < 0.05). Low-dose fimasartan improved functional outcomes at 14 days (74% recovery in fimasartan group vs. 43% in control group; p < 0.05). The low-dose fimasartan group exhibited a lower number of OX6-positive cells (fimsartan group: 157 ± 17 cells/mm 3 ; control: 86 ± 11 cell/mm 3 ; p < 0.05). The IkB degradation as a marker of NF-kB activation, was delayed, and phospho-STAT3 was decreased in the low-dose fimasartan group ( p < 0.05). Conclusion: We demonstrate that long-term treatment with fimasartan improves neurological outcome in transient focal ischemia in rats. This protective effect of fimasartan is independent blood pressure lowering.

Background: Chronic kidney disease (CKD) increases risk of cardiovascular diseases, which might be mediated by facilitation of atherosclerosis. However, impact of CKD on progression of atherosclerosis has not been fully evaluated, and we sought to investigate associations between CKD and extent of carotid atherosclerosis. Methods: Between January 2009 and February 2013, we enrolled a consecutive series of 147 CKD patients and compared the same number of age, sex and vascular risk factor-matched 147 control subjects who visited our hospital during the same period. Carotid atherosclerosis was examined with MR angiography of internal carotid artery (ICA). The degree of stenosis of the internal carotid artery (ICA) in each patient was classified into 5 grades; (1) normal; (2) mild ( Results: Mean age of the subjects was 72.2±8.7 years, and 208 were male (70.7%) among the total of 294 subjects. Significant stenosis of ICA (stenosis more than 50%) was more prevalent in CKD patients [odds ratio (OR) 6.7; 95% confidence interval (CI) 2.2-20.4, p=0.001). The presence of CKD was an independently risk factor for increasing the severity of stenosis of ICA (mild, OR 4.5, 95% CI 2.0-10.2; moderate, OR 3.9, 95% CI 1.3-22.4; severe, OR 12.0, 95% CI 4.3-34.6; occlusion, 14.1, 95% CI 2.1-92.2). Conclusion: In the current case-control study, we found that CKD is associated with incidence of significant carotid stenosis and increases the severity of carotid stenosis. Our results indicate that CKD should be treated as a new risk factor for carotid atherosclerosis.

Background and purpose: Warfarin is one of the most important prevention drugs against ischemic stroke. Factors influencing on warfarin adherence in patients with atrial fibrillation have been investigated. However, few studies have elaborated on the significance and related factors of warfarin adherence in patients with ischemic stroke or transient ischemic attack (TIA). Methods: A total of 46,219 patients with ischemic stroke or TIA were enrolled from October 2007 through December 2011 in Clinical Research Center for Stroke as a nationwide project in Korea. The morality information of all patients was based on computerized searches of death certificate data from the “Statistics Korea” of the Korean National Statistical Office, and the whole drug information was obtained from the Health Insurance Review Assessment and Review Service in Korea. Among them, warfarin was prescribed for 5,660 patients over 6 months. Warfarin adherence was defined as % adherence = (n of days’ supply) / (actual n of days to refill) х 100. Nonadherence was defined as < 80% adherence. We censored the mortality data on 31 December 2012. Results: From 5,660 patients using warfarin over 6 months, 801 patients (14.2%) were included in nonadherence group. The factors related to nonadherence for warfarin ware theses: old age, increased stroke severity, and the presence of diabetes or hyperlipidemia. Based on Cox regression analysis, compared with good adherence group, the adjusted hazard ratio (HR) of the nonadherence group for all-cause of mortality were 1.46 (95% confidence interval, 1.24 – 1.72) after controlling old age, stroke severity, and the presence of diabetes, hypertension, hyperlipidemia, and smoking. The presence of diabetes also predicted all-cause death after stroke independently in patients using warfarin over 6 months (adjusted HR, 1.28 ; 95% confidence interval, 1.10 – 1.49). Conclusion: Our study demonstrated that nonadherence for warfarin is independent predictor of all-cause death after ischemic stroke or TIA from nationwide multicenter follow-up study. The related factors to nonadherence for warfarin were old age, increased stroke severity, and the presence of diabetes or hyperlipidemia.

Background: Vascular calcification is strongly associated with cardiovascular morbidity and mortality by reducing arterial elastance. Recently alkaline phosphatase (ALP) is identified as the critical factor for vascular calcification, but no clinical studies investigating relevance of ALP and cerebral atherosclerosis have been reported. In this study, we assessed the hypothesis that increased levels of serum ALP may be associated with severity of cerebral atherosclerosis. Methods: From October 2010 to March 2012, we prospectively included total 518 patients (313 men/205 women) aged 25-96 years with acute ischemic stroke. Cardioembolic stroke patients were excluded because of the interference by acute arterial embolic occlusion. The patients were divided by baseline measurements into quantiles of ALP levels (90 IU/L). Bilateral middle cerebral arteries, distal internal carotid arteries and basilar artery were selected for the evaluation of intracranial atherosclerosis, bilateral proximal internal carotid arteries and common carotid arteries for the extracranial atherosclerosis. We defined significant arterial stenosis as moderate or more stenosis (50-100%) evaluated by at least one angiographic study using MR angiography, CT angiography or digital subtraction angiography. Statistical analyses were performed using the multivariate logistic regression analysis adjusted for age, gender, hypertension, diabetes, dyslipidemia, smoking, presence of secondary prevention, serum calcium levels. Results: In the multivariate logistic regression analysis, compared with the first ALP quantile, adjusted odds ratio of the third and fourth quantiles for significant intracranial atherosclerosis were 2.30 (95% confidence interval 1.06-5.01) and 3.84 (1.78-8.30). There was no significant correlation between ALP levels and significant extracranial atherosclerosis. Conclusions: In conclusion, our study demonstrated that increased serum levels of ALP are an independent risk factor for significant intracranial atherosclerosis.