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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.

Diabetes mellitus is an important risk factor for stroke, but whether there is differential gender-specific risk has not been fully elucidated. We aimed to explore the impact of gender on incidence and relative risks of hemorrhagic and ischemic stroke among the diabetic population in Taiwan.In this study, 500,868 diabetic patients and 500,248 age matched and-sex-matched nondiabetic individuals were linked to inpatient claims (1997-2002) to identify hospitalizations for nontraumatic hemorrhagic and ischemic stroke. Incidence density was calculated with the Poisson assumption, and Kaplan-Meier analysis was used to assess the cumulative incidence over a 6-year follow-up period. We also evaluated the relative hazards of stroke in relation to diabetes with the Cox proportional hazard model, adjusted with demographics and geographic regions.The incidence of hemorrhagic stroke in diabetic women was less than that in diabetic men except in those agedor =85, but the difference between male and female diabetic patients was less pronounced with ischemic stroke. The hazard ratios (HRs) of hemorrhagic and ischemic stroke among diabetic women were increased by a magnitude of 1.2 and 1.32, respectively, which were significantly higher than those of diabetic men. Further age-stratified analysis indicated that young and middle-aged diabetic women tended to have higher HRs and that diabetic women aged35 suffered from particularly high HRs (HR 7.69, 95% confidence interval [CI] 1.81-32.75 for hemorrhagic stroke, and HR = 8.46, 95% CI 4.28-16.75 for ischemic stroke).There was a significant gender-diabetes interactive effect on the incidence of hemorrhagic and ischemic stroke. Additionally, young Taiwanese diabetic patients were most vulnerable to an increased relative risk of hemorrhagic and ischemic stroke. Comprehensive diabetic care with stroke prevention measures should be emphasized in young diabetic people in order to prevent premature disability.

Background Discharge disposition planning is vital for poststroke patients. We investigated clinical factors associated with discharging patients to nursing homes, using the Taiwan Stroke Registry data collected from 39 major hospitals. Methods We randomly assigned 21,575 stroke inpatients registered from 2006 to 2008 into derivation and validation groups at a 3-to-1 ratio. We used the derivation group to develop a prediction model by measuring cumulative risk scores associated with potential predictors: age, sex, hypertension, diabetes mellitus, heart diseases, stroke history, snoring, main caregivers, stroke types, and National Institutes of Health Stroke Scale (NIHSS). Probability of nursing home care and odds ratio (OR) of nursing home care relative to home care by cumulative risk scores were measured for the prediction. The area under the receiver operating characteristic curve (AUROC) was used to assess the model discrimination against the validation group. Results Except for hypertension, all remaining potential predictors were significant independent predictors associated with stroke patient disposition to nursing home care after discharge from hospitals. The risk sharply increased with age and NIHSS. Patients with a cumulative risk score of 15 or more had an OR of 86.4 for the nursing home disposition. The AUROC plots showed similar areas under curves for the derivation group (.86, 95% confidence interval [CI], .85-.87) and for the validation group (.84, 95% CI, .83-.86). Conclusions The cumulative risk score is an easy-to-estimate tool for preparing stroke patients and their family for disposition on discharge.

The relationship between low estimated glomerular filtration rate (eGFR) and the outcome of ischemic stroke remains controversial, despite the close association between kidney dysfunction and atherosclerosis.This study conducted subgroup analysis using data from the prospective Taiwan Stroke Registry to investigate the relationship between eGFR at the time of admission and 6-month functional outcomes in patients with the large artery atherosclerotic (LAA) subtype of acute ischemic stroke. Stroke severity was assessed using the National Institutes of Health Stroke Scale (NIHSS), and outcomes were defined as modified Rankin Scale and mortality status at 6 months post stroke.Of the 8052 patients with the LAA subtype of acute ischemic stroke in this study, 3312 (41.1%) had eGFR60 mL/min/1.73 m(2). The adjusted odds ratios of worse functional outcomes following a stroke were 1.10 (95% confidence interval [CI], 0.95-1.28), 1.60 (95% CI, 1.22-2.11) and 1.60 (95% CI, 1.10-2.33) in patients with eGFR 30-59, 15-29, and15 as compared with those with eGFR 60-119 mL/min/1.73 m(2), respectively. Increased risk of mortality was closely and independently related to high NIHSS scores and low eGFR levels. Stroke severity and eGFR were also synergistically related to 6-month mortality, with an adjusted hazard ratio of 21.19 (95% CI, 9.69-46.35) in patients with NIHSS15 and eGFR15 mL/min/1.73 m(2), compared with those with NIHSS 0-5 and eGFR 60-119 mL/min/1.73 m(2).Low eGFR was significantly and independently associated with 6-month functional outcomes and mortality in patients with the LAA subtype of acute ischemic stroke. The deleterious relationship between low eGFR levels and mortality following stroke was exacerbated by its synergistic association with stroke severity.

In patients with antithyroid drug-induced agranulocytosis, prompt administration of granulocyte colony-stimulating factor (G-CSF) has been observed in individual cases. In the only prospective study performed, it was concluded that prolonged use of G-CSF at 100 μg/d to 200 μg/d is not beneficial for such patients. Additionally, G-CSF (75 μg/d) was found ineffective in management of antithyroid drug-induced agranulocytosis in symptomatic patients when granulocyte counts fell below 0.1 × 109/mL. This report describes a case of propylthiouracil-induced agranulocytosis in a symptomatic subject with a neutrophil count of zero at admission. After 9 days of antibiotic therapy, the subject remained febrile with a neutrophil count of zero. The patient recovered upon treatment with G-CSF at 300 μg/d. This case serves to highlight that, although early administration of G-CSF to patients at risk is desirable, G-CSF at adequate dosage may be beneficial even in symptomatic patients with prolonged and severe agranulocytosis.

Congenital vertebral artery (VA) hypoplasia is an uncommon embryonic variation of posterior circulation. The frequency of this congenital variation was reported to be 2-6% from autopsy and angiograms. Is it a congenital risk factor of ischemic stroke? In this review, we gave an overview of the literature concerning vertebral artery hypoplasia. VA hypoplasia served as an independent factor of a reduction of the posterior circulation blood flow velocity. VA hypoplasia can play a negative role in cases of occlusion of a major brain vessel since it limits the potential of compensatory blood circulation. VA hypoplasia may also lead to regional hypoperfusion and complex neurovascular consequences which correspond to vestibular neuronitis and migraine pathogenesis.

Backgrounds The circle of Willis (CoW) is a primary collateral pathway that compensates quickly for a drop in cerebral blood flow. Using the complete CoW as a surrogate marker for good collateral circulation, its prognostic value after intravenous thrombolysis was examined. Methods We prospectively studied 64 consecutive patients with acute ischemic stroke treated with tissue plasminogen activator within 3 hours of stroke onset between October 2005 and June 2012 in our hospital. The study protocol was based on standard guidelines for intravenous thrombolysis. On computed tomographic angiography 24 hours after thrombolysis, the CoW was complete in 21 (32.8%) cases and incomplete in 43 (67.2%). Results Patients with complete CoW were more likely to have early improvement in National Institute of Health Stroke Scale (NIHSS) score (median improvement 2 vs 0 at 2 hours; 4 vs 1 at 24 hours), be independent at 3 months (42% vs 19%). In the incomplete CoW group, the rate of symptomatic intracerebral haemorrhage (SICH) according to the Safe Implementation of Thrombolysis in Stroke-Monitoring Study (SITS-MOST) definition was almost 3 times higher. Complete CoW was one of the strongest predictors of good functional outcome at 3 months (odds ratio 2.32; P = .01). Conclusions Complete CoW independently predicted functional independence and survival.

Background: Bilateral high-grade internal carotid artery (ICA) stenosis is critical for brain perfusion, and mechanisms of cerebral infarct induced by bilateral high-grade ICA stenosis can be investigated by the infarct patterns on diffusion-weighted imaging (DWI). Methods: From January 2006 to October 2010, we retrospectively enrolled 21 acute infarct patients with bilateral high-grade ICA stenosis. The infarct patterns were divided into territory, cortical border-zone and internal border-zone by DWI. Results: The milder ICA stenosis side had a lower risk of ischemic stroke (4 of 20). None of the 8 patients with bilateral severe ICA stenosis (70–99%) suffered ischemic stroke ipsilateral to the milder ICA stenosis side. No single infarct mechanism was prominent: 10 of 21 infarcts were cortical border-zone pattern, followed by internal border-zone (7 of 21) and territory. The difference in frequency of bilateral severe ICA stenosis between the three infarct mechanisms was not significant (p = 0.856). Conclusions: Cerebral infarcts occurred less frequently in the ipsilateral to milder ICA stenosis side, especially in bilateral severe ICA stenosis. The similar frequencies and hemodynamic status between the three infarct pattern groups indicated that both artery-to-artery emboli and being hemodynamically compromised contribute synergistically to bilateral ICA stenosis.

Sheehan's syndrome is caused by pregnancy-related hemorrhage leading to ischemic necrosis of the anterior pituitary gland and hypopituitarism. Spontaneous pregnancy in Sheehan's syndrome is very rare. We report the case of a patient with Sheehan's syndrome who suffered from anterior pituitary insufficiency, but with sparing of gonadotropic function. The patient became pregnant spontaneously and, after her second delivery, thyrotropic function recovered. However, the patient's growth hormone and cortisol levels remained unresponsive to an insulin-tolerance test. This case demonstrates that pituitary function may recover from less extensive pituitary ischemia. We emphasize the importance of early identification of pregnancy in such cases. It is crucial to institute adequate hormone-replacement therapy during pregnancy, since hypopituitarism is associated with high fetal and maternal morbidity and mortality.

We report a rare case of Bartter's syndrome in a 35-year-old woman with type 2 diabetes mellitus. The patient presented with leg weakness, fatigue, polyuria and polydipsia. Hypokalemia, metabolic alkalosis, and high renin and aldosterone concentrations were present, but the patient was normotensive. Gitelman's syndrome was excluded because of the presence of hypercalciuria, secondary hyperparathyroidism and bilateral nephrocalcinosis. The patient's condition improved upon administration of a prostaglandin synthetase inhibitor (acemetacin), oral potassium chloride and potassium-sparing diuretics. Five months later, the patient discontinued acemetacin because of epigastric discomfort; at the same time, severe hypokalemia and hyperglycemia developed. Glucagon stimulation and water deprivation tests were performed. Type 2 diabetes mellitus with nephrogenic diabetes insipidus was diagnosed. To avoid further gastrointestinal complications, the patient was treated with celecoxib, a selective cyclooxygenase 2 inhibitor. This case serves as a reminder that Bartter's syndrome is associated with various metabolic derangements including nephrogenic diabetes insipidus, nephrocalcinosis and diabetes mellitus. When treating Bartter's syndrome, it is also prudent to remember that the long-term use of nonsteroidal anti-inflammatory drugs and potassium-sparing diuretics may result in serious adverse reactions.