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Mayer-Suess L, Rinner H, Lang W, Greisenegger S, Mikšová D, Gattringer T, Enzigner C, Sykora M, Vosko M, Mutzenbach JS, Ferrari J, Kiechl S, Knoflach M. Risk of stroke in patients with prior VKA or DOAC: A population-based real-world registry analysis. Eur Stroke J 2024; 9:418-423. [PMID: 38161290 DOI: 10.1177/23969873231223876] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2024] Open
Abstract
INTRODUCTION To date, risk assessment of suffering ischemic and hemorrhagic stroke in individuals under oral anticoagulation (OAC) is limited to hospital-based cohorts and patients with atrial fibrillation. PATIENTS AND METHODS Through the combination of three individual datasets, (1) the population-based Tyrolean Stroke Pathway database, prospectively documenting all (unselected) stroke patients in the entire federal state of the Tyrol and (2) nation-wide prescription data, detailing each reimbursed prescription in Austria as well as (3) the Austrian Stroke Unit Registry, a nation-wide registry comprising data on all patients admitted to any of the 38 stroke units in Austria, we assessed risk of stroke in patients with prior oral anticoagulation and compared characteristics of patients taking direct oral anticoagulants and Vitamin-K-Antagonists. RESULTS In Austria, oral anticoagulant prescription reimbursements increased from 292,475 in 2015 to 389,407 in 2021. In the Tyrol, prior oral anticoagulation treatment was evident in 586 of 3861 (15.2%) patients with ischemic and 131 of 523 (25.0%) with hemorrhagic stroke, with 20% and 35% of those stroke patients respectively having prior oral anticoagulation due to other indications than non-valvular atrial fibrillation. Considering prescription rates, treatment with direct oral anticoagulants was associated with a reduced stroke risk compared to Vitamin-K-Antagonists, especially in ischemic (1.05% vs 0.62%; RR 0.59, p < 0.001) but also in hemorrhagic stroke, even if less pronounced (0.21% vs 0.14%; RR 0.68, p = 0.06). In Austria, prior intake of direct oral anticoagulants was associated with lower risk of suffering acute large vessel occlusion stroke (RR 0.79, p = 0.003). DISCUSSION AND CONCLUSIONS One in seven patients suffering ischemic and one in four suffering hemorrhagic stroke had prior oral anticoagulation treatment. Both ischemic and hemorrhagic strokes are less frequent in those with direct oral anticoagulant intake compared to those taking Vitamin-K-Antagonists. Establishment of clear standard operating procedures on how to best care for acute stroke patients with oral anticoagulation is essential.
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Affiliation(s)
- Lukas Mayer-Suess
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | | | - Wilfried Lang
- Department of Neurology, Hospital Barmherzige Brüder Vienna, Vienna, Austria
| | | | - Dominika Mikšová
- Austrian National Public Health Institute/Austrian National Institute for Quality in Health Care, Vienna, Austria
| | | | | | - Marek Sykora
- Department of Neurology, Hospital Barmherzige Brüder Vienna, Vienna, Austria
| | - Milan Vosko
- Department of Neurology, Kepler University Hospital GmbH, Johannes Kepler University Linz, Austria
| | | | - Julia Ferrari
- Department of Neurology, Hospital Barmherzige Brüder Vienna, Vienna, Austria
| | - Stefan Kiechl
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
- VASCage, Research Centre on Clinical Stroke Research, Innsbruck, Austria
| | - Michael Knoflach
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
- VASCage, Research Centre on Clinical Stroke Research, Innsbruck, Austria
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Banyas P, Jadhav A. Stroke and Transient Ischemic Attack. Prim Care 2024; 51:283-297. [PMID: 38692775 DOI: 10.1016/j.pop.2024.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/03/2024]
Abstract
Cerebrovascular disease is a common and potentially life-threatening illness if not triaged and/or treated appropriately. The diagnosis is made based on a combination of clinical history and neuroimaging studies. The majority of strokes can be prevented, and this process often begins in the primary care office through the careful assessment of vascular risk factors. Appropriate workup aims to pinpoint a pathogenic mechanism and guide therapy. Stroke treatment has rapidly advanced over the past several years, resulting in improved outcomes.
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Affiliation(s)
- Paige Banyas
- Department of Neurology, HonorHealth Neurology Bob Bove Neuroscience Institute, 7242 E Osborn Road, Suite 400, Scottsdale, AZ 85251, USA.
| | - Ashutosh Jadhav
- Department of Neurology and Neurosurgery, Barrow Brain and Spine, 2910 North Third Avenue, Suite 200, Phoenix, AZ 85013, USA
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Sharma A, Pandit AK, Mishra B, Srivastava MVP, Srivastava AK, Vishnu VY, Singh RK. Early neurological deterioration in acute ischemic stroke. Ir J Med Sci 2024; 193:949-955. [PMID: 37561387 DOI: 10.1007/s11845-023-03485-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Accepted: 07/24/2023] [Indexed: 08/11/2023]
Abstract
BACKGROUND AND AIMS Early neurological deterioration (END) in acute ischemic stroke (AIS), patients is defined as clinical worsening or recurrence during first 72 h after onset of AIS. We have conducted this study to determine the association between END and functional outcome at 3 months of onset of AIS along with associated risk factors of END in AIS cases. METHODOLOGY This study was conducted after approval of Institute Ethics Committee. Two hundred three consecutive patients were admitted from September 2020 to January 2022 at a tertiary care hospital. One hundred ninety patients were included in the study; patients were divided into two groups: (1) early neurological deterioration (END) and (2) non-early neurological deterioration (non-END). Patients were followed-up either telephonically or in person at approximately 3 months using modified Rankin Scale 0-6. All the clinically significant prognostic markers and p < 0.10 variables were considered significant in univariate analysis; P < 0.05 were considered statistically significant for the multivariate analysis. RESULTS Out of 190 cases included in the cohort 34/190 (17.8%) cases showed END with mean age (56.56 (± 16.6)) and males (20/34 (58.8%)). END was independently associated with high blood glucose at admission (OR = 1.015; P = 0.002; 95%CI = 1.005-1.024) and low serum albumin (OR = 0.208; P = 0.002; 95%CI = 0.077-0.562). Patients with END showed poor functional outcome (mRS > 2) at end of 3 months (32 (94.1%); P < 0.001) and death was also statistically significant (22 (64.7%); P < 0.001) as compared to AIS cases having non-END. CONCLUSION Our study showed END may be associated with poor functional outcome in AIS patients. Higher blood glucose at admission and low serum albumin may be statistically significant causing END. Future prospective cohort with larger sample size may confirm the findings.
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Affiliation(s)
- Archana Sharma
- Fellowship Neuroendovascular Therapy, Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
| | - Awadh Kishor Pandit
- Fellowship Neuroendovascular Therapy, Department of Neurology, All India Institute of Medical Sciences, New Delhi, India.
| | - Biswamohan Mishra
- Fellowship Neuroendovascular Therapy, Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
| | | | - Achal Kumar Srivastava
- Fellowship Neuroendovascular Therapy, Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
| | - Venugopalan Y Vishnu
- Fellowship Neuroendovascular Therapy, Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
| | - Rajesh Kumar Singh
- Fellowship Neuroendovascular Therapy, Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
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Aoki J, Kimura K. Cilostazol addition to aspirin may worsen the short-term outcome in patients with large artery disease: ADS subanalysis. J Neurol Sci 2024; 456:122854. [PMID: 38154248 DOI: 10.1016/j.jns.2023.122854] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Revised: 11/26/2023] [Accepted: 12/17/2023] [Indexed: 12/30/2023]
Abstract
BACKGROUND Our previous acute dual study (ADS) reported that dual antiplatelet therapy (DAPT) using cilostazol and aspirin did not reduce the rate of neurological deterioration in non-cardioembolic stroke patients. In this post-hoc analysis, we investigated whether the impact of dual antiplatelet therapy (DAPT) may depend on neurological severity, as represented by large artery disease. METHODS Neurological deterioration was defined as neurological progression with an increment of the National Institutes of Health Stroke Scale (NIHSS) score of ≥2. NIHSS score subgroups were divided into that of 0-1, 2-4, 5-10, and >10. RESULTS Among 1014 patients, 203 (20%) had the large artery disease, and 811 (80%) did not. In the total cohort, the rate of neurological deterioration was 10.8% in the DAPT group and 8.3% in the aspirin group (P = 0.197). When we focused on the large artery disease group, DAPT group had a higher rate of neurological deterioration as 18.3% compared to 8.2% in the aspirin group (P = 0.036). Among patients with NIHSS score of 0-1 and 2-4, the rates of neurological deterioration were not different between the two group (both, P = 1.000). However, when NIHSS score elevated to 5-10, 45% in the DAPT group and 9.1% in the aspirin group deteriorated (P = 0.013). Among the patients with NIHSS score of >10, 60% in the DAPT group and none (0%) in the aspirin group had the neurological deterioration (P = 0.045). CONCLUSION DAPT with aspirin and cilostazol was associated with higher rate of neurological deterioration when patients have large artery disease and not mild neurological deficits.
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Affiliation(s)
- Junya Aoki
- Department of Neurology, Nippon Medical School Graduate School of Medicine, Japan.
| | - Kazumi Kimura
- Department of Neurology, Nippon Medical School Graduate School of Medicine, Japan
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Fandler-Höfler S, Mikšová D, Deutschmann H, Kneihsl M, Mutzenbach S, Killer-Oberpfalzer M, Gizewski ER, Knoflach M, Kiechl S, Sonnberger M, Vosko MR, Weber J, Hausegger KA, Serles W, Werner P, Staykov D, Sykora M, Lang W, Ferrari J, Enzinger C, Gattringer T. Endovascular stroke therapy outside core working hours in a nationwide stroke system. J Neurointerv Surg 2023; 15:e402-e408. [PMID: 36813552 DOI: 10.1136/jnis-2022-020044] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Accepted: 02/10/2023] [Indexed: 02/24/2023]
Abstract
BACKGROUND Endovascular therapy (EVT) has been established as a major component in the acute treatment of large vessel occlusion stroke. However, it is unclear whether outcome and other treatment-related factors differ if patients are treated within or outside core working hours. METHODS We analyzed data from the prospective nationwide Austrian Stroke Unit Registry capturing all consecutive stroke patients treated with EVT between 2016 and 2020. Patients were trichotomized according to the time of groin puncture into treatment within regular working hours (08:00-13:59), afternoon/evening (14:00-21:59) and night-time (22:00-07:59). Additionally, we analyzed 12 EVT treatment windows with equal patient numbers. Main outcome variables included favorable outcome (modified Rankin Scale scores of 0-2) 3 months post-stroke as well as procedural time metrics, recanalization status and complications. RESULTS We analyzed 2916 patients (median age 74 years, 50.7% female) who underwent EVT. Patients treated within core working hours more frequently had a favorable outcome (42.6% vs 36.1% treated in the afternoon/evening vs 35.8% treated at night-time; p=0.007). Similar results were found when analyzing 12 treatment windows. All these differences remained significant in multivariable analysis adjusting for outcome-relevant co-factors. Onset-to-recanalization time was considerably longer outside core working hours, which was mainly explained by longer door-to-groin time (p<0.001). There was no difference in the number of passes, recanalization status, groin-to-recanalization time and EVT-related complications. CONCLUSIONS The findings of delayed intrahospital EVT workflows and worse functional outcomes outside core working hours in this nationwide registry are relevant for optimization of stroke care, and might be applicable to other countries with similar settings.
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Affiliation(s)
| | | | - Hannes Deutschmann
- Division of Neuroradiology, Vascular and Interventional Radiology, Department of Radiology, Medical University of Graz, Graz, Austria
| | - Markus Kneihsl
- Department of Neurology, Medical University of Graz, Graz, Austria
| | - Sebastian Mutzenbach
- Department of Neurology, Christian Doppler Medical Center, Paracelsus Medical University Salzburg, Salzburg, Austria
| | - Monika Killer-Oberpfalzer
- Department of Neurology, Christian Doppler Medical Center, Paracelsus Medical University Salzburg, Salzburg, Austria
- Institute of Neurointervention, Christian Doppler Medical Center, Paracelsus Medical University Salzburg, Salzburg, Austria
| | - Elke R Gizewski
- Department of Neuroradiology, Medical University of Innsbruck, Innsbruck, Austria
| | - Michael Knoflach
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Stefan Kiechl
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Michael Sonnberger
- Institute of Neuroradiology, Kepler University Hospital Linz, Linz, Austria
| | - Milan R Vosko
- Department of Neurology, Kepler University Hospital Linz, Linz, Austria
| | - Jörg Weber
- Department of Neurology, Klinikum Klagenfurt, Klagenfurt, Austria
| | - Klaus A Hausegger
- Institute of Diagnostic and Interventional Radiology, Klinikum Klagenfurt, Klagenfurt, Austria
| | - Wolfgang Serles
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Philipp Werner
- Department of Neurology, State Hospital of Feldkirch/Rankweil, Rankweil, Austria
| | - Dimitre Staykov
- Department of Neurology, St. John's Hospital, Eisenstadt, Austria
| | - Marek Sykora
- Department of Neurology, St. John's Hospital, Vienna, Austria
| | - Wilfried Lang
- Department of Neurology, St. John's Hospital, Vienna, Austria
| | - Julia Ferrari
- Department of Neurology, St. John's Hospital, Vienna, Austria
| | | | - Thomas Gattringer
- Department of Neurology, Medical University of Graz, Graz, Austria
- Division of Neuroradiology, Vascular and Interventional Radiology, Department of Radiology, Medical University of Graz, Graz, Austria
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Sykora M, Krebs S, Miksova D, Badic I, Gattringer T, Fandler-Höfler S, Marko M, Greisenegger S, Knoflach M, Lang W, Ferrari J. IV Thrombolysis vs Early Dual Antiplatelet Therapy in Patients With Mild Noncardioembolic Ischemic Stroke. Neurology 2023; 101:e933-e939. [PMID: 37407270 PMCID: PMC10501095 DOI: 10.1212/wnl.0000000000207538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Accepted: 05/04/2023] [Indexed: 07/07/2023] Open
Abstract
BACKGROUND OBJECTIVES It is unclear whether IV thrombolysis (IVT) outperforms early dual antiplatelet therapy (DAPT) in the acute setting of mild ischemic stroke. The aim of this study was to compare the early safety and efficacy of IVT with that of DAPT. METHODS Data of mild noncardioembolic stroke patients with admission NIH Stroke Scale (NIHSS) score ≤3 who received IVT or early DAPT in the period 2018-2021 were extracted from a nationwide, prospective stroke unit registry. Study endpoints included symptomatic intracerebral hemorrhage (sICH), early neurologic deterioration ≥4 NIHSS points (END), and 3-month functional outcome by modified Rankin scale (mRS). RESULTS A total of 1,195 mild stroke patients treated with IVT and 2,625 patients treated with DAPT were included. IVT patients were younger (68.1 vs 70.8 years), had less hypertension (72.8% vs 83.5%), diabetes (19% vs 28.8%), and a history of myocardial infarction (7.6% vs 9.2%), and slightly higher admission NIHSS scores (median 2 vs median 1) when compared with DAPT patients. After propensity score matching and multivariable adjustment, IVT was associated with sICH (4 [1.2%] vs 0) and END (adjusted odds ratio [aOR] 2.8, 95% CI 1.1-7.5), and there was no difference in mRS 0-1 at 3 months (aOR 1.3, 95% CI 0.7-2.6). DISCUSSION This analysis from a prospective nationwide stroke unit network indicates that IVT is not superior to DAPT in the setting of mild noncardioembolic stroke and may eventually be associated with harm. Further research focusing on acute therapy of mild stroke is highly warranted. CLASSIFICATION OF EVIDENCE This study provides Class III evidence that IVT is not superior to DAPT in patients with acute mild (NIHSS score ≤3) noncardioembolic stroke. The study lacks the statistical precision to exclude clinically important superiority of either therapy.
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Affiliation(s)
- Marek Sykora
- From the Department Neurology (M.S., S.K., W.L., J.F.), St. Johns Hospital Vienna; Sigmund Freud University Vienna (M.S., I.B., W.L.); Austrian National Public Health Institute (D.M.), Vienna; Medical University of Graz (T.G., S.F.-H.); Medical University of Vienna (M.M., S.G.); and Medical University of Innsbruck (M.K.), Austria.
| | - Stefan Krebs
- From the Department Neurology (M.S., S.K., W.L., J.F.), St. Johns Hospital Vienna; Sigmund Freud University Vienna (M.S., I.B., W.L.); Austrian National Public Health Institute (D.M.), Vienna; Medical University of Graz (T.G., S.F.-H.); Medical University of Vienna (M.M., S.G.); and Medical University of Innsbruck (M.K.), Austria
| | - Dominika Miksova
- From the Department Neurology (M.S., S.K., W.L., J.F.), St. Johns Hospital Vienna; Sigmund Freud University Vienna (M.S., I.B., W.L.); Austrian National Public Health Institute (D.M.), Vienna; Medical University of Graz (T.G., S.F.-H.); Medical University of Vienna (M.M., S.G.); and Medical University of Innsbruck (M.K.), Austria
| | - Ines Badic
- From the Department Neurology (M.S., S.K., W.L., J.F.), St. Johns Hospital Vienna; Sigmund Freud University Vienna (M.S., I.B., W.L.); Austrian National Public Health Institute (D.M.), Vienna; Medical University of Graz (T.G., S.F.-H.); Medical University of Vienna (M.M., S.G.); and Medical University of Innsbruck (M.K.), Austria
| | - Thomas Gattringer
- From the Department Neurology (M.S., S.K., W.L., J.F.), St. Johns Hospital Vienna; Sigmund Freud University Vienna (M.S., I.B., W.L.); Austrian National Public Health Institute (D.M.), Vienna; Medical University of Graz (T.G., S.F.-H.); Medical University of Vienna (M.M., S.G.); and Medical University of Innsbruck (M.K.), Austria
| | - Simon Fandler-Höfler
- From the Department Neurology (M.S., S.K., W.L., J.F.), St. Johns Hospital Vienna; Sigmund Freud University Vienna (M.S., I.B., W.L.); Austrian National Public Health Institute (D.M.), Vienna; Medical University of Graz (T.G., S.F.-H.); Medical University of Vienna (M.M., S.G.); and Medical University of Innsbruck (M.K.), Austria
| | - Martha Marko
- From the Department Neurology (M.S., S.K., W.L., J.F.), St. Johns Hospital Vienna; Sigmund Freud University Vienna (M.S., I.B., W.L.); Austrian National Public Health Institute (D.M.), Vienna; Medical University of Graz (T.G., S.F.-H.); Medical University of Vienna (M.M., S.G.); and Medical University of Innsbruck (M.K.), Austria
| | - Stefan Greisenegger
- From the Department Neurology (M.S., S.K., W.L., J.F.), St. Johns Hospital Vienna; Sigmund Freud University Vienna (M.S., I.B., W.L.); Austrian National Public Health Institute (D.M.), Vienna; Medical University of Graz (T.G., S.F.-H.); Medical University of Vienna (M.M., S.G.); and Medical University of Innsbruck (M.K.), Austria
| | - Michael Knoflach
- From the Department Neurology (M.S., S.K., W.L., J.F.), St. Johns Hospital Vienna; Sigmund Freud University Vienna (M.S., I.B., W.L.); Austrian National Public Health Institute (D.M.), Vienna; Medical University of Graz (T.G., S.F.-H.); Medical University of Vienna (M.M., S.G.); and Medical University of Innsbruck (M.K.), Austria
| | - Wilfried Lang
- From the Department Neurology (M.S., S.K., W.L., J.F.), St. Johns Hospital Vienna; Sigmund Freud University Vienna (M.S., I.B., W.L.); Austrian National Public Health Institute (D.M.), Vienna; Medical University of Graz (T.G., S.F.-H.); Medical University of Vienna (M.M., S.G.); and Medical University of Innsbruck (M.K.), Austria
| | - Julia Ferrari
- From the Department Neurology (M.S., S.K., W.L., J.F.), St. Johns Hospital Vienna; Sigmund Freud University Vienna (M.S., I.B., W.L.); Austrian National Public Health Institute (D.M.), Vienna; Medical University of Graz (T.G., S.F.-H.); Medical University of Vienna (M.M., S.G.); and Medical University of Innsbruck (M.K.), Austria
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Ton MD, Phuong DV, Thom VT, Dung NT, Tho PQ, Thuan LD, Nguyen TN. Factors related to unfavorable outcome in minor ischemic stroke. J Stroke Cerebrovasc Dis 2023; 32:107203. [PMID: 37441912 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Revised: 05/29/2023] [Accepted: 05/30/2023] [Indexed: 07/15/2023] Open
Abstract
BACKGROUND Stroke recurrence and disability are important challenges to overcome in patients with minor ischemic stroke. The aim of our study was to determine the factors associated with unfavorable outcomes in patients with minor ischemic stroke. METHODS This was a prospective cohort study including patients with minor ischemic stroke with a National Institutes of Health Stroke Scale (NIHSS) score ≤ 4 who were treated at the Bach Mai Hospital stroke center from June 15, 2021, to September 15, 2022. Unfavorable outcome was defined as mRS 2-6 at 90 days. Multivariable logistic regression analysis was conducted to assess risk factors related to clinical outcomes. RESULTS Of 678 patients presenting with minor ischemic stroke, there were 90 (13.3%, 90/678) patients with no intracranial artery imaging. Hence, 588 were patients analyzed, of whom 6.0% received thrombolytic therapy, 8.5% developed NIHSS > 4 in 24 hours, and 30.4% had intracranial stenosis > 50%. Compared with the group of unfavorable outcomes, the favorable outcome group had more NIHSS 0-1 (29.9% vs.8.7%, P<0.001), lower cardioembolic (3.2% vs.7.9%, P=0.021), low IV-tPA ratio (4.8% vs.10.3%, P=0.019), lower NIHSS progression > 4 in the first 24 hours (3.9% vs.25.4%, P<0.001), and lower ICAS rate (28.1% vs.38.9%, P=0.02). Multivariable regression analysis of factors affecting unfavorable outcomes included baseline NIHSS 2-4 (OR, 3.85; 95% CI, 1.97-7.52), NIHSS progression > 4 (OR, 7.57; 95% CI, 3.80-15.10), and ICAS (OR 1.68; 95%CI, 1.07-2.64). CONCLUSIONS In patients with minor ischemic stroke, unfavorable outcomes were associated with baseline NIHSS 2-4, NIHSS progression > 4 points in 24 hours, and ICAS. These factors may identify a patient population in need of close monitoring and at higher risk of adverse outcomes.
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Affiliation(s)
- Mai Duy Ton
- Department of Stroke and Cerebrovascular disease, VNU-University of Medicine and Pharmacy, 144 Xuan Thuy, Cau Giay, Hanoi 10000, Vietnam; Stroke Center, Bach Mai hospital, 78 Giai phong road, Phương Mai ward, Dong Da district, Hanoi 10000, Vietnam; Hanoi Medical University, Vietnam
| | - Dao Viet Phuong
- Department of Stroke and Cerebrovascular disease, VNU-University of Medicine and Pharmacy, 144 Xuan Thuy, Cau Giay, Hanoi 10000, Vietnam; Stroke Center, Bach Mai hospital, 78 Giai phong road, Phương Mai ward, Dong Da district, Hanoi 10000, Vietnam; Hanoi Medical University, Vietnam
| | - Vu Thi Thom
- Department of Basic Science in Medicine and Pharmacy, VNU-University of Medicine and Pharmacy, 144 Xuan Thuy, Cau Giay, Hanoi, 100000, Vietnam
| | - Nguyen Tien Dung
- Department of Stroke and Cerebrovascular disease, VNU-University of Medicine and Pharmacy, 144 Xuan Thuy, Cau Giay, Hanoi 10000, Vietnam; Stroke Center, Bach Mai hospital, 78 Giai phong road, Phương Mai ward, Dong Da district, Hanoi 10000, Vietnam
| | - Pham Quang Tho
- Stroke Center, Bach Mai hospital, 78 Giai phong road, Phương Mai ward, Dong Da district, Hanoi 10000, Vietnam
| | | | - Thanh N Nguyen
- Boston Medical Center, 1 Boston Medical Center, Boston, MA 02118, United States.
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Li J, Zhang P, Zhu Y, Duan Y, Liu S, Fan J, Chen H, Wang C, Yi X. Serum neurofilament light chain levels are associated with early neurological deterioration in minor ischemic stroke. Front Neurol 2023; 14:1096358. [PMID: 36970517 PMCID: PMC10034185 DOI: 10.3389/fneur.2023.1096358] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2022] [Accepted: 02/16/2023] [Indexed: 03/11/2023] Open
Abstract
ObjectivesPatients with minor ischemic stroke (MIS) frequently suffer from early neurological deterioration (END) and become disabled. Our study aimed to explore the association between serum neurofilament light chain (sNfL) levels and END in patients with MIS.MethodsWe conducted a prospective observational study in patients with MIS [defined as a National Institutes of Health Stroke Scale (NIHSS) score 0–3] admitted within 24 h from the onset of symptoms. sNfL levels were measured at admission. The primary outcome was END, defined as an increase in the NIHSS score by ≥2 points within 5 days after admission. Univariate and multivariate analyses were performed to explore the risk factors associated with END. Stratified analyses and interaction tests were conducted to identify variables that might modify the association between sNfL levels and END.ResultsA total of 152 patients with MIS were enrolled, of which 24 (15.8%) developed END. The median sNfL level was 63.1 [interquartile range (IQR), 51.2–83.4] pg/ml on admission, which was significantly higher than that of 40 age- and sex-matched healthy controls (median 47.6, IQR 40.8–56.1 pg/ml; p < 0.001). Patients with MIS with END had a higher level of sNfL (with ND: median 74.1, IQR 59.5–89.8 pg/ml; without END: median 61.2, IQR 50.5–82.2 pg/ml; p = 0.026). After adjusting for age, baseline NIHSS score, and potential confounding factors in multivariate analyses, an elevated sNfL level (per 10 pg/mL) was associated with an increased risk of END [odds ratio (OR) 1.35, 95% confidence interval (CI) 1.04–1.77; p = 0.027). Stratified analyses and interaction tests demonstrated that the association between sNfL and END did not change by age group, sex, baseline NIHSS score, Fazekas' rating scale, hypertension, diabetes mellitus, intravenous thrombolysis, and dual antiplatelet therapy in patients with MIS (all p for interaction > 0.05). END was associated with an increased risk of unfavorable outcomes (modified Rankin scale score ranging from 3 to 6) at 3 months.ConclusionEarly neurological deterioration is common in minor ischemic stroke and is associated with poor prognosis. The elevated sNfL level was associated with an increased risk of early neurological deterioration in patients with minor ischemic stroke. sNfL might be a promising biomarker candidate that can help to identify patients with minor ischemic stroke at high risk of neurological deterioration, for reaching individual therapeutic decisions in clinical practice.
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Affiliation(s)
- Jie Li
- Department of Neurology, Deyang People's Hospital, Deyang, China
- *Correspondence: Jie Li
| | - Ping Zhang
- Department of Neurology, Deyang People's Hospital, Deyang, China
| | - Yalan Zhu
- Department of Neurology, Guanghan People's Hospital, Deyang, China
| | - Yong Duan
- Department of Neurology, Zhongjiang People's Hospital, Deyang, China
| | - Shan Liu
- Department of Neurology, Deyang Jingyang District Hospital of Traditional Chinese Medicine, Deyang, China
| | - Jie Fan
- Department of Neurology, Deyang Hospital of Integrated Traditional Chinese and Western Medicine, Deyang, China
| | - Hong Chen
- Department of Neurology, Deyang People's Hospital, Deyang, China
| | - Chun Wang
- Department of Neurology, Deyang People's Hospital, Deyang, China
| | - Xingyang Yi
- Department of Neurology, Deyang People's Hospital, Deyang, China
- Xingyang Yi
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9
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Han L, Hou Z, Ma M, Ding D, Wang D, Fang Q. Impact of glycosylated hemoglobin on early neurological deterioration in acute mild ischemic stroke patients treated with intravenous thrombolysis. Front Aging Neurosci 2023; 14:1073267. [PMID: 36711206 PMCID: PMC9877605 DOI: 10.3389/fnagi.2022.1073267] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Accepted: 12/28/2022] [Indexed: 01/13/2023] Open
Abstract
Objective In patients with acute mild ischemic stroke treated with intravenous thrombolysis, the relationship between chronic hyperglycemic status and their early neurological deterioration (END) and clinical outcomes is unclear. We attempted to analyze the relationship between glycated hemoglobin (HbA1c) levels and END and 90-day functional outcomes. Participants and methods The research comprised 267 patients with acute mild ischemic stroke. The incidence of END and functional outcomes at 90 days were evaluated between subgroups. END was defined in this study as a rise of at least 1 point in the National Institutes of Health Stroke Scale (NIHSS) score within 72 h of admission, with an excellent outcome of a modified Rankin Scale (mRS) score of 0-1 at 90 days following stroke beginning. The association between HbA1c and END, and clinical outcomes in patients with mild stroke, was assessed by logistic regression after adjusting for confounding factors. In addition, we used receiver operating characteristic (ROC) curves to predict the predictive value of HbA1c for the incidence of END. Results There were 38 patients who suffered END and 105 patients who had disabled functional outcomes at 90 days. In multivariate analysis, elevated HbA1c levels were associated with END (adjusted OR = 1.476; 95% CI: 1.129-1.928; p = 0.004). With HbA1c greater than 7.75%, the ROC curve predicted a higher risk of END. However, they were not associated with patients' functional outcomes at 90 days. Conclusion HbA1c levels were an independent predictor of END in patients with mild stroke, while there was no effect on functional outcomes at 90 days. The impact of HbA1c on functional prognosis may be a contributing factor rather than a direct factor.
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10
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Bhole R, Nouer SS, Tolley EA, Turk A, Siddiqui AH, Alexandrov AV, Arthur AS, Mocco J. Predictors of early neurologic deterioration (END) following stroke thrombectomy. J Neurointerv Surg 2022; 15:584-588. [PMID: 35584910 DOI: 10.1136/neurintsurg-2022-018844] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Accepted: 04/28/2022] [Indexed: 11/04/2022]
Abstract
BACKGROUND Early neurologic deterioration (END) following ischemic stroke is a serious event and is associated with poor outcomes. However, the incidence and predictors of END after stroke thrombectomy for emergent large vessel occlusion are largely unknown. METHODS The baseline characteristics of patients enrolled in the COMPASS trial (NCT02466893) were analyzed. The primary outcome was worsening of ≥4 National Institutes of Health Stroke Scale (NIHSS) points 24 hours post thrombectomy (4+ END24) and the secondary outcome was deterioration of ≥2 points (2+ END24). RESULTS Among 270 patients, 27 (10%) developed 4+ END24 and 42 (16%) had 2+ END24. Those with 4+ END24 were older (76.4±12.9 vs 70.9±12.9 years; p=0.04), had a higher prevalence of hypertension (96% vs 69%; p=0.003), diabetes (41% vs 27%; p=0.13) and higher pretreatment systolic blood pressure (SBP) (170.4±32.6 vs 157.6±28.1 mmHg; p=0.03). More 4+ END24 patients had failed reperfusion: Thrombolysis in Cerebral Infarction ≤2a (26% vs 8%; p=0.003). In unadjusted analysis, older patients and those with hypertension, diabetes, elevated SBP and failed reperfusion had higher odds of 4+ END24. In adjusted analysis, age increase by 5 years led to an increase in 4+ END24 of 28%, diabetes increased odds of 2.6 and failed reperfusion increased odds of 4.5. In the multivariable analysis for the secondary outcome, age (OR 1.33; 95% CI 1.109 to 1.593), diabetes (OR 2.7; 95% CI 1.247 to 5.764) and failed reperfusion (OR 7.2; 95% CI 0.055 to 0.349) were also significant predictors of 2+ END24. CONCLUSIONS Older patients with acute ischemic stroke who have a history of diabetes or hypertension, with elevated pretreatment SBP and failed reperfusion are at a higher risk of END following stroke thrombectomy for emergent large vessel occlusion.
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Affiliation(s)
- Rohini Bhole
- Department of Neurology, University of Virginia School of Medicine, Charlottesville, Virginia, USA
| | - Simonne S Nouer
- Department of Preventive Medicine, The University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Elizabeth A Tolley
- Department of Preventive Medicine, The University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Aquilla Turk
- Neurosurgery, Prisma Health Upstate, Greenville, South Carolina, USA
| | - Adnan H Siddiqui
- Neurosurgery and Radiology and Canon Stroke and Vascular Research Center, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York, USA.,Neurosurgery, Gates Vascular Institute, Buffalo, New York, USA
| | | | - Adam S Arthur
- Department of Neurosurgery, Semmes-Murphey Neurologic and Spine Institute, Memphis, Tennessee, USA.,Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - J Mocco
- Department of Neurosurgery, Mount Sinai Health System, New York, New York, USA
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11
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Wechsler PM, Parikh NS, Heier LA, Ruiz E, Fink ME, Navi BB, White H. Evaluation of Transient Ischemic Attack and Minor Stroke: A Rapid Outpatient Model for the COVID-19 Pandemic and Beyond. Neurohospitalist 2022; 12:38-47. [PMID: 34950385 PMCID: PMC8689541 DOI: 10.1177/19418744211000508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
The grim circumstances of the COVID-19 pandemic have highlighted the need to refine and adapt stroke systems of care. Patients' care-seeking behaviors have changed due to perceived risks of in-hospital treatment during the pandemic. In response to these challenges, we optimized a recently implemented, novel outpatient approach for the evaluation and management of minor stroke and transient ischemic attack, entitled RESCUE-TIA. This modified approach incorporated telemedicine visits and remote testing, and proved valuable during the pandemic. In this review article, we provide the evidence-based rationale for our approach, describe its operationalization, and provide data from our initial experience.
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Affiliation(s)
- Paul M. Wechsler
- Department of Neurology, Weill Cornell Medicine, New York, NY, USA
| | - Neal S. Parikh
- Department of Neurology, Weill Cornell Medicine, New York, NY, USA
| | - Linda A. Heier
- Department of Radiology, Weill Cornell Medicine, New York, NY, USA
| | - Evelyn Ruiz
- Department of Neurology, Weill Cornell Medicine, New York, NY, USA
| | - Matthew E. Fink
- Department of Neurology, Weill Cornell Medicine, New York, NY, USA
| | - Babak B. Navi
- Department of Neurology, Weill Cornell Medicine, New York, NY, USA
| | - Halina White
- Department of Neurology, Weill Cornell Medicine, New York, NY, USA,Halina White, Department of Neurology, Weill Cornell Medicine, 520 E 70th St, Starr 607, New York, NY 10021, USA.
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12
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Tatlisumak T, Putaala J. General Stroke Management and Stroke Units. Stroke 2022. [DOI: 10.1016/b978-0-323-69424-7.00055-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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13
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Sabir Rashid A, Huang-Link Y, Johnsson M, Wetterhäll S, Gauffin H. Predictors of Early Neurological Deterioration and Functional Outcome in Acute Ischemic Stroke: The Importance of Large Artery Disease, Hyperglycemia and Inflammatory Blood Biomarkers. Neuropsychiatr Dis Treat 2022; 18:1993-2002. [PMID: 36097537 PMCID: PMC9464020 DOI: 10.2147/ndt.s365758] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Accepted: 08/17/2022] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Early neurological deterioration (END) in acute ischemic stroke (AIS) can be associated with poor outcome. The aim of this study was to investigate the association between infarction subtypes, biomarkers and END, and to identify patients with risk of unfavorable functional outcome. MATERIALS AND METHODS This prospective study enrolled 101 patients with AIS. Neurological status was evaluated according to NIHSS at acute onset, on days 2, 3, and 90. END was defined as ≥2-point increase of NIHSS within 72 hours. Functional outcome was assessed using NIHSS and the modified Rankin Scale (mRS) at day 90. RESULTS END was observed in 20, 8%. Patients with large artery disease had higher risk of developing END compared with patients with cardioembolism or small vessel disease (p <0.01). Significant higher blood glucose level and leukocytes were observed in the END group. Patients with END had higher scores of mRS at day 90 (p <0.01). Levels of NSE, IL-6, hsCRP and NT-proBNP were higher in the patients with unfavorable compared with favorable functional outcome. CONCLUSION Large artery disease, high blood glucose and leukocytes levels are associated with END. Elevated levels of blood markers NSE, IL-6, HsCRP and NT-proBNP indicate poor functional outcome at 90 days after AIS. These patients must be identified and be offered treatment immediately in order to improve the functional outcome after AIS.
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Affiliation(s)
- Avan Sabir Rashid
- Department of Biomedical and Clinical Sciences (BKV), Faculty of Medicine and Health Sciences, Linköping University, Linköping, Sweden.,Department of Neurology, Linköping University Hospital, Region Östergötland, Linköping, Sweden
| | - Yumin Huang-Link
- Department of Biomedical and Clinical Sciences (BKV), Faculty of Medicine and Health Sciences, Linköping University, Linköping, Sweden.,Department of Neurology, Linköping University Hospital, Region Östergötland, Linköping, Sweden
| | - Marcus Johnsson
- Department of Biomedical and Clinical Sciences (BKV), Faculty of Medicine and Health Sciences, Linköping University, Linköping, Sweden.,Department of Neurology, Linköping University Hospital, Region Östergötland, Linköping, Sweden
| | - Simon Wetterhäll
- Department of Biomedical and Clinical Sciences (BKV), Faculty of Medicine and Health Sciences, Linköping University, Linköping, Sweden.,Department of Neurology, Linköping University Hospital, Region Östergötland, Linköping, Sweden
| | - Helena Gauffin
- Department of Biomedical and Clinical Sciences (BKV), Faculty of Medicine and Health Sciences, Linköping University, Linköping, Sweden.,Department of Neurology, Linköping University Hospital, Region Östergötland, Linköping, Sweden
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14
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Gómez-González A, Lazcano U, Vivanco-Hidalgo RM, Prats-Sánchez L, Guisado-Alonso D, Delgado-Mederos R, Camps-Renom P, Martínez Domeño A, Cuadrado-Godia E, Giralt Steinhauer E, Jiménez-Conde J, Soriano-Tárraga C, Avellaneda-Gómez C, Rodríguez-Campello A, Martí-Fábregas J, Ois A, Roquer J. Defining Minor Intracerebral Hemorrhage. Cerebrovasc Dis 2021; 50:435-442. [PMID: 33831860 DOI: 10.1159/000515169] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Accepted: 02/10/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND AND PURPOSE The minor stroke concept has not been analyzed in intracerebral hemorrhage (ICH) patients. Our purpose was to determine the optimal cut point on the NIH Stroke Scale (NIHSS) for defining a minor ICH (mICH) in patients with primary ICH. METHODS An ICH was considered minor if associated with a favorable 3-month outcome (modified Rankin Scale score ≤2). For supratentorial ICH, the discovery cohort consisted of 478 patients prospectively admitted at University Hospital del Mar. Association between NIHSS at admission and 3-month outcome was evaluated with area under the curve-receiver operating characteristics (AUC-ROC) and Youden's index to identify the optimal NIHSS cutoff point to define mICH. External validation was performed in a cohort of 242 supratentorial ICH patients from University Hospital Sant Pau. For infratentorial location, patients from both hospitals (n = 85) were analyzed together. RESULTS The best -NIHSS cutoff point defining supratentorial-mICH was 6 (AUC-ROC = 0.815 [0.774-0.857] in the discovery cohort and AUC-ROC = 0.819 [0.756-0.882] in the external validation cohort). For infratentorial ICH, the best cutoff point was 4 (AUC-ROC = 0.771 [0.664-0.877]). Using these cutoff points, 40.5% of all primary ICH cases were mICH. Of these, 70.2% were living independently at 3-month follow-up (72% for supratentorial ICH and 56.1% for infratentorial ICH) and 6.5% had died (5.3% for supratentorial ICH, and 14.6% for infratentorial ICH). For patients identified as non-mICH, good 3-month outcome was observed in 11.3% of cases; mortality was 51%. CONCLUSIONS The definition of mICH using the NIHSS cutoff point of 6 for supratentorial ICH and 4 for infratentorial ICH is useful to identify good outcome in ICH patients.
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Affiliation(s)
- Alejandra Gómez-González
- Department of Neurology, Neurology Neurovascular Research Unit Hospital del Mar Research Institute (IMIM), Barcelona, Spain
| | - Uxue Lazcano
- Department of Neurology, Neurology Neurovascular Research Unit Hospital del Mar Research Institute (IMIM), Barcelona, Spain
| | - Rosa Maria Vivanco-Hidalgo
- Department of Neurology, Neurology Neurovascular Research Unit Hospital del Mar Research Institute (IMIM), Barcelona, Spain
| | - Luis Prats-Sánchez
- Department of Neurology, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | | | | | - Pol Camps-Renom
- Department of Neurology, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | | | - Elisa Cuadrado-Godia
- Department of Neurology, Neurology Neurovascular Research Unit Hospital del Mar Research Institute (IMIM), Barcelona, Spain.,DCEXS, Universitat Pompeu Fabra, Barcelona, Spain
| | - Eva Giralt Steinhauer
- Department of Neurology, Neurology Neurovascular Research Unit Hospital del Mar Research Institute (IMIM), Barcelona, Spain
| | - Jordi Jiménez-Conde
- Department of Neurology, Neurology Neurovascular Research Unit Hospital del Mar Research Institute (IMIM), Barcelona, Spain
| | - Carolina Soriano-Tárraga
- Department of Neurology, Neurology Neurovascular Research Unit Hospital del Mar Research Institute (IMIM), Barcelona, Spain
| | - Carla Avellaneda-Gómez
- Department of Neurology, Neurology Neurovascular Research Unit Hospital del Mar Research Institute (IMIM), Barcelona, Spain
| | - Ana Rodríguez-Campello
- Department of Neurology, Neurology Neurovascular Research Unit Hospital del Mar Research Institute (IMIM), Barcelona, Spain.,Department of Medicine, Universitat Autónoma de Barcelona, Barcelona, Spain
| | - Joan Martí-Fábregas
- Department of Neurology, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Angel Ois
- Department of Neurology, Neurology Neurovascular Research Unit Hospital del Mar Research Institute (IMIM), Barcelona, Spain.,Department of Medicine, Universitat Autónoma de Barcelona, Barcelona, Spain
| | - Jaume Roquer
- Department of Neurology, Neurology Neurovascular Research Unit Hospital del Mar Research Institute (IMIM), Barcelona, Spain.,Department of Medicine, Universitat Autónoma de Barcelona, Barcelona, Spain
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15
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Sykora M, Krebs S, Simader F, Gattringer T, Greisenegger S, Ferrari J, Bernegger A, Posekany A, Lang W. Intravenous thrombolysis in stroke with admission NIHSS score 0 or 1. Int J Stroke 2021; 17:109-119. [PMID: 33568019 DOI: 10.1177/1747493021991969] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Up to 30% of stroke patients initially presenting with non-disabling or mild deficits may experience poor functional outcome. Despite, intravenous thrombolysis remains controversial in this subgroup of stroke patients due to its uncertain risk benefit ratio. AIM We aimed to analyze the real-world experience with intravenous thrombolysis in stroke patients presenting with very low NIHSS. METHODS Data of stroke patients presenting with mild initial stroke severity (NIHSS 0-5) including vascular risk factors, stroke syndrome and etiology, early neurological deterioration, symptomatic intracerebral haemorrhage (sICH), and functional outcome by modified Rankin Scale were extracted from a large nationwide stroke registry and analysed. Patients were categorized and compared according to admission severity NIHSS 0-1 versus NIHSS 2-5 and intravenous thrombolysis use. RESULTS Seven hundred and three (2%) of 35,113 patients presenting with NIHSS 0-1 and 6316 (13.9%) of 45,521 of patients presenting with NIHSS 2-5 underwent intravenous thrombolysis. In the NIHSS 0-1 group, intravenous thrombolysis was associated with early neurological deterioration (adjusted OR 8.84, CI 6.61-11.83), sICH (adjusted OR 9.32, CI 4.53-19.15) and lower rate of excellent outcome (mRS 0-1) at three months (adjusted OR 0.67, CI 0.5-0.9). In stroke patients with NIHSS 2-5, intravenous thrombolysis was associated with early neurological deterioration (adjusted OR 1.7, 1.47-1.98), sICH (adjusted OR 5.75, CI 4.45-7.45), and higher rate of excellent outcome (mRS 0-1) at three months (adjusted OR 1.21, CI 1.08-1.34). CONCLUSIONS Among patients with NIHSS 0-1, intravenous thrombolysis did not increase the likelihood of excellent outcome. Moreover, potential signals of harm were observed. Further research seems to be warranted.
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Affiliation(s)
- Marek Sykora
- Medical Faculty, Sigmund Freud University Vienna, Austria.,Department of Neurology, St John's Hospital, Vienna, Austria
| | - Stefan Krebs
- Department of Neurology, St John's Hospital, Vienna, Austria
| | | | | | | | - Julia Ferrari
- Department of Neurology, St John's Hospital, Vienna, Austria
| | | | - Alexandra Posekany
- Research Unit of Computational Statistics, University of Technology, Vienna
| | - Wilfried Lang
- Medical Faculty, Sigmund Freud University Vienna, Austria.,Department of Neurology, St John's Hospital, Vienna, Austria
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16
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Park TH, Lee JK, Park MS, Park SS, Hong KS, Ryu WS, Kim DE, Park MS, Choi KH, Kim JT, Kang J, Kim BJ, Han MK, Lee J, Cha JK, Kim DH, Kim JG, Lee SJ, Cho YJ, Kwon JH, Shin DI, Yeo MJ, Sohn SI, Hong JH, Lee JS, Choi JC, Kim WJ, Lee BC, Yu KH, Oh MS, Park JM, Kang K, Lee KB, Lee J, Gorelick PB, Bae HJ. Neurologic deterioration in patients with acute ischemic stroke or transient ischemic attack. Neurology 2020; 95:e2178-e2191. [PMID: 32817184 DOI: 10.1212/wnl.0000000000010603] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Accepted: 04/27/2020] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To improve epidemiologic knowledge of neurologic deterioration (ND) in patients with acute ischemic stroke (AIS). METHODS In this prospective observational study, we captured ND prospectively in 29,446 patients with AIS admitted to 15 hospitals in Korea within 7 days of stroke onset. ND was defined as an increase in NIH Stroke Scale (NIHSS) score ≥2 (total), or ≥1 (motor or consciousness), or any new neurologic symptoms. Change in incidence rate after stroke onset, causes, factors associated with ND, modified Rankin Scale (mRS) score at 3 months and 1 year, and a composite of stroke, myocardial infarction, and all-cause death at 1 year were assessed. RESULTS ND occurred in 4,299 (14.6%) patients. The highest rate, 6.95 per 1,000 person-hours incidence, was within the first 6 hours, which decreased to 2.09 within 24-48 hours, and 0.66 within 72-96 hours after stroke onset. Old age, female sex, diabetes, early arrival, large artery atherosclerosis as a stroke subtype, high NIHSS scores, glucose level, systolic blood pressure, leukocytosis at admission, recanalization therapy, TIA without a relevant lesion, and steno-occlusion of relevant arteries were associated with ND. The causes were stroke progression (71.8%) followed by recurrence (8.5%). Adjusted relative risks (95% CI) for poor outcome (mRS 3-6) at 3 months and 1 year were 1.75 (1.70-1.80) and 1.70 (1.65-1.75), respectively. The adjusted hazard ratio (95% CI) for the composite event was 1.59 (1.45-1.74). CONCLUSIONS ND should be taken into consideration as a factor that may influence the outcome in acute ischemic stroke.
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Affiliation(s)
- Tai Hwan Park
- From the Department of Neurology (T.H.P., M.-S.P., S.-S.P.), Seoul Medical Center; Department of Neurology, Cerebrovascular Center (J.-K.L., J.K., B.J.K., M.-K.H., H.-J.B.), Seoul National University Bundang Hospital, Seongnam; Department of Neurology (K.-S.H., Y.-J.C.), Ilsan Paik Hospital, Inje University, Goyang; Department of Neurology (W.-S.R., D.-E.K.), Dongguk University Ilsan Hospital, Goyang; Department of Neurology (M.S.P., K.-H.C., J.-T.K.), Chonnam National University Hospital, Gwangju; Department of Neurology (Jun Lee), Yeungnam University Hospital, Daegu; Department of Neurology (J.-K.C., D.-H.K.), Dong-A University Hospital, Busan; Department of Neurology (J.G.K., S.J.L.), Eulji University Hospital, Eulji University, Daejeon; Department of Neurology (J.-H.K., W.-J.K.), Ulsan University College of Medicine; Department of Neurology (D.-I.S., M.-J.Y.), Chungbuk National University Hospital, Cheongju; Department of Neurology (S.I.S., J.-H.H.), Keimyung University Dongsan Medical Center, Daegu; Clinical Research Center (J.S.L.), Asan Medical Center, Seoul; Department of Neurology (J.C.C.), Jeju National University Hospital, Jeju National University School of Medicine; Department of Neurology (B.-C.L., K.-H.Y., M.-S.O.), Hallym University Sacred Heart Hospital, Anyang; Department of Neurology (J.-M.P., K.K.), Eulji General Hospital, Eulji University, Seoul; Department of Neurology (K.B.L.), Soonchunhyang University Hospital, Seoul; Department of Biostatistics (Juneyoung Lee), Korea University College of Medicine, Seoul; and Department of Neurology (P.B.G.), Northwestern University Feinberg School of Medicine, Davee, Chicago, IL
| | - Jeong-Kon Lee
- From the Department of Neurology (T.H.P., M.-S.P., S.-S.P.), Seoul Medical Center; Department of Neurology, Cerebrovascular Center (J.-K.L., J.K., B.J.K., M.-K.H., H.-J.B.), Seoul National University Bundang Hospital, Seongnam; Department of Neurology (K.-S.H., Y.-J.C.), Ilsan Paik Hospital, Inje University, Goyang; Department of Neurology (W.-S.R., D.-E.K.), Dongguk University Ilsan Hospital, Goyang; Department of Neurology (M.S.P., K.-H.C., J.-T.K.), Chonnam National University Hospital, Gwangju; Department of Neurology (Jun Lee), Yeungnam University Hospital, Daegu; Department of Neurology (J.-K.C., D.-H.K.), Dong-A University Hospital, Busan; Department of Neurology (J.G.K., S.J.L.), Eulji University Hospital, Eulji University, Daejeon; Department of Neurology (J.-H.K., W.-J.K.), Ulsan University College of Medicine; Department of Neurology (D.-I.S., M.-J.Y.), Chungbuk National University Hospital, Cheongju; Department of Neurology (S.I.S., J.-H.H.), Keimyung University Dongsan Medical Center, Daegu; Clinical Research Center (J.S.L.), Asan Medical Center, Seoul; Department of Neurology (J.C.C.), Jeju National University Hospital, Jeju National University School of Medicine; Department of Neurology (B.-C.L., K.-H.Y., M.-S.O.), Hallym University Sacred Heart Hospital, Anyang; Department of Neurology (J.-M.P., K.K.), Eulji General Hospital, Eulji University, Seoul; Department of Neurology (K.B.L.), Soonchunhyang University Hospital, Seoul; Department of Biostatistics (Juneyoung Lee), Korea University College of Medicine, Seoul; and Department of Neurology (P.B.G.), Northwestern University Feinberg School of Medicine, Davee, Chicago, IL
| | - Moo-Seok Park
- From the Department of Neurology (T.H.P., M.-S.P., S.-S.P.), Seoul Medical Center; Department of Neurology, Cerebrovascular Center (J.-K.L., J.K., B.J.K., M.-K.H., H.-J.B.), Seoul National University Bundang Hospital, Seongnam; Department of Neurology (K.-S.H., Y.-J.C.), Ilsan Paik Hospital, Inje University, Goyang; Department of Neurology (W.-S.R., D.-E.K.), Dongguk University Ilsan Hospital, Goyang; Department of Neurology (M.S.P., K.-H.C., J.-T.K.), Chonnam National University Hospital, Gwangju; Department of Neurology (Jun Lee), Yeungnam University Hospital, Daegu; Department of Neurology (J.-K.C., D.-H.K.), Dong-A University Hospital, Busan; Department of Neurology (J.G.K., S.J.L.), Eulji University Hospital, Eulji University, Daejeon; Department of Neurology (J.-H.K., W.-J.K.), Ulsan University College of Medicine; Department of Neurology (D.-I.S., M.-J.Y.), Chungbuk National University Hospital, Cheongju; Department of Neurology (S.I.S., J.-H.H.), Keimyung University Dongsan Medical Center, Daegu; Clinical Research Center (J.S.L.), Asan Medical Center, Seoul; Department of Neurology (J.C.C.), Jeju National University Hospital, Jeju National University School of Medicine; Department of Neurology (B.-C.L., K.-H.Y., M.-S.O.), Hallym University Sacred Heart Hospital, Anyang; Department of Neurology (J.-M.P., K.K.), Eulji General Hospital, Eulji University, Seoul; Department of Neurology (K.B.L.), Soonchunhyang University Hospital, Seoul; Department of Biostatistics (Juneyoung Lee), Korea University College of Medicine, Seoul; and Department of Neurology (P.B.G.), Northwestern University Feinberg School of Medicine, Davee, Chicago, IL
| | - Sang-Soon Park
- From the Department of Neurology (T.H.P., M.-S.P., S.-S.P.), Seoul Medical Center; Department of Neurology, Cerebrovascular Center (J.-K.L., J.K., B.J.K., M.-K.H., H.-J.B.), Seoul National University Bundang Hospital, Seongnam; Department of Neurology (K.-S.H., Y.-J.C.), Ilsan Paik Hospital, Inje University, Goyang; Department of Neurology (W.-S.R., D.-E.K.), Dongguk University Ilsan Hospital, Goyang; Department of Neurology (M.S.P., K.-H.C., J.-T.K.), Chonnam National University Hospital, Gwangju; Department of Neurology (Jun Lee), Yeungnam University Hospital, Daegu; Department of Neurology (J.-K.C., D.-H.K.), Dong-A University Hospital, Busan; Department of Neurology (J.G.K., S.J.L.), Eulji University Hospital, Eulji University, Daejeon; Department of Neurology (J.-H.K., W.-J.K.), Ulsan University College of Medicine; Department of Neurology (D.-I.S., M.-J.Y.), Chungbuk National University Hospital, Cheongju; Department of Neurology (S.I.S., J.-H.H.), Keimyung University Dongsan Medical Center, Daegu; Clinical Research Center (J.S.L.), Asan Medical Center, Seoul; Department of Neurology (J.C.C.), Jeju National University Hospital, Jeju National University School of Medicine; Department of Neurology (B.-C.L., K.-H.Y., M.-S.O.), Hallym University Sacred Heart Hospital, Anyang; Department of Neurology (J.-M.P., K.K.), Eulji General Hospital, Eulji University, Seoul; Department of Neurology (K.B.L.), Soonchunhyang University Hospital, Seoul; Department of Biostatistics (Juneyoung Lee), Korea University College of Medicine, Seoul; and Department of Neurology (P.B.G.), Northwestern University Feinberg School of Medicine, Davee, Chicago, IL
| | - Keun-Sik Hong
- From the Department of Neurology (T.H.P., M.-S.P., S.-S.P.), Seoul Medical Center; Department of Neurology, Cerebrovascular Center (J.-K.L., J.K., B.J.K., M.-K.H., H.-J.B.), Seoul National University Bundang Hospital, Seongnam; Department of Neurology (K.-S.H., Y.-J.C.), Ilsan Paik Hospital, Inje University, Goyang; Department of Neurology (W.-S.R., D.-E.K.), Dongguk University Ilsan Hospital, Goyang; Department of Neurology (M.S.P., K.-H.C., J.-T.K.), Chonnam National University Hospital, Gwangju; Department of Neurology (Jun Lee), Yeungnam University Hospital, Daegu; Department of Neurology (J.-K.C., D.-H.K.), Dong-A University Hospital, Busan; Department of Neurology (J.G.K., S.J.L.), Eulji University Hospital, Eulji University, Daejeon; Department of Neurology (J.-H.K., W.-J.K.), Ulsan University College of Medicine; Department of Neurology (D.-I.S., M.-J.Y.), Chungbuk National University Hospital, Cheongju; Department of Neurology (S.I.S., J.-H.H.), Keimyung University Dongsan Medical Center, Daegu; Clinical Research Center (J.S.L.), Asan Medical Center, Seoul; Department of Neurology (J.C.C.), Jeju National University Hospital, Jeju National University School of Medicine; Department of Neurology (B.-C.L., K.-H.Y., M.-S.O.), Hallym University Sacred Heart Hospital, Anyang; Department of Neurology (J.-M.P., K.K.), Eulji General Hospital, Eulji University, Seoul; Department of Neurology (K.B.L.), Soonchunhyang University Hospital, Seoul; Department of Biostatistics (Juneyoung Lee), Korea University College of Medicine, Seoul; and Department of Neurology (P.B.G.), Northwestern University Feinberg School of Medicine, Davee, Chicago, IL
| | - Wi-Sun Ryu
- From the Department of Neurology (T.H.P., M.-S.P., S.-S.P.), Seoul Medical Center; Department of Neurology, Cerebrovascular Center (J.-K.L., J.K., B.J.K., M.-K.H., H.-J.B.), Seoul National University Bundang Hospital, Seongnam; Department of Neurology (K.-S.H., Y.-J.C.), Ilsan Paik Hospital, Inje University, Goyang; Department of Neurology (W.-S.R., D.-E.K.), Dongguk University Ilsan Hospital, Goyang; Department of Neurology (M.S.P., K.-H.C., J.-T.K.), Chonnam National University Hospital, Gwangju; Department of Neurology (Jun Lee), Yeungnam University Hospital, Daegu; Department of Neurology (J.-K.C., D.-H.K.), Dong-A University Hospital, Busan; Department of Neurology (J.G.K., S.J.L.), Eulji University Hospital, Eulji University, Daejeon; Department of Neurology (J.-H.K., W.-J.K.), Ulsan University College of Medicine; Department of Neurology (D.-I.S., M.-J.Y.), Chungbuk National University Hospital, Cheongju; Department of Neurology (S.I.S., J.-H.H.), Keimyung University Dongsan Medical Center, Daegu; Clinical Research Center (J.S.L.), Asan Medical Center, Seoul; Department of Neurology (J.C.C.), Jeju National University Hospital, Jeju National University School of Medicine; Department of Neurology (B.-C.L., K.-H.Y., M.-S.O.), Hallym University Sacred Heart Hospital, Anyang; Department of Neurology (J.-M.P., K.K.), Eulji General Hospital, Eulji University, Seoul; Department of Neurology (K.B.L.), Soonchunhyang University Hospital, Seoul; Department of Biostatistics (Juneyoung Lee), Korea University College of Medicine, Seoul; and Department of Neurology (P.B.G.), Northwestern University Feinberg School of Medicine, Davee, Chicago, IL
| | - Dong-Eog Kim
- From the Department of Neurology (T.H.P., M.-S.P., S.-S.P.), Seoul Medical Center; Department of Neurology, Cerebrovascular Center (J.-K.L., J.K., B.J.K., M.-K.H., H.-J.B.), Seoul National University Bundang Hospital, Seongnam; Department of Neurology (K.-S.H., Y.-J.C.), Ilsan Paik Hospital, Inje University, Goyang; Department of Neurology (W.-S.R., D.-E.K.), Dongguk University Ilsan Hospital, Goyang; Department of Neurology (M.S.P., K.-H.C., J.-T.K.), Chonnam National University Hospital, Gwangju; Department of Neurology (Jun Lee), Yeungnam University Hospital, Daegu; Department of Neurology (J.-K.C., D.-H.K.), Dong-A University Hospital, Busan; Department of Neurology (J.G.K., S.J.L.), Eulji University Hospital, Eulji University, Daejeon; Department of Neurology (J.-H.K., W.-J.K.), Ulsan University College of Medicine; Department of Neurology (D.-I.S., M.-J.Y.), Chungbuk National University Hospital, Cheongju; Department of Neurology (S.I.S., J.-H.H.), Keimyung University Dongsan Medical Center, Daegu; Clinical Research Center (J.S.L.), Asan Medical Center, Seoul; Department of Neurology (J.C.C.), Jeju National University Hospital, Jeju National University School of Medicine; Department of Neurology (B.-C.L., K.-H.Y., M.-S.O.), Hallym University Sacred Heart Hospital, Anyang; Department of Neurology (J.-M.P., K.K.), Eulji General Hospital, Eulji University, Seoul; Department of Neurology (K.B.L.), Soonchunhyang University Hospital, Seoul; Department of Biostatistics (Juneyoung Lee), Korea University College of Medicine, Seoul; and Department of Neurology (P.B.G.), Northwestern University Feinberg School of Medicine, Davee, Chicago, IL
| | - Man Seok Park
- From the Department of Neurology (T.H.P., M.-S.P., S.-S.P.), Seoul Medical Center; Department of Neurology, Cerebrovascular Center (J.-K.L., J.K., B.J.K., M.-K.H., H.-J.B.), Seoul National University Bundang Hospital, Seongnam; Department of Neurology (K.-S.H., Y.-J.C.), Ilsan Paik Hospital, Inje University, Goyang; Department of Neurology (W.-S.R., D.-E.K.), Dongguk University Ilsan Hospital, Goyang; Department of Neurology (M.S.P., K.-H.C., J.-T.K.), Chonnam National University Hospital, Gwangju; Department of Neurology (Jun Lee), Yeungnam University Hospital, Daegu; Department of Neurology (J.-K.C., D.-H.K.), Dong-A University Hospital, Busan; Department of Neurology (J.G.K., S.J.L.), Eulji University Hospital, Eulji University, Daejeon; Department of Neurology (J.-H.K., W.-J.K.), Ulsan University College of Medicine; Department of Neurology (D.-I.S., M.-J.Y.), Chungbuk National University Hospital, Cheongju; Department of Neurology (S.I.S., J.-H.H.), Keimyung University Dongsan Medical Center, Daegu; Clinical Research Center (J.S.L.), Asan Medical Center, Seoul; Department of Neurology (J.C.C.), Jeju National University Hospital, Jeju National University School of Medicine; Department of Neurology (B.-C.L., K.-H.Y., M.-S.O.), Hallym University Sacred Heart Hospital, Anyang; Department of Neurology (J.-M.P., K.K.), Eulji General Hospital, Eulji University, Seoul; Department of Neurology (K.B.L.), Soonchunhyang University Hospital, Seoul; Department of Biostatistics (Juneyoung Lee), Korea University College of Medicine, Seoul; and Department of Neurology (P.B.G.), Northwestern University Feinberg School of Medicine, Davee, Chicago, IL
| | - Kang-Ho Choi
- From the Department of Neurology (T.H.P., M.-S.P., S.-S.P.), Seoul Medical Center; Department of Neurology, Cerebrovascular Center (J.-K.L., J.K., B.J.K., M.-K.H., H.-J.B.), Seoul National University Bundang Hospital, Seongnam; Department of Neurology (K.-S.H., Y.-J.C.), Ilsan Paik Hospital, Inje University, Goyang; Department of Neurology (W.-S.R., D.-E.K.), Dongguk University Ilsan Hospital, Goyang; Department of Neurology (M.S.P., K.-H.C., J.-T.K.), Chonnam National University Hospital, Gwangju; Department of Neurology (Jun Lee), Yeungnam University Hospital, Daegu; Department of Neurology (J.-K.C., D.-H.K.), Dong-A University Hospital, Busan; Department of Neurology (J.G.K., S.J.L.), Eulji University Hospital, Eulji University, Daejeon; Department of Neurology (J.-H.K., W.-J.K.), Ulsan University College of Medicine; Department of Neurology (D.-I.S., M.-J.Y.), Chungbuk National University Hospital, Cheongju; Department of Neurology (S.I.S., J.-H.H.), Keimyung University Dongsan Medical Center, Daegu; Clinical Research Center (J.S.L.), Asan Medical Center, Seoul; Department of Neurology (J.C.C.), Jeju National University Hospital, Jeju National University School of Medicine; Department of Neurology (B.-C.L., K.-H.Y., M.-S.O.), Hallym University Sacred Heart Hospital, Anyang; Department of Neurology (J.-M.P., K.K.), Eulji General Hospital, Eulji University, Seoul; Department of Neurology (K.B.L.), Soonchunhyang University Hospital, Seoul; Department of Biostatistics (Juneyoung Lee), Korea University College of Medicine, Seoul; and Department of Neurology (P.B.G.), Northwestern University Feinberg School of Medicine, Davee, Chicago, IL
| | - Joon-Tae Kim
- From the Department of Neurology (T.H.P., M.-S.P., S.-S.P.), Seoul Medical Center; Department of Neurology, Cerebrovascular Center (J.-K.L., J.K., B.J.K., M.-K.H., H.-J.B.), Seoul National University Bundang Hospital, Seongnam; Department of Neurology (K.-S.H., Y.-J.C.), Ilsan Paik Hospital, Inje University, Goyang; Department of Neurology (W.-S.R., D.-E.K.), Dongguk University Ilsan Hospital, Goyang; Department of Neurology (M.S.P., K.-H.C., J.-T.K.), Chonnam National University Hospital, Gwangju; Department of Neurology (Jun Lee), Yeungnam University Hospital, Daegu; Department of Neurology (J.-K.C., D.-H.K.), Dong-A University Hospital, Busan; Department of Neurology (J.G.K., S.J.L.), Eulji University Hospital, Eulji University, Daejeon; Department of Neurology (J.-H.K., W.-J.K.), Ulsan University College of Medicine; Department of Neurology (D.-I.S., M.-J.Y.), Chungbuk National University Hospital, Cheongju; Department of Neurology (S.I.S., J.-H.H.), Keimyung University Dongsan Medical Center, Daegu; Clinical Research Center (J.S.L.), Asan Medical Center, Seoul; Department of Neurology (J.C.C.), Jeju National University Hospital, Jeju National University School of Medicine; Department of Neurology (B.-C.L., K.-H.Y., M.-S.O.), Hallym University Sacred Heart Hospital, Anyang; Department of Neurology (J.-M.P., K.K.), Eulji General Hospital, Eulji University, Seoul; Department of Neurology (K.B.L.), Soonchunhyang University Hospital, Seoul; Department of Biostatistics (Juneyoung Lee), Korea University College of Medicine, Seoul; and Department of Neurology (P.B.G.), Northwestern University Feinberg School of Medicine, Davee, Chicago, IL
| | - Jihoon Kang
- From the Department of Neurology (T.H.P., M.-S.P., S.-S.P.), Seoul Medical Center; Department of Neurology, Cerebrovascular Center (J.-K.L., J.K., B.J.K., M.-K.H., H.-J.B.), Seoul National University Bundang Hospital, Seongnam; Department of Neurology (K.-S.H., Y.-J.C.), Ilsan Paik Hospital, Inje University, Goyang; Department of Neurology (W.-S.R., D.-E.K.), Dongguk University Ilsan Hospital, Goyang; Department of Neurology (M.S.P., K.-H.C., J.-T.K.), Chonnam National University Hospital, Gwangju; Department of Neurology (Jun Lee), Yeungnam University Hospital, Daegu; Department of Neurology (J.-K.C., D.-H.K.), Dong-A University Hospital, Busan; Department of Neurology (J.G.K., S.J.L.), Eulji University Hospital, Eulji University, Daejeon; Department of Neurology (J.-H.K., W.-J.K.), Ulsan University College of Medicine; Department of Neurology (D.-I.S., M.-J.Y.), Chungbuk National University Hospital, Cheongju; Department of Neurology (S.I.S., J.-H.H.), Keimyung University Dongsan Medical Center, Daegu; Clinical Research Center (J.S.L.), Asan Medical Center, Seoul; Department of Neurology (J.C.C.), Jeju National University Hospital, Jeju National University School of Medicine; Department of Neurology (B.-C.L., K.-H.Y., M.-S.O.), Hallym University Sacred Heart Hospital, Anyang; Department of Neurology (J.-M.P., K.K.), Eulji General Hospital, Eulji University, Seoul; Department of Neurology (K.B.L.), Soonchunhyang University Hospital, Seoul; Department of Biostatistics (Juneyoung Lee), Korea University College of Medicine, Seoul; and Department of Neurology (P.B.G.), Northwestern University Feinberg School of Medicine, Davee, Chicago, IL
| | - Beom Joon Kim
- From the Department of Neurology (T.H.P., M.-S.P., S.-S.P.), Seoul Medical Center; Department of Neurology, Cerebrovascular Center (J.-K.L., J.K., B.J.K., M.-K.H., H.-J.B.), Seoul National University Bundang Hospital, Seongnam; Department of Neurology (K.-S.H., Y.-J.C.), Ilsan Paik Hospital, Inje University, Goyang; Department of Neurology (W.-S.R., D.-E.K.), Dongguk University Ilsan Hospital, Goyang; Department of Neurology (M.S.P., K.-H.C., J.-T.K.), Chonnam National University Hospital, Gwangju; Department of Neurology (Jun Lee), Yeungnam University Hospital, Daegu; Department of Neurology (J.-K.C., D.-H.K.), Dong-A University Hospital, Busan; Department of Neurology (J.G.K., S.J.L.), Eulji University Hospital, Eulji University, Daejeon; Department of Neurology (J.-H.K., W.-J.K.), Ulsan University College of Medicine; Department of Neurology (D.-I.S., M.-J.Y.), Chungbuk National University Hospital, Cheongju; Department of Neurology (S.I.S., J.-H.H.), Keimyung University Dongsan Medical Center, Daegu; Clinical Research Center (J.S.L.), Asan Medical Center, Seoul; Department of Neurology (J.C.C.), Jeju National University Hospital, Jeju National University School of Medicine; Department of Neurology (B.-C.L., K.-H.Y., M.-S.O.), Hallym University Sacred Heart Hospital, Anyang; Department of Neurology (J.-M.P., K.K.), Eulji General Hospital, Eulji University, Seoul; Department of Neurology (K.B.L.), Soonchunhyang University Hospital, Seoul; Department of Biostatistics (Juneyoung Lee), Korea University College of Medicine, Seoul; and Department of Neurology (P.B.G.), Northwestern University Feinberg School of Medicine, Davee, Chicago, IL
| | - Moon-Ku Han
- From the Department of Neurology (T.H.P., M.-S.P., S.-S.P.), Seoul Medical Center; Department of Neurology, Cerebrovascular Center (J.-K.L., J.K., B.J.K., M.-K.H., H.-J.B.), Seoul National University Bundang Hospital, Seongnam; Department of Neurology (K.-S.H., Y.-J.C.), Ilsan Paik Hospital, Inje University, Goyang; Department of Neurology (W.-S.R., D.-E.K.), Dongguk University Ilsan Hospital, Goyang; Department of Neurology (M.S.P., K.-H.C., J.-T.K.), Chonnam National University Hospital, Gwangju; Department of Neurology (Jun Lee), Yeungnam University Hospital, Daegu; Department of Neurology (J.-K.C., D.-H.K.), Dong-A University Hospital, Busan; Department of Neurology (J.G.K., S.J.L.), Eulji University Hospital, Eulji University, Daejeon; Department of Neurology (J.-H.K., W.-J.K.), Ulsan University College of Medicine; Department of Neurology (D.-I.S., M.-J.Y.), Chungbuk National University Hospital, Cheongju; Department of Neurology (S.I.S., J.-H.H.), Keimyung University Dongsan Medical Center, Daegu; Clinical Research Center (J.S.L.), Asan Medical Center, Seoul; Department of Neurology (J.C.C.), Jeju National University Hospital, Jeju National University School of Medicine; Department of Neurology (B.-C.L., K.-H.Y., M.-S.O.), Hallym University Sacred Heart Hospital, Anyang; Department of Neurology (J.-M.P., K.K.), Eulji General Hospital, Eulji University, Seoul; Department of Neurology (K.B.L.), Soonchunhyang University Hospital, Seoul; Department of Biostatistics (Juneyoung Lee), Korea University College of Medicine, Seoul; and Department of Neurology (P.B.G.), Northwestern University Feinberg School of Medicine, Davee, Chicago, IL
| | - Jun Lee
- From the Department of Neurology (T.H.P., M.-S.P., S.-S.P.), Seoul Medical Center; Department of Neurology, Cerebrovascular Center (J.-K.L., J.K., B.J.K., M.-K.H., H.-J.B.), Seoul National University Bundang Hospital, Seongnam; Department of Neurology (K.-S.H., Y.-J.C.), Ilsan Paik Hospital, Inje University, Goyang; Department of Neurology (W.-S.R., D.-E.K.), Dongguk University Ilsan Hospital, Goyang; Department of Neurology (M.S.P., K.-H.C., J.-T.K.), Chonnam National University Hospital, Gwangju; Department of Neurology (Jun Lee), Yeungnam University Hospital, Daegu; Department of Neurology (J.-K.C., D.-H.K.), Dong-A University Hospital, Busan; Department of Neurology (J.G.K., S.J.L.), Eulji University Hospital, Eulji University, Daejeon; Department of Neurology (J.-H.K., W.-J.K.), Ulsan University College of Medicine; Department of Neurology (D.-I.S., M.-J.Y.), Chungbuk National University Hospital, Cheongju; Department of Neurology (S.I.S., J.-H.H.), Keimyung University Dongsan Medical Center, Daegu; Clinical Research Center (J.S.L.), Asan Medical Center, Seoul; Department of Neurology (J.C.C.), Jeju National University Hospital, Jeju National University School of Medicine; Department of Neurology (B.-C.L., K.-H.Y., M.-S.O.), Hallym University Sacred Heart Hospital, Anyang; Department of Neurology (J.-M.P., K.K.), Eulji General Hospital, Eulji University, Seoul; Department of Neurology (K.B.L.), Soonchunhyang University Hospital, Seoul; Department of Biostatistics (Juneyoung Lee), Korea University College of Medicine, Seoul; and Department of Neurology (P.B.G.), Northwestern University Feinberg School of Medicine, Davee, Chicago, IL
| | - Jae-Kwan Cha
- From the Department of Neurology (T.H.P., M.-S.P., S.-S.P.), Seoul Medical Center; Department of Neurology, Cerebrovascular Center (J.-K.L., J.K., B.J.K., M.-K.H., H.-J.B.), Seoul National University Bundang Hospital, Seongnam; Department of Neurology (K.-S.H., Y.-J.C.), Ilsan Paik Hospital, Inje University, Goyang; Department of Neurology (W.-S.R., D.-E.K.), Dongguk University Ilsan Hospital, Goyang; Department of Neurology (M.S.P., K.-H.C., J.-T.K.), Chonnam National University Hospital, Gwangju; Department of Neurology (Jun Lee), Yeungnam University Hospital, Daegu; Department of Neurology (J.-K.C., D.-H.K.), Dong-A University Hospital, Busan; Department of Neurology (J.G.K., S.J.L.), Eulji University Hospital, Eulji University, Daejeon; Department of Neurology (J.-H.K., W.-J.K.), Ulsan University College of Medicine; Department of Neurology (D.-I.S., M.-J.Y.), Chungbuk National University Hospital, Cheongju; Department of Neurology (S.I.S., J.-H.H.), Keimyung University Dongsan Medical Center, Daegu; Clinical Research Center (J.S.L.), Asan Medical Center, Seoul; Department of Neurology (J.C.C.), Jeju National University Hospital, Jeju National University School of Medicine; Department of Neurology (B.-C.L., K.-H.Y., M.-S.O.), Hallym University Sacred Heart Hospital, Anyang; Department of Neurology (J.-M.P., K.K.), Eulji General Hospital, Eulji University, Seoul; Department of Neurology (K.B.L.), Soonchunhyang University Hospital, Seoul; Department of Biostatistics (Juneyoung Lee), Korea University College of Medicine, Seoul; and Department of Neurology (P.B.G.), Northwestern University Feinberg School of Medicine, Davee, Chicago, IL
| | - Dae-Hyun Kim
- From the Department of Neurology (T.H.P., M.-S.P., S.-S.P.), Seoul Medical Center; Department of Neurology, Cerebrovascular Center (J.-K.L., J.K., B.J.K., M.-K.H., H.-J.B.), Seoul National University Bundang Hospital, Seongnam; Department of Neurology (K.-S.H., Y.-J.C.), Ilsan Paik Hospital, Inje University, Goyang; Department of Neurology (W.-S.R., D.-E.K.), Dongguk University Ilsan Hospital, Goyang; Department of Neurology (M.S.P., K.-H.C., J.-T.K.), Chonnam National University Hospital, Gwangju; Department of Neurology (Jun Lee), Yeungnam University Hospital, Daegu; Department of Neurology (J.-K.C., D.-H.K.), Dong-A University Hospital, Busan; Department of Neurology (J.G.K., S.J.L.), Eulji University Hospital, Eulji University, Daejeon; Department of Neurology (J.-H.K., W.-J.K.), Ulsan University College of Medicine; Department of Neurology (D.-I.S., M.-J.Y.), Chungbuk National University Hospital, Cheongju; Department of Neurology (S.I.S., J.-H.H.), Keimyung University Dongsan Medical Center, Daegu; Clinical Research Center (J.S.L.), Asan Medical Center, Seoul; Department of Neurology (J.C.C.), Jeju National University Hospital, Jeju National University School of Medicine; Department of Neurology (B.-C.L., K.-H.Y., M.-S.O.), Hallym University Sacred Heart Hospital, Anyang; Department of Neurology (J.-M.P., K.K.), Eulji General Hospital, Eulji University, Seoul; Department of Neurology (K.B.L.), Soonchunhyang University Hospital, Seoul; Department of Biostatistics (Juneyoung Lee), Korea University College of Medicine, Seoul; and Department of Neurology (P.B.G.), Northwestern University Feinberg School of Medicine, Davee, Chicago, IL
| | - Jae Guk Kim
- From the Department of Neurology (T.H.P., M.-S.P., S.-S.P.), Seoul Medical Center; Department of Neurology, Cerebrovascular Center (J.-K.L., J.K., B.J.K., M.-K.H., H.-J.B.), Seoul National University Bundang Hospital, Seongnam; Department of Neurology (K.-S.H., Y.-J.C.), Ilsan Paik Hospital, Inje University, Goyang; Department of Neurology (W.-S.R., D.-E.K.), Dongguk University Ilsan Hospital, Goyang; Department of Neurology (M.S.P., K.-H.C., J.-T.K.), Chonnam National University Hospital, Gwangju; Department of Neurology (Jun Lee), Yeungnam University Hospital, Daegu; Department of Neurology (J.-K.C., D.-H.K.), Dong-A University Hospital, Busan; Department of Neurology (J.G.K., S.J.L.), Eulji University Hospital, Eulji University, Daejeon; Department of Neurology (J.-H.K., W.-J.K.), Ulsan University College of Medicine; Department of Neurology (D.-I.S., M.-J.Y.), Chungbuk National University Hospital, Cheongju; Department of Neurology (S.I.S., J.-H.H.), Keimyung University Dongsan Medical Center, Daegu; Clinical Research Center (J.S.L.), Asan Medical Center, Seoul; Department of Neurology (J.C.C.), Jeju National University Hospital, Jeju National University School of Medicine; Department of Neurology (B.-C.L., K.-H.Y., M.-S.O.), Hallym University Sacred Heart Hospital, Anyang; Department of Neurology (J.-M.P., K.K.), Eulji General Hospital, Eulji University, Seoul; Department of Neurology (K.B.L.), Soonchunhyang University Hospital, Seoul; Department of Biostatistics (Juneyoung Lee), Korea University College of Medicine, Seoul; and Department of Neurology (P.B.G.), Northwestern University Feinberg School of Medicine, Davee, Chicago, IL
| | - Soo Joo Lee
- From the Department of Neurology (T.H.P., M.-S.P., S.-S.P.), Seoul Medical Center; Department of Neurology, Cerebrovascular Center (J.-K.L., J.K., B.J.K., M.-K.H., H.-J.B.), Seoul National University Bundang Hospital, Seongnam; Department of Neurology (K.-S.H., Y.-J.C.), Ilsan Paik Hospital, Inje University, Goyang; Department of Neurology (W.-S.R., D.-E.K.), Dongguk University Ilsan Hospital, Goyang; Department of Neurology (M.S.P., K.-H.C., J.-T.K.), Chonnam National University Hospital, Gwangju; Department of Neurology (Jun Lee), Yeungnam University Hospital, Daegu; Department of Neurology (J.-K.C., D.-H.K.), Dong-A University Hospital, Busan; Department of Neurology (J.G.K., S.J.L.), Eulji University Hospital, Eulji University, Daejeon; Department of Neurology (J.-H.K., W.-J.K.), Ulsan University College of Medicine; Department of Neurology (D.-I.S., M.-J.Y.), Chungbuk National University Hospital, Cheongju; Department of Neurology (S.I.S., J.-H.H.), Keimyung University Dongsan Medical Center, Daegu; Clinical Research Center (J.S.L.), Asan Medical Center, Seoul; Department of Neurology (J.C.C.), Jeju National University Hospital, Jeju National University School of Medicine; Department of Neurology (B.-C.L., K.-H.Y., M.-S.O.), Hallym University Sacred Heart Hospital, Anyang; Department of Neurology (J.-M.P., K.K.), Eulji General Hospital, Eulji University, Seoul; Department of Neurology (K.B.L.), Soonchunhyang University Hospital, Seoul; Department of Biostatistics (Juneyoung Lee), Korea University College of Medicine, Seoul; and Department of Neurology (P.B.G.), Northwestern University Feinberg School of Medicine, Davee, Chicago, IL
| | - Yong-Jin Cho
- From the Department of Neurology (T.H.P., M.-S.P., S.-S.P.), Seoul Medical Center; Department of Neurology, Cerebrovascular Center (J.-K.L., J.K., B.J.K., M.-K.H., H.-J.B.), Seoul National University Bundang Hospital, Seongnam; Department of Neurology (K.-S.H., Y.-J.C.), Ilsan Paik Hospital, Inje University, Goyang; Department of Neurology (W.-S.R., D.-E.K.), Dongguk University Ilsan Hospital, Goyang; Department of Neurology (M.S.P., K.-H.C., J.-T.K.), Chonnam National University Hospital, Gwangju; Department of Neurology (Jun Lee), Yeungnam University Hospital, Daegu; Department of Neurology (J.-K.C., D.-H.K.), Dong-A University Hospital, Busan; Department of Neurology (J.G.K., S.J.L.), Eulji University Hospital, Eulji University, Daejeon; Department of Neurology (J.-H.K., W.-J.K.), Ulsan University College of Medicine; Department of Neurology (D.-I.S., M.-J.Y.), Chungbuk National University Hospital, Cheongju; Department of Neurology (S.I.S., J.-H.H.), Keimyung University Dongsan Medical Center, Daegu; Clinical Research Center (J.S.L.), Asan Medical Center, Seoul; Department of Neurology (J.C.C.), Jeju National University Hospital, Jeju National University School of Medicine; Department of Neurology (B.-C.L., K.-H.Y., M.-S.O.), Hallym University Sacred Heart Hospital, Anyang; Department of Neurology (J.-M.P., K.K.), Eulji General Hospital, Eulji University, Seoul; Department of Neurology (K.B.L.), Soonchunhyang University Hospital, Seoul; Department of Biostatistics (Juneyoung Lee), Korea University College of Medicine, Seoul; and Department of Neurology (P.B.G.), Northwestern University Feinberg School of Medicine, Davee, Chicago, IL
| | - Jee-Hyun Kwon
- From the Department of Neurology (T.H.P., M.-S.P., S.-S.P.), Seoul Medical Center; Department of Neurology, Cerebrovascular Center (J.-K.L., J.K., B.J.K., M.-K.H., H.-J.B.), Seoul National University Bundang Hospital, Seongnam; Department of Neurology (K.-S.H., Y.-J.C.), Ilsan Paik Hospital, Inje University, Goyang; Department of Neurology (W.-S.R., D.-E.K.), Dongguk University Ilsan Hospital, Goyang; Department of Neurology (M.S.P., K.-H.C., J.-T.K.), Chonnam National University Hospital, Gwangju; Department of Neurology (Jun Lee), Yeungnam University Hospital, Daegu; Department of Neurology (J.-K.C., D.-H.K.), Dong-A University Hospital, Busan; Department of Neurology (J.G.K., S.J.L.), Eulji University Hospital, Eulji University, Daejeon; Department of Neurology (J.-H.K., W.-J.K.), Ulsan University College of Medicine; Department of Neurology (D.-I.S., M.-J.Y.), Chungbuk National University Hospital, Cheongju; Department of Neurology (S.I.S., J.-H.H.), Keimyung University Dongsan Medical Center, Daegu; Clinical Research Center (J.S.L.), Asan Medical Center, Seoul; Department of Neurology (J.C.C.), Jeju National University Hospital, Jeju National University School of Medicine; Department of Neurology (B.-C.L., K.-H.Y., M.-S.O.), Hallym University Sacred Heart Hospital, Anyang; Department of Neurology (J.-M.P., K.K.), Eulji General Hospital, Eulji University, Seoul; Department of Neurology (K.B.L.), Soonchunhyang University Hospital, Seoul; Department of Biostatistics (Juneyoung Lee), Korea University College of Medicine, Seoul; and Department of Neurology (P.B.G.), Northwestern University Feinberg School of Medicine, Davee, Chicago, IL
| | - Dong-Ick Shin
- From the Department of Neurology (T.H.P., M.-S.P., S.-S.P.), Seoul Medical Center; Department of Neurology, Cerebrovascular Center (J.-K.L., J.K., B.J.K., M.-K.H., H.-J.B.), Seoul National University Bundang Hospital, Seongnam; Department of Neurology (K.-S.H., Y.-J.C.), Ilsan Paik Hospital, Inje University, Goyang; Department of Neurology (W.-S.R., D.-E.K.), Dongguk University Ilsan Hospital, Goyang; Department of Neurology (M.S.P., K.-H.C., J.-T.K.), Chonnam National University Hospital, Gwangju; Department of Neurology (Jun Lee), Yeungnam University Hospital, Daegu; Department of Neurology (J.-K.C., D.-H.K.), Dong-A University Hospital, Busan; Department of Neurology (J.G.K., S.J.L.), Eulji University Hospital, Eulji University, Daejeon; Department of Neurology (J.-H.K., W.-J.K.), Ulsan University College of Medicine; Department of Neurology (D.-I.S., M.-J.Y.), Chungbuk National University Hospital, Cheongju; Department of Neurology (S.I.S., J.-H.H.), Keimyung University Dongsan Medical Center, Daegu; Clinical Research Center (J.S.L.), Asan Medical Center, Seoul; Department of Neurology (J.C.C.), Jeju National University Hospital, Jeju National University School of Medicine; Department of Neurology (B.-C.L., K.-H.Y., M.-S.O.), Hallym University Sacred Heart Hospital, Anyang; Department of Neurology (J.-M.P., K.K.), Eulji General Hospital, Eulji University, Seoul; Department of Neurology (K.B.L.), Soonchunhyang University Hospital, Seoul; Department of Biostatistics (Juneyoung Lee), Korea University College of Medicine, Seoul; and Department of Neurology (P.B.G.), Northwestern University Feinberg School of Medicine, Davee, Chicago, IL
| | - Min-Ju Yeo
- From the Department of Neurology (T.H.P., M.-S.P., S.-S.P.), Seoul Medical Center; Department of Neurology, Cerebrovascular Center (J.-K.L., J.K., B.J.K., M.-K.H., H.-J.B.), Seoul National University Bundang Hospital, Seongnam; Department of Neurology (K.-S.H., Y.-J.C.), Ilsan Paik Hospital, Inje University, Goyang; Department of Neurology (W.-S.R., D.-E.K.), Dongguk University Ilsan Hospital, Goyang; Department of Neurology (M.S.P., K.-H.C., J.-T.K.), Chonnam National University Hospital, Gwangju; Department of Neurology (Jun Lee), Yeungnam University Hospital, Daegu; Department of Neurology (J.-K.C., D.-H.K.), Dong-A University Hospital, Busan; Department of Neurology (J.G.K., S.J.L.), Eulji University Hospital, Eulji University, Daejeon; Department of Neurology (J.-H.K., W.-J.K.), Ulsan University College of Medicine; Department of Neurology (D.-I.S., M.-J.Y.), Chungbuk National University Hospital, Cheongju; Department of Neurology (S.I.S., J.-H.H.), Keimyung University Dongsan Medical Center, Daegu; Clinical Research Center (J.S.L.), Asan Medical Center, Seoul; Department of Neurology (J.C.C.), Jeju National University Hospital, Jeju National University School of Medicine; Department of Neurology (B.-C.L., K.-H.Y., M.-S.O.), Hallym University Sacred Heart Hospital, Anyang; Department of Neurology (J.-M.P., K.K.), Eulji General Hospital, Eulji University, Seoul; Department of Neurology (K.B.L.), Soonchunhyang University Hospital, Seoul; Department of Biostatistics (Juneyoung Lee), Korea University College of Medicine, Seoul; and Department of Neurology (P.B.G.), Northwestern University Feinberg School of Medicine, Davee, Chicago, IL
| | - Sung Il Sohn
- From the Department of Neurology (T.H.P., M.-S.P., S.-S.P.), Seoul Medical Center; Department of Neurology, Cerebrovascular Center (J.-K.L., J.K., B.J.K., M.-K.H., H.-J.B.), Seoul National University Bundang Hospital, Seongnam; Department of Neurology (K.-S.H., Y.-J.C.), Ilsan Paik Hospital, Inje University, Goyang; Department of Neurology (W.-S.R., D.-E.K.), Dongguk University Ilsan Hospital, Goyang; Department of Neurology (M.S.P., K.-H.C., J.-T.K.), Chonnam National University Hospital, Gwangju; Department of Neurology (Jun Lee), Yeungnam University Hospital, Daegu; Department of Neurology (J.-K.C., D.-H.K.), Dong-A University Hospital, Busan; Department of Neurology (J.G.K., S.J.L.), Eulji University Hospital, Eulji University, Daejeon; Department of Neurology (J.-H.K., W.-J.K.), Ulsan University College of Medicine; Department of Neurology (D.-I.S., M.-J.Y.), Chungbuk National University Hospital, Cheongju; Department of Neurology (S.I.S., J.-H.H.), Keimyung University Dongsan Medical Center, Daegu; Clinical Research Center (J.S.L.), Asan Medical Center, Seoul; Department of Neurology (J.C.C.), Jeju National University Hospital, Jeju National University School of Medicine; Department of Neurology (B.-C.L., K.-H.Y., M.-S.O.), Hallym University Sacred Heart Hospital, Anyang; Department of Neurology (J.-M.P., K.K.), Eulji General Hospital, Eulji University, Seoul; Department of Neurology (K.B.L.), Soonchunhyang University Hospital, Seoul; Department of Biostatistics (Juneyoung Lee), Korea University College of Medicine, Seoul; and Department of Neurology (P.B.G.), Northwestern University Feinberg School of Medicine, Davee, Chicago, IL
| | - Jeong-Ho Hong
- From the Department of Neurology (T.H.P., M.-S.P., S.-S.P.), Seoul Medical Center; Department of Neurology, Cerebrovascular Center (J.-K.L., J.K., B.J.K., M.-K.H., H.-J.B.), Seoul National University Bundang Hospital, Seongnam; Department of Neurology (K.-S.H., Y.-J.C.), Ilsan Paik Hospital, Inje University, Goyang; Department of Neurology (W.-S.R., D.-E.K.), Dongguk University Ilsan Hospital, Goyang; Department of Neurology (M.S.P., K.-H.C., J.-T.K.), Chonnam National University Hospital, Gwangju; Department of Neurology (Jun Lee), Yeungnam University Hospital, Daegu; Department of Neurology (J.-K.C., D.-H.K.), Dong-A University Hospital, Busan; Department of Neurology (J.G.K., S.J.L.), Eulji University Hospital, Eulji University, Daejeon; Department of Neurology (J.-H.K., W.-J.K.), Ulsan University College of Medicine; Department of Neurology (D.-I.S., M.-J.Y.), Chungbuk National University Hospital, Cheongju; Department of Neurology (S.I.S., J.-H.H.), Keimyung University Dongsan Medical Center, Daegu; Clinical Research Center (J.S.L.), Asan Medical Center, Seoul; Department of Neurology (J.C.C.), Jeju National University Hospital, Jeju National University School of Medicine; Department of Neurology (B.-C.L., K.-H.Y., M.-S.O.), Hallym University Sacred Heart Hospital, Anyang; Department of Neurology (J.-M.P., K.K.), Eulji General Hospital, Eulji University, Seoul; Department of Neurology (K.B.L.), Soonchunhyang University Hospital, Seoul; Department of Biostatistics (Juneyoung Lee), Korea University College of Medicine, Seoul; and Department of Neurology (P.B.G.), Northwestern University Feinberg School of Medicine, Davee, Chicago, IL
| | - Ji Sung Lee
- From the Department of Neurology (T.H.P., M.-S.P., S.-S.P.), Seoul Medical Center; Department of Neurology, Cerebrovascular Center (J.-K.L., J.K., B.J.K., M.-K.H., H.-J.B.), Seoul National University Bundang Hospital, Seongnam; Department of Neurology (K.-S.H., Y.-J.C.), Ilsan Paik Hospital, Inje University, Goyang; Department of Neurology (W.-S.R., D.-E.K.), Dongguk University Ilsan Hospital, Goyang; Department of Neurology (M.S.P., K.-H.C., J.-T.K.), Chonnam National University Hospital, Gwangju; Department of Neurology (Jun Lee), Yeungnam University Hospital, Daegu; Department of Neurology (J.-K.C., D.-H.K.), Dong-A University Hospital, Busan; Department of Neurology (J.G.K., S.J.L.), Eulji University Hospital, Eulji University, Daejeon; Department of Neurology (J.-H.K., W.-J.K.), Ulsan University College of Medicine; Department of Neurology (D.-I.S., M.-J.Y.), Chungbuk National University Hospital, Cheongju; Department of Neurology (S.I.S., J.-H.H.), Keimyung University Dongsan Medical Center, Daegu; Clinical Research Center (J.S.L.), Asan Medical Center, Seoul; Department of Neurology (J.C.C.), Jeju National University Hospital, Jeju National University School of Medicine; Department of Neurology (B.-C.L., K.-H.Y., M.-S.O.), Hallym University Sacred Heart Hospital, Anyang; Department of Neurology (J.-M.P., K.K.), Eulji General Hospital, Eulji University, Seoul; Department of Neurology (K.B.L.), Soonchunhyang University Hospital, Seoul; Department of Biostatistics (Juneyoung Lee), Korea University College of Medicine, Seoul; and Department of Neurology (P.B.G.), Northwestern University Feinberg School of Medicine, Davee, Chicago, IL
| | - Jay Chol Choi
- From the Department of Neurology (T.H.P., M.-S.P., S.-S.P.), Seoul Medical Center; Department of Neurology, Cerebrovascular Center (J.-K.L., J.K., B.J.K., M.-K.H., H.-J.B.), Seoul National University Bundang Hospital, Seongnam; Department of Neurology (K.-S.H., Y.-J.C.), Ilsan Paik Hospital, Inje University, Goyang; Department of Neurology (W.-S.R., D.-E.K.), Dongguk University Ilsan Hospital, Goyang; Department of Neurology (M.S.P., K.-H.C., J.-T.K.), Chonnam National University Hospital, Gwangju; Department of Neurology (Jun Lee), Yeungnam University Hospital, Daegu; Department of Neurology (J.-K.C., D.-H.K.), Dong-A University Hospital, Busan; Department of Neurology (J.G.K., S.J.L.), Eulji University Hospital, Eulji University, Daejeon; Department of Neurology (J.-H.K., W.-J.K.), Ulsan University College of Medicine; Department of Neurology (D.-I.S., M.-J.Y.), Chungbuk National University Hospital, Cheongju; Department of Neurology (S.I.S., J.-H.H.), Keimyung University Dongsan Medical Center, Daegu; Clinical Research Center (J.S.L.), Asan Medical Center, Seoul; Department of Neurology (J.C.C.), Jeju National University Hospital, Jeju National University School of Medicine; Department of Neurology (B.-C.L., K.-H.Y., M.-S.O.), Hallym University Sacred Heart Hospital, Anyang; Department of Neurology (J.-M.P., K.K.), Eulji General Hospital, Eulji University, Seoul; Department of Neurology (K.B.L.), Soonchunhyang University Hospital, Seoul; Department of Biostatistics (Juneyoung Lee), Korea University College of Medicine, Seoul; and Department of Neurology (P.B.G.), Northwestern University Feinberg School of Medicine, Davee, Chicago, IL
| | - Wook-Joo Kim
- From the Department of Neurology (T.H.P., M.-S.P., S.-S.P.), Seoul Medical Center; Department of Neurology, Cerebrovascular Center (J.-K.L., J.K., B.J.K., M.-K.H., H.-J.B.), Seoul National University Bundang Hospital, Seongnam; Department of Neurology (K.-S.H., Y.-J.C.), Ilsan Paik Hospital, Inje University, Goyang; Department of Neurology (W.-S.R., D.-E.K.), Dongguk University Ilsan Hospital, Goyang; Department of Neurology (M.S.P., K.-H.C., J.-T.K.), Chonnam National University Hospital, Gwangju; Department of Neurology (Jun Lee), Yeungnam University Hospital, Daegu; Department of Neurology (J.-K.C., D.-H.K.), Dong-A University Hospital, Busan; Department of Neurology (J.G.K., S.J.L.), Eulji University Hospital, Eulji University, Daejeon; Department of Neurology (J.-H.K., W.-J.K.), Ulsan University College of Medicine; Department of Neurology (D.-I.S., M.-J.Y.), Chungbuk National University Hospital, Cheongju; Department of Neurology (S.I.S., J.-H.H.), Keimyung University Dongsan Medical Center, Daegu; Clinical Research Center (J.S.L.), Asan Medical Center, Seoul; Department of Neurology (J.C.C.), Jeju National University Hospital, Jeju National University School of Medicine; Department of Neurology (B.-C.L., K.-H.Y., M.-S.O.), Hallym University Sacred Heart Hospital, Anyang; Department of Neurology (J.-M.P., K.K.), Eulji General Hospital, Eulji University, Seoul; Department of Neurology (K.B.L.), Soonchunhyang University Hospital, Seoul; Department of Biostatistics (Juneyoung Lee), Korea University College of Medicine, Seoul; and Department of Neurology (P.B.G.), Northwestern University Feinberg School of Medicine, Davee, Chicago, IL
| | - Byung-Chul Lee
- From the Department of Neurology (T.H.P., M.-S.P., S.-S.P.), Seoul Medical Center; Department of Neurology, Cerebrovascular Center (J.-K.L., J.K., B.J.K., M.-K.H., H.-J.B.), Seoul National University Bundang Hospital, Seongnam; Department of Neurology (K.-S.H., Y.-J.C.), Ilsan Paik Hospital, Inje University, Goyang; Department of Neurology (W.-S.R., D.-E.K.), Dongguk University Ilsan Hospital, Goyang; Department of Neurology (M.S.P., K.-H.C., J.-T.K.), Chonnam National University Hospital, Gwangju; Department of Neurology (Jun Lee), Yeungnam University Hospital, Daegu; Department of Neurology (J.-K.C., D.-H.K.), Dong-A University Hospital, Busan; Department of Neurology (J.G.K., S.J.L.), Eulji University Hospital, Eulji University, Daejeon; Department of Neurology (J.-H.K., W.-J.K.), Ulsan University College of Medicine; Department of Neurology (D.-I.S., M.-J.Y.), Chungbuk National University Hospital, Cheongju; Department of Neurology (S.I.S., J.-H.H.), Keimyung University Dongsan Medical Center, Daegu; Clinical Research Center (J.S.L.), Asan Medical Center, Seoul; Department of Neurology (J.C.C.), Jeju National University Hospital, Jeju National University School of Medicine; Department of Neurology (B.-C.L., K.-H.Y., M.-S.O.), Hallym University Sacred Heart Hospital, Anyang; Department of Neurology (J.-M.P., K.K.), Eulji General Hospital, Eulji University, Seoul; Department of Neurology (K.B.L.), Soonchunhyang University Hospital, Seoul; Department of Biostatistics (Juneyoung Lee), Korea University College of Medicine, Seoul; and Department of Neurology (P.B.G.), Northwestern University Feinberg School of Medicine, Davee, Chicago, IL
| | - Kyung-Ho Yu
- From the Department of Neurology (T.H.P., M.-S.P., S.-S.P.), Seoul Medical Center; Department of Neurology, Cerebrovascular Center (J.-K.L., J.K., B.J.K., M.-K.H., H.-J.B.), Seoul National University Bundang Hospital, Seongnam; Department of Neurology (K.-S.H., Y.-J.C.), Ilsan Paik Hospital, Inje University, Goyang; Department of Neurology (W.-S.R., D.-E.K.), Dongguk University Ilsan Hospital, Goyang; Department of Neurology (M.S.P., K.-H.C., J.-T.K.), Chonnam National University Hospital, Gwangju; Department of Neurology (Jun Lee), Yeungnam University Hospital, Daegu; Department of Neurology (J.-K.C., D.-H.K.), Dong-A University Hospital, Busan; Department of Neurology (J.G.K., S.J.L.), Eulji University Hospital, Eulji University, Daejeon; Department of Neurology (J.-H.K., W.-J.K.), Ulsan University College of Medicine; Department of Neurology (D.-I.S., M.-J.Y.), Chungbuk National University Hospital, Cheongju; Department of Neurology (S.I.S., J.-H.H.), Keimyung University Dongsan Medical Center, Daegu; Clinical Research Center (J.S.L.), Asan Medical Center, Seoul; Department of Neurology (J.C.C.), Jeju National University Hospital, Jeju National University School of Medicine; Department of Neurology (B.-C.L., K.-H.Y., M.-S.O.), Hallym University Sacred Heart Hospital, Anyang; Department of Neurology (J.-M.P., K.K.), Eulji General Hospital, Eulji University, Seoul; Department of Neurology (K.B.L.), Soonchunhyang University Hospital, Seoul; Department of Biostatistics (Juneyoung Lee), Korea University College of Medicine, Seoul; and Department of Neurology (P.B.G.), Northwestern University Feinberg School of Medicine, Davee, Chicago, IL
| | - Mi-Sun Oh
- From the Department of Neurology (T.H.P., M.-S.P., S.-S.P.), Seoul Medical Center; Department of Neurology, Cerebrovascular Center (J.-K.L., J.K., B.J.K., M.-K.H., H.-J.B.), Seoul National University Bundang Hospital, Seongnam; Department of Neurology (K.-S.H., Y.-J.C.), Ilsan Paik Hospital, Inje University, Goyang; Department of Neurology (W.-S.R., D.-E.K.), Dongguk University Ilsan Hospital, Goyang; Department of Neurology (M.S.P., K.-H.C., J.-T.K.), Chonnam National University Hospital, Gwangju; Department of Neurology (Jun Lee), Yeungnam University Hospital, Daegu; Department of Neurology (J.-K.C., D.-H.K.), Dong-A University Hospital, Busan; Department of Neurology (J.G.K., S.J.L.), Eulji University Hospital, Eulji University, Daejeon; Department of Neurology (J.-H.K., W.-J.K.), Ulsan University College of Medicine; Department of Neurology (D.-I.S., M.-J.Y.), Chungbuk National University Hospital, Cheongju; Department of Neurology (S.I.S., J.-H.H.), Keimyung University Dongsan Medical Center, Daegu; Clinical Research Center (J.S.L.), Asan Medical Center, Seoul; Department of Neurology (J.C.C.), Jeju National University Hospital, Jeju National University School of Medicine; Department of Neurology (B.-C.L., K.-H.Y., M.-S.O.), Hallym University Sacred Heart Hospital, Anyang; Department of Neurology (J.-M.P., K.K.), Eulji General Hospital, Eulji University, Seoul; Department of Neurology (K.B.L.), Soonchunhyang University Hospital, Seoul; Department of Biostatistics (Juneyoung Lee), Korea University College of Medicine, Seoul; and Department of Neurology (P.B.G.), Northwestern University Feinberg School of Medicine, Davee, Chicago, IL
| | - Jong-Moo Park
- From the Department of Neurology (T.H.P., M.-S.P., S.-S.P.), Seoul Medical Center; Department of Neurology, Cerebrovascular Center (J.-K.L., J.K., B.J.K., M.-K.H., H.-J.B.), Seoul National University Bundang Hospital, Seongnam; Department of Neurology (K.-S.H., Y.-J.C.), Ilsan Paik Hospital, Inje University, Goyang; Department of Neurology (W.-S.R., D.-E.K.), Dongguk University Ilsan Hospital, Goyang; Department of Neurology (M.S.P., K.-H.C., J.-T.K.), Chonnam National University Hospital, Gwangju; Department of Neurology (Jun Lee), Yeungnam University Hospital, Daegu; Department of Neurology (J.-K.C., D.-H.K.), Dong-A University Hospital, Busan; Department of Neurology (J.G.K., S.J.L.), Eulji University Hospital, Eulji University, Daejeon; Department of Neurology (J.-H.K., W.-J.K.), Ulsan University College of Medicine; Department of Neurology (D.-I.S., M.-J.Y.), Chungbuk National University Hospital, Cheongju; Department of Neurology (S.I.S., J.-H.H.), Keimyung University Dongsan Medical Center, Daegu; Clinical Research Center (J.S.L.), Asan Medical Center, Seoul; Department of Neurology (J.C.C.), Jeju National University Hospital, Jeju National University School of Medicine; Department of Neurology (B.-C.L., K.-H.Y., M.-S.O.), Hallym University Sacred Heart Hospital, Anyang; Department of Neurology (J.-M.P., K.K.), Eulji General Hospital, Eulji University, Seoul; Department of Neurology (K.B.L.), Soonchunhyang University Hospital, Seoul; Department of Biostatistics (Juneyoung Lee), Korea University College of Medicine, Seoul; and Department of Neurology (P.B.G.), Northwestern University Feinberg School of Medicine, Davee, Chicago, IL
| | - Kyusik Kang
- From the Department of Neurology (T.H.P., M.-S.P., S.-S.P.), Seoul Medical Center; Department of Neurology, Cerebrovascular Center (J.-K.L., J.K., B.J.K., M.-K.H., H.-J.B.), Seoul National University Bundang Hospital, Seongnam; Department of Neurology (K.-S.H., Y.-J.C.), Ilsan Paik Hospital, Inje University, Goyang; Department of Neurology (W.-S.R., D.-E.K.), Dongguk University Ilsan Hospital, Goyang; Department of Neurology (M.S.P., K.-H.C., J.-T.K.), Chonnam National University Hospital, Gwangju; Department of Neurology (Jun Lee), Yeungnam University Hospital, Daegu; Department of Neurology (J.-K.C., D.-H.K.), Dong-A University Hospital, Busan; Department of Neurology (J.G.K., S.J.L.), Eulji University Hospital, Eulji University, Daejeon; Department of Neurology (J.-H.K., W.-J.K.), Ulsan University College of Medicine; Department of Neurology (D.-I.S., M.-J.Y.), Chungbuk National University Hospital, Cheongju; Department of Neurology (S.I.S., J.-H.H.), Keimyung University Dongsan Medical Center, Daegu; Clinical Research Center (J.S.L.), Asan Medical Center, Seoul; Department of Neurology (J.C.C.), Jeju National University Hospital, Jeju National University School of Medicine; Department of Neurology (B.-C.L., K.-H.Y., M.-S.O.), Hallym University Sacred Heart Hospital, Anyang; Department of Neurology (J.-M.P., K.K.), Eulji General Hospital, Eulji University, Seoul; Department of Neurology (K.B.L.), Soonchunhyang University Hospital, Seoul; Department of Biostatistics (Juneyoung Lee), Korea University College of Medicine, Seoul; and Department of Neurology (P.B.G.), Northwestern University Feinberg School of Medicine, Davee, Chicago, IL
| | - Kyung Bok Lee
- From the Department of Neurology (T.H.P., M.-S.P., S.-S.P.), Seoul Medical Center; Department of Neurology, Cerebrovascular Center (J.-K.L., J.K., B.J.K., M.-K.H., H.-J.B.), Seoul National University Bundang Hospital, Seongnam; Department of Neurology (K.-S.H., Y.-J.C.), Ilsan Paik Hospital, Inje University, Goyang; Department of Neurology (W.-S.R., D.-E.K.), Dongguk University Ilsan Hospital, Goyang; Department of Neurology (M.S.P., K.-H.C., J.-T.K.), Chonnam National University Hospital, Gwangju; Department of Neurology (Jun Lee), Yeungnam University Hospital, Daegu; Department of Neurology (J.-K.C., D.-H.K.), Dong-A University Hospital, Busan; Department of Neurology (J.G.K., S.J.L.), Eulji University Hospital, Eulji University, Daejeon; Department of Neurology (J.-H.K., W.-J.K.), Ulsan University College of Medicine; Department of Neurology (D.-I.S., M.-J.Y.), Chungbuk National University Hospital, Cheongju; Department of Neurology (S.I.S., J.-H.H.), Keimyung University Dongsan Medical Center, Daegu; Clinical Research Center (J.S.L.), Asan Medical Center, Seoul; Department of Neurology (J.C.C.), Jeju National University Hospital, Jeju National University School of Medicine; Department of Neurology (B.-C.L., K.-H.Y., M.-S.O.), Hallym University Sacred Heart Hospital, Anyang; Department of Neurology (J.-M.P., K.K.), Eulji General Hospital, Eulji University, Seoul; Department of Neurology (K.B.L.), Soonchunhyang University Hospital, Seoul; Department of Biostatistics (Juneyoung Lee), Korea University College of Medicine, Seoul; and Department of Neurology (P.B.G.), Northwestern University Feinberg School of Medicine, Davee, Chicago, IL
| | - Juneyoung Lee
- From the Department of Neurology (T.H.P., M.-S.P., S.-S.P.), Seoul Medical Center; Department of Neurology, Cerebrovascular Center (J.-K.L., J.K., B.J.K., M.-K.H., H.-J.B.), Seoul National University Bundang Hospital, Seongnam; Department of Neurology (K.-S.H., Y.-J.C.), Ilsan Paik Hospital, Inje University, Goyang; Department of Neurology (W.-S.R., D.-E.K.), Dongguk University Ilsan Hospital, Goyang; Department of Neurology (M.S.P., K.-H.C., J.-T.K.), Chonnam National University Hospital, Gwangju; Department of Neurology (Jun Lee), Yeungnam University Hospital, Daegu; Department of Neurology (J.-K.C., D.-H.K.), Dong-A University Hospital, Busan; Department of Neurology (J.G.K., S.J.L.), Eulji University Hospital, Eulji University, Daejeon; Department of Neurology (J.-H.K., W.-J.K.), Ulsan University College of Medicine; Department of Neurology (D.-I.S., M.-J.Y.), Chungbuk National University Hospital, Cheongju; Department of Neurology (S.I.S., J.-H.H.), Keimyung University Dongsan Medical Center, Daegu; Clinical Research Center (J.S.L.), Asan Medical Center, Seoul; Department of Neurology (J.C.C.), Jeju National University Hospital, Jeju National University School of Medicine; Department of Neurology (B.-C.L., K.-H.Y., M.-S.O.), Hallym University Sacred Heart Hospital, Anyang; Department of Neurology (J.-M.P., K.K.), Eulji General Hospital, Eulji University, Seoul; Department of Neurology (K.B.L.), Soonchunhyang University Hospital, Seoul; Department of Biostatistics (Juneyoung Lee), Korea University College of Medicine, Seoul; and Department of Neurology (P.B.G.), Northwestern University Feinberg School of Medicine, Davee, Chicago, IL
| | - Philip B Gorelick
- From the Department of Neurology (T.H.P., M.-S.P., S.-S.P.), Seoul Medical Center; Department of Neurology, Cerebrovascular Center (J.-K.L., J.K., B.J.K., M.-K.H., H.-J.B.), Seoul National University Bundang Hospital, Seongnam; Department of Neurology (K.-S.H., Y.-J.C.), Ilsan Paik Hospital, Inje University, Goyang; Department of Neurology (W.-S.R., D.-E.K.), Dongguk University Ilsan Hospital, Goyang; Department of Neurology (M.S.P., K.-H.C., J.-T.K.), Chonnam National University Hospital, Gwangju; Department of Neurology (Jun Lee), Yeungnam University Hospital, Daegu; Department of Neurology (J.-K.C., D.-H.K.), Dong-A University Hospital, Busan; Department of Neurology (J.G.K., S.J.L.), Eulji University Hospital, Eulji University, Daejeon; Department of Neurology (J.-H.K., W.-J.K.), Ulsan University College of Medicine; Department of Neurology (D.-I.S., M.-J.Y.), Chungbuk National University Hospital, Cheongju; Department of Neurology (S.I.S., J.-H.H.), Keimyung University Dongsan Medical Center, Daegu; Clinical Research Center (J.S.L.), Asan Medical Center, Seoul; Department of Neurology (J.C.C.), Jeju National University Hospital, Jeju National University School of Medicine; Department of Neurology (B.-C.L., K.-H.Y., M.-S.O.), Hallym University Sacred Heart Hospital, Anyang; Department of Neurology (J.-M.P., K.K.), Eulji General Hospital, Eulji University, Seoul; Department of Neurology (K.B.L.), Soonchunhyang University Hospital, Seoul; Department of Biostatistics (Juneyoung Lee), Korea University College of Medicine, Seoul; and Department of Neurology (P.B.G.), Northwestern University Feinberg School of Medicine, Davee, Chicago, IL
| | - Hee-Joon Bae
- From the Department of Neurology (T.H.P., M.-S.P., S.-S.P.), Seoul Medical Center; Department of Neurology, Cerebrovascular Center (J.-K.L., J.K., B.J.K., M.-K.H., H.-J.B.), Seoul National University Bundang Hospital, Seongnam; Department of Neurology (K.-S.H., Y.-J.C.), Ilsan Paik Hospital, Inje University, Goyang; Department of Neurology (W.-S.R., D.-E.K.), Dongguk University Ilsan Hospital, Goyang; Department of Neurology (M.S.P., K.-H.C., J.-T.K.), Chonnam National University Hospital, Gwangju; Department of Neurology (Jun Lee), Yeungnam University Hospital, Daegu; Department of Neurology (J.-K.C., D.-H.K.), Dong-A University Hospital, Busan; Department of Neurology (J.G.K., S.J.L.), Eulji University Hospital, Eulji University, Daejeon; Department of Neurology (J.-H.K., W.-J.K.), Ulsan University College of Medicine; Department of Neurology (D.-I.S., M.-J.Y.), Chungbuk National University Hospital, Cheongju; Department of Neurology (S.I.S., J.-H.H.), Keimyung University Dongsan Medical Center, Daegu; Clinical Research Center (J.S.L.), Asan Medical Center, Seoul; Department of Neurology (J.C.C.), Jeju National University Hospital, Jeju National University School of Medicine; Department of Neurology (B.-C.L., K.-H.Y., M.-S.O.), Hallym University Sacred Heart Hospital, Anyang; Department of Neurology (J.-M.P., K.K.), Eulji General Hospital, Eulji University, Seoul; Department of Neurology (K.B.L.), Soonchunhyang University Hospital, Seoul; Department of Biostatistics (Juneyoung Lee), Korea University College of Medicine, Seoul; and Department of Neurology (P.B.G.), Northwestern University Feinberg School of Medicine, Davee, Chicago, IL.
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17
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Liu Z, Lin W, Lu Q, Wang J, Liu P, Lin X, Wang F, Shi Y, Wang Q, Liu G, Wu S. Risk factors affecting the 1-year outcomes of minor ischemic stroke: results from Xi'an stroke registry study of China. BMC Neurol 2020; 20:379. [PMID: 33081723 PMCID: PMC7574206 DOI: 10.1186/s12883-020-01954-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Accepted: 10/07/2020] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND The prevalence of stroke recurrence, disability, and all-cause mortality of patients with minor ischemic stroke (MIS) remains problematic. The aim of the present study was to identify risk factors associated with adverse outcomes at 1 year after MIS in the Xi'an region of China. METHODS This prospective cohort study included MIS patients above 18 years old with National Institutes of Health Stroke Scale (NIHSS) score ≤ 3 who were treated in any of four hospitals in Xi'an region of China between January and December 2015. The 1-year prevalence of stroke recurrence, disability, and all-cause mortality were evaluated, respectively. Multivariate logistic regression analysis was performed to assess the association between the identified risk factors and clinical outcomes. RESULTS In this study, 131(10.5%, 131/1252) patients were lost to follow-up at 1 year. A total of 1121 patients were included for analysis, the prevalence of stroke recurrence, disability, and all-cause mortality at 1 year after MIS were 3.4% (38/1121), 9.3% (104/1121), and 3.3% (37/1121), respectively. Multivariate logistic regression analysis identified age, current smoking, and pneumonia as independent risk factors for stroke recurrence. Age, pneumonia, and alkaline phosphatase were independent risk factors for all-cause mortality. Independent risk factors for disability were age, pneumonia, NIHSS score on admission, and leukocyte count. CONCLUSIONS The 1-year outcomes of MIS in Xi'an region of China were not optimistic, especially with a high prevalence of disability. The present study indicated that age and pneumonia were the common independent risk factors affecting the 1-year outcomes of MIS in Xi'an region of China.
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Affiliation(s)
- Zhongzhong Liu
- The First Affiliated Hospital of Northwest University, Xi'an, 710069, Shaanxi, China.,Department of Neurology, The First Hospital of Xi'an, No.30, Fenxiang Road, South Street, Xi'an, 710002, Shaanxi, China
| | - Wenjuan Lin
- College of life Science, Northwest University, Xi'an, 710069, Shaanxi, China
| | - Qingli Lu
- The First Affiliated Hospital of Northwest University, Xi'an, 710069, Shaanxi, China.,Department of Neurology, The First Hospital of Xi'an, No.30, Fenxiang Road, South Street, Xi'an, 710002, Shaanxi, China
| | - Jing Wang
- The First Affiliated Hospital of Northwest University, Xi'an, 710069, Shaanxi, China.,Department of Neurology, The First Hospital of Xi'an, No.30, Fenxiang Road, South Street, Xi'an, 710002, Shaanxi, China
| | - Pei Liu
- The First Affiliated Hospital of Northwest University, Xi'an, 710069, Shaanxi, China.,Department of Neurology, The First Hospital of Xi'an, No.30, Fenxiang Road, South Street, Xi'an, 710002, Shaanxi, China
| | - Xuemei Lin
- The First Affiliated Hospital of Northwest University, Xi'an, 710069, Shaanxi, China.,Department of Neurology, The First Hospital of Xi'an, No.30, Fenxiang Road, South Street, Xi'an, 710002, Shaanxi, China
| | - Fang Wang
- The First Affiliated Hospital of Northwest University, Xi'an, 710069, Shaanxi, China.,Department of Neurology, The First Hospital of Xi'an, No.30, Fenxiang Road, South Street, Xi'an, 710002, Shaanxi, China
| | - Yaling Shi
- The First Affiliated Hospital of Northwest University, Xi'an, 710069, Shaanxi, China.,Department of Neurology, The First Hospital of Xi'an, No.30, Fenxiang Road, South Street, Xi'an, 710002, Shaanxi, China
| | - Qing Wang
- The First Affiliated Hospital of Northwest University, Xi'an, 710069, Shaanxi, China.,Department of Neurology, The First Hospital of Xi'an, No.30, Fenxiang Road, South Street, Xi'an, 710002, Shaanxi, China
| | - Guozheng Liu
- The First Affiliated Hospital of Northwest University, Xi'an, 710069, Shaanxi, China.,Department of Neurology, The First Hospital of Xi'an, No.30, Fenxiang Road, South Street, Xi'an, 710002, Shaanxi, China
| | - Songdi Wu
- The First Affiliated Hospital of Northwest University, Xi'an, 710069, Shaanxi, China. .,Department of Neurology, The First Hospital of Xi'an, No.30, Fenxiang Road, South Street, Xi'an, 710002, Shaanxi, China. .,College of life Science, Northwest University, Xi'an, 710069, Shaanxi, China.
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18
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Mechanical thrombectomy in patients with proximal occlusions and low NIHSS: Results from a large prospective registry. J Stroke Cerebrovasc Dis 2020; 29:105091. [PMID: 32912516 DOI: 10.1016/j.jstrokecerebrovasdis.2020.105091] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2020] [Revised: 05/29/2020] [Accepted: 06/22/2020] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Mechanical thrombectomy is now standard of care for treatment of acute ischemic stroke secondary to large vessel occlusion in the setting of high NIHSS. We analysed a large nationwide registry focusing on patients with large vessel occlusion and low NIHSS on admission to evaluate the efficacy and safety of thrombectomy in this patient population METHODS: 2826 patients treated with mechanical thrombectomy were included in a multicentre registry from January 1, 2011 to December 31, 2015. We included patients with large vessel occlusion and NIHSS ≤ 6 on admission. Baseline characteristics, imaging, clinical outcome, procedure adverse events and positive and negative outcome predictors were analysed. RESULTS 134 patients were included. 90/134 had an anterior circulation and 44 a posterior circulation stroke. One patient died before treatment. Successful revascularization (mTICI 2b-3) was achieved in 73.7% (98/133) of the patients. Intraprocedural adverse event was observed in 3% (4/133) of cases. Symptomatic intracranial haemorrhage rate was 5.3% (7/133). At three months, 70.9% (95/134) of the patients had mRS score 0-2, 15.7% (21/134) mRS 3-5 and 13.4% (18/134) mRS 6. Age and successful recanalization were significant predictors of a good clinical outcome on both univariate (p= 0.005 and p=0.007) and multivariable (p=0.0018 and p=0.009 [nat log]) analysis. Absence of vessel recanalization and symptomatic intracranial hemorrhage were independent predictors of poor outcome (p=0.021) . CONCLUSIONS Our study suggests that patients with large vessel occlusion and low NIHSS score on admission can benefit from mechanical thrombectomy. Randomized trials are warranted.
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19
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Zhao M, Guan L, Collet JP, Wang Y. Relationship between ischemic stroke locations, etiology subtypes, neurological outcomes, and autonomic cardiac function. Neurol Res 2020; 42:630-639. [PMID: 32701421 DOI: 10.1080/01616412.2020.1782103] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND Post-stroke autonomic nervous dysfunction measured with heart rate variability (HRV) is correlated with the traditional risk factors and poor outcome. This study aimed to investigate the association between HRV and infarct locations, etiology subtypes, and neurological functional outcomes in patients with acute ischemic stroke (AIS). METHODS In this prospective observational study, 186 consecutive patients were assigned to four major stroke severity categories based on the National Institutes of Health Stroke Scale score (NIHSS) and the modified Rankin Scale score (mRS): mild (NIHSS 0-4) stroke, moderate (NIHSS 5-14) stroke, 'favorable' (mRS 0-2) group, and 'unfavorable' (mRS 3-5) group. HRV time domain parameters were applied to evaluate the autonomic function of patients within 1 week after admission. All patients were classified into different etiology subtypes based on the TOAST (modified Trial of ORG 10172 in Acute Stroke Treatment) classification. The association of HRV with stroke location, etiology subtypes, neurological outcome was explored for all participants. Univariate and multivariate analyses were applied to explore the prediction value of HRV. RESULTS 160 participants had large artery atherosclerotic infarction (LAA), 61 had right internal carotid artery system infarction (R-ICA), and 61 had vertebrobasilar artery system infarction (VB). Root-mean-square of differences (RMSSD) of adjacent RR intervals and the proportion calculated by dividing the interbeat interval differences >50 ms (pNN50) in patients of VB group was significantly lower than those of patients in R-ICA group (P < 0.01). HRV parameters in the LAA group was significantly lower than non-LAA group (P < 0.01). At discharge, significant lower HRV presented in the unfavorable group and moderate group (P < 0.05). After logistic univariate and multivariate analysis, lower SDNN (OR = 1.019; 95% CI = 1.003-1.035; p= 0.021) was independently associated with unfavorable mRS and higher NIHSS at discharge (OR = 1.013; 95%CI = 1.003-1.024; p= 0.015). Only SDNN showed predictive value for mRS≥3 (OR = 1.012; 95%CI = 1.002-1.022; p= 0.016) at 1 year. CONCLUSIONS HRV measured after admission is related to the AIS infarction basin, TOAST subtypes, and neurological outcomes at discharge suggesting a possible role for HRV in evaluating AIS and identifying high-risk patients.
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Affiliation(s)
- Mengxi Zhao
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University , Beijing, China
| | - Ling Guan
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University , Beijing, China.,National Clinical Research Center for Neurological Diseases , Beijing, China
| | - Jean-Paul Collet
- Department of Medicine, BC Children's Hospital Research Institute, University of British Columbia , Vancouver, Canada.,Advanced Innovation Center for Human Brain Protection, Capital Medical University , Beijing, China
| | - Yilong Wang
- Advanced Innovation Center for Human Brain Protection, Capital Medical University , Beijing, China.,Department of Neurology, China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University , Beijing, China
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20
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Wang D, Zhang L, Hu X, Zhu J, Tang X, Ding D, Wang H, Kong Y, Cai X, Lin L, Fang Q. Intravenous Thrombolysis Benefits Mild Stroke Patients With Large-Artery Atherosclerosis but No Tandem Steno-Occlusion. Front Neurol 2020; 11:340. [PMID: 32431662 PMCID: PMC7214684 DOI: 10.3389/fneur.2020.00340] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Accepted: 04/07/2020] [Indexed: 01/01/2023] Open
Abstract
At present, there is controversy regarding whether thrombolysis is beneficial for patients suffering from a mild stroke. In this study, we therefore sought to determine whether the therapeutic benefit of thrombolysis is dependent upon stroke subtype for those with mild stroke. We conducted a retrospective analysis of data from consecutive mild stroke patients (National Institutes of Health Stroke Scale ≤5) with and without recombinant tissue plasminogen activator (rt-PA) therapy. The TOAST (Trial of Org 10172 in acute stroke treatment) criteria was used to determine stroke subtypes. Patients suffering from large-artery atherosclerosis (LAA) were subdivided based upon whether or not they exhibited tandem steno-occlusion, as defined by the association of a proximal intracranial occlusion and a cervical internal carotid artery lesion (complete occlusion or severe stenosis ≥ 90%). For this study, favorable outcomes at 90 days of onset (modified Rankin Scale Score [mRS] of 0–1) were the primary measured outcome. Three hundred thirty-nine patients were included in the study. For patients with non-LAA, there were not statistically significant improvements in favorable outcomes for rt-PA treatment (p = 0.889, 0.929, 0.708; respectively). For patients with LAA, compared with non-treated group, rt-PA-treated patients had a significant in the rate of favorable outcomes at 90 days (82.8 vs. 64.9%; OR 2.59; 95%CI, 1.13–5.92; P = 0.024). Among LAA patients exhibiting tandem lesions, favorable outcomes were observed in 66.7% of rt-PA-treated patients, with no significant differences to those observed in untreated patients (OR 1.00; 95%CI, 0.23–4.28; p = 1.000). Among LAA patients without tandem lesions, compared with non-treated group, we found that rt-PA treatment was associated with a significant beneficial impact on favorable outcomes after 90 days (64.4 vs. 88.4%; OR 4.20; 95%CI, 1.43–12.30; p = 0.009). Our findings suggest that intravenous rt-PA is only beneficial in mild stroke patients with LAA-type strokes that do not exhibit tandem steno-occlusion.
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Affiliation(s)
- Dapeng Wang
- Department of Neurology, First Affliated Hospital of Soochow University, Suzhou, China
| | - Lulu Zhang
- Department of Neurology, First Affliated Hospital of Soochow University, Suzhou, China
| | - Xiaowei Hu
- Department of Neurology, First Affliated Hospital of Soochow University, Suzhou, China
| | - Juehua Zhu
- Department of Neurology, First Affliated Hospital of Soochow University, Suzhou, China
| | - Xiang Tang
- Department of Neurology, First Affliated Hospital of Soochow University, Suzhou, China
| | - Dongxue Ding
- Department of Neurology, First Affliated Hospital of Soochow University, Suzhou, China
| | - Hui Wang
- Department of Neurology, First Affliated Hospital of Soochow University, Suzhou, China
| | - Yan Kong
- Department of Neurology, First Affliated Hospital of Soochow University, Suzhou, China
| | - Xiuying Cai
- Department of Neurology, First Affliated Hospital of Soochow University, Suzhou, China
| | - Longting Lin
- Hunter Medical Research Institute, University of Newcastle, New Lambton, NSW, Australia
| | - Qi Fang
- Department of Neurology, First Affliated Hospital of Soochow University, Suzhou, China
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21
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Sykora M, Kellert L, Michel P, Eskandari A, Feil K, Rémi J, Ferrari J, Krebs S, Lang W, Serles W, Siarnik P, Turcani P, Kovacik M, Bender B, Mengel A, Poli K, Poli S. Thrombolysis in Stroke With Unknown Onset Based on Non-Contrast Computerized Tomography (TRUST CT). J Am Heart Assoc 2020; 9:e014265. [PMID: 32067594 PMCID: PMC7070213 DOI: 10.1161/jaha.119.014265] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Intravenous thrombolysis (IVT) in wake‐up stroke (WUS) or stroke with unknown onset (SUO) has been recently proven to be safe and effective using advanced neuroimaging (magnetic resonance imaging or computerized tomography‐perfusion) for patient selection. However, in most of the thrombolyzing centers advanced neuroimaging is not instantly available. We hypothesize that pragmatic non‐contrast computed tomography‐based IVT in WUS/SUO may be feasible and safe. Methods and Results TRUST‐CT (Thrombolysis in Stroke With Unknown Onset Based on Non‐Contrast Computerized Tomography) is an international multicenter registry‐based study. WUS/SUO patients undergoing non‐contrast computed tomography‐based IVT with National Institute of Health Stroke Scale ≥4 and initial Alberta Stroke Program Early Computerized Tomography score ≥7 were included and compared with propensity score matched non‐thrombolyzed WUS/SUO controls. Primary end point was the incidence of symptomatic intracranial hemorrhage; secondary end points included 24‐hour National Institute of Health Stroke Scale improvement of ≥4 and modified Rankin Scale at 90 days. One hundred and seventeen WUS/SUO patients treated with non‐contrast computed tomography‐based IVT were included. As compared with 112 controls, the median admission National Institute of Health Stroke Scale was 10 and the median Alberta Stroke Program Early Computerized Tomography score was 10 in both groups. Four (3.4%) IVT patients and one control patient (0.9%) suffered symptomatic intracranial hemorrhage (adjusted odds ratio 7.9, 95% CI 0.65–96, P=0.1). A decrease of ≥4 National Institute of Health Stroke Scale points was observed in 67 (57.3%) of IVT patients as compared with 25 (22.3%) in controls (adjusted odds ratio 5.8, CI 3.0–11.2, P<0.001). A months, 39 (33.3%) IVT patients reached a modified Rankin Scale score of 0 or 1 versus 23 (20.5%) controls (adjusted odds ratio 1.94, CI 1.0–3.76, P=0.05). Conclusions Non‐contrast computed tomography‐based thrombolysis in WUS/SUO seems feasible and safe and may be effective. Randomized prospective comparisons are warranted. Clinical Trial Registration URL: https://www.clinicaltrials.gov/. Unique identifier: NCT03634748.
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Affiliation(s)
- Marek Sykora
- Department of Neurology St. John's Hospital Medical faculty Sigmund Freud University Vienna Austria
| | - Lars Kellert
- Department of Neurology Ludwig Maximilians University Munich Germany
| | - Patrik Michel
- Stroke Center, Neurology Service Department of Clinical Neurosciences Lausanne University Hospital Lausanne Switzerland
| | - Ashraf Eskandari
- Stroke Center, Neurology Service Department of Clinical Neurosciences Lausanne University Hospital Lausanne Switzerland
| | - Katharina Feil
- Department of Neurology Ludwig Maximilians University Munich Germany.,German Center for Vertigo and Balance Disorders Ludwig Maximilians University Munich Germany
| | - Jan Rémi
- Department of Neurology Ludwig Maximilians University Munich Germany
| | - Julia Ferrari
- Department of Neurology St. John's Hospital Medical faculty Sigmund Freud University Vienna Austria
| | - Stefan Krebs
- Department of Neurology St. John's Hospital Medical faculty Sigmund Freud University Vienna Austria
| | - Wilfried Lang
- Department of Neurology St. John's Hospital Medical faculty Sigmund Freud University Vienna Austria
| | | | - Pavel Siarnik
- Department of Neurology Comenius University Bratislava Slovakia
| | - Peter Turcani
- Department of Neurology Comenius University Bratislava Slovakia
| | - Michal Kovacik
- Department of Neurology General Hospital Liptovsky Mikulas Slovakia
| | - Benjamin Bender
- Department of Diagnostic and Interventional Neuroradiology University Hospital Tübingen Germany
| | - Annerose Mengel
- Department of Neurology with Focus on Neurovascular Diseases and Neurooncology and Hertie Institute for Clinical Brain Research University Hospital Tübingen Germany
| | - Khouloud Poli
- Department of Neurology with Focus on Neurovascular Diseases and Neurooncology and Hertie Institute for Clinical Brain Research University Hospital Tübingen Germany
| | - Sven Poli
- Department of Neurology with Focus on Neurovascular Diseases and Neurooncology and Hertie Institute for Clinical Brain Research University Hospital Tübingen Germany
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22
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Wang X, Tian X, Pei LL, Niu PP, Guo Y, Hu R, Liu K, Tian M, Li Y, Wang C, Wang X, Xu Y, Song B. The Association Between Serum Apelin-13 and the Prognosis of Acute Ischemic Stroke. Transl Stroke Res 2020; 11:700-707. [PMID: 31965512 DOI: 10.1007/s12975-019-00769-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Revised: 12/03/2019] [Accepted: 12/05/2019] [Indexed: 12/28/2022]
Abstract
While a number of studies have reported an association between apelin-13 and ischemic stroke, few have verified its clinical effect. We investigated the prognostic value of serum apelin-13 levels in patients with acute ischemic stroke (AIS). We prospectively recruited 244 AIS patients within 24 h after stroke onset, and 167 healthy controls. We assessed the serum apelin-13 levels using ELISA, and the severity of AIS using the National Institutes of Health Stroke Scale (NIHSS). The primary outcomes included death or major disability (modified Rankin Scale score, 3-6) and major disability (modified Rankin Scale score, 3-5). Secondary outcomes included recurrent stroke and combined events (all-cause death, or cardiovascular and cerebrovascular events). We found that the serum apelin-13 levels in the patients (38.63 ng/mL (interquartile range [IQR], 29.86-50.99)) were lower than those in the healthy controls (42.50 ng/mL [IQR, 31.25-59.17]) (P = 0.017). Patients with a NIHSS score ≤ 3 had higher apelin-13 levels than those with a NIHSS score > 3 (P = 0.048). At the 3-month follow-up, multivariate logistic regression analysis indicated an association between apelin-13 and death or major disability (OR 0.31; 95% CI 0.11-0.86; P = 0.024) and major disability (OR 0.32; 95% CI 0.11-0.90; P = 0.030). At the 1-year follow-up, the patients with high apelin-13 levels showed a lower incidence of stroke and combined events (Log-rank test P < 0.05). Our findings indicate that serum apelin-13 may be a potential prognostic biomarker for AIS.
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Affiliation(s)
- Xiao Wang
- Department of Neurology, the First Affiliated Hospital of Zhengzhou University, No. 1 Jianshe Road, Zhengzhou, 450052, Henan, China.,Henan Key Laboratory of Cerebrovascular Diseases, Zhengzhou, 450052, China
| | - Xuan Tian
- Department of Neurology, the First Affiliated Hospital of Zhengzhou University, No. 1 Jianshe Road, Zhengzhou, 450052, Henan, China.,Henan Key Laboratory of Cerebrovascular Diseases, Zhengzhou, 450052, China
| | - Lu-Lu Pei
- Department of Neurology, the First Affiliated Hospital of Zhengzhou University, No. 1 Jianshe Road, Zhengzhou, 450052, Henan, China.,Henan Key Laboratory of Cerebrovascular Diseases, Zhengzhou, 450052, China
| | - Peng-Peng Niu
- Department of Neurology, the First Affiliated Hospital of Zhengzhou University, No. 1 Jianshe Road, Zhengzhou, 450052, Henan, China.,Henan Key Laboratory of Cerebrovascular Diseases, Zhengzhou, 450052, China
| | - Yinan Guo
- Department of Neurology, the First Affiliated Hospital of Zhengzhou University, No. 1 Jianshe Road, Zhengzhou, 450052, Henan, China.,Henan Key Laboratory of Cerebrovascular Diseases, Zhengzhou, 450052, China
| | - Ruiyao Hu
- Department of Neurology, the First Affiliated Hospital of Zhengzhou University, No. 1 Jianshe Road, Zhengzhou, 450052, Henan, China.,Henan Key Laboratory of Cerebrovascular Diseases, Zhengzhou, 450052, China
| | - Kai Liu
- Department of Neurology, the First Affiliated Hospital of Zhengzhou University, No. 1 Jianshe Road, Zhengzhou, 450052, Henan, China.,Henan Key Laboratory of Cerebrovascular Diseases, Zhengzhou, 450052, China
| | - Mengke Tian
- Department of Neurology, the First Affiliated Hospital of Zhengzhou University, No. 1 Jianshe Road, Zhengzhou, 450052, Henan, China.,Henan Key Laboratory of Cerebrovascular Diseases, Zhengzhou, 450052, China
| | - Youfeng Li
- Department of Neurology, the First Affiliated Hospital of Zhengzhou University, No. 1 Jianshe Road, Zhengzhou, 450052, Henan, China.,Henan Key Laboratory of Cerebrovascular Diseases, Zhengzhou, 450052, China
| | - Chunhui Wang
- Department of Neurology, the First Affiliated Hospital of Zhengzhou University, No. 1 Jianshe Road, Zhengzhou, 450052, Henan, China.,Henan Key Laboratory of Cerebrovascular Diseases, Zhengzhou, 450052, China
| | - Xin Wang
- Department of Neurology, the First Affiliated Hospital of Zhengzhou University, No. 1 Jianshe Road, Zhengzhou, 450052, Henan, China.,Henan Key Laboratory of Cerebrovascular Diseases, Zhengzhou, 450052, China
| | - Yuming Xu
- Department of Neurology, the First Affiliated Hospital of Zhengzhou University, No. 1 Jianshe Road, Zhengzhou, 450052, Henan, China. .,Henan Key Laboratory of Cerebrovascular Diseases, Zhengzhou, 450052, China.
| | - Bo Song
- Department of Neurology, the First Affiliated Hospital of Zhengzhou University, No. 1 Jianshe Road, Zhengzhou, 450052, Henan, China. .,Henan Key Laboratory of Cerebrovascular Diseases, Zhengzhou, 450052, China.
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23
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Schellen C, Posekany A, Ferrari J, Krebs S, Lang W, Brainin M, Staykov D, Sykora M. Temporal trends in intracerebral hemorrhage: Evidence from the Austrian Stroke Unit Registry. PLoS One 2019; 14:e0225378. [PMID: 31747428 PMCID: PMC6867701 DOI: 10.1371/journal.pone.0225378] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2019] [Accepted: 11/04/2019] [Indexed: 12/21/2022] Open
Abstract
Background To assess changes in frequency, severity, complications, therapy and outcome of intracerebral hemorrhage in patients treated in stroke units in Austria, we evaluated data from the Austrian Stroke Unit Registry between 2008 and 2016. Methods and findings Data of 6707 cases of ICH covering a time span of 9 years and including information on age, risk factors, pre-stroke modified Rankin Score (mRS), baseline stroke severity (NIHSS), complications, therapy, functional outcome, and mortality were extracted from the Austrian Stroke Unit Registry. A multivariate regularized logistic regression model and linear models for temporal dependence were computed for analyzing statistical inference and time trends. Bonferroni correction was applied to correct for multiple testing. Between 2008 and 2016, the proportion of ICH admissions to stroke units in Austria declined, with a shift among patients towards older age (>70 years, p = 0.04) and lower admission NIHSS scores. While no significant time trends in risk factors, pre-stroke mRS and medical complications were observed, therapeutic interventions declined significantly (p<0.001). Three-month mortality increased over the years independently (p = 0.003). Conclusions Despite declining incidence and clinical severity of ICH we observed a clear increase in three-month mortality. This effect seems to be independent of predictors including age, admission NIHSS, pre-morbid MRS, or medical complications. The observations from this large retrospective database cohort study underline an urgent call for action in the therapy of ICH.
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Affiliation(s)
- Christoph Schellen
- Department of Radiology, Rudolf Foundation Hospital ("Krankenanstalt Rudolfstiftung"), Vienna, Austria
| | - Alexandra Posekany
- Department for Clinical Neurosciences and Preventive Medicine, Danube University, Krems, Austria
| | - Julia Ferrari
- Department of Neurology, St. John's Hospital, Vienna, Austria
| | - Stefan Krebs
- Department of Neurology, St. John's Hospital, Vienna, Austria
| | - Wilfried Lang
- Department of Neurology, St. John's Hospital, Vienna, Austria
- Medical Faculty, Sigmund Freud University, Vienna, Austria
| | - Michael Brainin
- Department for Clinical Neurosciences and Preventive Medicine, Danube University, Krems, Austria
| | - Dimitre Staykov
- Department of Neurology, St. John's Hospital, Eisenstadt, Austria
| | - Marek Sykora
- Department of Neurology, St. John's Hospital, Vienna, Austria
- Medical Faculty, Sigmund Freud University, Vienna, Austria
- I. Department of Neurology, Comenius University, Bratislava, Slovakia
- * E-mail:
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24
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Chen YW, Sung SF, Chen CH, Tang SC, Tsai LK, Lin HJ, Huang HY, Po HL, Sun Y, Chen PL, Chan L, Wei CY, Lee JT, Hsieh CY, Lin YY, Yeh SJ, Lien LM, Jeng JS. Intravenous Thrombolysis Administration 3-4.5 h After Acute Ischemic Stroke: A Retrospective, Multicenter Study. Front Neurol 2019; 10:1038. [PMID: 31681138 PMCID: PMC6803783 DOI: 10.3389/fneur.2019.01038] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Accepted: 09/13/2019] [Indexed: 12/13/2022] Open
Abstract
Background and Objectives: Intravenous recombinant tissue plasminogen activator (rt-PA) has been approved for acute ischemic stroke (AIS) within 3 h after onset and the treatment was then extended to 4.5 h. However, the Food and Drug Administration did not approve the indication in the expanded time window. This retrospective, matched cohort study aims to investigate the effectiveness and safety of rt-PA in AIS at 3-4.5 h after onset. Materials and Methods: The treatment group included AIS patients receiving rt-PA at 3-4.5 h after onset, otherwise complying with the regulation, in the stroke registries in 16 hospitals between 2008 and 2017. The control group included age- and sex-matched patients not receiving intravenous thrombolysis from the same registries, excluding those with contraindications. The primary outcome was modified Rankin Scale (mRS) 0-1 at day 90. The safety outcomes were any intracerebral hemorrhage (ICH), early neurological deterioration and 3-month mortality. Results: Each group had 374 patients. There were 34.0% of patients with 3-month mRS 0-1 in the treatment group vs. 22.7% in the control group with an odds ratio of 1.75 (95% confidence intervals, 1.27 to 2.42, P = 0.001). There was no difference in symptomatic ICH, early neurological deterioration and 3-month mortality rates between two groups. The 3-month mRS and symptomatic ICH did not differ significantly in patients receiving standard dose or low dose of rt-PA. Conclusions: Our results support the prescription of rt-PA in AIS patients 3-4.5 h after onset as an effective and tolerable treatment in their functional recovery.
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Affiliation(s)
- Yu-Wei Chen
- Department of Neurology, Landseed International Hospital, Taoyuan, Taiwan.,Stroke Center and Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
| | - Sheng-Feng Sung
- Division of Neurology, Department of Internal Medicine, Ditmanson Medical Foundation Chiayi Christian Hospital, Chiayi, Taiwan
| | - Chih-Hung Chen
- Department of Neurology, National Cheng Kung University Hospital, Tainan, Taiwan
| | - Sung-Chun Tang
- Stroke Center and Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
| | - Li-Kai Tsai
- Stroke Center and Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
| | - Huey-Juan Lin
- Department of Neurology, Chi Mei Medical Center, Tainan, Taiwan
| | - Hung-Yu Huang
- Department of Neurology, China Medical University Hospital, Taichung, Taiwan
| | - Helen L Po
- Department of Neurology, Mackay Memorial Hospital, Taipei, Taiwan
| | - Yu Sun
- Department of Neurology, En Chu Kong Hospital, New Taipei City, Taiwan
| | - Po-Lin Chen
- Department of Neurology, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Lung Chan
- Department of Neurology and Stroke Center, Taipei Medical University-Shuang Ho Hospital, New Taipei City, Taiwan.,Taipei Neuroscience Institute, Taipei Medical University, New Taipei City, Taiwan.,Department of Neurology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Cheng-Yu Wei
- Department of Neurology, Chang Bing Show Chwan Memorial Hospital, Changhwa, Taiwan
| | - Jiunn-Tay Lee
- Department of Neurology, Tri Service General Hospital, Taipei, Taiwan
| | - Cheng-Yang Hsieh
- Department of Neurology, Tainan Sin Lau Hospital, Tainan, Taiwan
| | - Yung-Yang Lin
- Department of Neurology and Department of Critical Care Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Shoou-Jeng Yeh
- Department of Neurology, Cheng Ching General Hospital, Taichung, Taiwan
| | - Li-Ming Lien
- Department of Neurology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan.,Department of Neurology, Shin Kong WHS Memorial Hospital, Taipei, Taiwan
| | - Jiann-Shing Jeng
- Stroke Center and Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
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25
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Haeberlin MI, Held U, Baumgartner RW, Georgiadis D, Valko PO. Impact of intravenous thrombolysis on functional outcome in patients with mild ischemic stroke without large vessel occlusion or rapidly improving symptoms. Int J Stroke 2019; 15:429-437. [PMID: 31514684 DOI: 10.1177/1747493019874719] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Optimal treatment strategy in patients with mild ischemic stroke remains uncertain. While functional dependency or death has been reported in up to one-third of non-thrombolyzed mild ischemic stroke patients, intravenous thrombolysis is currently not recommended in this patient group. Emerging evidence suggests two risk factors-rapid early improvement and large vessel occlusion-as main associates of unfavorable outcome in mild ischemic stroke patients not undergoing intravenous thrombolysis. AIMS To analyze natural course as well as safety and three-month outcome of intravenous thrombolysis in mild ischemic stroke without rapid early improvement or large vessel occlusion. METHODS Mild ischemic stroke was defined by a National Institute of Health Stroke Scale score ≤6. We used the modified Rankin Scale (mRS) to compare three-month functional outcome in 370 consecutive mild ischemic stroke patients without early rapid improvement and without large vessel occlusion, who either underwent intravenous thrombolysis (n = 108) or received best medical treatment (n = 262). RESULTS Favorable outcome (mRS ≤ 1) was common in both groups (intravenous thrombolysis: 91%; no intravenous thrombolysis: 90%). Although intravenous thrombolysis use was independently associated with a higher risk of asymptomatic hemorrhagic transformation (OR = 4.62, p = 0.002), intravenous thrombolysis appeared as an independent predictor of mRS = 0 at three months (OR = 3.33, p < 0.0001). CONCLUSIONS Mild ischemic stroke patients without rapidly improving symptoms and without large vessel occlusion have a high chance of favorable three-month outcome, irrespective of treatment type. Patients receiving intravenous thrombolysis, however, more often achieved complete remission of symptoms, which particularly in mild ischemic stroke may constitute a meaningful endpoint.
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Affiliation(s)
- Marcellina Isabelle Haeberlin
- Department of Neurology, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Ulrike Held
- Horten Center for Patient Oriented Research and Knowledge Transfer, University of Zurich, Zurich, Switzerland
| | - Ralf W Baumgartner
- NeuroCenter, Swiss Neuro Institute, Clinic Hirslanden, Zurich, Switzerland
| | - Dimitrios Georgiadis
- Department of Neurology, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Philipp O Valko
- Department of Neurology, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Zurich, Switzerland
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26
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You W, Li Y, Ouyang J, Li H, Yang S, Hu Q, Zhong J. Predictors of Poor Outcome in Patients with Minor Ischemic Stroke by Using Magnetic Resonance Imaging. J Mol Neurosci 2019; 69:478-484. [PMID: 31325109 DOI: 10.1007/s12031-019-01379-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Accepted: 07/09/2019] [Indexed: 02/06/2023]
Abstract
Although the symptoms of minor ischemic stroke are mild, poor prognosis may occur if left untreated. Therefore, it is particularly important to identify the predictors that associated with poor outcome in patients presenting minor ischemic stroke. The aim of this study was to elucidate the predictors of progression by using magnetic resonance imaging (MRI). A total of 516 patients diagnosed with minor ischemic stroke were enrolled in this study. They were divided into two groups, the progressive group and non-progressive group, according to the modified Rankin Scale (mRS) with the cutoff value of 2 points on day 90 after the stroke onset. We compared the results of MRI scan between the two groups to investigate the potential independent determinants of progression using multivariate logistic regression analysis. Ninety of 516 patients (17.44%) underwent progression. There were 9 factors that were independently associated with poor outcome, including age (OR = 1.045, 95% CI 1.017-1.074), heart disease (OR = 2.021, 95% CI 1.063-3.841), baseline NIHSS score (OR = 1.662, 95% CI 1.177-2.347), limb motor disturbance (OR = 2.430, 95% CI 1.010-5.850), ataxia (OR = 2.929, 95% CI 1.188-7.221), early neurological deterioration (OR = 50.994, 95% CI 17.659-147.258), diameter of infarction (OR = 1.279, 95% CI 1.075-1.521), non-responsible vessel size (OR = 2.518, 95% CI 1.145-5.536), and large-artery atherosclerosis (OR = 2.010, 95% CI 1.009-4.003). This study indicated that age, heart disease, motor disturbance of limb, ataxia, early neurological deterioration, diameter of infarction, size of non-responsible vessels, and large-artery atherosclerosis can be used to assess the prognosis of patients with minor ischemic stroke.
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Affiliation(s)
- Wenxia You
- Department of Neurology, Shunde Hospital, Southern Medical University (The First People's Hospital of Shunde), No.1 Jiazi Road, Lunjiao, Shunde District, Foshan, Guangdong Province, 528308, China
| | - Yongxin Li
- Department of Neurology, Shunde Hospital, Southern Medical University (The First People's Hospital of Shunde), No.1 Jiazi Road, Lunjiao, Shunde District, Foshan, Guangdong Province, 528308, China
| | - Jipeng Ouyang
- Department of Neurology, Shunde Hospital, Southern Medical University (The First People's Hospital of Shunde), No.1 Jiazi Road, Lunjiao, Shunde District, Foshan, Guangdong Province, 528308, China
| | - Hongzhuang Li
- Department of Neurology, Shunde Hospital, Southern Medical University (The First People's Hospital of Shunde), No.1 Jiazi Road, Lunjiao, Shunde District, Foshan, Guangdong Province, 528308, China
| | - Shaomin Yang
- Department of Radiology, Shunde Hospital, Southern Medical University (The First People's Hospital of Shunde), No.1 Jiazi Road, Lunjiao, Shunde District, Foshan, Guangdong Province, 528308, China
| | - Qiugen Hu
- Department of Radiology, Shunde Hospital, Southern Medical University (The First People's Hospital of Shunde), No.1 Jiazi Road, Lunjiao, Shunde District, Foshan, Guangdong Province, 528308, China
| | - Jianping Zhong
- Department of Neurology, Shunde Hospital, Southern Medical University (The First People's Hospital of Shunde), No.1 Jiazi Road, Lunjiao, Shunde District, Foshan, Guangdong Province, 528308, China.
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27
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Koge J. [Reperfusion therapy in patients with minor or mild ischemic stroke]. Rinsho Shinkeigaku 2019; 59:84-92. [PMID: 30700691 DOI: 10.5692/clinicalneurol.cn-001255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
A significant number of patients with minor or mild stroke symptoms on initial presentation subsequently develop neurological deterioration and poor clinical outcomes at hospital discharge. The presence of an underlying large vessel occlusion is a strong predictor of both clinical worsening and poor outcome. Although patients with a low baseline National Institutes of Health Stroke Scale (NIHSS) could have been included in some randomized controlled trials, the benefits of the mechanical thrombectomy for patients with a low NIHSS score are unknown. The causes of neurological deterioration in patients with underlying large vessel occlusion are heterogeneous, but include collateral failure, and no straightforward mechanisms are found in the majority of cases. Patients with internal carotid artery occlusion, but with a patent middle cerebral artery (MCA), can occasionally have good collateral circulation and develop only minor or mild stroke. These patients exhibit collateral MCA flow via the circle of Willis despite ipsilateral internal carotid artery occlusion. However, thrombus migration may cause occlusion of collateral MCA flow, leading to dramatic neurological deterioration. Careful observation and detailed assessment are required for the management of these patients. Recent studies have examined the efficacy and optimal timing of thrombolysis or mechanical thrombectomy for patients with minor or mild stroke. Herein, we review the mechanisms of neurological deterioration, and the efficacy of reperfusion therapy, for patients with minor or mild stroke.
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Affiliation(s)
- Junpei Koge
- Division of Neurology, Saiseikai Fukuoka General Hospital
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28
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Gattringer T, Posekany A, Niederkorn K, Knoflach M, Poltrum B, Mutzenbach S, Haring HP, Ferrari J, Lang W, Willeit J, Kiechl S, Enzinger C, Fazekas F. Predicting Early Mortality of Acute Ischemic Stroke. Stroke 2019; 50:349-356. [DOI: 10.1161/strokeaha.118.022863] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Background and Purpose—
Several risk factors are known to increase mid- and long-term mortality of ischemic stroke patients. Information on predictors of early stroke mortality is scarce but often requested in clinical practice. We therefore aimed to develop a rapidly applicable tool for predicting early mortality at the stroke unit.
Methods—
We used data from the nationwide Austrian Stroke Unit Registry and multivariate regularized logistic regression analysis to identify demographic and clinical variables associated with early (≤7 days poststroke) mortality of patients admitted with ischemic stroke. These variables were then used to develop the Predicting Early Mortality of Ischemic Stroke score that was validated both by bootstrapping and temporal validation.
Results—
In total, 77 653 ischemic stroke patients were included in the analysis (median age: 74 years, 47% women). The mortality rate at the stroke unit was 2% and median stay of deceased patients was 3 days. Age, stroke severity measured by the National Institutes of Health Stroke Scale, prestroke functional disability (modified Rankin Scale >0), preexisting heart disease, diabetes mellitus, posterior circulation stroke syndrome, and nonlacunar stroke cause were associated with mortality and served to build the Predicting Early Mortality of Ischemic Stroke score ranging from 0 to 12 points. The area under the curve of the score was 0.879 (95% CI, 0.871–0.886) in the derivation cohort and 0.884 (95% CI, 0.863–0.905) in the validation sample. Patients with a score ≥10 had a 35% (95% CI, 28%–43%) risk to die within the first days at the stroke unit.
Conclusions—
We developed a simple score to estimate early mortality of ischemic stroke patients treated at a stroke unit. This score could help clinicians in short-term prognostication for management decisions and counseling.
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Affiliation(s)
- Thomas Gattringer
- From the Department of Neurology, Medical University of Graz, Austria (T.G., K.N., B.P., C.E., F.F.)
| | - Alexandra Posekany
- Danube University Krems and Gesundheit Österreich GmbH/BIQG, Vienna, Austria (A.P.)
| | - Kurt Niederkorn
- From the Department of Neurology, Medical University of Graz, Austria (T.G., K.N., B.P., C.E., F.F.)
| | - Michael Knoflach
- Department of Neurology, Medical University of Innsbruck, Austria (M.K., J.W., S.K.)
| | - Birgit Poltrum
- From the Department of Neurology, Medical University of Graz, Austria (T.G., K.N., B.P., C.E., F.F.)
| | | | - Hans-Peter Haring
- Department of Neurology 1, Kepler Universitätsklinikum, Neuromed Campus, Linz, Austria (H.-P.H.)
| | - Julia Ferrari
- Department of Neurology, Hospital Barmherzige Brüder Vienna, Austria (J.F., W.L.)
| | - Wilfried Lang
- Department of Neurology, Hospital Barmherzige Brüder Vienna, Austria (J.F., W.L.)
| | - Johann Willeit
- Department of Neurology, Medical University of Innsbruck, Austria (M.K., J.W., S.K.)
| | - Stefan Kiechl
- Department of Neurology, Medical University of Innsbruck, Austria (M.K., J.W., S.K.)
| | - Christian Enzinger
- From the Department of Neurology, Medical University of Graz, Austria (T.G., K.N., B.P., C.E., F.F.)
| | - Franz Fazekas
- From the Department of Neurology, Medical University of Graz, Austria (T.G., K.N., B.P., C.E., F.F.)
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29
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He L, Wang J, Zhang L, Zhang X, Dong W, Yang H. Decreased fractal dimension of heart rate variability is associated with early neurological deterioration and recurrent ischemic stroke after acute ischemic stroke. J Neurol Sci 2019; 396:42-47. [DOI: 10.1016/j.jns.2018.11.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Revised: 10/12/2018] [Accepted: 11/04/2018] [Indexed: 12/27/2022]
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30
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Shkirkova K, Saver JL, Starkman S, Wong G, Weng J, Hamilton S, Liebeskind DS, Eckstein M, Stratton S, Pratt F, Conwit R, Sanossian N. Frequency, Predictors, and Outcomes of Prehospital and Early Postarrival Neurological Deterioration in Acute Stroke: Exploratory Analysis of the FAST-MAG Randomized Clinical Trial. JAMA Neurol 2018; 75:1364-1374. [PMID: 30039165 PMCID: PMC6248118 DOI: 10.1001/jamaneurol.2018.1893] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2017] [Accepted: 05/17/2018] [Indexed: 12/17/2022]
Abstract
Importance Studies of neurological deterioration in stroke have focused on the subacute period, but stroke treatment is increasingly migrating to the prehospital setting, where the neurological course has not been well delineated. Objective To describe the frequency, predictors, and outcomes of neurological deterioration among patients in the ultra-early period following ischemic stroke or intracranial hemorrhage. Design, Settings, and Participants Exploratory analysis of the prehospital, randomized Field Administration of Stroke Therapy-Magnesium (FAST-MAG) Trial conducted from 2005 to 2013 within 315 ambulances and 60 stroke patient receiving hospitals in Southern California. Participants were consecutively enrolled patients with suspected acute stroke who were transported by ambulance within 2 hours of stroke onset. Main Outcomes and Measures The main outcome was neurological deterioration, defined as a worsening of 2 or more points on the Glasgow Coma Scale (GCS), a level of consciousness scale ranging from 3 to 15, with higher scores indicating more alertness. Imaging outcomes were ischemic or hemorrhagic injury extent identified during the first brain imaging scan. Outcomes at 3 months included global disability level (assessed using the modified Rankin Scale [mRS]; range, 0-6, with higher numbers indicating greater disability) and mortality. Results Among the 1690 patients (99.4%), the mean (SD) age was 69.4 (13.5) years, and 43% were female. Final diagnoses were acute cerebral ischemia in 1237 patients (73.2%), intracranial hemorrhage in 386 patients (22.8%), and neurovascular mimic in 67 patients (4.0%). The median (interquartile range [IQR]) minutes between the last well-known time and GCS assessments were 23 (14-42) minutes for prehospital, 58 (46-79) minutes for ED arrival, and 149 (120-180) minutes for early ED course assessments. From prehospital to early postarrival, ultra-early neurological deterioration (U-END) occurred in 200 of 1690 patients (11.8%), more often among patients with intracranial hemorrhage than among those with acute cerebral ischemia (119 of 386 [30.8%] vs 75 of 1237 [6.1%], P < .001). Patterns of U-END were prehospital U-END without early recovery in 30 of 965 patients (3.1%), stable prehospital course but early ED deterioration in 49 of 965 patients (5.1%), and continuous deterioration in both prehospital and early ED phases in 27 of 965 patients (2.8%). Ultra-early neurological deterioration was associated with worse 3-month outcomes, including increased global disability (mRS score, 4.6 vs 2.4; P < .001), reduced functional independence (mRS score 0-2, 32 of 200 [16.0%] vs 844 of 1490 [56.6%]; P < .001), and increased mortality (87 of 200 [43.5%] vs 176 of 1490 [11.8%]; P < .001). Conclusions and Relevance Ultra-early neurological deterioration occurs in 1 in 8 ambulance-transported patients with acute cerebrovascular disease, including 1 in 3 patients with intracranial hemorrhage and 1 in 16 patients with acute cerebral ischemia, and is associated with markedly reduced functional independence and increased mortality. Averting U-END may be a target for future prehospital therapeutics. Trial Registration ClinicalTrials.gov Identifier: NCT00059332.
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Affiliation(s)
- Kristina Shkirkova
- Stroke Center, Department of Neurology, University of California, Los Angeles
| | - Jeffrey L. Saver
- Stroke Center, Department of Neurology, University of California, Los Angeles
| | - Sidney Starkman
- Department of Emergency Medicine, University of California, Los Angeles
| | - Gregory Wong
- Department of Emergency Medicine, University of California, Los Angeles
| | - Julius Weng
- Department of Emergency Medicine, University of California, Los Angeles
| | - Scott Hamilton
- Department of Neurology, Stanford University, Stanford, California
| | - David S. Liebeskind
- Stroke Center, Department of Neurology, University of California, Los Angeles
| | - Marc Eckstein
- Department of Emergency Medicine, University of Southern California, Los Angeles
- Los Angeles Fire Department, Los Angeles, California
| | - Samuel Stratton
- Department of Emergency Medicine, Harbor-University of California, Los Angeles Medical Center, Los Angeles
- Los Angeles EMS Agency, Los Angeles, California
- Orange County EMS Agency, Orange County, California
| | - Frank Pratt
- Los Angeles County Department of Public Health, Los Angeles, California
| | - Robin Conwit
- National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, Maryland
| | - Nerses Sanossian
- Department of Neurology, University of Southern California, Los Angeles
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Tan Z, Meng H, Dong D, Zhao Y, Xu A. Blood pressure variability estimated by ARV is a predictor of poor short-term outcomes in a prospective cohort of minor ischemic stroke. PLoS One 2018; 13:e0202317. [PMID: 30142202 PMCID: PMC6108465 DOI: 10.1371/journal.pone.0202317] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2017] [Accepted: 08/01/2018] [Indexed: 11/25/2022] Open
Abstract
Prior studies have shown that patients with minor ischemic stroke have substantial disability rates at hospital discharge. We sought to determine whether blood pressure variability (BPV) estimated by average real variability (ARV) is one of the predictors of poor outcome at 90 days. Four hundred fifty-one consecutive patients with ischemic stroke treated within 7 days after onset were enrolled prospectively. Baseline magnetic resonance imaging (MRI) was performed on all subjects. Blood pressure was measured for all recruited patients every 2 hours in the first 24 hours after admission, followed by measurements collected every 4 hours from day 2 to day 7 after admission. ARV was used to estimate BPV. A total of 192 patients with minor ischemic stroke were enrolled, and 11 of them (5.7%) had poor outcomes. Univariate regression analysis showed that early neurological deterioration (X2 = 21.44, P = 0.000), severe symptomatic large artery stenosis or occlusion (X2 = 9.260, P = 0.000), large artery atherosclerotic stroke (X2 = 7.14, P = 0.002), total cholesterol (TC), and D2-7 SBP-ARV (t = 5.449, P = 0.001) of the poor outcome group were significantly higher than those of the good outcome group. Multivariate logistic regression analysis showed that early neurological deterioration (OR 4.369, 95% CI 3.54, 15.65; P = 0.001), severe symptomatic large artery stenosis or occlusion (OR 5.56, 95% CI 3.56, 13.65; P = 0.000), large artery atherosclerotic stroke (OR 3.56, 95% CI 1.45, 7.48; P = 0.004), and D2-7 SBP-ARV (OR 3.96, 95% CI 1.90, 20.18, P = 0.008) were significantly related to poor outcomes. In conclusion, approximately 5.7% of minor ischemic stroke patients had poor outcomes. D2-7 SBP-ARV, early neurologic deterioration, severe symptomatic artery stenosis or occlusion, and large atherosclerotic stroke were the independent risk factors of poor short-term outcomes.
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Affiliation(s)
- Zefeng Tan
- Department of Neurology, the First Affiliated Hospital, Jinan University, Guangzhou, Guangdong, China
| | - Heng Meng
- Department of Neurology, the First Affiliated Hospital, Jinan University, Guangzhou, Guangdong, China
| | - Dawei Dong
- Department of Neurology, the First Affiliated Hospital, Jinan University, Guangzhou, Guangdong, China
| | - Ying Zhao
- Department of Neurology, the First Affiliated Hospital, Jinan University, Guangzhou, Guangdong, China
| | - Anding Xu
- Department of Neurology, the First Affiliated Hospital, Jinan University, Guangzhou, Guangdong, China
- * E-mail:
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Systematic dysphagia screening and dietary modifications to reduce stroke-associated pneumonia rates in a stroke-unit. PLoS One 2018; 13:e0192142. [PMID: 29389984 PMCID: PMC5794132 DOI: 10.1371/journal.pone.0192142] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2017] [Accepted: 01/17/2018] [Indexed: 11/19/2022] Open
Abstract
Background and purpose While formal screening for dysphagia following acute stroke is strongly recommended, there is little evidence on how multi-consistency screening and dietary modifications affect the rate of stroke-associated pneumonia (SAP). This observational study reports which factors affect formal screening on a stroke-unit and how dietary recommendations relate to SAP. Method Analyses from a database including 1394 patients admitted with acute stroke at our stroke-unit in Austria between 2012 and 2014. Dietary modifications were performed following the recommendations from the Gugging Swallowing Screen (GUSS). Patients evaluated with GUSS were compared to the unscreened patients. Results Overall, 993 (71.2%) patients were screened with GUSS; of these 50 (5.0%) developed SAP. In the 401 unscreened patients, the SAP rate was similar: 22 (5.5%). Multivariable analysis showed that either mild to very mild strokes or very severe strokes were less likely to undergo formal screening. Older age, pre-existing disability, history of hypertension, atrial fibrillation, stroke severity, cardiological and neurological complications, nasogastric tubes, and intubation were significant markers for SAP. Out of 216 patients, 30 (13.9%) developed SAP in spite of receiving nil per mouth (NPO). Conclusion The routine use of GUSS is less often applied in either mild strokes or very severe strokes. While most patients with high risk of SAP were identified by GUSS and assigned to NPO, dietary modifications could not prevent SAP in 1 of 7 cases. Other causes of SAP such as silent aspiration, bacteraemia or central breathing disturbances should be considered.
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33
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Geng HH, Wang Q, Li B, Cui BB, Jin YP, Fu RL, Zhang Q, Wang JJ, Wang PX. Early neurological deterioration during the acute phase as a predictor of long-term outcome after first-ever ischemic stroke. Medicine (Baltimore) 2017; 96:e9068. [PMID: 29390435 PMCID: PMC5758137 DOI: 10.1097/md.0000000000009068] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Early neurological deterioration (END) is associated with increased risk of functional disability and mortality. However, data are limited regarding the long-term risk of poor functional outcomes. Thus we explored the association between END and long-term outcomes in patients with acute ischemic stroke.A total of 1064 patients were enrolled with acute ischemic stroke who were consecutively admitted to the 3 stroke units of Huai-He Hospital, Kaifeng, China. END was defined as an increment change of at least one point in motor power or total National Institute of Health Stroke Scale (NIHSS) score deterioration ≥2 points within the first week after admission. We retrospectively assessed the risk factors of END and prospectively explored the relationship between END and the long-term outcomes by multivariable regression models after adjusting the potential confounding factors. Outcomes were evaluated at 18 months based on modified Rankin scale (MRS) scores.Approximately 32% of first-ever ischemic stroke patients experienced END during the acute phase. END was associated with diabetes (odds ratio [OR], 2.218; 95% confidence interval [CI] 1.619-3.037), NIHSS score at admission (OR, 1.052; 95% CI 1.023-1.082), C-reactive protein (CRP) levels (OR, 1.224; 95% CI 1.066-1.406]), and homocysteine (HCY) levels (OR, 1.203; 95% CI 1.061-1.365) after adjusting related factors, such as hypertension, diabetes, NIHSS at admission, and some blood laboratory values, including direct bilirubin, total cholesterol, low-density lipoprotein, glucose, CRP, HCY, and D-dimer levels. During the follow-up period, 52 (4.9%) patients died, 160 (15.0%) recrudesced, and 317 (29.8%) suffered poor outcomes. Multivariate logistic regression analyses revealed that poor outcome was associated with END (OR, 3.366; 95% CI 2.495-4.542), age (OR, 1.028; 95% CI 1.015-1.041), body mass index (OR, 1.096; 95% CI 1.051-1.144), coronary heart disease (OR, 1.637; 95% CI 1.108-2.416), and CRP (OR, 2.474; 95% CI 1.840-3.326).The risk factors of END are multifaceted. Diabetes, NIHSS score at admission, CRP, and HCY are independent predictors of END. In addition, the results of this study indicate that END is an important predictor of poor functional outcome.
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Affiliation(s)
- He-Hong Geng
- Institute of Public Health, School of Nursing, Henan University, Kaifeng
- Henan Children's Hospital, Zhengzhou
| | - Qiang Wang
- Institute of Public Health, School of Nursing, Henan University, Kaifeng
| | - Bo Li
- Institute of Public Health, School of Nursing, Henan University, Kaifeng
| | - Bin-Bin Cui
- School of Basic Medical Science, Henan University, Kaifeng
| | - Yong-Ping Jin
- Institute of Public Health, School of Nursing, Henan University, Kaifeng
| | - Rong-Li Fu
- Department of Neurology of Huai-He Hospital, Kaifeng, China
| | - Qing Zhang
- Institute of Public Health, School of Nursing, Henan University, Kaifeng
| | - Jing-Jie Wang
- Institute of Public Health, School of Nursing, Henan University, Kaifeng
| | - Pei-Xi Wang
- Institute of Public Health, School of Nursing, Henan University, Kaifeng
- Department of Preventive Medicine, School of Public Health, Guangzhou Medical University, Guangzhou
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Dong Q, Dong Y, Liu L, Xu A, Zhang Y, Zheng H, Wang Y. The Chinese Stroke Association scientific statement: intravenous thrombolysis in acute ischaemic stroke. Stroke Vasc Neurol 2017; 2:147-159. [PMID: 28989804 PMCID: PMC5628383 DOI: 10.1136/svn-2017-000074] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2017] [Revised: 03/20/2017] [Accepted: 03/22/2017] [Indexed: 12/30/2022] Open
Abstract
The most effective medical treatment for acute ischaemic stroke (AIS) is to offer intravenous thrombolysis during the ultra-early period of time after the onset. Even based on the Consensus of Chinese Experts on Intravenous Thrombolysis for AIS in 2012 and 2014 Chinese Guidelines on the Diagnosis and Treatment of AIS, the rate of thrombolysis for AIS in China remained around 2.4%, and the rate of intravenous tissue plasminogen activator usage was only about 1.6% in real world. The indication of thrombolysis for AIS has been expanded, and contraindications have been reduced with recently published studies. In order to facilitate the standardisation of treating AIS, improve the rate of thrombolysis and benefit patients who had a stroke, Chinese Stroke Association has organised and developed this scientific statement.
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Affiliation(s)
- Qiang Dong
- Department of Neurology, Huashan Hospital affiliated to Fudan University, Shanghai Shi, China
| | - Yi Dong
- Department of Neurology, Huashan Hospital affiliated to Fudan University, Shanghai Shi, China
| | - Liping Liu
- Department of Neurology, Beijing Tiantan Hospital affiliated to Capital Medical University, Beijing, China
| | - Anding Xu
- Department of Neurology and Stroke Center, First Affiliated Hospital, Jinan University, Guangzhou Shi, China
| | - Yusheng Zhang
- Department of Neurology and Stroke Center, First Affiliated Hospital, Jinan University, Guangzhou Shi, China
| | - Huaguang Zheng
- Department of Neurology, Beijing Tiantan Hospital affiliated to Capital Medical University, Beijing, China
| | - Yongjun Wang
- Department of Neurology, Beijing Tiantan Hospital affiliated to Capital Medical University, Beijing, China
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35
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Intravenous Thrombolysis in Chinese Patients with Different Subtype of Mild Stroke: Thrombolysis in Patients with Mild Stroke. Sci Rep 2017; 7:2299. [PMID: 28536425 PMCID: PMC5442116 DOI: 10.1038/s41598-017-02579-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2016] [Accepted: 04/13/2017] [Indexed: 12/04/2022] Open
Abstract
Thrombolysis treatment for patients with mild stroke is controversial. The aim of our study was to investigate whether patients with mild stroke or its specific etiologic subtype might benefit from rt-PA therapy. Data were derived from two cohorts of patients with and without rt-PA treatment: (1) the Thrombolysis Implementation and Monitor of Acute Ischemic Stroke in China (TIMS-China) and (2) the China National Stroke Registry (CNSR) database. Patients with mild stroke (defined as National Institutes of Health Stroke Scale ≤5) receiving the rt-PA therapy and without rt-PA therapy were matched in 1:2 for age, sex, stroke severity and etiologic subtype. A total of 134 rt-PA-treated patients were matched to 249 non-rt-PA-treated patients in the study. Among them, 104 (76%) rt-PA-treated patients with mild stroke had good outcome after 3 months compared with 173 (69.5%) non-rt-PA-treated matching cases (odds ratio [OR], 1.48; 95% confidence interval [CI], 0.91–2.43; P = 0.12). Compared with non-rt-PA-treated group, rt-PA-treated patients had good outcome after 3 months in those with stroke subtype of large-artery atherosclerosis (LAA) (80.5% vs 65.1%; OR, 2.19; 95%CI, 1.14–4.21; P = 0.02). For patients with mild stroke, intravenous rt-PA treatment may be effective. Patients with stroke subtype of LAA might benefit more from rt-PA treatment.
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Sommer P, Seyfang L, Posekany A, Ferrari J, Lang W, Fertl E, Serles W, Töll T, Kiechl S, Greisenegger S. Prehospital and intra-hospital time delays in posterior circulation stroke: results from the Austrian Stroke Unit Registry. J Neurol 2016; 264:131-138. [PMID: 27822599 PMCID: PMC5225195 DOI: 10.1007/s00415-016-8330-x] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2016] [Revised: 09/25/2016] [Accepted: 10/26/2016] [Indexed: 01/17/2023]
Abstract
Therapeutic effect of recombinant tissue-plasminogen activator (rt-PA) is time dependent. There is limited evidence whether localization of stroke within the posterior circulation (PCS) is associated with a treatment delay. We aimed to analyze within a nationwide multicenter cohort whether duration of pre- and intra-hospital patient management differs between patients with PCS and anterior circulation strokes (ACS). We studied onset-to-door-times (ODT) and door-to-needle-times (DNT) of all patients with acute ischemic stroke (IS) enrolled in the Austrian Stroke Unit Registry according to infarct localization. Classification into PCS and ACS was based on clinical presentation applying the criteria used in the Oxfordshire Community Stroke Project. Relationships between ODT, respectively, DNT and explanatory variables were modeled by multivariate linear regression. Between 2003 and 2015, 71010 patients with IS were enrolled, 11,924 with PCS and 59,086 with ACS. Overall, the ODT was significantly longer in PCS: median (IQR): 170 (25th, 75th‰: 79,420) min versus 110 (60,240); p < 0.001; this finding held true in multivariable analysis. In 10535 rt-PA-treated patients (1022 PCS/9832 ACS), ODT and DNT were significantly longer among those with PCS: ODT: median: 80 min (55,120) versus 72 (50,110), p < 0.001; DNT: 57 (35.90) versus 45 (30.67), p < 0.001. In the multivariate model, PCS was significantly associated with delay in the DNT. In conclusion, in this large nationwide cohort, patient management was significantly slower in PCS as compared to ACS. Increasing awareness about these delays and further elaboration of the underlying causes may translate into higher proportions of patients with PCS receiving rt-PA.
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Affiliation(s)
- Peter Sommer
- Department of Neurology, Krankenanstalt Rudolfstiftung, Vienna, Austria
| | - Leonhard Seyfang
- Danube University Krems and Gesundheit Österreich GmbH/BIQG, Vienna, Austria
| | - Alexandra Posekany
- Danube University Krems and Gesundheit Österreich GmbH/BIQG, Vienna, Austria
| | - Julia Ferrari
- Department of Neurology, Krankenhaus Barmherzige Brüder, Vienna, Austria
| | - Wilfried Lang
- Department of Neurology, Krankenhaus Barmherzige Brüder, Vienna, Austria
| | - Elisabeth Fertl
- Department of Neurology, Krankenanstalt Rudolfstiftung, Vienna, Austria
| | - Wolfgang Serles
- Department of Neurology, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Thomas Töll
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Stefan Kiechl
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Stefan Greisenegger
- Department of Neurology, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria.
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Matz K, Seyfang L, Dachenhausen A, Teuschl Y, Tuomilehto J, Brainin M. Post-stroke pneumonia at the stroke unit - a registry based analysis of contributing and protective factors. BMC Neurol 2016; 16:107. [PMID: 27430328 PMCID: PMC4949772 DOI: 10.1186/s12883-016-0627-y] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2015] [Accepted: 06/17/2016] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND To investigate prevalence and risk factors for post stroke pneumonia (PSP) in patients with acute ischemic stroke treated at stroke units (SU). METHOD We analysed data from the Austrian Stroke Unit registry concerning admissions from January 2003 to December 2013 and assessed the prevalence of PSP at the stroke unit. Patients with and without PSP were compared in univariate and multivariate models searching for factors associated with the occurrence of PSP at the SU. RESULTS Three thousand one hundred eleven patients (5.2%) of 59,558 analysed patients were diagnosed with PSP. While age and stroke severity were non-modifiable factors associated with PSP, modifiable risk factors included chronic alcohol consumption and atrial fibrillation. Patients who developed neurological, cardiac, and other infective complications showed a higher prevalence of PSP, an increased prevalence was also found in connection with the placement of nasogastric tubes or urinary catheters. Female sex, left hemispheric stroke, cryptogenic stroke pathogenesis and additionally, treatment with lipid lowering drugs were factors associated with a lower PSP prevalence. CONCLUSION Pneumonia in acute ischemic stroke is associated with a variety of modifiable and unmodifiable factors that allow to identify patients at high risk of developing PSP and to focus on early preventive measures at the SU. Further studies could use the results of this study to explore potential benefits of specific interventions targeted at these factors.
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Affiliation(s)
- Karl Matz
- Department for Clinical Neurosciences and Preventive Medicine, Danube University Krems, Dr.-Karl-Dorrek-Str. 30, A-3500, Krems, Austria. .,Department of Neurology, University Clinic Tulln, Karl Landsteiner Privatuniversität für Gesundheitswissenschaften, Krems, Austria.
| | - Leonhard Seyfang
- Department for Clinical Neurosciences and Preventive Medicine, Danube University Krems, Dr.-Karl-Dorrek-Str. 30, A-3500, Krems, Austria
| | - Alexandra Dachenhausen
- Department for Clinical Neurosciences and Preventive Medicine, Danube University Krems, Dr.-Karl-Dorrek-Str. 30, A-3500, Krems, Austria
| | - Yvonne Teuschl
- Department for Clinical Neurosciences and Preventive Medicine, Danube University Krems, Dr.-Karl-Dorrek-Str. 30, A-3500, Krems, Austria
| | - Jaakko Tuomilehto
- Department for Clinical Neurosciences and Preventive Medicine, Danube University Krems, Dr.-Karl-Dorrek-Str. 30, A-3500, Krems, Austria.,Department of Chronic Disease Prevention, National Institute for Health and Welfare, 00271, Helsinki, Finland.,Diabetes Research Group, King Abdulaziz University, 21589, Jeddah, Saudi Arabia
| | - Michael Brainin
- Department for Clinical Neurosciences and Preventive Medicine, Danube University Krems, Dr.-Karl-Dorrek-Str. 30, A-3500, Krems, Austria.,Department of Neurology, University Clinic Tulln, Karl Landsteiner Privatuniversität für Gesundheitswissenschaften, Krems, Austria
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38
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Pan Y, Wang Y, Li H, Gaisano HY, Wang Y, He Y. Association of Diabetes and Prognosis of Minor Stroke and Its Subtypes: A Prospective Observational Study. PLoS One 2016; 11:e0153178. [PMID: 27070309 PMCID: PMC4829263 DOI: 10.1371/journal.pone.0153178] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2016] [Accepted: 03/24/2016] [Indexed: 12/15/2022] Open
Abstract
Background The association between diabetes mellitus (DM) and prognosis of minor stroke is unclear. The aim of this study is to investigate whether DM contributes to the prognosis of minor stroke or its specific subtype. Methods All minor ischemic stroke patients were derived from the China National Stroke Registry and classified into 5 subtypes according to the TOAST (Trial of Org 10172 in Acute Stroke Treatment) criteria. DM was defined as either self-reported physician diagnosis of diabetes or use of hypoglycemic medications during hospitalization or at discharge. Patients were followed up for 1 year for clinical outcomes of recurrent stroke, death and functional outcome. Poor functional outcomes were defined as a score of 2–6 for modified Rankin Score. Associations between DM and prognosis of minor stroke and its subtypes were analyzed by univariable and multivariable logistic regression. Results Of 4,548 patients with minor stroke, 1,230(27.0%) patients had DM, 1,038(22.8%) had poor outcomes and 570(13.0%) of 4,401 patients had recurrent stroke at 1 year. In multivariable analyses, DM were significantly associated with 1-year stroke recurrence (Odds Ratio [OR], 1.31; 95% confidence interval [CI]: 1.08–1.59) and poor outcome (OR, 1.51; 95%CI: 1.28–1.77). Among the subtypes of minor stroke, DM was only significantly associated with 1-year stroke recurrence (OR, 1.63; 95%CI: 1.07–2.50) and poor outcome (OR, 1.73; 95%CI: 1.22–2.45) in the small-artery occlusion subtype. Conclusions DM significantly increased the risk of stroke recurrence and poor outcome in the small-artery occlusion subtype, but not in other subtypes of minor stroke.
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Affiliation(s)
- Yuesong Pan
- Department of Epidemiology and Health Statistics, School of Public Health, Capital Medical University, Beijing, China
- Beijing Municipal Key Laboratory of Clinical Epidemiology, Beijing, China
| | - Yongjun Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
- Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China
- Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Hao Li
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
- Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China
- Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Herbert Y. Gaisano
- Department of Physiology, University of Toronto, Toronto, Ontario, Canada
| | - Yilong Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
- Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China
- Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
- * E-mail: (YH); (Yilong Wang)
| | - Yan He
- Department of Epidemiology and Health Statistics, School of Public Health, Capital Medical University, Beijing, China
- Beijing Municipal Key Laboratory of Clinical Epidemiology, Beijing, China
- * E-mail: (YH); (Yilong Wang)
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The Ischemic Stroke Predictive Risk Score Predicts Early Neurological Deterioration. J Stroke Cerebrovasc Dis 2016; 25:819-24. [DOI: 10.1016/j.jstrokecerebrovasdis.2015.12.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2015] [Accepted: 12/09/2015] [Indexed: 11/21/2022] Open
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40
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Serles W, Gattringer T, Mutzenbach S, Seyfang L, Trenkler J, Killer-Oberpfalzer M, Deutschmann H, Niederkorn K, Wolf F, Gruber A, Hausegger K, Weber J, Thurnher S, Gizewski E, Willeit J, Karaic R, Fertl E, Našel C, Brainin M, Erian J, Oberndorfer S, Karnel F, Grisold W, Auff E, Fazekas F, Haring HP, Lang W. Endovascular stroke therapy in Austria: a nationwide 1-year experience. Eur J Neurol 2016; 23:906-11. [PMID: 26843095 DOI: 10.1111/ene.12958] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2015] [Accepted: 12/07/2015] [Indexed: 11/27/2022]
Abstract
BACKGROUND AND PURPOSE Based on a tight network of stroke units (SUs) and interventional centres, endovascular treatment of acute major intracranial vessel occlusion has been widely implemented in Austria. Documentation of all patients in the nationwide SU registry has thereby become mandatory. METHODS Demographic, clinical and interventional characteristics of patients who underwent endovascular treatment for acute ischaemic stroke in 11 Austrian interventional centres between 1 October 2013 and 30 September 2014 were analysed. RESULTS In total, 301 patients (50.5% women; median age 70.5 years; median National Institutes of Health Stroke Scale score 17) were identified.193 patients (64.1%) additionally received intravenous thrombolysis. The most frequent vessel occlusion sites were the M1 segment of the middle cerebral artery (n = 161, 53.5%), the intracranial internal carotid artery (n = 60, 19.9%) and the basilar artery (n = 40, 13.3%). Stent retrievers were used in 235 patients (78.1%) and adequate reperfusion (modified Thrombolysis in Cerebral Infarction scores 2b and 3, median onset to reperfusion time 254 min) was achieved in 242 patients (81.4%). Symptomatic intracranial haemorrhage occurred in 7%. 43.8% of patients (n = 132) had good functional outcome (modified Rankin Scale score 0-2) and the mortality rate was 20.9% (n = 63) after 3 months. Compared to the anterior circulation, vertebrobasilar stroke patients had higher mortality. Patients with secondary hospital transportation had better outcomes after 3 months than in-house treated patients. CONCLUSION Our results document nationwide favourable outcome and safety rates of endovascular stroke treatment comparable to recent randomized trials. The ability to provide such data and the need to further optimize such an approach also underscore the contribution of respective registries.
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Affiliation(s)
- W Serles
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - T Gattringer
- Department of Neurology, Medical University of Graz, Graz, Austria
| | - S Mutzenbach
- Department of Neurology, Paracelsus Medical University Salzburg, Salzburg, Austria
| | - L Seyfang
- Danube University Krems and Gesundheit Österreich GmbH/BIQG, Vienna, Austria
| | - J Trenkler
- Department of Neuroradiology, Wagner-Jauregg Hospital, Linz, Austria
| | - M Killer-Oberpfalzer
- Department of Neurology, Paracelsus Medical University Salzburg, Salzburg, Austria.,Research Institute of Neurointervention, Paracelsus Medical University Salzburg, Salzburg, Austria
| | - H Deutschmann
- Division of Vascular and Interventional Radiology, Department of Radiology, Medical University of Graz, Graz, Austria
| | - K Niederkorn
- Department of Neurology, Medical University of Graz, Graz, Austria
| | - F Wolf
- Department of Cardiovascular and Interventional Radiology, Medical University of Vienna, Vienna, Austria
| | - A Gruber
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
| | - K Hausegger
- Institute of Diagnostic and Interventional Radiology, Klinikum Klagenfurt, Klagenfurt, Austria
| | - J Weber
- Department of Neurology, Klinikum Klagenfurt, Klagenfurt, Austria
| | - S Thurnher
- Department of Radiology and Nuclear Medicine, Krankenhaus Barmherzige Brüder, Vienna, Austria
| | - E Gizewski
- Department of Neuroradiology, Medical University of Innsbruck, Innsbruck, Austria
| | - J Willeit
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - R Karaic
- Department of Radiology, Krankenanstalt Rudolfstiftung, Vienna, Austria
| | - E Fertl
- Department of Neurology, Krankenanstalt Rudolfstiftung, Vienna, Austria
| | - C Našel
- Department of Radiology, University Clinic Tulln, Tulln, Austria
| | - M Brainin
- Department of Neurology, University Clinic Tulln, Tulln, Austria
| | - J Erian
- Institute of Medical Radiology, University Clinic St Pölten, St Pölten, Austria
| | - S Oberndorfer
- Department of Neurology, University Clinic St Pölten, St Pölten, Austria
| | - F Karnel
- Department of Radiology, Kaiser Franz Josef Hospital Vienna, Vienna, Austria
| | - W Grisold
- Department of Neurology, Kaiser Franz Josef Hospital Vienna, Vienna, Austria
| | - E Auff
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - F Fazekas
- Department of Neurology, Medical University of Graz, Graz, Austria
| | - H-P Haring
- Department of Neurology, Wagner-Jauregg Hospital, Linz, Austria
| | - W Lang
- Department of Neurology, Krankenhaus Barmherzige Brüder, Vienna, Austria
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Demaerschalk BM, Kleindorfer DO, Adeoye OM, Demchuk AM, Fugate JE, Grotta JC, Khalessi AA, Levy EI, Palesch YY, Prabhakaran S, Saposnik G, Saver JL, Smith EE. Scientific Rationale for the Inclusion and Exclusion Criteria for Intravenous Alteplase in Acute Ischemic Stroke. Stroke 2016; 47:581-641. [DOI: 10.1161/str.0000000000000086] [Citation(s) in RCA: 442] [Impact Index Per Article: 55.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Purpose—
To critically review and evaluate the science behind individual eligibility criteria (indication/inclusion and contraindications/exclusion criteria) for intravenous recombinant tissue-type plasminogen activator (alteplase) treatment in acute ischemic stroke. This will allow us to better inform stroke providers of quantitative and qualitative risks associated with alteplase administration under selected commonly and uncommonly encountered clinical circumstances and to identify future research priorities concerning these eligibility criteria, which could potentially expand the safe and judicious use of alteplase and improve outcomes after stroke.
Methods—
Writing group members were nominated by the committee chair on the basis of their previous work in relevant topic areas and were approved by the American Heart Association Stroke Council’s Scientific Statement Oversight Committee and the American Heart Association’s Manuscript Oversight Committee. The writers used systematic literature reviews, references to published clinical and epidemiology studies, morbidity and mortality reports, clinical and public health guidelines, authoritative statements, personal files, and expert opinion to summarize existing evidence and to indicate gaps in current knowledge and, when appropriate, formulated recommendations using standard American Heart Association criteria. All members of the writing group had the opportunity to comment on and approved the final version of this document. The document underwent extensive American Heart Association internal peer review, Stroke Council Leadership review, and Scientific Statements Oversight Committee review before consideration and approval by the American Heart Association Science Advisory and Coordinating Committee.
Results—
After a review of the current literature, it was clearly evident that the levels of evidence supporting individual exclusion criteria for intravenous alteplase vary widely. Several exclusionary criteria have already undergone extensive scientific study such as the clear benefit of alteplase treatment in elderly stroke patients, those with severe stroke, those with diabetes mellitus and hyperglycemia, and those with minor early ischemic changes evident on computed tomography. Some exclusions such as recent intracranial surgery are likely based on common sense and sound judgment and are unlikely to ever be subjected to a randomized, clinical trial to evaluate safety. Most other contraindications or warnings range somewhere in between. However, the differential impact of each exclusion criterion varies not only with the evidence base behind it but also with the frequency of the exclusion within the stroke population, the probability of coexistence of multiple exclusion factors in a single patient, and the variation in practice among treating clinicians.
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Tatlisumak T, Roine RO. General Stroke Management and Stroke Units. Stroke 2016. [DOI: 10.1016/b978-0-323-29544-4.00053-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Gattringer T, Enzinger C, Fischer R, Seyfang L, Niederkorn K, Khalil M, Ferrari J, Lang W, Brainin M, Willeit J, Fazekas F. IV thrombolysis in patients with ischemic stroke and alcohol abuse. Neurology 2015; 85:1592-7. [PMID: 26446065 DOI: 10.1212/wnl.0000000000002078] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2014] [Accepted: 07/06/2015] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To determine whether chronic alcohol consumption or acute alcohol intoxication affects the rate of IV thrombolysis (IVT) and associated risk of symptomatic intracranial hemorrhage (SICH) in patients with acute ischemic stroke (IS). METHODS We analyzed data from the nationwide Austrian Stroke Unit Registry for all patients with IS admitted to one of 35 stroke units between 2004 and 2014. We compared demographic and clinical characteristics for patients with chronic alcohol consumption (>2 drinks/d) or acute intoxication and for patients without these factors and their rates of IVT and associated SICH. RESULTS We identified 47,422 patients with IS. Of these patients, 3,999 (8.5%) consumed alcohol chronically and 216 (0.5%) presented with acute intoxication. Alcohol abusers were younger, more frequently men, and less often functionally disabled before the index event. Stroke severity was comparable between alcoholic and nonalcoholic IS patients. Nevertheless, patients who abused alcohol were less likely to receive IVT (16.6% vs 18.9%) and this difference remained after accounting for possible confounders. Rates of SICH after IVT were not increased in patients who abused alcohol (2.1% vs 3.7%, p = 0.04). Multivariate analysis including age, NIH Stroke Scale score, and time from symptom onset to IVT treatment showed that alcohol abuse was not an independent risk factor for SICH and was not protective (odds ratio 0.73, 95% confidence interval 0.43-1.25, p = 0.2). CONCLUSIONS IS patients with chronic alcohol consumption or acute intoxication have decreased likelihood of receiving IVT and are not at an increased risk of associated SICH. This supports current practice guidelines, which do not list chronic alcohol consumption or acute intoxication as an exclusion criterion.
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Affiliation(s)
- Thomas Gattringer
- From the Department of Neurology (T.G., C.E., R.F., K.N., M.K., F.F.) and Division of Neuroradiology, Department of Radiology (C.E.), Medical University of Graz; Center of Clinical Neurosciences (L.S., M.B.), Danube University of Krems; Department of Neurology (J.F., W.L.), Hospital Barmherzige Brueder Vienna; Department of Neurology (M.B.), University Hospital Tulln; and Department of Neurology (J.W.), Medical University of Innsbruck, Austria.
| | - Christian Enzinger
- From the Department of Neurology (T.G., C.E., R.F., K.N., M.K., F.F.) and Division of Neuroradiology, Department of Radiology (C.E.), Medical University of Graz; Center of Clinical Neurosciences (L.S., M.B.), Danube University of Krems; Department of Neurology (J.F., W.L.), Hospital Barmherzige Brueder Vienna; Department of Neurology (M.B.), University Hospital Tulln; and Department of Neurology (J.W.), Medical University of Innsbruck, Austria
| | - Renate Fischer
- From the Department of Neurology (T.G., C.E., R.F., K.N., M.K., F.F.) and Division of Neuroradiology, Department of Radiology (C.E.), Medical University of Graz; Center of Clinical Neurosciences (L.S., M.B.), Danube University of Krems; Department of Neurology (J.F., W.L.), Hospital Barmherzige Brueder Vienna; Department of Neurology (M.B.), University Hospital Tulln; and Department of Neurology (J.W.), Medical University of Innsbruck, Austria
| | - Leonhard Seyfang
- From the Department of Neurology (T.G., C.E., R.F., K.N., M.K., F.F.) and Division of Neuroradiology, Department of Radiology (C.E.), Medical University of Graz; Center of Clinical Neurosciences (L.S., M.B.), Danube University of Krems; Department of Neurology (J.F., W.L.), Hospital Barmherzige Brueder Vienna; Department of Neurology (M.B.), University Hospital Tulln; and Department of Neurology (J.W.), Medical University of Innsbruck, Austria
| | - Kurt Niederkorn
- From the Department of Neurology (T.G., C.E., R.F., K.N., M.K., F.F.) and Division of Neuroradiology, Department of Radiology (C.E.), Medical University of Graz; Center of Clinical Neurosciences (L.S., M.B.), Danube University of Krems; Department of Neurology (J.F., W.L.), Hospital Barmherzige Brueder Vienna; Department of Neurology (M.B.), University Hospital Tulln; and Department of Neurology (J.W.), Medical University of Innsbruck, Austria
| | - Michael Khalil
- From the Department of Neurology (T.G., C.E., R.F., K.N., M.K., F.F.) and Division of Neuroradiology, Department of Radiology (C.E.), Medical University of Graz; Center of Clinical Neurosciences (L.S., M.B.), Danube University of Krems; Department of Neurology (J.F., W.L.), Hospital Barmherzige Brueder Vienna; Department of Neurology (M.B.), University Hospital Tulln; and Department of Neurology (J.W.), Medical University of Innsbruck, Austria
| | - Julia Ferrari
- From the Department of Neurology (T.G., C.E., R.F., K.N., M.K., F.F.) and Division of Neuroradiology, Department of Radiology (C.E.), Medical University of Graz; Center of Clinical Neurosciences (L.S., M.B.), Danube University of Krems; Department of Neurology (J.F., W.L.), Hospital Barmherzige Brueder Vienna; Department of Neurology (M.B.), University Hospital Tulln; and Department of Neurology (J.W.), Medical University of Innsbruck, Austria
| | - Wilfried Lang
- From the Department of Neurology (T.G., C.E., R.F., K.N., M.K., F.F.) and Division of Neuroradiology, Department of Radiology (C.E.), Medical University of Graz; Center of Clinical Neurosciences (L.S., M.B.), Danube University of Krems; Department of Neurology (J.F., W.L.), Hospital Barmherzige Brueder Vienna; Department of Neurology (M.B.), University Hospital Tulln; and Department of Neurology (J.W.), Medical University of Innsbruck, Austria
| | - Michael Brainin
- From the Department of Neurology (T.G., C.E., R.F., K.N., M.K., F.F.) and Division of Neuroradiology, Department of Radiology (C.E.), Medical University of Graz; Center of Clinical Neurosciences (L.S., M.B.), Danube University of Krems; Department of Neurology (J.F., W.L.), Hospital Barmherzige Brueder Vienna; Department of Neurology (M.B.), University Hospital Tulln; and Department of Neurology (J.W.), Medical University of Innsbruck, Austria
| | - Johann Willeit
- From the Department of Neurology (T.G., C.E., R.F., K.N., M.K., F.F.) and Division of Neuroradiology, Department of Radiology (C.E.), Medical University of Graz; Center of Clinical Neurosciences (L.S., M.B.), Danube University of Krems; Department of Neurology (J.F., W.L.), Hospital Barmherzige Brueder Vienna; Department of Neurology (M.B.), University Hospital Tulln; and Department of Neurology (J.W.), Medical University of Innsbruck, Austria
| | - Franz Fazekas
- From the Department of Neurology (T.G., C.E., R.F., K.N., M.K., F.F.) and Division of Neuroradiology, Department of Radiology (C.E.), Medical University of Graz; Center of Clinical Neurosciences (L.S., M.B.), Danube University of Krems; Department of Neurology (J.F., W.L.), Hospital Barmherzige Brueder Vienna; Department of Neurology (M.B.), University Hospital Tulln; and Department of Neurology (J.W.), Medical University of Innsbruck, Austria
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Shrestha S, Poudel RS, Khatiwada D, Thapa L. Stroke subtype, age, and baseline NIHSS score predict ischemic stroke outcomes at 3 months: a preliminary study from Central Nepal. J Multidiscip Healthc 2015; 8:443-8. [PMID: 26491342 PMCID: PMC4598209 DOI: 10.2147/jmdh.s90554] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND The combined medications practice of using antithrombotic agents and statins with or without antihypertensive agents is common in the treatment of acute ischemic stroke in Nepal. Short-term outcomes of the current practice have been studied. We aim to explore the predictors of ischemic stroke outcomes at 3 months, with the current combined medications practice. METHODS The study population (N=56) included acute ischemic stroke patients treated at the Neurology Department of the College of Medical Sciences-Teaching Hospital, Chitwan, Nepal, from May 2014 to August 2014 and followed up at 3 months. Death or disability (modified Rankin scale >2) was defined as poor outcomes. Multivariate logistic regression analysis (P<0.10) using potential variables from bivariate analysis (P≤0.20) was adjusted to predict outcomes at 3 months. RESULTS At 3 months, 29 (51.8%) patients were independent, eleven (19.6%) were dependent, while 16 (28.6%) died. Stroke subtype and baseline National Institute of Health Stroke Scale (NIHSS) scores were associated with death/disability (27, 48.2%) at 3 months. Regression analysis showed that large-artery stroke (odds ratio [OR] =284.145, 95% confidence interval [CI] =5.221-15,465.136, P=0.006), age (OR =1.113, 95% CI =1.002-1.236, P=0.045), and baseline NIHSS score (OR =1.557, 95% CI =1.194-2.032, P=0.001) were significant predictors of poor outcome at 3 months. CONCLUSION Stroke subtype, age, and baseline NIHSS score are predictors of ischemic stroke outcomes in Nepalese population treated with the current practice of using combined antithrombotic and statins with or without antihypertensive agents, and these predictors can be used for the improvement of selection of patients for the appropriate treatment.
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Affiliation(s)
- Shakti Shrestha
- Department of Pharmacy, Shree Medical and Technical College, Chitwan, Nepal
| | - Ramesh Sharma Poudel
- Department of Pharmacy, College of Medical Sciences-Teaching Hospital, Chitwan, Nepal
| | - Dipendra Khatiwada
- Department of Community Medicine, College of Medical Sciences-Teaching Hospital, Chitwan, Nepal
| | - Lekhjung Thapa
- Department of Neurology, College of Medical Sciences-Teaching Hospital, Chitwan, Nepal
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Ferrari J, Shiue I, Seyfang L, Matzarakis A, Lang W. Weather as physiologically equivalent was not associated with ischemic stroke onsets in Vienna, 2004-2010. ENVIRONMENTAL SCIENCE AND POLLUTION RESEARCH INTERNATIONAL 2015; 22:8756-8762. [PMID: 25877904 DOI: 10.1007/s11356-015-4494-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/03/2014] [Accepted: 04/05/2015] [Indexed: 06/04/2023]
Abstract
Stroke rates were found to have seasonal variations. However, previous studies using air temperature, humidity, or air pressure separately were not adequate, and the study catchment was not clearly drawn. Therefore, here we proposed to use a thermal index called physiologically equivalent temperature (PET) that incorporates air temperature, humidity, wind speed, cloud cover, air pressure and radiation flux from a biometeorological approach to estimate the effect of weather as physiologically equivalent on ischemic stroke onsets in an Austrian population. Eight thousand four hundred eleven stroke events in Vienna registered within the Austrian Stroke Unit Register from January 1, 2004 to December 31, 2010 were included and were correlated with the weather data, obtained from the Central Institute for Meteorology and Geodynamics in the same area and study time period and calculated as PET (°C). Statistical analysis involved Poisson regression modeling. The median age was 74 years, and men made up 49 % of the entire population. Eighty percent had hypertension while 25.4 % were current smokers. Of note, 26.5 % had diabetes mellitus, 28.9 % had pre-stroke, and 11.5 % had pre-myocardial infarction. We have observed that onsets were higher on the weekdays than on the weekend. However, we did not find any significant association between PETs and ischemic stroke onsets by subtypes in Vienna. We did not observe any significant associations between PETs and ischemic stroke onsets by subtypes in Vienna. Hospital admission peaks on the weekdays might be due to hospital administration reasons.
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Affiliation(s)
- Julia Ferrari
- Department of Neurology, St. John of God Hospital, Vienna, Austria
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Bi Q, Li JY, Li XQ, Li Q, Luo D, Qiao QB. Impact of Intracranial Artery Disease and Prior Cerebral Infarction on Central Nervous System Complications After Off-Pump Coronary Artery Bypass Grafting. NEUROPHYSIOLOGY+ 2015. [DOI: 10.1007/s11062-015-9480-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Seners P, Turc G, Oppenheim C, Baron JC. Incidence, causes and predictors of neurological deterioration occurring within 24 h following acute ischaemic stroke: a systematic review with pathophysiological implications. J Neurol Neurosurg Psychiatry 2015; 86:87-94. [PMID: 24970907 DOI: 10.1136/jnnp-2014-308327] [Citation(s) in RCA: 161] [Impact Index Per Article: 17.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Early neurological deterioration (END) following ischaemic stroke is a serious event with manageable causes in only a fraction of patients. The incidence, causes and predictors of END occurring within 24 h of acute ischaemic stroke (END24) have not been systematically reviewed. We systematically reviewed Medline and Embase from January 1990 to April 2013 for all studies on END24 following acute ischaemic stroke (<8 h from onset). We recorded the incidence and presumed causes of and factors associated with END24. Thirty-six studies were included. Depending on the definition used, the incidence of END24 markedly varied among studies. Using the most widely used change in National Institutes of Health Stroke Scale ≥4 definition, the pooled incidence was 13.8% following thrombolysis, ascribed to intracranial haemorrhage and malignant oedema each in ∼20% of these. As other mechanisms were rarely reported, in the majority no clear cause was identified. Few data on END24 occurring in non-thrombolysed patients were available. Across thrombolysed and non-thrombolysed samples, the strongest and most consistent admission predictors were hyperglycaemia, no prior aspirin use, prior transient ischaemic attacks, proximal arterial occlusion and presence of early CT changes, and the most consistent 24 h follow-up associated factors were no recanalisation/reocclusion, large infarcts and intracranial haemorrhage. Finally, END24 was strongly predictive of poor outcome. The above findings are discussed with emphasis on END without a clear mechanism. Data on incidence and predictors of the latter subtype is scarce, and future studies using systematic imaging protocols should address its underlying pathophysiology. This may in turn lead to rational preventative and therapeutic measures for this ominous event.
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Affiliation(s)
- Pierre Seners
- Sorbonne Paris Cité, INSERM UMR S894, Service de Neurologie, Université Paris Descartes, Hôpital Sainte-Anne, Paris, France
| | - Guillaume Turc
- Sorbonne Paris Cité, INSERM UMR S894, Service de Neurologie, Université Paris Descartes, Hôpital Sainte-Anne, Paris, France
| | - Catherine Oppenheim
- Sorbonne Paris Cité, INSERM UMR S894, Service de Neuroradiologie, Centre Hospitalier Sainte-Anne, Université Paris Descartes, Paris, France
| | - Jean-Claude Baron
- Sorbonne Paris Cité, INSERM UMR S894, Service de Neurologie, Université Paris Descartes, Hôpital Sainte-Anne, Paris, France
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Desai JA, Abuzinadah AR, Imoukhuede O, Bernbaum ML, Modi J, Demchuk AM, Coutts SB. Etiologic Classification of TIA and Minor Stroke by A-S-C-O and Causative Classification System as Compared to TOAST Reduces the Proportion of Patients Categorized as Cause Undetermined. Cerebrovasc Dis 2014; 38:121-6. [DOI: 10.1159/000365500] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2014] [Accepted: 06/25/2014] [Indexed: 11/19/2022] Open
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Kim JT, Heo SH, Lee JS, Park MH, Oh DS, Choi KH, Kim IG, Ha YS, Chang H, Choo IS, Ahn SH, Jeong SK, Shin BS, Park MS, Cho KH. To do or not to do; dilemma of intra-arterial revascularization in acute ischemic stroke. PLoS One 2014; 9:e99261. [PMID: 24906122 PMCID: PMC4048270 DOI: 10.1371/journal.pone.0099261] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2013] [Accepted: 05/12/2014] [Indexed: 01/19/2023] Open
Abstract
Background There has still been lack of evidence for definite imaging criteria of intra-arterial revascularization (IAR). Therefore, IAR selection is left largely to individual clinicians. In this study, we sought to investigate the overall agreement of IAR selection among different stroke clinicians and factors associated with good agreement of IAR selection. Methods From the prospectively registered data base of a tertiary hospital, we identified consecutive patients with acute ischemic stroke. IAR selection based on the provided magnetic resonance imaging (MRI) results and clinical information were independently performed by 5 independent stroke physicians currently working at 4 different university hospitals. MRI results were also reviewed by 2 independent experienced neurologists blinded to clinical data and physicians' IAR selection. The Alberta Stroke Program Early Computed Tomography Score (ASPECTS) was calculated on initial DWI and MTT. We arbitrarily used ASPECTS differences between DWI and MTT (D-M ASPECTS) to quantitatively evaluate mismatch. Results The overall interobserver agreement of IAR selection was fair (kappa = 0.398). In patients with DWI-ASPECTS >6, interobserver agreement was moderate to substantial (0.398–0.620). In patients with D-M ASPECTS >4, interobserver agreement was moderate to almost perfect (0.532–1.000). Patients with higher DWI or D-M ASPECTS had better agreement of IAR selection. Conclusion Our study showed that DWI-ASPSECTS >6 and D-M ASPECTS >4 had moderate to substantial agreement of IAR selection among different stroke physicians. However, there is still poor agreement as to whether IAR should not be performed in patients with lower DWI and D-M ASPECTS.
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Affiliation(s)
- Joon-Tae Kim
- Department of Neurology, Cerebrovascular Center, Chonnam National University Hospital, Gwangju, Korea
- * E-mail: (JTK); (MSP)
| | - Suk-Hee Heo
- Department of Radiology, Chonnam National University Hwasun Hospital, Hwasun, Korea
| | - Ji Sung Lee
- Biostatistical Consulting Unit, Soonchunhyang University Medical Center, Seoul, Korea
| | - Myeong-Ho Park
- Department of Neurology, Cerebrovascular Center, Chonnam National University Hospital, Gwangju, Korea
| | - Dong-Seok Oh
- Department of Neurology, Cerebrovascular Center, Chonnam National University Hospital, Gwangju, Korea
| | - Kang-Ho Choi
- Department of Neurology, Cerebrovascular Center, Chonnam National University Hospital, Gwangju, Korea
| | - Ihn-Gyu Kim
- Department of Neurology, Cerebrovascular Center, Chonnam National University Hospital, Gwangju, Korea
| | - Yeon Soo Ha
- Department of Neurology, Wonkwang University Hospital, Iksan, Korea
| | - Hyuk Chang
- Department of Neurology, Wonkwang University Hospital, Iksan, Korea
| | - In Sung Choo
- Department of Neurology, Chosun University Hospital, Gwangju, Korea
| | - Seong Hwan Ahn
- Department of Neurology, Chosun University Hospital, Gwangju, Korea
| | - Seul-Ki Jeong
- Department of Neurology, Chonbuk National University Medical School and Hospital, Jeonju, Korea
| | - Byoung-Soo Shin
- Department of Neurology, Chonbuk National University Medical School and Hospital, Jeonju, Korea
| | - Man-Seok Park
- Department of Neurology, Cerebrovascular Center, Chonnam National University Hospital, Gwangju, Korea
- * E-mail: (JTK); (MSP)
| | - Ki-Hyun Cho
- Department of Neurology, Cerebrovascular Center, Chonnam National University Hospital, Gwangju, Korea
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Sato S, Uehara T, Ohara T, Suzuki R, Toyoda K, Minematsu K. Factors associated with unfavorable outcome in minor ischemic stroke. Neurology 2014; 83:174-81. [PMID: 24907232 DOI: 10.1212/wnl.0000000000000572] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVES The purpose of this study was to elucidate the factors that correlate with unfavorable outcomes and to develop a simple validated model for assessing risk of unfavorable outcomes in patients with minor ischemic stroke. METHODS The derivation cohort included 1,313 patients hospitalized within 72 hours after onset with an initial NIH Stroke Scale score of 0 to 3 enrolled in a prospective, multicenter, observational study. Unfavorable outcome was defined as dependency (modified Rankin Scale score of 3-5) or death at 90 days. The predictive values of factors related to unfavorable outcome were evaluated. External validation was performed in 879 patients from a single-center stroke registry. RESULTS In the derivation cohort, a total of 203 patients (15%) had unfavorable outcomes. On multivariable analysis, women (odds ratio [OR] 1.95, 95% confidence interval [CI] 1.30-2.94), age ≥72 years (OR 2.80, 95% CI 1.83-4.36), intra/extracranial vascular occlusive lesion (OR 2.80, 95% CI 1.82-4.28), leg weakness (OR 1.72, 95% CI 1.06-2.82), and extinction/inattention (OR 5.55, 95% CI 1.30-21.71) were independently associated with unfavorable outcome. Patients having both a vascular lesion and either leg weakness or extinction/inattention showed 4.63 (95% CI 2.23-9.33) times the risk of unfavorable outcome compared with those having neither. In the validation cohort, the risk was similar, at 3.77 (95% CI 1.64-8.37). CONCLUSIONS Intra- and extracranial vascular imaging, NIH Stroke Scale items such as leg weakness and extinction/inattention, and their combination, as well as female sex and advanced age, may be useful for predicting unfavorable outcomes in patients with minor stroke.
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Affiliation(s)
- Shoichiro Sato
- From the Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan.
| | - Toshiyuki Uehara
- From the Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Tomoyuki Ohara
- From the Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Rieko Suzuki
- From the Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Kazunori Toyoda
- From the Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Kazuo Minematsu
- From the Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
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