Viral Etiology of Aseptic Meningitis and Clinical Prediction of Herpes Simplex Virus Type 2 Meningitis.

BACKGROUND: Aseptic meningitis comprises meningeal inflammation and cerebrospinal fluid (CSF) pleocytosis without positive Gram stain and culture. Regional differences exist in the prevalence of viral etiologies of aseptic meningitis. We aimed to assess the etiologies of aseptic meningitis in immunocompetent adults, focusing on herpes simplex virus type 2 (HSV-2). METHODS: This study retrospectively analyzed immunocompetent adults diagnosed with meningitis at a Korean tertiary care hospital from 2016 to 2018. Aseptic meningitis was defined through clinical and CSF analysis. We compared clinical and laboratory characteristics across viral etiologies and investigated predictors of HSV-2 meningitis. RESULTS: A total of 98 patients (46.9% female) with aseptic meningitis were finally enrolled. The etiologies of aseptic meningitis were identified in 62 patients (63.3%), including enterovirus (28.5%), HSV-2 (16.3%), and varicella zoster virus (VZV, 15.3%). HSV-2 showed female predominance, with shorter admission times with longer hospital stays and a recurrent meningitis history. Compared to other viral etiologies, HSV-2 showed higher CSF white blood cell (WBC) counts and protein levels but lower C-reactive protein (CRP) levels. A random forest model identified previous meningitis history and serum CRP level as key predictors of HSV-2 meningitis. CONCLUSIONS: This study provides insights into the etiologies of aseptic meningitis in a specific Korean region, identifying HSV-2 as a notable cause. The prediction model suggested that the clinical history of previous meningitis and serum CRP level may guide clinical assessment of meningitis.

Validation of the Korean version of the Sleep Hygiene Practice Scale in a Non-Clinical Population.

OBJECTIVES: This study aimed to validate the Korean version of the sleep hygiene practice scale (SHPS-K) and determine its effectiveness in screening poor sleepers with insomnia. METHODS: Online survey was conducted using translated SHPS in Korean, the Korean versions of the Pittsburgh Sleep Quality Index (PSQI-K), Insomnia Severity Index (ISI-K), and Epworth Sleepiness Scale (KESS) in a non-clinical population. The internal consistency and test-retest reliability of the SHPS-K were assessed using Cronbach's alpha and intraclass correlation coefficients (ICC), respectively. Construct validity was evaluated using correlation analyses with other questionnaires and confirmatory factor analysis. We determined the cutoff values that could identify poor sleepers with insomnia symptoms (PSQI-K > 5 and ISI-K ≥ 15) using receiver operating characteristic analysis. RESULTS: A total of 484 participants (242 women, mean age of 43.8 years) were enrolled. The average SHPS-K score was 71.2, with no significant sex differences. Women had poorer sleep scheduling and timing behaviors, and men had poorer eating and drinking behaviors. Good internal consistency (Cronbach's alpha = 0.88) and test-retest reliability (ICC = 0.80) were observed. The SHPS-K was positively correlated with the PSQI-K (r = 0.55), ISI-K (r = 0.54), and KESS (r = 0.42). A cutoff value of 73 identified poor sleepers with insomnia (area under the curve = 0.828). CONCLUSIONS: The SHPS-K is a reliable instrument for evaluating sleep hygiene in non-clinical Korean populations.

Cognitive Impairment in a Child With Anti-N-Methyl-D-Aspartate Receptor Encephalitis: A Case Report.

Anti-N-methyl-D-aspartate-receptor encephalitis is a complex autoimmune inflammatory neurological disorder that presents with epileptic seizures and rapid functional deterioration, including movement disorders and cognitive impairment, especially in young patients. Despite aggressive initial treatment with immune therapy, such as corticosteroids, intravenous immunoglobulin, and plasmapheresis, patients often need intensive rehabilitative therapies for their long-lasting deficits. We report a pediatric case of anti-N-methyl-D-aspartate receptor encephalitis in Korea that presented with symptoms of muscle weakness of the four extremities, dysarthria, dysphagia, and cognitive impairment in the acute phase. The patient underwent 4 weeks of comprehensive rehabilitative treatment, including physical therapy, occupational therapy, swallowing rehabilitation therapy, cognitive rehabilitation therapy, and speech therapy. At the follow-up evaluation after 4 weeks of treatment, she showed significant improvements in limb muscle strength, balance ability, swallowing, language function, and the ability to perform activities of daily living. However, when assessed using the Korean Wechsler Intelligence Scale for Children-IV, there was little improvement in cognitive function, particularly in working memory. While only a few cases have reported the progression of cognitive function using a standardized cognitive evaluation tool in patients with anti-N-methyl-D-aspartate receptor encephalitis, this present case report adds to the accumulation of evidence of neurocognitive deficits in these patients.

National Estimates of Narcolepsy in Korea.

BACKGROUND AND PURPOSE: Epidemiological data on narcolepsy are rare in South Korea. We aimed to provide an overview of the burden of narcolepsy and its temporal trend in South Korea. METHODS: Patients with narcolepsy were identified by their registration in the Rare and Intractable Disease (RID) register and the Health Insurance Review and Assessment database. Individuals registered in the RID program with the code V234 were considered as having 'definite narcolepsy', while those who claimed health insurance with G47.4 as the primary diagnostic code were considered as having 'probable narcolepsy'. We estimated the annual prevalence, incidence, and medical costs of narcolepsy between 2010 and 2019. RESULTS: The prevalence of definite narcolepsy was 8.4/100,000 in 2019, peaking at 32.0/100,000 in those aged 15-19 years. The prevalence was higher in males, with a relative risk of 1.72. The prevalence has increased over the past 6 years, with an average annual growth rate (AAGR) of 12.2%. The prevalence of probable narcolepsy was 10.7/100,000 in 2019. The incidence of definite narcolepsy increased up to 1.3/100,000 in 2019 with an AAGR of 7.1%. Annual medical expenditure for definite narcolepsy gradually increased up to 4.1 billion KRW in 2019, with a compound annual growth rate of 11.9%. CONCLUSIONS: This study has provided the first nationwide estimates for narcolepsy in South Korea. The prevalence of diagnosed narcolepsy in South Korea was at the low end of the range of narcolepsy prevalence rates reported for other countries. However, the prevalence and incidence have been steadily increasing over the past decade.

Sex Differences in Obstructive Sleep Apnea by Bioelectrical Impedance Analysis.

BACKGROUND AND PURPOSE: Obesity is known of one of the risk factors for obstructive sleep apnea (OSA). Although body mass index (BMI) can be an indicator for obesity, it does not represent the actual body composition of fat or muscle. We hypothesized that bioelectrical impedance analysis (BIA) can help analyze the fat and muscle distributions in males and females with OSA. METHODS: This study screened subjects who visited the Department of Neurology, Samsung Medical Center, Seoul, Korea due to sleep disturbances with symptoms suggestive of OSA from December 2017 to December 2019. All subjects underwent overnight type I polysomnography (PSG) and BIA. RESULTS: PSG and BIA were completed in 2,064 OSA patients who had an apnea-hypopnea index (AHI) of ≥5/hour (77.1% males and 22.9% females). The females had remarkably higher fat indicators and lower muscle indicators. The AHI was significant correlated with all BIA parameters in all OSA patients: body fat mass (ρ=0.286, p<0.001), percentage body fat (ρ=0.130, p<0.001), visceral fat area (VFA) (ρ=0.257, p<0.001), muscle mass (ρ=0.275, p<0.001), and skeletal muscle mass (SMM) (ρ=0.270, p<0.001). The correlations in males were similar to those in all patients, where those in females were not. In females with OSA, all of the BIA fat indicators were correlated with AHI, whereas the muscle indicators were not. Adjusting age and BMI when analyzing the SMM/VFA ratio showed a strong correlation in males with OSA (p=0.015) but not in females with OSA (p=0.354). CONCLUSIONS: This study has revealed that the body composition of fat and muscle has different patterns in OSA patients. The SMM/VFA as measured using BIA is the factor most significantly associated with AHI in males but not in females after adjusting for age and BMI.

Asian accreditation of sleep medicine physicians and technologists: practice guidelines by the Asian Society of Sleep Medicine.

Due to the rapid growth in sleep medicine's professional content, several countries have recognized sleep medicine as an independent specialty. The practice of sleep medicine and the demand for this service in Asian countries are expanding. At this point of growth, the accreditation of sleep medicine specialists is paramount to patient care and the training of physicians and technologists. The Asian Society of Sleep Medicine (ASSM) mandated a taskforce committee for the accreditation of sleep medicine practice. This taskforce developed Asian accreditation practice guidelines for sleep medicine physicians and technologists. This paper presents the newly approved Asian accreditation practice guidelines for sleep medicine physicians and technologists by the ASSM.

Complete Oculomotor Palsy after Influenza Vaccination in a Young Healthy Adult: A Case Report.

Influenza vaccines are known to have a few neurological complications, such as Guillain-Barre syndrome, chronic inflammatory demyelinating polyneuropathy, and acute disseminated encephalomyelitis. However, oculomotor palsy caused by influenza vaccination is extremely rare. We present a case report of a 25-year-old woman without any medical history who developed complete oculomotor palsy 2 weeks after influenza vaccination. Other possible causes of oculomotor nerve palsy, such as stroke, compressive lesions, infections, and autoimmune disorders, were eliminated by blood tests, cerebrospinal fluid examination, and imaging studies. Hence, influenza vaccine was considered as the likely cause.

Novel association between asthma and osteoarthritis: a nationwide health and nutrition examination survey.

BACKGROUND: Asthma and osteoarthritis (OA) are medical conditions that inhibit physical activity and adversely affect quality of life. Despite the high prevalence, there are limited studies focusing on the comorbid condition and association between asthma and OA. The aim of this study was to assess the prevalence of OA co-occurring with asthma and to identify the relevant clinical considerations. METHODS: Adult participants aged over 40 years who completed questionnaire assessments and spirometry tests were enrolled from the Korean National Health and Nutrition Examination Survey. Asthma and OA were defined based on the medical history of a diagnosis made by a doctor. Radiographic severities of OA were measured using the Kellgren-Lawrence grading system. Chronic obstructive pulmonary disease (COPD), as a comparative respiratory disease, was diagnosed based on the spirometric results. RESULTS: A total of 9344 subjects were enrolled, and the prevalence of asthma and COPD were 4.6% ± 0.3% and 12.0% ± 0.5%, respectively. The prevalence of OA in the asthma group was 31.9% ± 2.8%, which was significantly higher than that in the COPD (17.8% ± 1.5%) or control (16.2% ± 0.6%) groups. OA was more prevalent in patients with asthma after adjusting for age, sex, body mass index, and smoking status (OR 1.65; 95% CI 1.27-2.13). Furthermore, after adjustment of this model for the prescription of OA medication, OA remained independently associated with asthma (OR 1.56; 95% CI 1.10-2.20). Conversely, the relationship of OA medication with asthma was not significant (P = 0.64). This relationship was evident in patients with asthma without airflow limitation measured by spirometry (OR 1.97; 95% CI 1.32-2.93). Moreover, the radiographic severity of knee OA correlated with asthma (OR 1.10; 95% CI 1.0-||1.21). CONCLUSIONS: OA shows a high prevalence in patients with asthma, higher than in patients with COPD or the controls. The comorbid characteristics of these two conditions need to be considered in clinical practice.

The impact of the shift system on health and quality of life of sleep technicians.

BACKGROUND: Sleep technicians are at high risk of shift work sleep disorders. We therefore aimed to identify the optimal shift system for sleep technicians. METHODS: We performed a nationwide survey of the work schedules, health and quality of life of sleep technicians using e-mail questionnaires including the Insomnia Severity Index (ISI), Epworth Sleep Scale (ESS), Functional Outcomes of Sleep Questionnaire-10 (FOSQ-10), Short Form-12 Health Survey (SF-12), and Hospital Anxiety and Depression Scale (HADS) in Korea. A multivariate general linear model was used to assess the effect of shift schedules on health and quality of life. RESULTS: Fifty-four technicians from 30 sleep laboratories participated. Their work schedules were classified as fixed night (F) (n = 18), slow rotation alternating from a night-only to a day-only schedule with a 3-months to one-year interval (S) (n = 20), rapid rotation within a week (R) (n = 5), night once a week (D+) (n = 5) and day (D) (n = 6). The adjusted ISI and HADS-anxiety scores were higher in F, S, and R than D and D+. Among night shift-dominant schedules, a less favorable profile was observed for R followed by F, and S regarding the ISI, FOSQ-10, mental SF-12 and HADS-depression. The physical SF-12 was lower in the order of R, S and F. The HADS-anxiety score was higher in the order of F, R and S. CONCLUSIONS: The S system appears to have the least negative effect on health and quality of life among night shift-dominant systems. The development of consensus guidelines for scheduling shifts in sleep laboratories is urged.

Insomnia Symptoms and Mood Disturbances in Shift Workers with Different Chronotypes and Working Schedules.

BACKGROUND AND PURPOSE: Shift workers frequently suffer from insomnia and mood disturbances, but little is known about the relationships of these conditions with the chronotypes and different working schedules of shift workers. We hypothesized that different shift-work schedules are associated with different severities of sleep and mood disturbances, and that the individual chronotype plays a role in sleep disturbances in shift workers. METHODS: This study enrolled 276 participants, comprising 77 nurses working in a three-shift schedule (3S, 27.9%), 60 firefighters working in a 24-h-every-other-day shift schedule (EOD, 21.7%), and 139 day workers (DW, 50.4%). All of the participants completed the following questionnaires to assess their sleep disturbances, mood, and chronotype: Insomnia Severity Index (ISI), Epworth Sleepiness Scale, Hospital Anxiety and Depression Scale, and Morningness-Eveningness Questionnaire. RESULTS: ISI questionnaires were worse in both shift workers compare to DW, 35.1% of 3S, 23% of EOD had clinically significant insomnia (ISI score >14). Depressive mood and anxiety symptom were significantly worse in 3S compare to EOD. The sleep disturbance by ISI score had significant correlations with depressive mood and anxiety symptoms for both EOD and 3S (EOD: rho=0.57, rho=0.57, 3S: rho=0.37, rho=0.33 respectively). Chronotype type in shift workers had no significant correlation with sleep disturbance, depressive mood, nor anxiety symptom. However, after adjustment, the eveningness chronotype have relationship to the depressive mood in shift workers. CONCLUSIONS: Sleep disturbances are more frequent in shift workers than DW. Depressive mood and anxiety symptoms were frequently reported in 3S, then EOD. Different shift schedules cab be a determinant of depressive mood and anxiety symptom.

Endosulfan-Induced Prolonged Super-Refractory Status Epilepticus.

Endosulfan is a highly toxic pesticide that causes hyperstimulation of the central nervous system by antagonizing gamma aminobutyric acid-mediated inhibition. Seizure is the most important manifestation of endosulfan poisoning, frequently progressing to status epilepticus and refractory status epilepticus. Here, we report a recent case of a 64-year-old man with endosulfan-induced super-refractory status epilepticus, which persisted for a remarkably longer period than has been described in previous reports. The patient arrived at the emergency room with continuous generalized tonic-clonic seizures. Electroencephalogram-recorded seizures that persisted even after intravenous administration of lorazepam and antiepileptic drugs. Intravenous anesthetic agents were administered for 9 days to confront the persistently recurring seizures. Immediately after this treatment period, the seizures subsided, and the patient showed marked neurological improvement. After 2 months however, he died of multiple systemic complications. This case report elucidates the importance of aggressive evaluation and management including continuous EEG monitoring in cases of endosulfan-related status epilepticus.

Propofol-Induced Green Urine in a Patient with Refractory Status Epilepticus.

Propofol is commonly used for induction and maintenance of anesthesia, and sedation in the intensive care unit. In addition, it is also used as an anesthetic coma treatment for refractory status epilepticus. We present the case of a 52-year-old man, who developed green urine following propofol coma therapy for status epilepticus. The urine color recovered following discontinuation of propofol infusion. The green discoloration of urine is a rare and benign condition, which occurs when clearance of propofol exceeds the hepatic and extrahepatic elimination.

Hand grip strength in patients with chronic obstructive pulmonary disease.

PURPOSE: Hand grip strength (HGS) is a simple way of predicting the risk of cardiovascular disease and all-cause mortality in the general population. However, the practical significance of grip strength in patients with COPD is uncertain. The aim of this study was to compare HGS between subjects with and without COPD and to evaluate its clinical relevance in patients with COPD by using a national survey. METHODS: Data were collected from the Korean National Health and Nutrition Examination Survey. The study included 421 adults with COPD and 2,542 controls who completed questionnaires, spirometry, and a HGS test. HGS was compared between subjects with and without COPD, and the association between grip strength, lung function, and quality of life (QoL) was evaluated. RESULTS: The mean HGS was 33.3±9.1 kg in the COPD group and 29.9±9.5 kg in the non-COPD group; adjusted HGS was 30.9±0.33 kg and 30.9±0.11 kg, respectively (P=0.99). HGS was not related to forced vital capacity (ß=0.04, P=0.70) or forced expiratory volume in 1 second (ß=0.11, P=0.24) in multivariable analysis. HGS was independently associated with the EQ-5D index, but the relationship was stronger in the COPD group (ß=0.30, P<0.001) than in the non-COPD group (ß=0.21, P<0.001). The results were similar for each component of the EQ-5D, including mobility (ß=-0.25, P<0.001), daily activity (ß=-0.19, P=0.01), pain/discomfort (ß=-0.32, P<0.001), and anxiety/depression (ß=-0.16, P=0.01). CONCLUSION: HGS was not different between subjects with and without COPD, but was associated with QoL - including mobility, daily activity, pain/discomfort, and anxiety/depression - in patients with COPD. The HGS test could be used as a marker of QoL in patients with COPD and could assist risk stratification in clinical practice.

Systemic White Blood Cell Count as a Biomarker Associated with Severity of Chronic Obstructive Lung Disease.

BACKGROUND: Chronic obstructive pulmonary disease (COPD), is a chronic inflammatory disorder. We evaluated whether white blood cell (WBC) count, is associated with the severity of COPD, independent of other inflammatory conditions, such as metabolic syndrome. METHODS: The WBC counts were compared between 1227 COPD patients and 8679 non-COPD adults older than 40. The relationships between the WBC count, lung function, and symptoms score in COPD patients, were determined, using general linear regression analyses. RESULTS: The WBC count was negatively associated with forced vital capacity (FVC, L), FVC (% predicted), forced expiry volume in one second (FEV1, L), and FEV1 (% predicted) in COPD patients. Additionally, the WBC count was independently associated with the quality of life measure, by EQ5D-index score. However, this relationship between WBC count, and disease severity, was not significant in current smokers, because of the confounding effect of smoking, on the WBC count. CONCLUSION: The WBC count is associated with current smoking status and COPD severity, and a risk factor for poor lung function, and quality of life, especially in non-currently smoking COPD patients. The WBC count can be used, as an easily measurable COPD biomarker.

Fatigue in patients with neuromyelitis optica spectrum disorder and its impact on quality of life.

Fatigue is a prevalent symptom and major burden in neuroimmunological diseases. In neuromyelitis optica spectrum disorder (NMOSD), a severe autoimmune central nervous system (CNS) inflammatory disease with autoantibodies reactive to aquaporin-4, there are few reports about fatigue and quality of life (QOL). We aimed to evaluate the severity of fatigue and its relationship with QOL in patients with NMOSD. We prospectively studied patients with NMOSD who were in remission and seropositive for anti-aquaporin-4 antibody, and they were divided into 2 groups based on the presence of fatigue assessed using the Functional Assessment of Chronic Illness Therapy-fatigue score. Sleep quality, depression, pain, and QOL were also evaluated. A total of 35 patients were enrolled (mean age, 46.5 ± 14.1 years; female: male = 29:6), and the median Expanded Disability Status Scale (EDSS) score was 2.0 (range, 0 to 8.0). The patients with fatigue (N = 25, 71.4%) had poorer sleep quality and more severe depression than those without fatigue (p = 0.009 and p = 0.001). Both the physical and mental QOL scores were lower in patients with fatigue than in those without fatigue (p = 0.033 and p = 0.004). Multiple linear regression analyses showed that the degree of fatigue with EDSS score and pain were independent predictors of physical aspects of QOL (B = 0.382, p = 0.001), whereas depression was the only predictor of the mental components of QOL (B = -0.845, p = <0.001). Fatigue is a common symptom and an important predictor of QOL in patients with NMOSD.

An MSC2 Promoter-lacZ Fusion Gene Reveals Zinc-Responsive Changes in Sites of Transcription Initiation That Occur across the Yeast Genome.

The Msc2 and Zrg17 proteins of Saccharomyces cerevisiae form a complex to transport zinc into the endoplasmic reticulum. ZRG17 is transcriptionally induced in zinc-limited cells by the Zap1 transcription factor. In this report, we show that MSC2 mRNA also increases (~1.5 fold) in zinc-limited cells. The MSC2 gene has two in-frame ATG codons at its 5' end, ATG1 and ATG2; ATG2 is the predicted initiation codon. When the MSC2 promoter was fused at ATG2 to the lacZ gene, we found that unlike the chromosomal gene this reporter showed a 4-fold decrease in lacZ mRNA in zinc-limited cells. Surprisingly, ß-galactosidase activity generated by this fusion gene increased ~7 fold during zinc deficiency suggesting the influence of post-transcriptional factors. Transcription of MSC2ATG2-lacZ was found to start upstream of ATG1 in zinc-replete cells. In zinc-limited cells, transcription initiation shifted to sites just upstream of ATG2. From the results of mutational and polysome profile analyses, we propose the following explanation for these effects. In zinc-replete cells, MSC2ATG2-lacZ mRNA with long 5' UTRs fold into secondary structures that inhibit translation. In zinc-limited cells, transcripts with shorter unstructured 5' UTRs are generated that are more efficiently translated. Surprisingly, chromosomal MSC2 did not show start site shifts in response to zinc status and only shorter 5' UTRs were observed. However, the shifts that occur in the MSC2ATG2-lacZ construct led us to identify significant transcription start site changes affecting the expression of ~3% of all genes. Therefore, zinc status can profoundly alter transcription initiation across the yeast genome.

Gene-based rare allele analysis identified a risk gene of Alzheimer's disease.

Alzheimer's disease (AD) has a strong propensity to run in families. However, the known risk genes excluding APOE are not clinically useful. In various complex diseases, gene studies have targeted rare alleles for unsolved heritability. Our study aims to elucidate previously unknown risk genes for AD by targeting rare alleles. We used data from five publicly available genetic studies from the Alzheimer's Disease Neuroimaging Initiative (ADNI) and the database of Genotypes and Phenotypes (dbGaP). A total of 4,171 cases and 9,358 controls were included. The genotype information of rare alleles was imputed using 1,000 genomes. We performed gene-based analysis of rare alleles (minor allele frequency≤3%). The genome-wide significance level was defined as meta P<1.8×10(-6) (0.05/number of genes in human genome = 0.05/28,517). ZNF628, which is located at chromosome 19q13.42, showed a genome-wide significant association with AD. The association of ZNF628 with AD was not dependent on APOE ε4. APOE and TREM2 were also significantly associated with AD, although not at genome-wide significance levels. Other genes identified by targeting common alleles could not be replicated in our gene-based rare allele analysis. We identified that rare variants in ZNF628 are associated with AD. The protein encoded by ZNF628 is known as a transcription factor. Furthermore, the associations of APOE and TREM2 with AD were highly significant, even in gene-based rare allele analysis, which implies that further deep sequencing of these genes is required in AD heritability studies.

Greater stroke severity predominates over all other factors for the worse outcome of cardioembolic stroke.

BACKGROUND: Cardioembolic (CE) strokes are more disabling and more fatal than non-CE strokes. Multiple prognostic factors have been recognized, but the magnitude of their relative contributions has not been well explored. METHODS: Using a prospective stroke outcome database, we compared the 3-month outcomes of CE and non-CE strokes. We assessed the relative contribution of each prognostic factor of initial stroke severity, poststroke complications, and baseline characteristics with multivariable analyses and model fitness improvement using -2 log-likelihood and Nagelkerke R2. RESULTS: This study included 1233 patients with acute ischemic stroke: 193 CE strokes and 1040 non-CE strokes. Compared with the non-CE group, CE group had less modified Rankin Scale (mRS) 0-2 outcomes (47.2% versus 68.5%; odds ratio [95% confidence interval], .41 [.30-.56]), less mRS 0-1 outcomes (33.7% versus 53.5%; .44 [.32-.61]), more mRS 5-6 outcomes (32.1% versus 10.9%; 3.88 [2.71-5.56]), and higher mortality (19.2% versus 5.2%; 4.33 [2.76-6.80]) at 3 months. When adjusting either baseline characteristics or poststroke complications, the outcome differences between the 2 groups remained significant. However, adjusting initial National Institute of Health Stroke Scale (NIHSS) score alone abolished all outcome differences except for mortality. For mRS 0-2 outcomes, the decrement of -2 log-likelihood and the Nagelkerke R2 of the model adjusting initial NIHSS score alone approached 70.2% and 76.7% of the fully adjusting model. CONCLUSION: Greater stroke severity predominates over all other factors for the worse outcome of CE stroke. Primary prevention and more efficient acute therapy for stroke victims should be given top priorities to reduce the burden of CE strokes.

Validation of minor stroke definitions for thrombolysis decision making.

BACKGROUND: Patients with low National Institutes of Health Stroke Scale (NIHSS) scores are frequently excluded from thrombolysis, but more than 25% of them remain disabled. We sought to define a validated minor stroke definition to reduce the inappropriate treatment exclusion. METHODS: From an outcome database, untreated patients with an NIHSS score of 5 or less presenting within a 4.5-hour window were identified and 3-month modified Rankin Scale (mRS) outcomes were analyzed according to individual isolated symptoms and total NIHSS scores. The validity of the following minor stroke definitions were assessed: (1) the National Institute of Neurological Disorders and Stroke Tissue Plasminogen Activator (NINDS-TPA) trials' definition, (2) the total NIHSS score, varying a cutoff point from 0 to 4, and (3) our proposed definition that included an NIHSS score = 0 or an NIHSS score = 1 on the items of level of consciousness (LOC), gaze, facial palsy, sensory, or dysarthria. RESULTS: Of 647 patients, 172 patients (26.6%) had a 3-month unfavorable outcome (mRS score 2-6). Favorable outcome was achieved in more than 80% of patients with an NIHSS score of 1 or less or with an isolated symptom on the LOC, gaze, facial palsy, sensory, or dysarthria item. In contrast, unfavorable outcome proportion was more than 25% in patients with an NIHSS score of 2 or more. When the NINDS-TPA trials' definition, our definition, or the definition of an NIHSS score of 1 or less were applied, more than 75% of patients with an unfavorable outcome were defined as a non-minor stroke and less than 15% of patients with an unfavorable outcome were defined as a minor stroke. CONCLUSION: Implementation of an optimal definition of minor stroke into thrombolysis decision-making process would decrease the unfavorable outcomes in patients with low NIHSS scores.