Topographic Consideration on the Occurrence of Ipsilesional Facial Paresis in Lateral Medullary Infarction.

INTRODUCTION: The purpose of this study was to identify course of the corticobulbar tract and factors associated with the occurrence of facial paresis (FP) in lateral medullary infarction (LMI). METHODS: Patients diagnosed with LMI who were admitted to tertiary hospital were retrospectively investigated and divided into two groups based on the presence of FP. FP was defined as grade 2 or more by the House-Brackmann scale. Differences between the two groups were analyzed with respect to anatomical location of the lesions, demographic data (age, sex), risk factors (diabetes, hypertension, smoking, prior stroke, atrial fibrillation, and other cardiac risk factors for stroke), large vessel involvement on magnetic resonance angiography, other symptoms and signs (sensory symptoms, gait ataxia, limb ataxia, dizziness, Horner syndrome, hoarseness, dysphagia, dysarthria, nystagmus, nausea/vomiting, headache, neck pain, diplopia, and hiccup). RESULTS: Among 44 LMI patients, 15 patients (34%) had FP, and all of them had ipsilesional central-type FP. The FP group tended to involve upper (p < 0.0001) and relative ventral (p = 0.019) part of the lateral medulla. Horizontally large lesion was also related to the presence of FP (p = 0.044). Dysphagia (p = 0.001), dysarthria (p = 0.003), and hiccups (p = 0.034) were more likely to be accompanied by FP. Otherwise, there were no significant differences. CONCLUSION: The results of present study indicate that the corticobulbar fibers innervating the lower face decussate at the upper level of the medulla and ascend through the dorsolateral medulla, where the concentration of the fibers is densest near the nucleus ambiguus.

Treatment pattern and response for cluster headache in Korea: A prospective multicenter observation study.

BACKGROUND: Only limited data are available regarding the treatment status and response to cluster headache in an Asian population. Therefore, this study aimed to provide a real-world treatment pattern of cluster headache and the response rate of each treatment in an Asian population. METHODS: Patients with cluster headache were recruited between September 2016 and January 2019 from 16 hospitals in Korea. At the baseline visit, we surveyed the patients about their previous experience of cluster headache treatment, and acute and/or preventive treatments were prescribed at the physician's discretion. Treatment response was prospectively evaluated using a structured case-report form at 2 ± 2 weeks after baseline visit and reassessed after three months. RESULTS: Among 295 recruited patients, 262 experiencing active bouts were included. Only one-third of patients reported a previous experience of evidence-based treatment. At the baseline visit, oral triptans (73.4%), verapamil (68.3%), and systemic steroids (55.6%) were the three most common treatments prescribed by the investigators. Most treatments were given as combination. For acute treatment, oral triptans and oxygen were effective in 90.1% and 86.8% of the patients, respectively; for preventive treatment, evidence-based treatments, i.e. monotherapy or different combinations of verapamil, lithium, systemic steroids, and suboccipital steroid injection, helped 75.0% to 91.8% of patients. CONCLUSION: Our data provide the first prospective analysis of treatment responses in an Asian population with cluster headache. The patients responded well to treatment despite the limited availability of treatment options, and this might be attributed at least in part by combination of medications. Most patients were previously undertreated, suggesting a need to raise awareness of cluster headache among primary physicians.

Association Between Hyperacute Blood Pressure Variability and Hematoma Expansion After Intracerebral Hemorrhage: Secondary Analysis of the FAST-MAG Database.

BACKGROUND: Blood pressure variability (BPV) has emerged as a significant factor associated with clinical outcomes after intracerebral hemorrhage (ICH). Although hematoma expansion (HE) is associated with clinical outcomes, the relationship between BPV that encompasses prehospital data and HE is unknown. We hypothesized that BPV was positively associated with HE. METHODS: We analyzed 268 patients with primary ICH enrolled in the National Institutes of Health-funded Field Administration of Stroke Therapy-Magnesium (FAST-MAG) study who received head computed tomography or magnetic resonance imaging on arrival to the emergency department (ED) and repeat imaging within 6-48 h. BPV was calculated by standard deviation (SD) and coefficient of variation (CV) from prehospital data as well as systolic blood pressure (SBP) measurements taken on ED arrival, 15 min post antihypertensive infusion start, 1 h post maintenance infusion start, and 4 h after ED arrival. HE was defined by hematoma volume expansion increase > 6 mL or by 33%. Univariate logistic regression was used for presence of HE in quintiles of SD and CV of SBP for demographics and clinical characteristics. RESULTS: Of the 268 patients analyzed from the FAST-MAG study, 116 (43%) had HE. Proportions of patients with HE were not statistically significant in the higher quintiles of the SD and CV of SBP for either the hyperacute or the acute period. Presence of HE was significantly more common in patients on anticoagulation. CONCLUSIONS: Higher BPV was not found to be associated with occurrence of HE in the hyperacute or the acute period of spontaneous ICH. Further study is needed to determine the relationship.

Characteristics of pre-cluster symptoms in cluster headache: A cross-sectional multicentre study.

BACKGROUND: Contrary to pre-attack symptoms before an individual cluster headache attack, little is known about the pre-cluster symptoms before the onset of cluster bouts. We previously described pre-attack symptoms before cluster headache attacks. The aim of this study was to investigate characteristics of pre-cluster symptoms in patients with episodic cluster headache. METHODS: In this multicentre study, 184 patients with episodic cluster headache were recruited between October 2018 and December 2020. They were interviewed by investigators and completed a structured questionnaire. To investigate pre-cluster and pre-attack symptoms, we assessed 20 symptoms and signs using the questionnaire. RESULTS: The upcoming cluster bout was predictable in 35.3% (n = 65/184) of the patients. When present, pre-cluster symptoms occurred at a median duration of 7 days (interquartile range, 2.3-14 days) before the onset of the cluster bout. Patients with pre-cluster symptoms showed a higher proportion of women, prevalence of pre-attack symptoms and seasonal rhythmicity, frequency of cluster headache attacks per day, and total number of cluster bouts compared to patients without pre-cluster symptoms. In univariable and multivariable logistic regression analyses, female sex was associated with the predictability of pre-cluster symptoms (odds ratio = 2.297, p = 0.016). CONCLUSIONS: The upcoming cluster bout was predicted in approximately 35% of patients with episodic cluster headache, which may allow for an earlier preventive treatment and help understand the pathophysiology.

Association Between Frailty-Related Factors and Depression among Older Adults.

OBJECTIVES: We analyzed the association between individual frailty-related factors and depression in older adults. METHODS: A total of 796 older adults who underwent geriatric assessments were included in this cross-sectional study. The frailty-related factors studied were grip strength, physical activity, walking speed, weight loss, and recurrent falls. Depression was based on the Geriatric Depression Scale. RESULTS: After adjustment for covariates, recurrent falls were associated with depression in males (OR 3.84, 95% CI 1.30-11.35). Among females, weakest grip strength, slow walking speed, and weight loss were associated with depression (OR 2.61, 95% CI 1.52-4.49; OR 1.78, 95% CI 1.02-3.11; and OR 2.52, 95% CI 1.17-5.44, respectively). Having more frailty-related factors was also associated with higher odds of depression. CONCLUSIONS: The associations between individual frailty-related factors and depression differed among males and females. Further prospective studies on depression and individual frailty-related factors by sex may help elucidate specific targets to be prioritized for clinical assessment and intervention. CLINICAL IMPLICATIONS: Older adults affected by depression and frailty may present different clinical manifestations based on sex, and require different treatment approaches. Clinicians should assess both physical and psychological needs for integrated care in frail older adults.

Clinical characteristics of pre-attack symptoms in cluster headache: A large series of Korean patients.

BACKGROUND: Previous studies have reported notable differences in demographic and clinical features of cluster headache between Western and Asian populations, including lower prevalence of the chronic type and in women. Recently, prodromal symptoms of migraine and pre-attack symptoms of cluster headache have drawn attention regarding their potential pathophysiological implications and pre-emptive treatment. However, pre-attack symptoms of cluster headache have not been studied in the Asian population. METHODS: A total of 136 patients with cluster headache (21 first-onset, 110 episodic, and five chronic cases) were recruited in this multi-center study between October 2018 and December 2019. We evaluated the characteristics of pre-attack symptoms in a current bout using a structured questionnaire. Univariable and multivariable logistic regression analyses were performed to evaluate the factors associated with presence of pre-attack symptoms. RESULTS: Pre-attack symptoms were reported in 71.3% of our patients with cluster headache. When present, pre-attack symptoms occurred at a median of 20 minutes (range 1-120) before the attack. The prevalence of local and painful, local and painless sensory, autonomic, and general symptoms was 58.8%, 14.7%, 11.0%, and 30.1%, respectively. Multivariable logistic regression analysis revealed that higher number of bouts was associated with higher prevalence of pre-attack symptoms (OR = 1.464, p = 0.044). CONCLUSIONS: Pre-attack symptoms were frequently observed in Korean patients with cluster headache, which was consistent with previous Western studies.

Temporal changes of circadian rhythmicity in cluster headache.

OBJECTIVE: To investigate the temporal changes of circadian rhythmicity in relation to the disease course in patients with cluster headache. METHODS: In this multicenter study, patients with cluster headache were recruited between September 2016 and July 2018. We evaluated the patients for circadian rhythmicity and time of cluster headache attacks in the current bout and any experience of bout-to-bout change in circadian rhythmicity. We analyzed the patterns of circadian rhythmicity in relation to the disease progression (the number of total lifetime bouts, grouped into deciles). RESULTS: Of the 175 patients in their active, within-bout period, 86 (49.1%) had circadian rhythmicity in the current bout. The prevalence of circadian rhythmicity in the active period was overall similar regardless of disease progression. Sixty-three (46.3%) out of 136 patients with ≥2 bouts reported bout-to-bout changes in circadian rhythmicity. The most frequent time of cluster headache attacks was distributed evenly throughout the day earlier in the disease course and dichotomized into hypnic and midday as the number of lifetime bouts increased (p = 0.037 for the homogeneity of variance). When grouped into nighttime and daytime, nighttime attacks were predominant early in the disease course, while daytime attacks increased with disease progression (up to 7th deciles of total lifetime bouts, p = 0.001) and decreased in patients with the most advanced disease course (p = 0.013 for the non-linear association). CONCLUSIONS: Circadian rhythmicity is not a fixed factor, and changes according to the disease course. Our findings will be valuable in providing a new insight into the stability of functional involvement of the suprachiasmatic nucleus in the pathophysiology of cluster headache.

Visceral adiposity index and longitudinal risk of incident metabolic syndrome: Korean genome and epidemiology study (KoGES).

Available data is insufficient to identify the influence of visceral adiposity assessed by visceral adiposity index (VAI) on incident MetS. This study was to evaluate the association of VAI with incident MetS. In a cohort of Korean genome epidemiology study, 5,807 free of MetS were followed-up for 10 years. They were subdivided into 3 tertile groups according to VAI score. Cox proportional hazard model was used to evaluate the hazard ratios (HRs) and 95% confidential interval (CI) [adjusted HRs (95% CI)] for MetS according to VAI tertiles. Subgroup analyses were conducted for VAI and waist circumference (WC). Receiver operating characteristic (ROC) and area under curve (AUC) analyses were conducted to compare the discriminative ability for Mets among indices. The risk for MetS increased proportionally to VAI tertiles in all participants, which was similarly observed in both men and women. Subgroup analysis indicated that group with high VAI and low WC had the increased risk for MetS (all participants: 2.76 [2.48-3.07], men: 2.77 [2.40-3.19] and women: 2.55 [2.16-3.00]), compared with groups with low VAI and low WC. Group with low VAI and high WC generally had the higher adjusted HRs for MetS than group with the high VAI and low WC. In AUC analyses, WC had the highest discriminative ability for Mets. In conclusion, elevated VAI was significantly associated with the increased long-term risk of MetS. VAI is a useful supplementary to classic anthropometric indices in screening high risk group of MetS.

The impact of remission and coexisting migraine on anxiety and depression in cluster headache.

BACKGROUND: Our aim was to investigate the relationship between coexisting cluster headache (CH) and migraine with anxiety and depression during active cluster bouts, and how symptoms change during remission. METHODS: We analyzed data from 222 consecutive CH patients and 99 age- and sex-matched controls using a prospective multicenter registry. Anxiety or depression was evaluated using the Generalized Anxiety Disorder-7 (GAD-7) or Patient Health Questionnaire-9 (PHQ-9), respectively. Moderate-to-severe anxiety or depression was defined as a score of ≥10 at baseline (during a cluster bout). We assessed for changes in anxiety and depression during CH remission periods. RESULTS: Among the CH patients, the prevalence of moderate-to-severe anxiety and depression was seen in 38.2% and 34.6%, respectively. Compared with controls, CH patients were associated with moderate-to-severe anxiety and depression (multivariable-adjusted odds ratio [aOR] = 7.32, 95% confidence intervals [CI] = 3.35-15.99 and aOR = 4.95, 95% CI = 2.32-10.57, respectively). CH patients with migraine were significantly more likely to have moderate-to-severe anxiety and depression (aOR = 32.53, 95% CI = 6.63-159.64 and aOR = 16.88, 95% CI = 4.16-68.38, respectively), compared to controls without migraine. The GAD-7 and PHQ-9 scores were significantly reduced between cluster bout and remission periods (from 6.8 ± 5.6 to 1.6 ± 2.8; P < 0.001, and from 6.1 ± 5.0 to 1.8 ± 2.4; P < 0.001, respectively). CONCLUSIONS: Our results indicate that CH patients are at increased risk of anxiety and depression, especially in the presence of coexisting migraine. However, the anxiety and depression can improve during remission periods.

Field testing the diagnostic criteria of cluster headache in the third edition of the International Classification of Headache Disorders: A cross-sectional multicentre study.

BACKGROUND: *These authors are shared first authors. The recently published third edition of the International Classification of Headache Disorders (ICHD-3) revised the criteria for accompanying symptoms of cluster headache (CH) and the remission period of chronic cluster headache (CCH). This study aimed at testing the validity of the ICHD-3 criteria for CH by using data from the Korean Cluster Headache Registry. METHODS: Consecutive patients with CH and probable cluster headache (PCH) were prospectively recruited from 15 hospitals. We analysed the validity of the revised ICHD-3 criteria for CH against the beta version of the third edition of the ICHD (ICHD-3ß). RESULTS: In total, 193 patients were enrolled: 140 (72.5%), 5 (2.6%) and 22 (11.4%) had episodic cluster headache (ECH), CCH, and PCH, respectively. The remaining 26 (13.5%) had CH with undetermined remission periods. One patient with ECH and one with PCH had only forehead and facial flushing and were diagnosed with PCH and non-cluster headache, respectively, according to the ICHD-3. Four participants with ECH according to the ICHD-3ß had remission periods of > 1 month and between 1 and 3 months and were newly diagnosed with CCH according to the ICHD-3. CONCLUSION: The change from ICHD-3ß to ICHD-3 resulted in few differences in the diagnoses of CH and PCH.

Increased suicidality in patients with cluster headache.

OBJECTIVE: To investigate suicidality related to cluster headache and factors associated with increased suicidality in cluster headache patients. METHODS: In this multicenter study, 193 cluster headache patients were recruited between September 2016 and August 2018. Patients were asked about their suicidality during and between attacks, specifically about passive suicidal ideation, active suicidal ideation, suicide plan, and suicide attempt. Univariable and multivariable logistic regression analyses were performed to evaluate the factors associated with high ictal suicidality (sum of positive response ≥ 2). Patients were followed up when they were in the between-bouts period. RESULTS: A total of 175 cluster headache patients in the in-bout period were included in this study. Passive suicidal ideation, active suicidal ideation, suicidal planning, and suicidal attempt were reported by 111 (64.2%), 62 (35.8%), 10 (5.8%), and four (2.3%) patients during attacks; seven (4.0%), six (3.5%), five (2.9%) and two (1.2%) patients interictally; and none (0%), one (1.9%), one (1.9%), and none (0%) among patients in the between-bouts period. Factors associated with high ictal suicidality were longer disease duration, the Headache Impact Test score, and the Patient Health Question-9 score (multivariable OR = 1.90 per 10-year increase in disease duration, 95% CI = 1.18-3.05, p = 0.008; multivariable OR = 3.19 per 10-point increase in HIT-6, 95% CI = 1.73-5.87, p < 0.001; multivariable OR = 2.11 per 10-point increase in PHQ-9, 95% CI = 1.13-3.95, p = 0.020, respectively). CONCLUSIONS: Cluster headache attack carries a high suicidality compared to the interictal or between-bouts state. An intensive treatment to reduce cluster headache burden may be helpful to alleviate suicide risk in cluster headache patients.

Mildly Decreased Renal Function and Its Relation to Left Ventricular Geometry Change.

BACKGROUND: It is believed that left ventricular (LV) geometry change contributes to the elevated cardiovascular risk in patients with chronic kidney disease. However, data are less available on the association between LV geometry change and mildly decreased renal function within estimated glomerular filtration rate (eGFR) from 60 to 89 (mL/min/1.73 m2).Methods and Results:In a cohort of 47,730 Koreans undergoing echocardiography as part of a health check-up, we evaluated the association of LV hypertrophy (LVH) and abnormal relative wall thickness (RWT) with 4 levels and 3 levels of eGFR in men (≥90, 89.99-80, 79.99-70, 69.99-60) and women (≥90, 89.99-80, 79.99-60), respectively. Multivariate logistic regression analysis was used to calculate the odds ratios (OR) and 95% confidence intervals (CI) for LVH and abnormal RWT, adjusting for conventional cardiovascular risk factors (adjusted OR [95% CI]). In the fully adjustment model, men did not show a significant association between LVH and levels of eGFR between 60 and 89. However, abnormal RWT was significantly associated with the levels of eGFR between 60 and 89. Women did not show a significant association of LVH and abnormal RWT with levels of eGFR between 60 and 89. CONCLUSIONS: Men with mildly decreased renal function (eGFR between 60 and 89 mL/min/1.73 m2) had increased probability of LV geometry change represented by abnormal RWT.

Differences of Cluster Headache on the Basis of Sex in the Korean Cluster Headache Registry.

BACKGROUND: Most of the clinical characteristics of cluster headache (CH) have been established through the observation of men with CH. Epidemiological data of CH in women are scarce especially in the Asian population. Here, we sought to assess the prevalence and clinical characteristics of women with CH in comparison to men in a prospective CH registry. METHODS: Data used in this study were obtained from the Korean Cluster Headache Registry, a prospective, cross-sectional, multicenter headache registry that collected data from consecutive patients diagnosed with CH. Demographics and clinical characteristics were compared between the sexes. RESULTS: In total, 250 patients were enrolled in this study; 41 (16.4%) were women (male to female ratio 5.1:1). Mean age of onset did not differ between women and men (30.7 ± 15.5 vs 29.0 ± 11.1 years). The clinical features of CH in women and men were similar, with no differences in pain severity, duration, and attack frequency. Among autonomic features, facial and forehead sweating was significantly rare in women (4.9%) compared to men with CH (33.0%). Headache-related disability assessed by Headache Impact Test-6 did not differ between the sexes; however, depression scale assessed by Patients Health Questionnaire-9 (11.0 ± 8.5 vs 7.0 ± 5.8, P = .009) and stress (Perceived Stress Scale 4, 7.5 ± 3.4 vs 6.4 ± 3.0, P = .045) were significantly higher in women with CH. CONCLUSIONS: Although decreasing male preponderance was suggested in recent Western CH studies, CH in women is still far less prevalent than in men in the Korean population. Clinical and demographic characteristics were similar between the sexes. However, psychiatric comorbidities might be highly associated in women with CH.

Levels of Systolic and Diastolic Blood Pressure and Their Relation to Incident Metabolic Syndrome.

BACKGROUND: Elevated blood pressure (BP) is a component of the metabolic syndrome (MetS), and one third of individuals with hypertension simultaneously have MetS. However, the evidence is still unclear regarding the predictive ability of BP for incident MetS. METHODS: In total, 5,809 Koreans without baseline MetS were grouped by baseline systolic (SBP) and diastolic BP (DBP) and monitored for 10 years to identify incident MetS. A Cox proportional hazards model was used to evaluate the HR and 95% CI for MetS according to SBP and DBP. Subgroup analysis was conducted in the normotensive population based on a new guideline of the American College of Cardiology and the American Heart Association. RESULTS: High-BP groups tended to have worse metabolic profiles than the lowest-BP group in both SBP and DBP categories. In all of the participants, elevated SBP and DBP levels were significantly associated with the increased HR for MetS, even after adjusting for covariates. Subgroup analysis for normotensive participants indicated that the HR for MetS increased proportionally to both SBP (<110 mm Hg: reference, 110-119 mm Hg: HR = 1.60 [95% CI 1.40-1.84], and 120-129 mm Hg: HR = 2.12 [95% CI 1.82-2.48]) and DBP levels (<70 mm Hg: reference, 71-74 mm Hg: HR = 1.31 [95% CI 1.09-1.58], and 75-79 mm Hg: HR = 1.51 [95% CI 1.25-1.81]). CONCLUSION: The risk of incident MetS increased proportionally to baseline SBP and DBP, and this was identically observed even in normotensive participants.

Non-Alcoholic Fatty Liver Disease and Its Association with Depression in Korean General Population.

BACKGROUND: Recent studies have indicated the significant association between non-alcoholic fatty liver disease (NAFLD) and depression. However, there is ongoing debate on whether the risk for depression is actually related with the presence and severity of NAFLD. Thus, this study was conducted to investigate the association between depression and NAFLD evaluated by diverse modalities. METHODS: A total of 112,797 participants from the Korean general population were enrolled. The study participants were categorized into three groups according to degree of NAFLD evaluated by ultrasonography, fatty liver index (FLI) and fibrosis-4 score (FIB-4). Depression was defined as a score of Center for Epidemiological Studies-Depression (CES-D) ≥ 16, and the odd ratios (ORs) and 95% confidence interval (CI) for depression (adjusted ORs [95% CI]) were assessed by multiple logistic regression analyses. RESULTS: In the unadjusted model, the presence and severity of NAFLD was not significantly associated with depressive symptoms. However, in the fully adjusted model, ORs for depression increased in proportion to the degree of ultrasonographically detected NAFLD (mild fatty liver: 1.14 [1.06-1.22]; and moderate to severe fatty liver: 1.32 [1.17-1.48]). An association was also observed between depression and FLI (30 ≤ FLI < 60: 1.06 [0.98-1.15]; FLI ≥ 60: 1.15 [1.02-1.29]). CONCLUSION: The presence and severity of NAFLD is significantly associated with depressive symptoms. In addition, this association was more distinct after adjusting for covariates including age, gender and insulin resistance. This finding indicates the necessity of further study evaluating the incidental relationship of depression with NAFLD.

Association Between Hyperacute Stage Blood Pressure Variability and Outcome in Patients With Spontaneous Intracerebral Hemorrhage.

BACKGROUND AND PURPOSE: Increased blood pressure (BP) variability, in addition to high BP, may contribute to adverse outcome in intracerebral hemorrhage. However, degree and association with outcome of BP variability (BPV) in the hyperacute period, 15 minutes to 5 hours after onset, have not been delineated. METHODS: Among consecutive patients with intracerebral hemorrhage enrolled in the FAST-MAG trial (Field Administration of Stroke Therapy-Magnesium), BPs were recorded by paramedics in the field and during the first 24 hours of hospital course. BP was analyzed in the hyperacute period, from 0 to 4-6 hours, and in the acute period, from 0 to 24-26 hours after onset. BPV was analyzed by SD, coefficient of variation, and successive variation. RESULTS: Among 386 patients with intracerebral hemorrhage, first systolic BP at median 23 minutes (interquartile range, 14-38.5) after onset was median 176 mm Hg, second systolic BP on emergency department arrival at 57 minutes (interquartile range, 45-75) after onset was 178 mm Hg, and systolic BP 24 hours after arrival was 138 mm Hg. Unfavorable outcome at 3 months (modified Rankin Scale, 3-6) occurred in 270 (69.9%). Neither mean nor maximum systolic BP was associated with outcome in multivariable analysis. However, all 3 parameters of BPV, in both the hyperacute and the acute stages, were associated with poor outcome. In the hyperacute phase, BPV was associated with poor outcome with adjusted odds ratios of 3.73 for the highest quintile of SD, 4.78 for the highest quintile of coefficient of variation, and 3.39 for the highest quintile of successive variation. CONCLUSIONS: BPV during the hyperacute first minutes and hours after onset in patients with intracerebral hemorrhage was independently associated with poor functional outcome. Stabilization of BPV during this vulnerable period, in the pre-hospital and early emergency department course, is a potential therapeutic target for future clinical trials. CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov. Unique identifier: NCT00059332.

Medication Adherence of Statin Users after Acute Ischemic Stroke.

Although statins are established therapy for the secondary prevention of ischemic stroke, factors associated with adherence to statin treatment following ischemic stroke are not well known. To address this, we assessed the 6-month statin adherence using 8-item Morisky Medication Adherence Scale-8 in patients with acute ischemic stroke. Of 991 patients, 65.6% were adherent to statin at 6-month after discharge. Multiple logistic regression analysis showed that patients' awareness of hyperlipidemia (OR 1.62; 95% CI 1.07-2.43), large artery stroke subtype (versus non-large artery stroke, OR 1.79; 95% CI 1.19-2.68), and alcohol drinking habits (OR 1.64; 95% CI 1.06-2.53) were positively associated, while high statin dose (versus low dose, OR 0.6; 95% CI 0.40-0.90) and higher daily number of medication pills (OR 0.93; 95% CI 0.88-0.97) were found to have a negative association with self-reported good adherence to statin medication after acute ischemic stroke. However, stroke severity and diagnosis of hyperlipidemia were not associated with adherence. These results suggest that educational and motivational interventions may enhance statin adherence because modifiable factors were associated with statin adherence.

Impact of cluster headache on employment status and job burden: a prospective cross-sectional multicenter study.

BACKGROUND: Cluster headaches (CH) are recurrent severe headaches, which impose a major burden on the life of patients. We investigated the impact of CH on employment status and job burden. METHODS: The study was a sub-study of the Korean Cluster Headache Registry. Patients with CH were enrolled from September 2016 to February 2018 from 15 headache clinics in Korea. We also enrolled a headache control group with age-sex matched patients with migraine or tension-type headache. Moreover, a control group including individuals without headache complaints was recruited. All participants responded to a questionnaire that included questions on employment status, type of occupation, working time, sick leave, reductions in productivity, and satisfaction with current occupation. The questionnaire was administered to participants who were currently employed or had previous occupational experience. RESULTS: We recruited 143 patients with CH, 38 patients with other types of headache (migraine or tension-type headache), and 52 headache-free controls. The proportion of employees was lower in the CH group compared with the headache and headache-free control groups (CH: 67.6% vs. headache controls: 84.2% vs. headache-free controls: 96.2%; p = 0.001). The CH group more frequently experienced difficulties at work and required sick leave than the other groups (CH: 84.8% vs. headache controls: 63.9% vs. headache-free controls: 36.5%; p <  0.001; CH: 39.4% vs. headache controls: 13.9% vs. headache-free controls: 3.4%; p <  0.001). Among the patients with CH, sick leave was associated with younger age at CH onset (25.8 years vs. 30.6 years, p = 0.014), severity of pain rated on a visual analogue scale (9.3 vs. 8.8, p = 0.008), and diurnal periodicity during the daytime (p = 0.003). There were no significant differences with respect to the sick leave based on sex, age, CH subtypes, and CH recurrence. CONCLUSIONS: CH might be associated with employment status. Most patients with CH experienced substantial burdens at work.

Burden of Intracranial Atherosclerosis Is Associated With Long-Term Vascular Outcome in Patients With Ischemic Stroke.

BACKGROUND AND PURPOSE: Ischemic stroke patients often have intracranial atherosclerosis (ICAS), despite heterogeneity in the cause of stroke. We tested the hypothesis that ICAS burden can independently reflect the risk of long-term vascular outcome. METHODS: This was a retrospective cohort study analyzing data from a prospective stroke registry enrolling consecutive patients with acute ischemic stroke or transient ischemic attack. A total of 1081 patients were categorized into no ICAS, single ICAS, and advanced ICAS (ICAS ≥2 different intracranial arteries) groups. Primary and secondary end points were time to occurrence of recurrent ischemic stroke and composite vascular outcome, respectively. Study end points by ICAS burden were compared using Cox proportional hazards models in overall and propensity-matched patients. RESULTS: ICAS was present in 405 patients (37.3%). During a median 5-year follow-up, recurrent stroke and composite vascular outcome occurred in 6.8% and 16.8% of patients, respectively. As the number of ICAS increased, the risk for study end points increased after adjustment of potential covariates (hazard ratio per 1 increase in ICAS, 1.19; 95% confidence interval, 1.01-1.42 for recurrent ischemic stroke and hazard ratio, 1.18; 95% confidence interval, 1.05-1.33 for composite vascular outcome). The hazard ratios (95% confidence interval) for recurrent stroke and composite vascular outcome in patients with advanced ICAS compared with those without ICAS were 1.56 (0.88-2.74) and 1.72 (1.17-2.53), respectively, in the overall patients. The corresponding values in the propensity-matched patients were 1.28 (0.71-2.30) and 1.95 (1.27-2.99), respectively. CONCLUSIONS: ICAS burden was independently associated with the risk of subsequent composite vascular outcome in patients with ischemic stroke. These findings suggest that ICAS burden can reflect the risk of long-term vascular outcome.

Field Validation of the Los Angeles Motor Scale as a Tool for Paramedic Assessment of Stroke Severity.

BACKGROUND AND PURPOSE: The Los Angeles Motor Scale (LAMS) is a 3-item, 0- to 10-point motor stroke-deficit scale developed for prehospital use. We assessed the convergent, divergent, and predictive validity of the LAMS when performed by paramedics in the field at multiple sites in a large and diverse geographic region. METHODS: We analyzed early assessment and outcome data prospectively gathered in the FAST-MAG trial (Field Administration of Stroke Therapy-Magnesium phase 3) among patients with acute cerebrovascular disease (cerebral ischemia and intracranial hemorrhage) within 2 hours of onset, transported by 315 ambulances to 60 receiving hospitals. RESULTS: Among 1632 acute cerebrovascular disease patients (age 70±13 years, male 57.5%), time from onset to prehospital LAMS was median 30 minutes (interquartile range 20-50), onset to early postarrival (EPA) LAMS was 145 minutes (interquartile range 119-180), and onset to EPA National Institutes of Health Stroke Scale was 150 minutes (interquartile range 120-180). Between the prehospital and EPA assessments, LAMS scores were stable in 40.5%, improved in 37.6%, and worsened in 21.9%. In tests of convergent validity, against the EPA National Institutes of Health Stroke Scale, correlations were r=0.49 for the prehospital LAMS and r=0.89 for the EPA LAMS. Prehospital LAMS scores did diverge from the prehospital Glasgow Coma Scale, r=-0.22. Predictive accuracy (adjusted C statistics) for nondisabled 3-month outcome was as follows: prehospital LAMS, 0.76 (95% confidence interval 0.74-0.78); EPA LAMS, 0.85 (95% confidence interval 0.83-0.87); and EPA National Institutes of Health Stroke Scale, 0.87 (95% confidence interval 0.85-0.88). CONCLUSIONS: In this multicenter, prospective, prehospital study, the LAMS showed good to excellent convergent, divergent, and predictive validity, further establishing it as a validated instrument to characterize stroke severity in the field.