Stress Is Associated with Poor Outcome of Acute Treatment for Chronic Migraine: A Multicenter Study.

Background: Chronic migraine (CM) is associated with severe psychological symptoms and disabilities. Information on the relationship between stress and the outcomes of acute CM treatment is limited. Methods: We evaluated the clinical presentation and stress levels of patients with CM who visited the neurology departments of 14 hospitals between September and December 2015. The patients were divided into stress and reference groups on the basis of the Korean version of the Brief Encounter Psychosocial Instrument (BEPSI-K). Quality of life was evaluated using EuroQol Five Dimension Questionnaire Three-Level. The Migraine Assessment of Current Therapy questionnaire was used to assess the outcomes of acute treatment. Results: This study included 186 CM patients. On the basis of the BEPSI-K score, 79 and 107 patients were assigned to the stress and reference groups, respectively. The stress group had more patients with poor outcomes of acute treatment than the reference group (67.1% vs 40.2%, P < 0.001). In a multivariate analysis, female gender (odds ratio [OR] = 3.266, 95% confidence interval [CI] = 1.172-9.103, P = 0.024), the number of headache-free days per month (OR = 0.932, 95% CI = 0.883-0.985, P = 0.012), and BEPSI-K score (OR = 1.667, 95% CI = 1.051-2.643, P = 0.030) predicted poor outcomes of acute treatment. Conclusions: High levels of stress were reported by 42.5% of patients with CM. The association between stress and the outcomes of acute treatment suggests that stress is an important clinical variable for improving the management of CM.

Vestibular migraine in multicenter neurology clinics according to the appendix criteria in the third beta edition of the International Classification of Headache Disorders.

BACKGROUND: Vestibular migraine (VM), the common term for recurrent vestibular symptoms with migraine features, has been recognized in the appendix criteria of the third beta edition of the International Classification of Headache Disorders (ICHD-3ß). We applied the criteria for VM in a prospective, multicenter headache registry study. METHODS: Nine neurologists enrolled consecutive patients visiting outpatient clinics for headache. The presenting headache disorder and additional VM diagnoses were classified according to the ICHD-3ß. The rates of patients diagnosed with VM and probable VM using consensus criteria were assessed. RESULTS: A total of 1414 patients were enrolled. Of 631 migraineurs, 65 were classified with VM (10.3%) and 16 with probable VM (2.5%). Accompanying migraine subtypes in VM were migraine without aura (66.2%), chronic migraine (29.2%), and migraine with aura (4.6%). Probable migraine (75%) was common in those with probable VM. The most common vestibular symptom was head motion-induced dizziness with nausea in VM and spontaneous vertigo in probable VM. The clinical characteristics of VM did not differ from those of migraine without VM. CONCLUSION: We diagnosed VM in 10.3% of first-visit migraineurs in neurology clinics using the ICHD-3ß. Applying the diagnosis of probable VM can increase the identification of VM.

Comprehensive Application of the International Classification of Headache Disorders Third Edition, Beta Version.

The purpose of this study was to test the feasibility and usefulness of the International Classification of Headache Disorders, third edition, beta version (ICHD-3ß), and compare the differences with the International Classification of Headache Disorders, second edition (ICHD-2). Consecutive first-visit patients were recruited from 11 headache clinics in Korea. Headache classification was performed in accordance with ICHD-3ß. The characteristics of headaches were analyzed and the feasibility and usefulness of this version was assessed by the proportion of unclassified headache disorders compared with ICHD-2. A total of 1,627 patients were enrolled (mean age, 47.4±14.7 yr; 62.8% female). Classification by ICHD-3ß was achieved in 97.8% of headache patients, whereas 90.0% could be classified by ICHD-2. Primary headaches (n=1,429, 87.8%) were classified as follows: 697 migraines, 445 tension-type headaches, 22 cluster headaches, and 265 other primary headache disorders. Secondary headache or painful cranial neuropathies/other facial pains were diagnosed in 163 patients (10.0%). Only 2.2% were not classified by ICHD-3ß. The main reasons for missing classifications were insufficient information (1.6%) or absence of suitable classification (0.6%). The diagnoses differed from those using ICHD-2 in 243 patients (14.9%). Among them, 165 patients were newly classified from unclassified with ICHD-2 because of the relaxation of the previous strict criteria or the introduction of a new diagnostic category. ICHD-3ß would yield a higher classification rate than its previous version, ICHD-2. ICHD-3ß is applicable in clinical practice for first-visit headache patients of a referral hospital.

Korean Version of Inventory of Complicated Grief Scale: Psychometric Properties in Korean Adolescents.

We aimed to validate the Inventory of Complicated Grief (ICG)-Korean version among 1,138 Korean adolescents, representing a response rate of 57% of 1,997 students. Participants completed a set of questionnaires including demographic variables (age, sex, years of education, experience of grief), the ICG, the Children's Depression Inventory (CDI) and the Lifetime Incidence of Traumatic Events-Child (LITE-C). Exploratory factor analysis was performed to determine whether the ICG items indicated complicated grief in Korean adolescents. The internal consistency of the ICG-Korean version was Cronbach's α=0.87. The test-retest reliability for a randomly selected sample of 314 participants in 2 weeks was r=0.75 (P<0.001). Concurrent validity was assessed using a correlation between the ICG total scores and the CDI total scores (r=0.75, P<0.001). The criterion-related validity based on the comparison of ICG total scores between adolescents without complicated grief (1.2 ± 3.7) and adolescent with complicated grief (3.2 ± 6.6) groups was relatively high (t=5.71, P<0.001). The data acquired from the 1,138 students was acceptable for a factor analysis (Kaiser-Meyer-Olkin Measure of Sampling Adequacy=0.911; Bartlett's Test of Sphericity, χ(2)=13,144.7, P<0.001). After omission of 3 items, the value of Cronbach's α increased from 0.87 for the 19-item ICG-Korean version to 0.93 for the 16-item ICG-Korean version. These results suggest that the ICG is a useful tool in assessing for complicated grief in Korean adolescents. However, the 16-item version of the ICG appeared to be more valid compared to the 19-item version of the ICG. We suggest that the 16-item version of the ICG be used to screen for complicated grief in Korean adolescents.

The frequency and risk of preclinical coronary artery disease detected using multichannel cardiac computed tomography in patients with ischemic stroke.

BACKGROUND: Atherosclerosis is a systemic disease. Many ischemic stroke patients may have concomitant coronary artery disease (CAD). Detection and treatment of preclinical CAD in stroke patients may improve long-term outcome and survival because CAD is a major cause of death during follow-up in stroke patients. However, association between coronary and cerebral artery atherosclerosis in stroke patients has not fully been investigated. This study aimed at examining the frequency and high-risk groups of CAD in ischemic stroke patients. METHODS: Consecutive patients who were admitted due to acute ischemic stroke between July 2006 and June 2010 were prospectively enrolled in this study. A total of 1,304 patients who underwent MSCT coronary angiography and cerebral angiography were included in this study. By using 64-multislice computed tomography coronary angiography, we investigated the frequency of CAD and association between coronary and cerebral artery atherosclerosis in terms of location and burden (severity and extent) in stroke patients. We also sought to identify high-risk groups for CAD among stroke patients. RESULTS: The frequency of significant (≥50%) CAD was 32.3% and the frequency of any degree of CAD was 70.1%. Diabetes mellitus, serum levels of total cholesterol, high-density lipoprotein cholesterol and triglyceride, and significant stenosis of the extracranial carotid, intracranial vertebral and basilar arteries were independently associated with CAD. However, no association was found between CAD and significant stenosis of the anterior, middle and posterior cerebral arteries. The association between CAD and cerebral atherosclerosis was stronger with increased severity and extent of cerebral atherosclerosis. When compared to patients with <2 risk factors and without significant cerebral atherosclerosis, those with multiple (≥2) risk factors and atherosclerosis in both the carotid and the vertebrobasilar arteries had very high risks of CAD [odds ratio (OR) 8.36; 95% confidence interval (CI) 4.15-16.87]. The risk was also high in patients with multiple risk factors and atherosclerosis in either the carotid or the vertebrobasilar artery (OR 4.13; 95% CI 2.62-6.51), and in those with <2 risk factors but atherosclerosis in both the carotid and the vertebrobasilar arteries (OR 3.40; 95% CI 1.22-9.47). CONCLUSIONS: A substantial portion of stroke patients had preclinical CAD, and there was a clear relationship between coronary and cerebral artery atherosclerosis in terms of location and burden. The risk of CAD was particularly high in stroke patients with multiple risk factors and atherosclerosis of the carotid and/or vertebrobasilar arteries.

Neutrophil Recruitment in Arterial Thrombus and Characteristics of Stroke Patients with Neutrophil-Rich Thrombus.

PURPOSE: Neutrophils contribute to thrombosis. However, there is limited information on the temporal course of neutrophil recruitment in thrombosis, the contribution of neutrophils to thrombus growth, and the characteristics of stroke patients with neutrophil-rich thrombi. MATERIALS AND METHODS: After inducing carotid artery thrombosis in Institute of Cancer Research mice using ferric chloride, aged thrombi were produced by ligating the distal portion of the carotid artery in mice for 0.5, 1, 2, 3, 6, or 24 h. For thrombus analysis in stroke patients, we used registry data and thrombi that were obtained during intra-arterial thrombectomy. Immunohistochemistry was performed to determine thrombus composition. RESULTS: In the thrombi of 70 mice, Ly6G positive cell counts (neutrophils) and histone H3-positive cell counts increased in a time-dependent manner (both p<0.001). Ly6G-positive cell count was strongly correlated with histone H3-positive cell counts (r=0.910, p<0.001), but not with thrombus size (p=0.320). In 75 stroke patients, atrial fibrillation and cardioembolism were more frequent in the higher neutrophil group (32/37, 86.5%) than in the lower neutrophil group (19/38, 50%) (p=0.002). The median erythrocyte fraction was higher [52.0 (interquartile range 39.9-57.8)] in the higher neutrophil group than in the lower neutrophil group [40.3 (interquartile range 23.5-53.2)]. The fraction of neutrophils was positively correlated with that of erythrocytes (R=0.35, p=0.002). CONCLUSION: Neutrophils were recruited and increased in arterial thrombosis in a time-dependent manner; however, they were not associated with the growth of formed thrombi. Neutrophil fractions in the thrombi of stroke patients appeared to be associated with atrial fibrillation and erythrocyte fraction.

Increases in cerebral atherosclerosis according to CHADS2 scores in patients with stroke with nonvalvular atrial fibrillation.

BACKGROUND AND PURPOSE: The CHADS(2) score is used for risk stratification of ischemic stroke in patients with nonvalvular atrial fibrillation and high CHADS(2) scores are associated with increased risk of stroke. Most components of the CHADS(2) score are also risk factors for atherosclerosis. Therefore, high CHADS(2) scores can be associated with concomitant cerebral atherosclerosis and subsequently atherothrombotic stroke. The aim of this study was to determine whether there are differences in the presence and burden of concomitant cerebral atherosclerosis according to CHADS(2) scores in patients with stroke with nonvalvular atrial fibrillation. METHODS: We included 780 consecutive patients with nonvalvular atrial fibrillation who had undergone angiographic studies at index stroke between August 1994 and March 2010 in the present study. We investigated the relationships between the CHADS(2) score and the presence, severity, and pattern of cerebral atherosclerosis and stroke mechanism. RESULTS: Of the 780 patients, concomitant arterial stenosis (≥50%) was found in 231 patients (29.6%). The number of arteries with atherosclerosis increased as the CHADS(2) score increased (P<0.001) as did the proportion of combined extracranial and intracranial atherosclerosis (P<0.001). Multivariate analyses showed that high risk based on the CHADS(2) score was an independent predictor of concomitant cerebral atherosclerosis (OR, 3.121; 95% CI, 1.770 to 5.504) and the presence of proximal stenosis at the symptomatic artery (OR, 3.043; 95% CI, 1.458 to 6.350). CONCLUSIONS: The CHADS(2) score can predict the presence of concomitant cerebral artery atherosclerosis. Increased risk of stroke in patients with high CHADS(2) scores may be partly explained by increased frequency and burden of cerebral atherosclerosis.

Determinants of infarction patterns in cardioembolic stroke.

BACKGROUND: Embolic infarctions from the heart are known to cause multiple scattered infarct lesions as well as single, large territorial infarctions. However, it remains unknown which factors contribute to these different infarction patterns in patients with potential cardiac sources of embolism (PCSE). METHODS: We examined 388 ischemic stroke patients with a high-risk PCSE using diffusion-weighted imaging. Infarction patterns were categorized into a single large lesion, a single small lesion, confluent and additional lesions, or small scattered lesions. The relationships between infarction patterns and clinical and hematologic parameters were investigated. RESULTS: Of the 388 patients, a single large lesion was detected in 139 (35.8%), a single small lesion in 29 (7.5%), confluent and additional lesions in 171 (44.1%), and small scattered lesions in 49 (12.7%). Prior use of antiplatelet agents and anticoagulant were associated with the pattern of small scattered lesions and a single small lesion, respectively. Additionally, higher white blood cell counts were associated with confluent and additional lesions. The type of high-risk PCSE was not related to a specific infarction pattern. CONCLUSIONS: These results suggest that platelet function and inflammatory processes may directly affect the thrombus formation in the cardiac chamber.

Effect of leukopenia induced by cyclophosphamide on the initial stage of arterial thrombosis in mice.

INTRODUCTION: Leukocytes are found in organizing thrombi and are associated with thrombus growth. However, their role in the initial stage of thrombus formation is not well known. We investigated the role of leukocytes in the early stage of arterial thrombosis by inducing leukopenia. METHODS: In this double-blind, randomized, placebo-controlled study, 72 Institute of Cancer Research mice were randomly treated with intraperitoneal 100 mg/kg cyclophosphamide or normal saline. The primary outcome was time to occlusion after FeCl3 treatment. We also compared thrombus size, histological composition, and association with peripheral blood cell counts between cyclophosphamide and control groups. RESULTS: Cyclophosphamide treatment significantly decreased leukocyte counts by 82.8% compared to placebo (P < 0.001). The time to occlusion was significantly longer in the cyclophosphamide group (3.31 ± 1.59 min) than in the control group (2.30 ± 1.14 min; P = 0.003). The immunoreactivity for Ly6G-positive cells, intracellular histone H3, and released histone H3 in thrombi was significantly reduced in the cyclophosphamide group by 92.8%, 50.2%, and 34.3%, respectively. Time to occlusion had a moderate negative correlation with leukocyte count in peripheral blood (r = -0.326, P = 0.022) in the entire group. CONCLUSIONS: Cyclophosphamide-induced leukopenia attenuated thrombus formation during the early stage of arterial thrombosis. Our findings suggest the potential role of leukocytes in the initial stage of arterial thrombosis.

A computerized in-hospital alert system for thrombolysis in acute stroke.

BACKGROUND AND PURPOSE: An effective stroke code system that can expedite rapid thrombolytic treatment requires effective notification/communication and an organized team approach. We developed a stroke code program based on the computerized physician order entry (CPOE) system and investigated whether implementation of this CPOE-based program is useful for reducing the time from arrival at emergency departments (ED) to evaluation steps and the initiation of thrombolytic treatment in various hospital settings. METHODS: The CPOE-based program was implemented by 10 hospitals. Time intervals from arrival at the ED to blood tests, computed tomography scanning, and thrombolytic treatment during the 1-year period before and the 1-year period after the program implementation were compared. RESULTS: Time intervals from ED arrival to evaluation steps were significantly reduced after implementation of the CPOE-based program. Times from ED arrival to CT scan, complete blood counts, and prothrombin time testing were reduced by 7.7 minutes, 5.6 minutes, and 26.8 minutes, respectively (P<0.001). The time from ED arrival to intravenous thrombolysis was reduced from 71.7+/-33.6 minutes to 56.6+/-26.9 minutes (P<0.001). The number of patients who were treated with thrombolysis increased from 3.4% (199/5798 patients) before the CPOE-based program to 5.8% (312/5405 patients) afterward (P<0.001). The CPOE implementation also improved the inverse relationship between onset-to-door time and door-to-needle time. CONCLUSIONS: The CPOE-based stroke code could be successfully implemented to reduce in-hospital time delay in thrombolytic therapy in various hospital settings. CPOE may be used as an efficient tool to facilitate in-hospital notification/communication and an organized team approach.

Collateral augmentation treatment with a combination of acetazolamide and head-down tilt in a rat ischemic stroke model.

Cerebral collaterals is crucially important in the pathophysiology of acute ischemic stroke and associated with outcome after reperfusion therapy. We explored the effectiveness of collateral augmentation treatment with a combination of acetazolamide (ACZ) and head-down tilt (HDT) in the transient middle cerebral artery occlusion (MCAO) rat model. Transient MCAO was induced in all animals for 1.5 h, followed by reperfusion for 22.5 h. Seventy-two male Wistar rats were divided into four treatment groups: control, ACZ, HDT, and combination. Twenty sham rats, which underwent surgery, were randomly allocated to these groups. Twenty-four hours after MCAO or sham surgery, we measured the infarction volume, brain edema (aquaporin-4 [AQP4], and brain water content), and neurological deficits (Garcia and Longa tests). Collateral augmentation treatments were associated with reduced infarction volume, less brain edema, and better neurological outcomes compared with untreated animals. More specifically, ACZ and HDT treatments resulted in small infarction volumes, and HDT was associated with a low AQP4 expression and improved neurological score, while the combination of ACZ and HDT improved neurological scores and reduced brain water content. This study shows that collateral augmentation treatments are associated with a better stroke prognosis compared with untreated animals after transient MCAO. The combination of ACZ and HDT seems to have some synergistic effect, but was not proven to be superior to HDT treatment alone.

Factors Associated with Incidental Neuroimaging Abnormalities in New Primary Headache Patients.

BACKGROUND AND PURPOSE: Deciding whether or not to perform neuroimaging in primary headache is a dilemma for headache physicians. The aim of this study was to identify clinical predictors of incidental neuroimaging abnormalities in new patients with primary headache disorders. METHODS: This cross-sectional study was based on a prospective multicenter headache registry, and it classified 1,627 consecutive first-visit headache patients according to the third edition (beta version) of the International Classification of Headache Disorders (ICHD-3ß). Primary headache patients who underwent neuroimaging were finally enrolled in the analysis. Serious intracranial pathology was defined as serious neuroimaging abnormalities with a high degree of medical urgency. Univariable and multivariable logistic regression analyses were conducted to identify factors associated with incidental neuroimaging abnormalities. RESULTS: Neuroimaging abnormalities were present in 170 (18.3%) of 927 eligible patients. In multivariable analysis, age ≥40 years [multivariable-adjusted odds ratio (aOR)=3.37, 95% CI=2.07-6.83], male sex (aOR=1.61, 95% CI=1.12-2.32), and age ≥50 years at headache onset (aOR=1.86, 95% CI=1.24-2.78) were associated with neuroimaging abnormalities. In univariable analyses, age ≥40 years was the only independent variable associated with serious neuroimaging abnormalities (OR=3.37, 95% CI=1.17-9.66), which were found in 34 patients (3.6%). These associations did not change after further adjustment for neuroimaging modality. CONCLUSIONS: Incidental neuroimaging abnormalities were common and varied in a primary headache diagnosis. A small proportion of the patients incidentally had serious neuroimaging abnormalities, and they were predicted by age ≥40 years. These findings can be used to guide the performing of neuroimaging in primary headache disorders.

Associations of Elderly Onset Headache With Occurrence of Poor Functional Outcome, Cardiovascular Disease, and Cognitive Dysfunction During Long-term Follow-up.

BACKGROUND: Although the frequency and intensity of headaches decrease in older adults, headaches in this population are still an important neurological disorder. The purpose of this study was to investigate the associations of headache characteristics in older adults with the development of cardiovascular disease and cognitive dysfunction. METHODS: We prospectively enrolled 125 older (≥65 years old) patients with headache who were making their first visit to outpatient clinics and who had no prior history of cognitive dysfunction from 11 hospitals in Korea between August 2014 and February 2015. We investigated the occurrence of newly developed/or recurrent headache, cardiovascular disease, cognitive dysfunction, and poor functional outcomes. RESULTS: The mean age of all included patients was 72.6 years, 68.8% were women, and 43 (34.4%) had newly developed/or recurrent headache during follow-up. During a median follow-up of 31 months (interquartile range, 28-34 months), 21 participants (16.8%) experienced cardiovascular disease, and 26 (20.8%) developed cognitive dysfunction. Upon multivariate analysis and after adjusting for sex, age, and other factors, presence of newly developed/or recurrent headache was found to be associated with cardiovascular disease (hazard ratio [HR], 4.03; 95% confidence interval [CI], 1.28-12.61; p=0.017) and frequency of headache for the recent 3 months was related with cognitive dysfunction (HR, 1.05; 95% CI, 1.00-1.09; p=0.017) and poor functional outcomes (HR, 1.06; 95% CI, 1.01-1.11; p=0.011). CONCLUSION: Our study demonstrated that there is an increased risk of cardiovascular disease, cognitive dysfunction, and poor functional outcomes in older patients with frequent, newly developed, or recurrent headache.

Timely Interventions can Increase Smoking Cessation Rate in Men with Ischemic Stroke.

PURPOSE: Smoking cessation is strongly recommended for every smoker after ischemic stroke, but many patients fail to quit smoking. An improved smoking cessation rate has been reported with intensive behavioral therapy during hospitalization and supportive contact after discharge. The aim of this study was to demonstrate the usefulness of the timely interventions for smoking cessation in men with acute ischemic stroke. METHODS: Patients who participated in the timely interventions strategy (TI group) were compared with those who received conventional counseling (CC group). In the TI group, a certified nurse provided comprehensive education during admission and additional counseling after discharge. Outcome was measured by point smoking success rate and sustained smoking cessation rate for 12 months. RESULTS: Participants, 157 men (86 of the TI group and 71 of the CC group), were enrolled. Mean age was 58.25 ± 11.23 years and mean initial National Institutes of Health Stroke Scale score was 4.68 ± 5.46. The TI group showed a higher point smoking success rate compared with the CC group (p= .003). Multiple logistic regression analysis showed that the TI group was 2.96-fold (95% CI, 1.43~6.13) more likely to sustain smoking cessation for 12 months than the CC group. CONCLUSION: Findings indicate that multiple interventions initiated during hospital stay and regular follow-up after discharge are more effective than conventional smoking cessation counseling in men with acute ischemic stroke.

Chronic Daily Headache and Medication Overuse Headache in First-Visit Headache Patients in Korea: A Multicenter Clinic-Based Study.

BACKGROUND AND PURPOSE: Chronic daily headache (CDH) is defined as a headache disorder in which headaches occur on a daily or near-daily basis (at least 15 days/month) for more than 3 months. Chronic migraine (CM) and medication overuse headache (MOH) are very disabling headaches that remain underdiagnosed. The aim of this study was to establish the frequency of CDH and its various subtypes, and examine the associations with MOH among first-visit headache patients presenting at neurology outpatient clinics in Korea. METHODS: Eleven neurologists enrolled first-visit patients with complaints of headaches into outpatient clinics for further assessment. Headache disorders were classified according to the International Classification of Headache Disorder (third edition beta version) by each investigator. RESULTS: Primary CDH was present in 248 (15.2%) of the 1,627 included patients, comprising CM (143, 8.8%), chronic tension-type headache (CTTH) (98, 6%), and definite new daily persistent headache (NDPH) (7, 0.4%). MOH was associated with headache in 81 patients (5%). The association with MOH was stronger among CM patients (34.5%) than patients with CTTH (13.3%) or NDPH (14.3%) (p=0.001). The frequency of CDH did not differ between secondary and tertiary referral hospitals. CONCLUSIONS: The frequencies of CDH and MOH diagnoses were 15.2% and 5%, respectively in first-visit headache patients presented at secondary or tertiary referral hospitals in Korea. CM was the most common subtype of CDH and was most frequently associated with MOH.

Characteristics of Elderly-Onset (≥65 years) Headache Diagnosed Using the International Classification of Headache Disorders, Third Edition Beta Version.

BACKGROUND AND PURPOSE: New-onset headache in elderly patients is generally suggestive of a high probability of secondary headache, and the subtypes of primary headache diagnoses are still unclear in the elderly. This study investigated the characteristics of headache with an older age at onset (≥65 years) and compared the characteristics between younger and older age groups. METHODS: We prospectively collected demographic and clinical data of 1,627 patients who first visited 11 tertiary hospitals in Korea due to headache between August 2014 and February 2015. Headache subtype was categorized according to the International Classification of Headache Disorders, Third Edition Beta Version. RESULTS: In total, 152 patients (9.3%, 106 women and 46 men) experienced headache that began from 65 years of age [elderly-onset group (EOG)], while the remaining 1,475 patients who first experienced headache before the age of 65 years were classified as the younger-age-at-onset group (YOG). Among the primary headache types, tension-type headache (55.6% vs. 28.8%) and other primary headache disorders (OPH, 31.0% vs. 17.3%) were more common in the EOG than in the YOG, while migraine was less frequent (13.5% vs. 52.2%) (p=0.001) in the EOG. Among OPH, primary stabbing headache (87.2%) was more frequent in the EOG than in the YOG (p=0.032). The pain was significantly less severe (p=0.026) and the frequency of medication overuse headache was higher in EOG than in YOG (23.5% vs. 7.6%, p=0.040). CONCLUSIONS: Tension-type headache and OPH headaches, primarily stabbing headache, were more common in EOG patients than in YOG patients. The pain intensity, distribution of headache diagnoses, and frequency of medication overuse differed according to the age at headache onset.

Long-term mortality in patients with coexisting potential causes of ischemic stroke.

BACKGROUND: Multiple potential causes of stroke may coexist in ischemic stroke patients, which may affect long-term outcome. AIM: We investigated whether there are differences in long-term mortality among stroke patients with coexisting potential causes. METHODS: We evaluated the long-term all-cause mortality and stroke or cardiovascular mortality of ischemic stroke patients with multiple potential stroke mechanisms, large artery atherosclerosis, cardioembolism, small vessel occlusion, and negative evaluation admitted to a single center between January 1996 and December 2008. Mortality data were obtained from a National Death Certificate system. RESULTS: Total 3533 patients were included in this study: 286 multiple potential mechanisms (138 large artery atherosclerosis + cardioembolism, 105 small vessel occlusion + large artery atherosclerosis, 43 small vessel occlusion + cardioembolism), 1045 large artery atherosclerosis, 701 cardioembolism, 606 small vessel occlusion, and 895 negative evaluation. During a mean follow-up of 3.9 years, as referenced to small vessel occlusion mortality rate, the adjusted mortality hazard ratio was 4.387 (95% confidence interval 3.157-6.096) for large artery atherosclerosis + cardioembolism group, 3.903 (95% confidence interval 3.032-5.024) for cardioembolism group, and 2.121 (95% confidence interval 1.655-2.717) for large artery atherosclerosis. The risk of long-term ischemic stroke mortality or cardiovascular mortality also showed comparable findings: highest in the large artery atherosclerosis + cardioembolism, followed by cardioembolism, and large artery atherosclerosis groups. However, the outcome of small vessel occlusion + large artery atherosclerosis or small vessel occlusion + cardioembolism group was not significantly different from that of small vessel occlusion. CONCLUSIONS: Coexisting potential causes of ischemic stroke impact on long-term mortality. Identification of coexisting potential causes may help to predict stroke outcomes and to guide planning secondary prevention strategies.

Factors associated with ischemic stroke on therapeutic anticoagulation in patients with nonvalvular atrial fibrillation.

PURPOSE: In this study, we investigated the stroke mechanism and the factors associated with ischemic stroke in patients with nonvalvular atrial fibrillation (NVAF) who were on optimal oral anticoagulation with warfarin. MATERIALS AND METHODS: This was a multicenter case-control study. The cases were consecutive patients with NVAF who developed cerebral infarction or transient ischemic attack (TIA) while on warfarin therapy with an international normalized ratio (INR) ≥2 between January 2007 and December 2011. The controls were patients with NVAF without ischemic stroke who were on warfarin therapy for more than 1 year with a mean INR ≥2 during the same time period. We also determined etiologic mechanisms of stroke in cases. RESULTS: Among 3569 consecutive patients with cerebral infarction or TIA who had NVAF, 55 (1.5%) patients had INR ≥2 at admission. The most common stroke mechanism was cardioembolism (76.0%). Multivariate analysis demonstrated that smoking and history of previous ischemic stroke were independently associated with cases. High CHADS2 score (≥3) or CHA2DS2-VASc score (≥5), in particular, with previous ischemic stroke along with ≥1 point of other components of CHADS2 score or ≥3 points of other components of CHA2DS2-VASc score was a significant predictor for development of ischemic stroke. CONCLUSION: NVAF patients with high CHADS2/CHA2DS2-VASc scores and a previous ischemic stroke or smoking history are at high risk of stroke despite optimal warfarin treatment. Some other measures to reduce the risk of stroke would be necessary in those specific groups of patients.

A case of cerebellar infarction caused by acute subclavian thrombus following minor trauma.

Subclavian steal syndrome caused by an acute thrombus is very rare. We present a case of cerebellar infarction with proximal subclavian artery thrombosis. A 56-year-old woman was admitted for sudden vertigo. One day prior to admission, she received a shoulder massage comprised of chiropractic manipulation. On examination, her left hand was pale and radial pulses were absent. Blood pressure was weak in the left arm. Downbeat nystagmus and a right falling tendency were observed. Brain MRI showed multiple acute infarctions in the left cerebellum. The findings of Doppler ultrasonography in the left vertebral artery were compatible with a partial subclavian artery steal phenomenon. Digital subtraction angiography demonstrated a large thrombus in the left subclavian artery. After heparin infusion, thrombus size markedly decreased. Cerebellar infarction caused by acute subclavian thrombosis following minor trauma is rare, but the thrombus can be successfully resolved with anticoagulation.

Stroke units and stroke care services in Korea.

Organized stroke care systems improve stroke outcomes, but require resources and quality-improvement programs. This study was aimed at understanding the current status of stroke care services and stroke units in Korea. An on-line survey to investigate stroke services was conducted using a structured questionnaire for physicians who were in charge of stroke services or neurology departments of Korean hospitals that had neurology resident training programs. Of the 86 neurology training hospitals in Korea, 67 (78·0%) participated in this study. Brain computed tomography and computed tomography angiography were available 24 h a day and seven days a week (24/7) in all hospitals. More than 95% of hospitals offered transcranial Doppler, carotid duplex sonography, echocardiography, and conventional catheter angiography. Intravenous thrombolysis and hemicraniectomy for ischemic brain edema were provided 24/7 in all hospitals, and 50 hospitals (74·6%) were capable of intra-arterial thrombolysis. Stent or angioplasty was more frequently performed than endarterectomy. Performance measures were monitored in 57 hospitals (85·1%). Twenty-nine (43·3%) hospitals had stroke units. Stroke units were more common as the number of beds in the hospital increased (P = 0·001). When compared with hospitals without stroke units, stroke coordinators, use of general management protocol and education program for stroke team were more frequently available in the hospitals with stroke units. Most neurology training hospitals in Korea offered competent acute stroke care services. However, stroke units have not been widely implemented. Encouragement and support at the government or national stroke society level would promote the implementation of stroke units with little additional effort.