Trends in Prehospital Visits as a Cause of Delayed Admission in Korean Stroke Patients over a 10-Year Period: A National Health Insurance Claims Data Study.

Background: A prehospital delay from symptom onset to hospital arrival resulted in stroke-related complications or in-hospital deaths in acute stroke patients. We aimed to investigate trends in prehospital visits as a cause of prehospital delay using data from the Korean Health Insurance Service. Methods: This nationwide, population-based, retrospective cohort study included 524,524 newly-diagnosed stroke patients admitted via the emergency departments of secondary and tertiary hospitals. We obtained the prehospital visits rate from 2010 to 2019 and identified the related characteristics. Results: Prehospital visits were observed in 111,465 patients (21.3%). The prehospital visits rate decreased from 25.1% in 2010 to 17.8% in 2019, but the number of patients increased from 11,255 cases in 2010 to 11,747 cases in 2019. Fortunately, the rate of delayed admission for more than one day decreased from 26.7% to 21.3%. However, 10.4% of patients were diagnosed more than two days later. Young, females, or patients with higher income status and living in low urbanization areas exhibited a higher rate of prehospital visits. Conclusions: Prehospital visits in Korean stroke patients decreased from 25.1% in 2010 to 17.8% in 2019. However, more than 10,000 patients still visited other medical institutions before admission to treatment.

Endovascular management of multiple intracranial dural arteriovenous fistulas.

BACKGROUND AND PURPOSE: Multiply occurring intracranial dural arteriovenous fistulas (dAVFs) have been documented but rarely occur, and neither pathogenesis nor prognosis is clearly understood. This study was conducted to analyze angiographic characteristics of multiple dAVFs and to chronicle our treatment experience. METHODS: Between April, 2002 and January, 2018, data prospectively collected from 310 patients with intracranial dAVFs were systematically reviewed, assessing clinical and anatomic outcomes of endovascular treatment in 32 patients with multiple dAVFs (≥ 2 fistulas each). Lesions were categorized as multifocal or diffuse type, depending on presentation, and further characterized as progressive or non-progressive disease. RESULTS: Overall, 18 patients (56.3%) experienced aggressive presentations, including intracerebral hemorrhage or venous infarction. Cortical venous reflux (CVR) was observed in 26 patients (81.3%), and sinus thrombosis or occlusion was seen in 24 (75.0%). Clinical outcomes in patients with multifocal fistulas (n = 11) were excellent (100%), marked by a moderately high rate of complete occlusion (54.5%). Those with progressive disease (n = 10) regularly displayed certain angiographic findings, namely diffuse configuration (100%), sinus thrombosis (100%), and CVR (100%). Complete anatomic obliteration was achieved in 12 patients (37.5%), and in 26 patients (81.3%), clinical outcomes were favorable. CONCLUSION: Multiple dAVFs are typically aggressive at presentation, given strong associations with CVR and sinus thrombosis. In diffuse-type fistulas, the potential to recur or progress is high. Although definitive treatment poses a challenge, outcomes of endovascular therapeutics may be still optimized in this setting through strategic procedural modifications and careful follow-up monitoring.

Does stent type impact coil embolization outcomes in extended follow-up of small-sized aneurysms (< 10 mm)?

PURPOSE: Self-expandable stents have enabled endovascular treatment of wide-necked aneurysms (ordinarily viewed as technically prohibitive), with favorable outcomes. However, the impact of stent type on occlusive stability has not been adequately investigated. In small-sized unruptured saccular aneurysms, we generated estimates of stent-assisted coil embolization outcomes during follow-up monitoring. Stent type and other risk factors linked to recanalization were analyzed. METHODS: A cohort of 286 patients harboring 312 small-sized unruptured aneurysms (< 10 mm) was subjected to mid-term and extended follow-up monitoring after stent-assisted coiling. Three types of stents (Enterprise, 192; Neuroform, 27; LVIS, 93) were deployed in this population; all medical records and radiologic data of which were reviewed. Mid-term recanalization rates and related risk factors were assessed using binary logistic regression analysis. RESULTS: A total of 49 aneurysms (15.7%) displayed recanalization at 6 months postembolization, with 34 and 15 instances of minor and major recanalization, respectively. Multivariate analysis indicated that wide-necked aneurysms (> 4 mm) (HR = 2.362; p = 0.017), incomplete occlusion at time of coiling (HR = 2.949; p = 0.002), and stent type (p = 0.048) were significant factors in mid-term recanalization, whereas hypertension (p = 0.095) and packing density ≤ 30% (p = 0.213) fell short of statistical significance. Compared with Enterprise (HR = 2.828) or Neuroform (HR = 4.206) stents, outcomes proved more favorable with use of LVIS. CONCLUSIONS: Above findings demonstrate that in addition to occlusive status at time of coil embolization and neck size, stent type may affect follow-up outcomes of stent-assisted coil embolization in small-sized aneurysms. LVIS (vs Enterprise or Neuroform stents) performed best during follow-up monitoring in terms of limiting recanalization.

Correction to: Does stent type impact coil embolization outcomes in extended follow-up of small-sized aneurysms (< 10 mm)?

The original version of this article contained a mistake in Fig. 4: Fig. 4a and d were interchanged. The correct figure is shown below. The original article has been corrected.

Association between Prehospital Visits and Poor Health Outcomes in Korean Acute Stroke Patients: A National Health Insurance Claims Data Study.

This study aimed to determine whether prehospital visits to other medical institutions before admission are associated with prolonged hospital stay, readmission, or mortality rates in acute stroke patients. Using the claims data from the Korean Health Insurance Service, a cross-sectional study was conducted on 58,418 newly diagnosed stroke patients aged ≥ 20 years from 1 January 2019 to 31 December 2019. Extended hospital stay (≥7 days; median value) following initial admission, readmission within 180 days after discharge, and all-cause mortality within 30 days were measured as health outcomes using multiple logistic regression analysis after adjusting for age, sex, income, residential area, and medical history. Stroke patients with a prehospital visit (10,992 patients, 18.8%) had a higher risk of long hospitalization (odds ratio = 1.06; 95% confidence interval = 1.02-1.10), readmission (1.19; 1.14-1.25), and mortality (1.23; 1.13-1.33) compared with patients without a prehospital visit. Female patients and those under 65 years of age had increased unfavorable outcomes (p < 0.05). Prehospital visits were associated with unfavorable health outcomes.

Temporal trend of first-ever ischaemic stroke incidence from 2010 to 2019 in South Korea: a nationwide retrospective cohort study.

OBJECTIVE: Ischaemic stroke incidence is on the decline globally, but the trend in South Korea is unknown. In this study, the 10-year incidence trends of first-ever ischaemic stroke in South Korea were evaluated. DESIGN, SETTING AND PARTICIPANTS: The National Health Insurance Services medical claim data were used to construct 10 annual cohorts of adults aged 20 years and older, who had not been diagnosed with stroke, to find out the incidence trends of first-ever ischaemic stroke from 2010 to 2019. OUTCOME MEASURES: The primary outcomes were crude and age-adjusted incidence rates for 10 years. Crude incidence rates of the age groups and incidence age statistics were calculated. For comparison among the income groups, age-adjusted incidence rates were used. Incidence rates in all the groups were analysed separately by sex. RESULTS: Age-standardised incidence rates of ischaemic stroke per 100 000 were 101.0 in men, and 67.6 in women in 2010; and 92.2 in men, and 55.0 in women in 2019. By age group, there was a decrease in women over 40 years of age, and men over 60 years of age. The relative difference in stroke incidence rates between medical aid beneficiaries and the highest income group increased from 1.5 to 1.87 over 10 years. CONCLUSIONS: Age-standardised incidence rate of ischaemic stroke has decreased from 2010 to 2019 for both man and women. The incidence rate was stable in the younger age groups and decreased in the older age groups, and the disparities between income groups have widened over the past decade. Stroke prevention strategies are needed for the younger age group and the low-income group. Further research is needed to study the risk factors contributing to the incidence of ischaemic stroke in different groups.

Sex and Economic Disparity Related to Reperfusion Therapies for Patients with Acute Ischemic Stroke in South Korea across a 10-Year Period: A Nationwide Population-Based Study Using the National Health Insurance Database.

A complete enumeration study was conducted to evaluate trends related to reperfusion therapies (intravenous thrombolysis (IVT) and endovascular treatment (EVT)) in acute ischemic stroke (AIS) in South Korea, according to sex, economic status, and age, over a 10-year period retrospectively, using the National Health Information Database (NHIS-2020-1-481). This study included AIS patients aged ≥20 years who were hospitalized in a general hospital or tertiary hospital for ≥4 days and underwent brain imaging during the same period. Study participants were classified by sex, economic status (Medical Aid beneficiaries and National Health Insurance beneficiaries) and age (20-44, 45-64, 65-79, and ≥80 years). Women showed a significantly lower OR (Odds ratio) than men in IVT (OR: 0.75; 95% CI: 0.73-0.77), EVT (OR: 0.96; 95% CI: 0.93-0.99), and any therapy (OR: 0.82; 95% CI: 0.80-0.84). The Medical Aid beneficiaries showed significantly lower OR in IVT (OR 0.91, 95% CI 0.88-0.95), EVT (OR 0.93, 95% CI 0.89-0.98), and either therapy (OR 0.92, 95% CI 0.90-0.95) than the National Health Insurance beneficiaries. This study showed sex and economic disparity related to reperfusion therapies in patients with AIS in Korea.

Different risk factor profiles between silent brain infarction and symptomatic lacunar infarction.

BACKGROUND/AIMS: It is generally assumed that silent brain infarction (SBI) and symptomatic lacunar infarction (sLAC) share common vascular risk factors and their pathogeneses are known to be similar. However, few studies have conducted a risk factor profile analysis of the two diseases in a single study design. METHODS: This study included 64 subjects with SBI lesions, 140 patients with sLAC, and 342 controls by retrospective investigation of brain MRI. Topographic findings and vascular risk factor profiles were compared. RESULTS AND CONCLUSION: Compared to the controls, the SBI group was found to be associated with hypertension (p = 0.002) and elevated plasma total homocysteine level (p = 0.02). The sLAC group was found to be associated with hypertension (p = 0.001), diabetes (p = 0.004), smoking (p = 0.002), ischemic heart disease (p = 0.01) and hyperlipidemia (p = 0.04). In the present study, risk factor profiles of the SBI and sLAC were not exactly the same, indicating a different pathogenesis between the two diseases.

Kinetic tremor and cerebellar ataxia as initial manifestations of Kikuchi-Fujimoto's disease.

Involvement of central nervous system occasionally occurs as a form of aseptic meningitis in Kikuchi-Fujimoto disease (KFD). However, acute cerebellar symptoms are very rare in KFD. We describe a 42 year-old woman presenting kinetic tremor and gait ataxia preceding cervical lymphadenopathy. The diagnosis of KFD was made based on pathology. Lymphocyte-dominant pleocytosis was observed in cerebrospinal fluid. Brain and spinal magnetic resonance imaging showed no structural abnormalities. Acute cerebellar symptoms and cervical lymphadenopathy disappeared spontaneously within 2 months. This case of KFD involved unusual acute cerebellar symptoms. Selective involvement of the cerebellar system by viral or immunologic response may be attributed to acute cerebellar symptoms in KFD.

Growth of Asymptomatic Intracranial Fusiform Aneurysms : Incidence and Risk Factors.

PURPOSE: Growth of intracranial fusiform aneurysms (IFA) may become clinically problematic through a mass effect or rupture. We investigated the growth rate and factors contributing to growth in asymptomatic untreated IFA. METHOD: As a retrospective review, we assessed patients diagnosed with asymptomatic IFA between August 2000 and September 2014, all untreated. No acute or symptomatic dissecting lesions were considered. Clinical and serial angiographic follow-up data were analyzed, defining growth as expansion > 2 mm in one or more dimensions. A binary logistic regression model and Kaplan-Meier method were applied for statistical analysis. RESULTS: The mean follow-up in the 82 eligible patients was 47.7 months (range 12-190 months). Among them, 7 aneurysms (8.5%, 2.1% per aneurysm year) demonstrated growth (in any dimension). In univariate analysis, height and multiplicity of aneurysms emerged as significant factors in terms of growth. Height remained an independent risk factor in the binary logistic regression model, with receiver operating curves indicating a threshold of 6.9 mm initial height in determining IFA growth (area under the curve 0.804). Of the patients six (except one who underwent endovascular treatment) were observed during continued follow-up monitoring. All six lesions were stable in serial imaging tests, without further detectable growth or rupture (mean 33 months). CONCLUSION: Most (91.5%) of the asymptomatic and untreated IFAs studied proved to be stable, with no continued growth; however, because aneurysm height proved to be independently predictive of growth (lesions > 6.9 mm being at risk), periodic imaging is required in those left untreated. Growing but still asymptomatic aneurysms call for the utmost caution and care in decision-making.

Growth of Untreated Unruptured Small-sized Aneurysms (≺7mm): Incidence and Related Factors.

PURPOSE: The need to treat small (<7 mm) unruptured aneurysms is still controversial, despite data collected through several large cohort studies. Such lesions typically are incidental findings, usually followed for potential growth through serial imaging. For this study, growth estimates for untreated unruptured small-sized aneurysms were generated, examining incidence and related risk factors. METHODS: A cohort of 135 consecutive patients harboring 173 untreated unruptured small-sized aneurysms (<7 mm) was subjected to extended monitoring (mean, 73.1 ± 30.0 months). Growth was defined as a 1-mm increase at minimum in one or more aneurysmal dimensions or as a significant change in shape. Medical records and radiological data were reviewed. Cumulative growth rate and related risk factors were analyzed via Cox proportional hazards regression and Kaplan-Meier product-limit estimator. RESULTS: A total of 28 aneurysms (16.2%) displayed growth during continued surveillance (1054.1 aneurysm-years). The annual growth rate was 2.65% per aneurysm-year, with 15 surfacing within 60 months and 13 after 60 months. Multivariate analysis indicated that bifurcation type was the sole significant risk factor (hazard ratio HR = 7.64; p < 0.001) in terms of growth. Cumulative survival rates without growth were significantly lower in subjects with bifurcation aneurysms than with side-wall aneurysms (p < 0.001). During the follow-up period, one patient suffered a subarachnoid hemorrhage and then aneurysm growth was detected. CONCLUSION: Most (83.8%) untreated unruptured small-sized aneurysms (<7 mm) remained stable and devoid of growth in long-term follow-up. Because bifurcation aneurysms were prone to eventual growth, careful long-term monitoring at regular intervals is advised if left untreated.

Long-term outcomes of Low-profile Visualized Intraluminal Support device usage in stent-assisted coiling of intracranial aneurysm.

Stent-assisted coil embolization technique have broadened indications for endovascular therapy of aneurysms. The Low-profile Visualized Intraluminal Support device (LVIS) is a self-expanding, nitinol single-braid and closed-cell device introduced fairly recently. We aim to evaluate long-term outcome of LVIS device in stent-assisted coiling of intracranial aneurysms. Between October 2012 and February 2013, a total of 55 patients with unruptured wide-necked intracranial aneurysms underwent coil embolization procedures involving LVIS devices. Clinical and anatomic parameters assessed included extent of aneurysmal occlusion, stent deployment status, and delayed complications. Anatomic outcomes were evaluated via DSA, MRA, and plain radiography (PR). Three patients were lost to follow-up after 6 months, but in 37 of 52 qualifying patients (mean follow-up, 27.1 months; range, 12-36 months) post-coiling recanalization was evaluable by DSA or MRA. Only one patient (2.7%) experienced minor recanalization, all others (97.3%) showing complete occlusion. Coil configurations were consistently stable by PR in 15 other patients (mean follow-up, 34.1 months; range, 30-39 months). No migration or altered expansion of stents was evident in 30 patients with available DSA and/or PR images. Three patients (5.8%) suffered delayed cerebral ischemia without neurologic sequelae, all as transient ischemic attacks and all related to withdrawal or change of anti-platelet medications. LVIS device usage in stent-assisted coil embolization of intracranial aneurysms provides excellent long-term results in terms of safety, efficacy and durability.

Staged carotid artery stenting in patients with severe carotid stenosis: Multicenter experience.

Cerebral hyperperfusion syndrome (CHS) is serious complication after carotid artery stenting (CAS) caused by decreased cerebral vasoreactivity (CVR) due to long standing hypoperfusion of the brain. We hypothesized that partial dilatation of carotid stenosis would allow the recovery of CVR, and prevent CHS when definitive angioplasty with stent is performed afterward. In this study, we aimed to evaluate the safety and efficacy of staged CAS in patients with severe carotid artery stenosis with evident hemodynamic compromise in regard to preventing hyperperfusion syndrome. From January 2005 to February 2016, 53 patients with 55 severe carotid artery stenosis lesions showing decreased CVR and/or cerebral basal flow at the perfusion studies underwent staged CAS in three institutes. The procedure consisted of initial partial balloon angioplasty (BA), recovery period, and delayed definitive stenting (DS). We analyzed immediate results, complications, recoil and CHS related to staged CAS. We experienced no symptomatic manifestation of CHS except self-limited headache after the procedures. The median of intervals between BA and DS stages were 10 days. There was no case of severe recoil during the interval between BA and DS stage. Where perfusion imaging data was available, hyperperfusion was present in three and one patients after BA and DS stage, respectively, with no clinical symptom of CHS. In conclusion, staged CAS was feasible in patients with severe carotid artery stenosis and hemodynamic compromise, without inducing severe complication of CHS such as intracranial hemorrhage.

Association between kinase insert domain-containing receptor gene polymorphism and haplotypes and ischemic stroke.

BACKGROUND: Kinase insert domain-containing receptor (KDR), a type 2 vascular endothelial growth factor receptor, plays a crucial role in angiogenesis and vascular integrity of blood vessels. We evaluated whether single nucleotide polymorphisms (SNPs) and haplotype of kinase insert domain-containing receptor (KDR) are associated with increased risk of ischemic stroke in the Korean population. METHODS: Totals of 501 patients with ischemic stroke and 478 controls were screened for the KDR -604T>C, +1192G>A, and +1719A>T SNPs. Subgroup analysis was performed to determine whether the effect of KDR polymorphism is specific to certain etiological subtypes of ischemic stroke. In addition, haplotype frequencies of these three SNPs were analyzed in stroke patients and controls. RESULTS: The SNP +1719T allele was associated with risk of ischemic stroke in a dose-dependent manner (TT vs. AA: adjusted OR: 1.90, 95% CIs: 1.29-2.81, p=0.001 and false discovery rate (FDR)=0.003). Subgroup analysis showed that the SNP +1719T allele had a slight but significant association with small vessel disease type (TT vs. AA: adjusted OR: 1.91, 95% CIs: 1.11-3.29, p=0.02). There was no association between SNP -604 and SNP +1192 and ischemic stroke risk. In haplotype analysis, the T-G-T (-604/+1192/+1719), T-A-T, and C-G-T haplotypes increased the relative risk of ischemic stroke. CONCLUSIONS: The KDR +1719A>T polymorphism and its haplotypes are possible genetic determinants for the risk of ischemic stroke.