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Background@#During the coronavirus disease 2019 (COVID-19) pandemic, patients with myasthenia gravis (MG) were more susceptible to poor outcomes owing to respiratory muscle weakness and immunotherapy. Several studies conducted in the early stages of the COVID-19 pandemic reported higher mortality in patients with MG compared to the general population. This study aimed to investigate the clinical course and prognosis of COVID-19 in patients with MG and to compare these parameters between vaccinated and unvaccinated patients in South Korea. @*Methods@#This multicenter, retrospective study, which was conducted at 14 tertiary hospitals in South Korea, reviewed the medical records and identified MG patients who contracted COVID-19 between February 2022 and April 2022. The demographic and clinical characteristics associated with MG and vaccination status were collected. The clinical outcomes of COVID-19 infection and MG were investigated and compared between the vaccinated and unvaccinated patients. @*Results@#Ninety-two patients with MG contracted COVID-19 during the study. Nine (9.8%) patients required hospitalization, 4 (4.3%) of whom were admitted to the intensive care unit. Seventy-five of 92 patients were vaccinated before contracting COVID-19 infection, and 17 were not. During the COVID-19 infection, 6 of 17 (35.3%) unvaccinated patients were hospitalized, whereas 3 of 75 (4.0%) vaccinated patients were hospitalized (P < 0.001). The frequencies of ICU admission and mechanical ventilation were significantly lower in the vaccinated patients than in the unvaccinated patients (P = 0.019 and P = 0.032, respectively). The rate of MG deterioration was significantly lower in the vaccinated patients than in the unvaccinated patients (P = 0.041). Logistic regression after weighting revealed that the risk of hospitalization and MG deterioration after COVID-19 infection was significantly lower in the vaccinated patients than in the unvaccinated patients. @*Conclusion@#This study suggests that the clinical course and prognosis of patients with MG who contracted COVID-19 during the dominance of the omicron variant of COVID-19 may be milder than those at the early phase of the COVID-19 pandemic when vaccination was unavailable. Vaccination may reduce the morbidity of COVID-19 in patients with MG and effectively prevent MG deterioration induced by COVID-19 infection.
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Background@#and Purpose The accurate prediction of functional outcomes in patients with acute ischemic stroke (AIS) is crucial for informed clinical decision-making and optimal resource utilization. As such, this study aimed to construct an ensemble deep learning model that integrates multimodal imaging and clinical data to predict the 90-day functional outcomes after AIS. @*Methods@#We used data from the Korean Stroke Neuroimaging Initiative database, a prospective multicenter stroke registry to construct an ensemble model integrated individual 3D convolutional neural networks for diffusion-weighted imaging and fluid-attenuated inversion recovery (FLAIR), along with a deep neural network for clinical data, to predict 90-day functional independence after AIS using a modified Rankin Scale (mRS) of 3–6. To evaluate the performance of the ensemble model, we compared the area under the curve (AUC) of the proposed method with that of individual models trained on each modality to identify patients with AIS with an mRS score of 3–6. @*Results@#Of the 2,606 patients with AIS, 993 (38.1%) achieved an mRS score of 3–6 at 90 days post-stroke. Our model achieved AUC values of 0.830 (standard cross-validation [CV]) and 0.779 (time-based CV), which significantly outperformed the other models relying on single modalities: b-value of 1,000 s/mm2 (P<0.001), apparent diffusion coefficient map (P<0.001), FLAIR (P<0.001), and clinical data (P=0.004). @*Conclusion@#The integration of multimodal imaging and clinical data resulted in superior prediction of the 90-day functional outcomes in AIS patients compared to the use of a single data modality.
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Objective@#To compare the outcomes of digital breast tomosynthesis (DBT) screening combined with ultrasound (US) with those of digital mammography (DM) combined with US in women with dense breasts. @*Materials and Methods@#A retrospective database search identified consecutive asymptomatic women with dense breasts who underwent breast cancer screening with DBT or DM and whole-breast US simultaneously between June 2016 and July 2019. Women who underwent DBT + US (DBT cohort) and DM + US (DM cohort) were matched using 1:2 ratio according to mammographic density, age, menopausal status, hormone replacement therapy, and a family history of breast cancer. The cancer detection rate (CDR) per 1000 screening examinations, abnormal interpretation rate (AIR), sensitivity, and specificity were compared. @*Results@#A total of 863 women in the DBT cohort were matched with 1726 women in the DM cohort (median age, 53 years; interquartile range, 40–78 years) and 26 breast cancers (9 in the DBT cohort and 17 in the DM cohort) were identified. The DBT and DM cohorts showed comparable CDR (10.4 [9 of 863; 95% confidence interval {CI}: 4.8–19.7] vs. 9.8 [17 of 1726;95% CI: 5.7–15.7] per 1000 examinations, respectively; P = 0.889). DBT cohort showed a higher AIR than the DM cohort (31.6% [273 of 863; 95% CI: 28.5%–34.9%] vs. 22.4% [387 of 1726; 95% CI: 20.5%–24.5%]; P < 0.001). The sensitivity for both cohorts was 100%. In women with negative findings on DBT or DM, supplemental US yielded similar CDRs in both DBT and DM cohorts (4.0 vs. 3.3 per 1000 examinations, respectively; P = 0.803) and higher AIR in the DBT cohort (24.8% [188 of 758; 95% CI: 21.8%–28.0%] vs. 16.9% [257 of 1516; 95% CI: 15.1%–18.9%; P < 0.001). @*Conclusion@#DBT screening combined with US showed comparable CDR but lower specificity than DM screening combined with US in women with dense breasts.
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Background@#and Purpose This study aimed to investigate the applicability of deep learning (DL) model using diffusion-weighted imaging (DWI) data to predict the severity of aphasia at an early stage in acute stroke patients. @*Methods@#We retrospectively analyzed consecutive patients with aphasia caused by acute ischemic stroke in the left middle cerebral artery territory, who visited Asan Medical Center between 2011 and 2013. To implement the DL model to predict the severity of post-stroke aphasia, we designed a deep feed-forward network and utilized the lesion occupying ratio from DWI data and established clinical variables to estimate the aphasia quotient (AQ) score (range, 0 to 100) of the Korean version of the Western Aphasia Battery. To evaluate the performance of the DL model, we analyzed Cohen’s weighted kappa with linear weights for the categorized AQ score (0–25, very severe; 26–50, severe; 51–75, moderate; ≥76, mild) and Pearson’s correlation coefficient for continuous values. @*Results@#We identified 225 post-stroke aphasia patients, of whom 176 were included and analyzed. For the categorized AQ score, Cohen’s weighted kappa coefficient was 0.59 (95% confidence interval [CI], 0.42 to 0.76; P<0.001). For continuous AQ score, the correlation coefficient between true AQ scores and model-estimated values was 0.72 (95% CI, 0.55 to 0.83; P<0.001). @*Conclusions@#DL approaches using DWI data may be feasible and useful for estimating the severity of aphasia in the early stage of stroke.
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Background@#and Purpose Long-term changes in post-stroke depression (PSD), post-stroke emotional incontinence (PSEI), and post-stroke anger (PSA) have rarely been studied. @*Methods@#This is a sub-study of EMOTION, a randomized, placebo-controlled trial, that examined the efficacy of escitalopram on PSD, PSEI, and PSA in patients with stroke. We interviewed patients at the long-term period (LTP) using predefined questionnaires: Montgomery-Åsberg depression rating scale (MADRS) for PSD, modified Kim’s criteria for PSEI, and Spielberger trait anger scale for PSA. Additionally, the ENRICHD Social Support Instrument (ESSI) for the social support state and the modified Rankin Scale (mRS) were measured. We investigated the changes in and factors behind PSD, PSEI, and PSA at LTP. @*Results@#A total of 222 patients were included, and the median follow-up duration was 59.5 months (interquartile range, 50 to 70). Compared to the data at 6 months post-stroke, the prevalence of PSEI (11.7% at 6 months, 6.3% at LTP; P=0.05) and mean anger score (21.62, 16.24; P<0.01) decreased, while the prevalence of PSD (35.6%, 44.6%; P=0.03) and mean MADRS (6.16, 8.67; P<0.01) increased at LTP. ESSI was associated with PSD and PSA, but not with PSEI. The effect of the baseline National Institutes of Health Stroke Scale score on PSD decreased over time. The effect of low social support on PSD was greater than that of mRS at LTP. @*Conclusions@#The prevalence and degree of PSD significantly increased, while those of PSEI and PSA decreased at LTP. PSD in this stage appeared to be more closely associated with a lack of social support than patients' physical disabilities.
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Background@#and Purpose Long-term changes in post-stroke depression (PSD), post-stroke emotional incontinence (PSEI), and post-stroke anger (PSA) have rarely been studied. @*Methods@#This is a sub-study of EMOTION, a randomized, placebo-controlled trial, that examined the efficacy of escitalopram on PSD, PSEI, and PSA in patients with stroke. We interviewed patients at the long-term period (LTP) using predefined questionnaires: Montgomery-Åsberg depression rating scale (MADRS) for PSD, modified Kim’s criteria for PSEI, and Spielberger trait anger scale for PSA. Additionally, the ENRICHD Social Support Instrument (ESSI) for the social support state and the modified Rankin Scale (mRS) were measured. We investigated the changes in and factors behind PSD, PSEI, and PSA at LTP. @*Results@#A total of 222 patients were included, and the median follow-up duration was 59.5 months (interquartile range, 50 to 70). Compared to the data at 6 months post-stroke, the prevalence of PSEI (11.7% at 6 months, 6.3% at LTP; P=0.05) and mean anger score (21.62, 16.24; P<0.01) decreased, while the prevalence of PSD (35.6%, 44.6%; P=0.03) and mean MADRS (6.16, 8.67; P<0.01) increased at LTP. ESSI was associated with PSD and PSA, but not with PSEI. The effect of the baseline National Institutes of Health Stroke Scale score on PSD decreased over time. The effect of low social support on PSD was greater than that of mRS at LTP. @*Conclusions@#The prevalence and degree of PSD significantly increased, while those of PSEI and PSA decreased at LTP. PSD in this stage appeared to be more closely associated with a lack of social support than patients' physical disabilities.
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Objective@#Early identification of dysphagia after stroke helps in preventing aspiration pneumonia. However, data are limited regarding the effectiveness of formal dysphagia screening for reducing the risk of aspiration pneumonia.The current study evaluates the effectiveness of formal dysphagia screening in stroke patients, to prevent future episodes of aspiration pneumonia. @*Methods@#The stroke registry of a tertiary hospital was retrospectively reviewed. We compared clinical variables and the incidence of aspiration pneumonia of patients hospitalized between 2014 and 2015 after formal screening was implemented, and patients hospitalized in 2011 when no established dysphagia screening protocol was in place.Additionally, we identified the incidence of pneumonia according to stroke severity, and evaluated the association with results obtained for incidence of pneumonia and dysphagia screening. @*Results@#A total of 2,902 patients were identified to have suffered acute stroke (2,018 who underwent formal dysphagia screening; 884 without screening). Patients with formal dysphagia screening developed pneumonia less frequently than patients not administered screening (1.3% with formal screening vs. 3.4% no formal screening, P＜0.001).Pneumonia was significantly lower in patients with moderate and severe stroke who underwent formal dysphagia screening. Furthermore, failure of the dysphagia screening test, presentation with severe dysarthria, and conditions where dysarthria could not be evaluated, were independent predictors of pneumonia among patients who underwent formal screening. @*Conclusion@#Our findings demonstrate the association of formal dysphagia screening with reduced risk of poststroke aspiration pneumonia, and indicates the efficacy of the procedure in identifying patients at higher risk of contracting pneumonia.
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Background@#and purpose Whether pharmacologically altered high-density lipoprotein cholesterol (HDL-C) affects the risk of cardiovascular events is unknown. Recently, we have reported the Prevention of Cardiovascular Events in Asian Patients with Ischaemic Stroke at High Risk of Cerebral Haemorrhage (PICASSO) trial that demonstrated the non-inferiority of cilostazol to aspirin and superiority of probucol to non-probucol for cardiovascular prevention in ischemic stroke patients (clinicaltrials.gov: NCT01013532). We aimed to determine whether on-treatment HDL-C changes by cilostazol and probucol influence the treatment effect of each study medication during the PICASSO study. @*Methods@#Of the 1,534 randomized patients, 1,373 (89.5%) with baseline cholesterol parameters were analyzed. Efficacy endpoint was the composite of stroke, myocardial infarction, and cardiovascular death. Cox proportional hazards regression analysis examined an interaction between the treatment effect and changes in HDL-C levels from randomization to 1 month for each study arm. @*Results@#One-month post-randomization mean HDL-C level was significantly higher in the cilostazol group than in the aspirin group (1.08 mmol/L vs. 1.00 mmol/L, P<0.001). The mean HDL-C level was significantly lower in the probucol group than in the non-probucol group (0.86 mmol/L vs. 1.22 mmol/L, P<0.001). These trends persisted throughout the study. In both study arms, no significant interaction was observed between HDL-C changes and the assigned treatment regarding the risk of the efficacy endpoint. @*Conclusions@#Despite significant HDL-C changes, the effects of cilostazol and probucol treatment on the risk of cardiovascular events were insignificant. Pharmacologically altered HDL-C levels may not be reliable prognostic markers for cardiovascular risk.
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No abstract available.
الموضوعات
Humans , Carotid Artery, Internal , Embolization, Therapeutic , Endovascular Procedures , Intracranial Aneurysm , Oculomotor Nerve Diseases , Paralysisالملخص
BACKGROUND AND PURPOSE: The pathophysiology of post-stroke depression (PSD) is complex and may differ according to an individual’s mood immediately after stroke. Here, we compared the therapeutic response and clinical characteristics of PSD at a later stage between patients with and without depression immediately after stroke. METHODS: This study involved a post hoc analysis of data from EMOTION (ClinicalTrials.gov NCT01278498), a placebo-controlled, double-blind trial that examined the efficacy of escitalopram (10 mg/day) on PSD and other emotional disturbances among 478 patients with acute stroke. Participants were classified into the Baseline-Blue (patients with baseline depression at the time of randomization, defined per the Montgomery-Asberg Depression Rating Scale [MADRS] ≥8) or the Baseline-Pink groups (patients without baseline depression). We compared the efficacy of escitalopram and predictors of 3-month PSD (MADRS ≥8) between these groups. RESULTS: There were 203 Baseline-Pink and 275 Baseline-Blue patients. The efficacy of escitalopram in reducing PSD risk was more pronounced in the Baseline-Pink than in the Baseline-Blue group (p for interaction=0.058). Several risk factors differentially affected PSD development based on the presence of baseline depression (p for interaction < 0.10). Cognitive dysfunction was an independent predictor of PSD in the Baseline-Blue, but not in the Baseline-Pink group, whereas the non-use of escitalopram and being female were more strongly associated with PSD in the Baseline-Pink group. CONCLUSIONS: Responses to escitalopram and predictors of PSD 3 months following stroke differed based on the presence of baseline depression. Our data suggest that PSD pathophysiology is heterogeneous; therefore, different therapeutic strategies may be needed to prevent PSD emergence following stroke.
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Female , Humans , Affective Symptoms , Anger , Citalopram , Depression , Random Allocation , Risk Factors , Strokeالملخص
Bilateral internuclear ophthalmoplegia (INO) refers to a specific gaze abnormality of bilateral adduction deficits, often accompanied by dissociated abducting nystagmus, caused by medial longitudinal fasciculus lesions usually due to multiple sclerosis or stroke. We report a 63-year-old man with clinical features of Miller-Fisher syndrome (MFS), consisting of ataxia, areflexia, and external ophthalmoplegia which mimicked bilateral-INO without an identifiable central lesion. Although bilateral adduction deficits are usually caused by central lesions, peripheral nervous damage by MFS is needed to be considered.
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Humans , Middle Aged , Ataxia , Miller Fisher Syndrome , Multiple Sclerosis , Ocular Motility Disorders , Ophthalmoplegia , Strokeالملخص
Artificial intelligence (AI), a computer system aiming to mimic human intelligence, is gaining increasing interest and is being incorporated into many fields, including medicine. Stroke medicine is one such area of application of AI, for improving the accuracy of diagnosis and the quality of patient care. For stroke management, adequate analysis of stroke imaging is crucial. Recently, AI techniques have been applied to decipher the data from stroke imaging and have demonstrated some promising results. In the very near future, such AI techniques may play a pivotal role in determining the therapeutic methods and predicting the prognosis for stroke patients in an individualized manner. In this review, we offer a glimpse at the use of AI in stroke imaging, specifically focusing on its technical principles, clinical application, and future perspectives.
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Humans , Artificial Intelligence , Brain , Computer Systems , Diagnosis , Intelligence , Machine Learning , Patient Care , Prognosis , Strokeالملخص
BACKGROUND AND PURPOSE: Decreasing the time delay for thrombolysis, including intravenous thrombolysis (IVT) with tissue plasminogen activator and intra-arterial thrombectomy (IAT), is critical for decreasing the morbidity and mortality of patients experiencing acute stroke. We aimed to decrease the in-hospital delay for both IVT and IAT through a multidisciplinary approach that is feasible 24 h/day. METHODS: We implemented the Stroke Alert Team (SAT) on May 2, 2016, which introduced hospital-initiated ambulance prenotification and reorganized in-hospital processes. We compared the patient characteristics, time for each step of the evaluation and thrombolysis, thrombolysis rate, and post-thrombolysis intracranial hemorrhage from January 2014 to August 2016. RESULTS: A total of 245 patients received thrombolysis (198 before SAT; 47 after SAT). The median door-to-CT, door-to-MRI, and door-to-laboratory times decreased to 13 min, 37.5 min, and 8 min, respectively, after SAT implementation (P<0.001). The median door-to-IVT time decreased from 46 min (interquartile range [IQR] 36–57 min) to 20.5 min (IQR 15.8–32.5 min; P<0.001). The median door-to-IAT time decreased from 156 min (IQR 124.5–212.5 min) to 86.5 min (IQR 67.5–102.3 min; P<0.001). The thrombolysis rate increased from 9.8% (198/2,012) to 15.8% (47/297; P=0.002), and the post-thrombolysis radiological intracranial hemorrhage rate decreased from 12.6% (25/198) to 2.1% (1/47; P=0.035). CONCLUSIONS: SAT significantly decreased the in-hospital delay for thrombolysis, increased thrombolysis rate, and decreased post-thrombolysis intracranial hemorrhage. Time benefits of SAT were observed for both IVT and IAT and during office hours and after-hours.
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Humans , Ambulances , Cerebral Infarction , Intracranial Hemorrhages , Mortality , Stroke , Thrombectomy , Thrombolytic Therapy , Tissue Plasminogen Activatorالملخص
The purpose of this paper is to show the radiologic features of various lesions appearing as skin thickening or enhancement under the breast MRI. And histopathologic results of the skin lesions were correlated. Radiologist must be familiar with normal appearance of the breast skin under the MRI and a wide variety of conditions may affect the skin of the breast.
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Female , Humans , Breast , Magnetic Resonance Imaging , Skinالملخص
BACKGROUND AND PURPOSE: Little is known about the relationships between provoking risk factors, prognosis, and optimal duration of anticoagulation in patients with cerebral venous thrombosis (CVT), especially in Asians. We aimed to investigate whether the prognosis and required duration of anticoagulation in CVT patients differ according to the provoking risk factors. METHODS: Prospectively recorded data from a tertiary medical center in South Korea were retrospectively reviewed. CVTs were categorized into three groups: unprovoked, those with possibly resolved provoking factors (PR), and those with persistent provoking factors (PP). The baseline characteristics, treatment, and prognosis of patients in these three groups were analyzed. RESULTS: From 2000 to 2015, 61 patients presented with CVT: 19 (31.1%) unprovoked, 11 (18.0%) with PR, and 31 (50.9%) with PP. The patients in our cohort had a slight female predominance and lower frequency of oral contraceptive use compared to Western cohorts. Median follow-up and duration of anticoagulation were 35 and 8 months, respectively. Despite the similarities in baseline characteristics, deaths (n=3; P=0.256) and recurrences (n=7; P=0.020) were observed only in the PP group. The median intervals to death and recurrence were 9 and 13 months, respectively. Death was associated with underlying disease activity, not with CVT progression. Recurrences in the PP group were associated with lack of anticoagulation (P=0.012). CONCLUSIONS: Although the prognosis of CVT is generally benign in Koreans, recurrence and death were observed in patients with persistent risk factors, suggesting their need for long-term treatment with anticoagulants.
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Female , Humans , Anticoagulants , Asian People , Cohort Studies , Follow-Up Studies , Korea , Prognosis , Prospective Studies , Recurrence , Retrospective Studies , Risk Factors , Venous Thrombosisالملخص
With the advances in magnetic resonance imaging, previously unrecognized small brain lesions, which are mostly asymptomatic, have been increasingly detected. Diffusion-weighted imaging can identify small ischemic strokes, while gradient echo T2* imaging and susceptibility-weighted imaging can reveal tiny hemorrhagic strokes (microbleeds). In this article, we review silent brain lesions appearing soon after acute stroke events, including silent new ischemic lesions and microbleeds appearing 1) after acute ischemic stroke and 2) after acute intracerebral hemorrhage. Moreover, we briefly discuss the clinical implications of these silent new brain lesions.
الموضوعات
Brain , Cerebral Hemorrhage , Magnetic Resonance Imaging , Strokeالملخص
With the advances in magnetic resonance imaging, previously unrecognized small brain lesions, which are mostly asymptomatic, have been increasingly detected. Diffusion-weighted imaging can identify small ischemic strokes, while gradient echo T2* imaging and susceptibility-weighted imaging can reveal tiny hemorrhagic strokes (microbleeds). In this article, we review silent brain lesions appearing soon after acute stroke events, including silent new ischemic lesions and microbleeds appearing 1) after acute ischemic stroke and 2) after acute intracerebral hemorrhage. Moreover, we briefly discuss the clinical implications of these silent new brain lesions.
الموضوعات
Brain , Cerebral Hemorrhage , Magnetic Resonance Imaging , Strokeالملخص
BACKGROUND AND OBJECTIVES: It is suggested that some patients with benign paroxysmal vertigo of childhood (BPVC) go on to develop migraine. However, neither the natural course nor the clinical features of BPVC have been determined, and therefore, the aim of this study was to investigate the clinical characteristics and the natural course of BPVC. MATERIALS AND METHODS: During the period January 2002 to December 2009, we reviewed the clinical records of 58 patients diagnosed with BPVC. All patients were approached by telephone and using a questionnaire. The clinical characteristics of vertigo, such as sex and age distribution, duration and frequency of vertigo, associated symptoms, development of migraine, and neurologic abnormalities, were analyzed. RESULTS: Mean follow-up duration was 73.2 months (range, 31-119 months). Patients had a mean age at onset of 11.8 years and a mean duration of 6.1 years. An obvious female predilection was found, and 40% of BPVC developed to migraine had a family history of migraine. Of the 32 patients, symptoms resolved in 68.7% but were unchanged in five patients (15.6%). BPVC developed to migraine in five patients (15.6%). CONCLUSION: This study suggests that vertigo spontaneously resolves in the majority of cases. However, the incidence of development to migraine in the BPVC patients is higher than that in general population.
الموضوعات
Child , Female , Humans , Age Distribution , Follow-Up Studies , Incidence , Migraine Disorders , Surveys and Questionnaires , Telephone , Vertigoالملخص
Intracranial lipomas are unfrequent tumors developed from mesenchymatous cells. The corpus callosum is the most frequent location (50%) in the intracranial regions, and these tumors are rarely present in the cerebellopontine angle, the internal acoustic meatus, or intravestibular lesions. With a review of literature, authors report a rare case of the left-sided intravestibular lipoma presented as sudden hearing loss in 17-year-old female. Furthermore, differential diagnostic magnetic resonance imaging characteristics of lipomas are discussed in detail.
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Female , Humans , Acoustics , Cerebellopontine Angle , Corpus Callosum , Hearing Loss, Sudden , Lipoma , Magnetic Resonance Imaging , Vestibule, Labyrinthالملخص
The granular cell tumor (GCT) is an uncommon, benign lesion with a preference for subcutaneous sites. In the head and neck, the tongue is the most common site, followed by the larynx. We experienced a case of a 27-year-old woman with lingual squamous cell carcinoma (SCC) surrounded by GCT. The pathological findings established that the lesion was SCC covered by GCT in the midline of the tongue. The size of the mass was very small, however, so we excised it in a diamond shape. There is an interesting association between GCTs and other malignant neoplasms. However, no causal relationship between GCT and these other carcinomas has been established. Here we report on an SCC coexisting with GCT at the same site as a median tongue lesion and review the literature.