Stroke-Specific Predictors of Major Bleeding in Anticoagulated Patients With Stroke and Atrial Fibrillation: A Nationwide Multicenter Registry-Based Study

Background@#and Purpose The congestive heart failure, hypertension, age, diabetes, previous stroke/transient ischemic attack (CHA2DS2-VASc) and hypertension, abnormal renal/liver function, stroke, bleeding history or predisposition, labile international normalized ratio, elderly, drugs/alcohol (HAS-BLED) scores have been validated in estimating the risks of ischemic stroke and major bleeding, respectively, in patients with atrial fibrillation (AF). This study investigated stroke-specific predictors of major bleeding in patients with stroke and AF who were taking oral anticoagulants (OACs). @*Methods@#Subjects were selected from patients enrolled in the Korean ATrial fibrillaTion EvaluatioN regisTry in Ischemic strOke patieNts (K-ATTENTION) nationwide multicenter registry between 2013 and 2015. Patients were excluded if they were not taking OACs, had no brain imaging data, or had intracranial bleeding directly related to the index stroke. Major bleeding was defined according to International Society of Thrombosis and Haemostasis criteria. Cox regression analyses were performed to assess the associations between clinical variables and major bleeding and Kaplan-Meier estimates were performed to analyze event-free survival. @*Results@#Of a total of 3,213 patients, 1,414 subjects (mean age of 72.6 years, 52.5% males) were enrolled in this study. Major bleeding was reported in 34 patients during the median follow-up period of 1.73 years. Multivariable analysis demonstrated that initial National Institutes of Health Stroke Scale scores (hazard ratio [HR] 1.07, p=0.006), hypertension (HR 3.18, p=0.030), persistent AF type (HR 2.51, p=0.016), and initial hemoglobin level (HR 0.74, p=0.001) were independently associated with major bleeding risk. Except for hypertension, these associations remained significant after adjusting for the HAS-BLED score. Intracranial atherosclerosis presented a trend of association without statistical significance (HR 2.21, p=0.050). @*Conclusions@#This study found that major bleeding risk was independently associated with stroke-specific factors in anticoagulated patients with stroke and AF. This has the clinical implication that baseline characteristics of patients with stroke and AF should be considered in secondary prevention, which would bring the net clinical benefit of balancing recurrent stroke prevention with minimal bleeding complications.

Temporal association between the age-specific incidence of Guillain-Barré syndrome and SARS-CoV-2 vaccination in Republic of Korea: a nationwide time-series correlation study

Objectives@#The incidence of Guillain-Barré syndrome (GBS) changed significantly during the coronavirus disease 2019 (COVID-19) pandemic. Emerging reports suggest that viral vector-based vaccines may be associated with an elevated risk of GBS. @*Methods@#In this nationwide time-series correlation study, we examined the age-specific incidence of GBS from January 2011 to August 2022, as well as data on severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccinations and infections from February 2021 to August 2022. We compared the forecasted estimates of age-specific GBS incidence, using the pre-SARS-CoV-2 period as a benchmark, with the actual incidence observed during the post-vaccination period of the pandemic. Furthermore, we assessed the temporal association between GBS, SARS-CoV-2 vaccinations, and COVID-19 for different age groups. @*Results@#In the age group of 60 and older, the rate ratio was significantly elevated during June-August and November 2021. A significant, strong positive association was observed between viral vector-based vaccines and GBS incidence trends in this age group (r=0.52, p=0.022). For the 30 to 59 years age group, the rate ratio was notably high in September 2021. A statistically significant, strong positive association was found between mRNA-based vaccines and GBS incidence in this age group (r=0.61, p=0.006). @*Conclusion@#Viral vector-based SARS-CoV-2 vaccines were found to be temporally associated with an increased risk of GBS, particularly in older adults. To minimize age-specific and biological mechanism-specific adverse events, future vaccination campaigns should adopt a more personalized approach, such as recommending homologous mRNA-based SARS-CoV-2 vaccines for older adults to reduce the heightened risk of GBS.

Medical hypnotic management associated with drug dependence in patients with insomnia and neurological disorders

@#Objectives: We aimed to investigate the demographics and medical management factors associated with dependence on hypnotics among outpatients with neurological disorders and insomnia. Methods: We reviewed electronic medical records of patients who received an initial hypnotic prescription between January 2014 and January 2016 and had later visited a neurological outpatient clinic before January 2018. We assessed patient demographics, the effectiveness of hypnotics, prescription periods, and hypnotic intake methods during the follow-up period. Results: Of 242 patients diagnosed with insomnia, we enrolled 114 patients (more women than men, at 61.4 versus 38.6%) who visited outpatient clinics regularly during the follow-up period. The mean age at onset was 65.8 ± 14.4 years. The most frequent neurological disorder was cerebrovascular disease, followed by neurodegenerative disease. During the 2-year period, 35.9% of participants remained hypnotics-free. Patients on zolpidem showed significantly greater insomnia improvement with hypnotic discontinuation than those on benzodiazepines and combination therapy (p=0.004). However, the type of hypnotics and demographic factors were not found to be independent risk factors. Multivariable analysis showed that longer periods between regular visits and a lower ratio of receiving number of pills to the time interval (days) between regular visits were independent risk factors for dependence on hypnotics. Conclusions: We found that low-dose and/or intermittent intake of hypnotics as well as frequent doctor visits could prevent dependence on hypnotics. It is important to establish the best practical guidelines for medical hypnotics management in outpatient primary care settings, including neurological clinics.

Anti-LGI1 Antibody Encephalitis Mimicking Jumping Stump Syndrome

Jumping stump syndrome is considered to be a peripherally induced movement disorder due to damage to peripheral nerves leading to dystonia or myoclonus. Anti-leucine-rich glioma-inactivated 1 antibody (anti-LGI 1 Ab) encephalitis is clinically characterized with progressive cognitive dysfunction and seizure including facial brachial dystonic seizure. We report a case of a woman with a history of intractable involuntary movement on amputated forearm diagnosed as anti-LGI 1 Ab encephalitis, mimicking symptoms of jumping stump syndrome.

Cerebral Venous Thrombosis Presenting in Pregnancy with Thrombocytosis and Janus Kinase 2 Valine-to-Phenylalanine Mutation

A 30-year-old woman in her first pregnancy was admitted with headache and horizontal diplopia indicating left abducens nerve palsy. Brain magnetic resonance imaging revealed a cerebral venous thrombosis. She had thrombocytosis in the peripheral blood, and a genetic test for thrombocytosis revealed the presence of the valine-to-phenylalanine (V617F) mutation of the Janus kinase 2 (JAK2) gene. Treatment with low-molecular-weight heparin resolved her symptoms of headache and diplopia. The presence of genetic disorders such as the JAK2-V617F gene mutation should be assessed in patients with cerebral venous thrombosis and coexisting thrombocytosis.