Fasting and Non-Fasting Triglycerides in Patients With Acute Ischemic Stroke.

BACKGROUND: Clinical implications of elevated fasting triglycerides (FTGs) and non-fasting triglycerides (NFTGs) in acute ischemic stroke (AIS) remain unknown. We aimed to elucidate the correlation and clinical significance of FTG and NFTG levels in AIS patients. METHODS: Using a multicenter prospective stroke registry, we identified AIS patients hospitalized within 24 hours of onset with available NFTG results. The primary outcome was a composite of stroke recurrence, myocardial infarction, and all-cause mortality up to one year. RESULTS: This study analyzed 2,176 patients. The prevalence of fasting and non-fasting hypertriglyceridemia was 11.5% and 24.6%, respectively. Multivariate analysis revealed that younger age, diabetes, higher body mass index and initial systolic blood pressure were independently associated with both fasting and non-fasting hypertriglyceridemia (all P < 0.05). Patients with higher quartiles of NFTG were more likely to be male, younger, ever-smokers, diabetic, and have family histories of premature coronary heart disease and stroke (all P < 0.05). Similar tendencies were observed for FTG. The composite outcome was not associated with FTG or NFTG quartiles. CONCLUSION: The fasting and non-fasting hypertriglyceridemia were prevalent in AIS patients and showed similar clinical characteristics and outcomes. High FTG and NFTG levels were not associated with occurrence of subsequent clinical events up to one year.

A Methodological Perspective on the Longitudinal Cognitive Change after Stroke.

BACKGROUND/AIMS: Most studies of poststroke cognitive impairment (PSCI) have analyzed cognitive levels at specific time points rather than their changes over time. Furthermore, they seldom consider correlations between cognitive domains. We aimed to investigate the effects of these methodological considerations on determining significant PSCI predictors in a longitudinal stroke cohort. METHODS: In patients who underwent neuropsychological tests at least twice after stroke, we adopted a multilevel hierarchical mixed-effects model with domain-specific cognitive changes and a multivariate model for multiple outcomes to reflect their correlations. RESULTS: We enrolled 375 patients (median follow-up of 34.1 months). Known predictors of PSCI were generally associated with cognitive levels; however, most of the statistical significances disappeared when cognitive changes were set as outcomes, except age for memory, prior stroke and baseline cognition for executive/attention domain, and baseline cognition for visuospatial function. The multivariate analysis which considered multiple outcomes simultaneously further altered these associations. CONCLUSIONS: This study shows that defining outcomes as changes over time and reflecting correlations between outcomes may affect the identification of predictors of PSCI.

The Role of the Signal Intensity Ratio on Fluid-Attenuated Inversion Recovery in Stroke Patients Achieving Successful Recanalization with Endovascular Treatment.

BACKGROUND: This study aimed to investigate whether fluid-attenuated inversion recovery (FLAIR) imaging hyperintensity can be used as a surrogate marker for the severity of ischemic insult and predict lesion growth. METHODS: Based on a prospective stroke registry database, we identified patients with ischemic stroke who were treated with endovascular treatment (EVT) within 8 hours of onset and achieved successful recanalization (modified thrombolysis in cerebral infarction ≥2B). FLAIR hyperintensity was measured using the signal intensity ratio (SIR), defined as the mean SIR of diffusion-restricted lesions to the corresponding areas in the contralateral hemisphere. Lesion growth was defined as the ratio of final infarct volume on follow-up FLAIR to initial infarct volume on diffusion-weighted imaging. RESULTS: For 69 patients meeting the eligibility criteria, the median FLAIR SIR was 1.17 (interquartile range, 1.08-1.23) and the median lesion growth ratio was 1.70 (interquartile range, 1.35-2.79) (Pearson's r = -.146, P = .231). In multiple linear regression models, the FLAIR SIR was not significantly correlated with the lesion growth ratio. Interestingly, the time interval from initial magnetic resonance imaging (MRI) to successful recanalization was independently correlated with the lesion growth ratio (ß = .072, P < .001). With respect to clinical outcomes, the FLAIR SIR was not associated with either discharge modified Rankin scale score ≤2 (ß = -3.41, P = .30) or symptomatic hemorrhagic transformation (ß = 2.75; P = .63). CONCLUSIONS: Contrary to our hypothesis, FLAIR hyperintensity on initial MRI before EVT was not associated with lesion growth in patients who were recanalized successfully with EVT. Instead, our results suggest that time interval from MRI acquisition to recanalization is an independent predictor of lesion growth.

Utility of Items of Baseline National Institutes of Health Stroke Scale as Predictors of Functional Outcomes at Three Months after Mild Ischemic Stroke.

BACKGROUND: Predicting outcomes of acute stroke patients initially presenting with mild neurologic deficits is crucial in decision making regarding thrombolytic therapy. We examined the utility of individual National Institutes of Health Stroke Scale (NIHSS) score items or clusters of items as predictors of functional outcomes at 3 months after mild stroke. METHODS: Using a multicenter stroke registry database, we identified patients with acute ischemic stroke who presented within 4.5 hours of symptom onset and had baseline NIHSS scores less than or equal to 5. Functional outcomes at 3 months were dichotomized as favorable (modified RankinScale [mRS] score 0 or 1) or unfavorable (mRS 2-6). Individual NIHSS items, clusters of items, and the total score were tested for their ability to predict outcomes in multivariable models. Area under the receiver operating characteristic curve (AUC) was used to assess model performance. RESULTS: Of the 2209 patients who met eligibility criteria, 588 (26.6%) exhibited unfavorable functional outcomes at 3 months. Of the 15 items of the NIHSS, all except item 8 (sensory) and item 11 (extinction) were significantly associated with unfavorable functional outcomes in bivariate analysis (P's < .05). Among the multivariable models, the model with the total NIHSS score exhibited an AUC similar to that of the model with all NIHSS items in predicting functional outcomes (.758 [95% confidence interval .739-.775] versus .759 [.740-.776]; P = .75 for pairwise comparison). CONCLUSIONS: Simply using the total NIHSS score was as effective as using all individual items in predicting outcomes of mild stroke patients.

Family History and Risk of Recurrent Stroke.

BACKGROUND AND PURPOSE: The association between family history of stroke and stroke recurrence remains unclear. METHODS: Using a web-based multicenter stroke registry database, information on history of stroke in first-degree relatives was collected prospectively for acute ischemic stroke patients who were hospitalized within 7 days of onset. The collected information was categorized as follows: type of the affected relative(s) with stroke (paternal, maternal, sibling, or 2 or more) and age of the relative's stroke onset (<50, 50-59, 60-69, and ≥70 years). Stroke recurrence was captured prospectively using a predetermined protocol. Subgroup analyses were performed according to the patient's age at the index stroke. RESULTS: Among 7642 patients, 937 (12.3%) had a history of stroke in their first-degree relatives and 475 (6.2%: 201 within and 274 after 3 weeks from index stroke) experienced stroke recurrence (median follow-up, 365 days). In multivariable Cox proportional hazard models, overall family history was not associated with stroke recurrence (hazard ratio, 1.08; 95% confidence interval, 0.81-1.43). However, the details of their family histories, including relative's age at stroke onset (<50 years: hazard ratio, 2.14; 95% confidence interval, 1.004-4.54) and stroke history in a sibling (hazard ratio, 1.67; 95% confidence interval, 1.09-2.58), were independently associated with stroke recurrence after adjusting for potential confounders. The associations appeared to be stronger in young adults with stroke (age, <55 years) than in older stroke patients. CONCLUSIONS: This study suggests that elevated risks of recurrent stroke are associated with having relatives with early-onset stroke and siblings with stroke histories, implying that additional precautions may be needed in such populations.

Impact of Guidelines on Clinical Practice: Intravenous Heparin Use for Acute Ischemic Stroke.

BACKGROUND AND PURPOSE: Since its introduction, controversy has existed about the administration of intravenous heparin for the treatment of acute ischemic stroke. We studied trends in the intravenous heparin use during a 6-year time period and the potential influence of clinical guidelines in national language on intravenous heparin administration in Korea. METHODS: On the basis of a prospective nationwide multicenter stroke registry, we collected data on patients with acute ischemic stroke who arrived within 7 days of symptom onset during the time period 2008 to 2013. We studied patient demographics, prestroke medical history, stroke characteristics, and stroke treatment. Data from a total of 23 425 patients from 12 university hospitals or regional stroke centers were analyzed. RESULTS: The administration of intravenous heparin steadily decreased throughout the study period: 9.7% in 2008, 10.9% in 2009, 9.4% in 2010, 6.0% in 2011, 4.7% in 2012, and 4.3% in 2013 (P for trend <0.001). The reduced intravenous heparin use was associated with moderate stroke severity, atrial fibrillation, and stroke of cardioembolic, other-, and undetermined etiology. In a multivariable logistic model, increase of 1 calendar year (odds ratio, 0.89; 95% confidence interval, 0.84-0.95; P<0.001) and release of clinical practice guidelines in Korean (odd ratio, 0.74; 95% confidence interval, 0.59-0.91; P<0.01) were independent factors associated with reduction in the frequency of intravenous heparin use. CONCLUSIONS: Use of intravenous heparin for acute ischemic stroke treatment has decreased in Korea, and this change may be attributable to the spread and successful implementation of regional clinical practice guidelines.

Effect of pre-stroke statin use on stroke severity and early functional recovery: a retrospective cohort study.

BACKGROUND: Experimental studies suggest that pre-stroke statin treatment has a dual effect of neuroprotection during ischemia and neurorestoration after ischemic injury. The aim of this study was to evaluate the effect of pre-stroke statin use on initial stroke severity and early clinical outcome. METHODS: We used a prospective database enrolling patients with acute ischemic stroke from 12 hospitals in Korea between April 2008 and January 2012. Primary endpoint was the initial stroke severity as measured by the National Institutes of Health Stroke Scale (NIHSS) score. Secondary endpoints were good outcome (modified Rankin Scale [mRS], 0-2) and overall mRS distribution at discharge. Multivariable regression model and propensity score (PS) matching were used for statistical analyses. RESULTS: Among the 8340 patients included in this study, 964 patients (11.6%) were pre-stroke statin users. The initial NIHSS score (mean [95% CI]) was lower among pre-stroke statin users vs. non-users in multivariable analysis (5.7 [5.2-6.3] versus 6.4 [5.9-6.9], p = 0.002) and PS analysis (5.2 [4.7-5.7] versus 5.7 [5.4-6.0], p = 0.043). Pre-stroke statin use was associated with increased achievement of mRS 0-2 outcome (multivariable analysis: OR [95% CI], 1.55 [1.25-1.92], p < 0.001; PS matching: OR [95% CI], 1.47 [1.16-1.88]; p = 0.002) and favorable shift on the overall mRS distribution (multivariable analysis: OR [95% CI], 1.29 [1.12-1.51], p = 0.001; PS matching: OR [95% CI], 1.31 [1.11-1.54]; p = 0.001). CONCLUSIONS: Pre-stroke statin use was independently associated with lesser stroke severity at presentation and better early functional recovery in patients with acute ischemic stroke.

A Simple Geometric Assessment of Perfusion Lesion Volume at Hyperacute Stage of Ischemic Stroke in Patients with Symptomatic Steno-Occlusion of Major Cerebral Arteries and Risk of Subsequent Cerebral Ischemic Events.

Our objective is to elucidate the association of baseline perfusion lesion volume on perfusion-weighted magnetic resonance imaging (PWI) obtained at hyperacute stage of ischemic stroke with subsequent cerebral ischemic events (SIEs) in patients with symptomatic steno-occlusion of major cerebral arteries. Using a prospective stroke registry database, patients arriving within 24 hours of onset with symptomatic steno-occlusion of major supratentorial cerebral arteries were identified. On baseline PWI, time-to-peak lesion volume (TTP-LV) was determined by a simple geometric method and dichotomized into the highest tertile (large) and the other tertiles (small to medium) according to the vascular territory of occluded arteries. Primary outcome was a time to SIE up to 1 year after stroke onset. A total of 385 patients (a median time delay from onset to arrival, 2.2 hours) were enrolled. During the first year of stroke, the SIE rate of the large TTP-LV group was twice that of the small-to-medium TTP-LV group (35.7% versus 17.4%; P < .001). Large TTP-LV independently raised the hazard of SIE (hazard ratio, 2.24; 95% confidence interval, 1.45-3.44). This study demonstrates that TTP-LV on PWI measured through a simple geometric method at an emergency setting can be used to predict progression or recurrence of ischemic stroke in patients with symptomatic steno-occlusion of major cerebral arteries.

Cortical hubs and subcortical cholinergic pathways as neural substrates of poststroke dementia.

BACKGROUND AND PURPOSE: A role of neural networks in the development of poststroke dementia has not been clearly established. We hypothesized that stroke-mediated disruption of subcortical cholinergic pathway or large-scale neural networks contributes to poststroke dementia. METHODS: A matched case-control study was conducted in a predetermined cohort with acute ischemic stroke. Cases were defined as newly developed dementia diagnosed >3 months after stroke using the Korean Vascular Cognitive Impairment Harmonization Standards. Each case was matched to 2 controls for age, education, and initial stroke severity. The Cholinergic Pathways HyperIntensities Scale was applied with some modifications to characterize disruption of cholinergic pathways by acute stroke lesions. Involvement of major cortical hub locations of the default mode network, central executive network, and salience network was also investigated. RESULTS: After matching, 38 cases and 66 matched controls were included. Cholinergic Pathways HyperIntensities Scale scores were significantly higher in cases than in controls (2.2±2.9 versus 0.9±1.4). Acute ischemic lesions affecting the default mode and central executive networks were more frequently observed in cases compared with controls (36.8% versus 7.6% and 26.3% versus 6.1%, respectively). These findings remained significant in the multiple logistic regression models adjusted for various sets of potential confounders. Lesion location analysis revealed that cases were more likely to have acute lesions in the left corona radiata, hippocampal formation, and posterior parietal cortex. CONCLUSIONS: Disruption of cholinergic pathways and major hubs of large-scale neural networks might contribute to newly developed dementia after acute ischemic stroke.

Impact of both ends of the hemoglobin range on clinical outcomes in acute ischemic stroke.

BACKGROUND AND PURPOSE: Although both ends of the hemoglobin range may negatively influence clinical outcomes in acute ischemic stroke, most studies have examined the linear relationship or focused on the lower end of the range. Furthermore, it is unclear whether hemoglobin concentrations at different time points during hospitalization correlate with clinical outcomes in the same manner. METHODS: We identified 2681 consecutive patients with acute ischemic stroke from a prospective stroke registry database and grouped them into hemoglobin concentration quintiles using the following 5 indices: initial, nadir, time-averaged, discharge hemoglobin, and hemoglobin drop. To examine the effect of both ends of hemoglobin range, the third quintile was selected as a reference category except for hemoglobin drop, for which the first quintile was used. As outcome variables, 3-month modified Rankin Scale as an ordinal scale and 3-month mortality were used. RESULTS: With respect to higher modified Rankin Scale scores, the adjusted odds ratios and 95% confidence intervals of the first quintiles of initial, nadir, time-averaged, and discharge hemoglobin were 1.74 (1.31-2.31), 2.64 (2.09-3.33), 1.81 (1.42-2.30), and 1.65 (1.29-2.13), respectively. The opposite ends of these hemoglobin indices were not significantly associated. The adjusted odds ratio of the fifth quintile of hemoglobin drop (greatest hemoglobin drop) was 2.09 (1.51-2.89). The mortality analysis showed similar results except for initial hemoglobin. CONCLUSIONS: In acute ischemic stroke, poor outcome was related to the lower but not the higher end of the hemoglobin range, regardless of when and how hemoglobin concentrations were measured.

Validation of FLAIR hyperintense lesions as imaging biomarkers to predict the outcome of acute stroke after intra-arterial thrombolysis following intravenous tissue plasminogen activator.

BACKGROUND: Intravenous tissue plasminogen activator (tPA) given within 4.5 h of symptom onset is accepted as the standard treatment of ischemic stroke. Persistent occlusion of cerebral arteries despite intravenous thrombolysis and unremitting neurologic deficits lead us to consider additional intra-arterial approaches. The aim of this study was to elucidate the potential of fluid-attenuated inversion recovery (FLAIR) MRI performed during or immediately after intravenous thrombolysis for predicting clinical outcomes of subsequent intra-arterial thrombolysis. METHODS: With a prospective stroke registry database of patients hospitalized in our institution from January 2004 to February 2010, we identified ischemic stroke patients with the following conditions: (1) presentation within 2.5 h of onset, (2) treated with intravenous tPA based on brain CT, (3) persistent occlusion on subsequent MRI/MR angiography, including a FLAIR sequence, and (4) eventually treated with intra-arterial thrombolysis. Demographic, clinical and laboratory findings including initial National Institutes of Health Stroke Scale (NIHSS), follow-up NIHSS at the 7th day or discharge, modified Rankin scale (mRS) score at 3 months, and symptomatic hemorrhagic transformation were captured. FLAIR images were reviewed by 2 investigators blinded to clinical information independently and dichotomized into the absence and presence of FLAIR change within the diffusion-restriction lesions. RESULTS: Of the 57 patients who met these conditions, FLAIR-hyperintense lesions (FHL) were observed in 32 (56.1%). The FHL-negative group was 69.1 ± 12.1 years old on average and the FHL-positive group 67.3 ± 11.0 years old. In both groups, hypertension was the most common vascular risk factor, cardioembolic stroke was the most common subtype, and distal middle cerebral artery was the most common site of occlusion. The incidence of symptomatic hemorrhagic transformation was 4.0% in the FHL-negative group and 9.4% in the FHL-positive group (p = 0.62). NIHSS scores of 0-1 on the 7th day of hospitalization or at discharge were observed in 36% of the FHL-negative group and in 9.4% of the FHL-positive group; mRS scores of 0-1 at 3 months was 32% in the FHL-negative group and 21% in the FHL-positive group. An ordinal logistic regression analysis showed that the presence of FHL was associated with higher 7-day NIHSS scores (adjusted for relevant covariates) but not with higher 3-month mRS scores. CONCLUSIONS: This study suggests that the FHL might be used as imaging biomarker to predict outcomes for additional intra-arterial thrombolysis in patients treated with intravenous tPA.

Is aortic atherothrombotic disease detected using multidetector-row CT associated with an increased risk of early ischemic lesion recurrence after acute ischemic stroke?

BACKGROUND AND PURPOSE: Multidetector-row CT (MDCT) is emerging as a new tool for diagnosing aortic atherothrombotic disease (AAD). We elucidated whether MDCT-detected AAD is associated with an increased risk of early ischemic lesion recurrence on diffusion-weighted MRI after ischemic stroke. METHODS: A consecutive series of patients with acute ischemic stroke confirmed using diffusion-weighted MRI who were hospitalized within 48 hours after symptom onset and underwent MDCT were identified in a prospective stroke registry database. AAD on MDCT was defined as the presence of plaque formation that was noncalcified and ≥4 mm thick, ulcerative, or soft and thrombosed (vulnerable) in the proximal aortic arch. Ischemic lesion recurrence on diffusion-weighted MRI was defined as the occurrence of any new lesion separate from the index lesion on follow-up diffusion-weighted MRI performed within 14 days after symptom onset. RESULTS: A total of 138 patients was selected. MDCT detected AAD in 24 of 138 (17.4%); ≥4 mm thickness in 17 of 138 (12.3%); ulcerated plaque in 20 of 138 (14.5%); and vulnerable plaque in 16 of 138 (11.6%). With respect to diffusion-weighted MRI lesion recurrence, the crude ORs (95% CIs) were as follows: AAD, 3.56 (1.43-8.89); vulnerable plaque, 3.21 (1.11-9.30); ulcerated plaque, 3.37 (1.27-8.95); and ≥4 mm thickness of the noncalcified plaque, 4.23 (1.11-16.19). These results remained significant after adjustments for potential confounders were made. CONCLUSIONS: This study shows that AAD detected by MDCT increases the risk of early ischemic lesion recurrence after acute ischemic stroke, thus supporting the role of MDCT in diagnosing AAD and assessing its contribution to recurrence.

Relationship between blood pressure and outcome changes over time in acute ischemic stroke.

OBJECTIVE: To evaluate whether the relationship between systolic blood pressure (SBP) and stroke outcome varies during the acute stage of ischemic stroke as a function of the elapsed time after stroke onset. METHODS: Patients who were hospitalized due to ischemic stroke within 6 hours of onset were retrospectively analyzed. SBP data were collected at 8 time points (1, 2, 4, 8, 16, 24, 48, and 72 hours after onset). The primary functional outcome measure was a poor outcome, defined as a modified Rankin Scale score of >2 at 3 months after stroke. Linear and quadratic models were constructed at each time point to assess relationships between SBP and outcome. RESULTS: Of the 2,546 patients, 728 (28.6%) had a poor outcome. SBP, as either a linear or quadratic term, had a significant effect on functional outcome, except at 4 hours after onset. For the initial 2 hours after onset, SBP had nonlinear U-shaped relationships with functional outcome, and patients with SBP of approximately 165 mm Hg were the least likely to have a poor outcome. Quadratic models exhibited a significantly better model fit. For 8-24 hours postonset, SBP exhibited linear relationships with functional outcome. For 48-72 hours postonset, SBP exhibited a J-shaped relationship with functional outcome, and the predicted probability of poor outcome was the lowest in patients with SBP of approximately 125 mm Hg. These relationships were relatively consistent across various sensitivity analyses. CONCLUSION: This study revealed that the relationship between SBP and functional outcome may depend on elapsed time from stroke onset.

Blood pressure variability in subacute stage and risk of major vascular events in ischemic stroke survivors.

BACKGROUND: We aimed to investigate whether blood pressure (BP) in the subacute stage of ischemic stroke affects subsequent vascular events after acute ischemic stroke. METHODS: From a prospective stroke registry database, consecutive ischemic stroke patients arriving within 48 h of onset were identified. The mean and SD of SBP per patient (SBPmean and SBPSD) in the subacute stage (from 72 h of onset to discharge), were calculated. Primary outcome was a composite of stroke, myocardial infarction and vascular death that occurred within 1 year after hospital discharge. A Cox proportional hazards model was applied to elucidate whether the increase of SBPmean and SBPSD would increase the hazards of the primary outcome. RESULTS: Of 4415 patients (age, 66.7 ±â€Š13.2 years; men, 69.5%), mean ±â€ŠSD of SBPmean and SBPSD in the subacute stage was 137.3 ±â€Š15.4 and 13.3 ±â€Š3.9 mmHg, respectively. Primary outcome events occurred in 6.9% during the first year after stroke. There was a significant dose-response relationship between the SBPSD and the risk of the primary outcome (P = 0.004), but not between SBPmean and the risk (P = 0.78). Interpolating the change of adjusted hazard ratio using restricted cubic spine function suggested an existence of a threshold effect of SBPSD and a U-shaped relationship of SBPmean for the composite event. CONCLUSION: This study shows that BP variability but not mean BP in the subacute stage of ischemic stroke may increase 1-year risk of major vascular events in patients surviving its acute stage.

Adherence to Guidelines for Antithrombotic Therapy in Patients with Atrial Fibrillation According to CHADS2 Score before and after Stroke: A Multicenter Observational Study from Korea.

BACKGROUND AND PURPOSE: A substantial proportion of patients with atrial fibrillation (AF) are not treated optimally; however, the inappropriateness of drug therapy has never been evaluated before or after a stroke event. We investigated the adherence to guidelines for therapy in AF patients hospitalized with acute ischemic stroke (AIS) before stroke onset and at discharge, with the aim of identifying the factors associated with inappropriate therapy. METHODS: AIS patients with AF hospitalized within 7 days of onset were identified from a prospective nine-center stroke registry database. Two cohorts were defined: patients diagnosed with AF prior to the stroke event (admission cohort) and patients diagnosed with AF at discharge from hospital (discharge cohort). Any of the following conditions were regarded as nonadherence to guidelines in this study: use of anticoagulant or nonuse of antithrombotics with CHADS2 score=0, nonuse of antithrombotics with CHADS2 score=1, or nonuse of anticoagulant with CHADS2 score ≥2. RESULTS: Overall, 406 patients were enrolled in the admission cohort and 518 in the discharge cohort. The rates of nonadherence before a stroke event and at discharge were 77.8% and 33.3%, respectively. These rates varied widely for both cohorts, with interhospital differences being statistically significant. Multivariable analysis revealed that old age, stroke history, and congestive heart failure were associated with nonadherence before stroke. At discharge, males, coronary heart disease, inappropriate antithrombotic use before stroke, and functional disability at discharge were associated with nonadherence. CONCLUSIONS: This study shows that antithrombotic use in AIS patients with AF might be not optimal before and after stroke in Korea.

Moderate alcohol intake reduces risk of ischemic stroke in Korea.

OBJECTIVE: We undertook a population-based, case-control study to examine a dose-response relationship between alcohol intake and risk of ischemic stroke in Koreans who had different alcoholic beverage type preferences than Western populations and to examine the effect modifications by sex and ischemic stroke subtypes. METHODS: Cases (n = 1,848) were recruited from patients aged 20 years or older with first-ever ischemic stroke. Stroke-free controls (n = 3,589) were from the fourth and fifth Korean National Health and Nutrition Examination Survey and were matched to the cases by age (±3 years), sex, and education level. All participants completed an interview using a structured questionnaire about alcohol intake. RESULTS: Light to moderate alcohol intake, 3 or 4 drinks (1 drink = 10 g ethanol) per day, was significantly associated with a lower odds of ischemic stroke after adjusting for potential confounders (no drinks: reference; <1 drink: odds ratio 0.38, 95% confidence interval 0.32-0.45; 1-2 drinks: 0.45, 0.36-0.57; and 3-4 drinks: 0.54, 0.39-0.74). The threshold of alcohol effect in women was slightly lower than that in men (up to 1-2 drinks in women vs up to 3-4 drinks in men), but this difference was not statistically significant. There was no statistical interaction between alcohol intake and the subtypes of ischemic stroke (p = 0.50). The most frequently used alcoholic beverage was one native to Korea, soju (78% of the cases), a distilled beverage with 20% ethanol by volume. CONCLUSIONS: Our findings suggest that light to moderate distilled alcohol consumption may reduce the risk of ischemic stroke in Koreans.

Blood pressure variability and the development of early neurological deterioration following acute ischemic stroke.

OBJECTIVES: Early neurological deterioration (END) is a common condition associated with poor outcome after acute ischemic stroke. We studied association between blood pressure (BP) variability and development of END. METHODS: In this retrospective observational study, we studied a consecutive series of patients hospitalized for acute ischemic stroke within 24 h of onset. The primary outcome of interest was the development of END according to predefined criteria within the first 72 h of stroke onset. During this period, the mean, maximum (max), and minimum (min) values for the SBP and DBP were measured. The following parameters of BP variability were calculated for the SBP and DBP: the difference between the maximum and minimum (max-min), the SD, and the coefficient of variation. RESULTS: Of the 1161 patients enrolled in the study (mean age, 67.5 ±â€Š13.3 years; 59.6% men), 210 (18.1%) developed END. All of the BP variability parameters were linearly associated with END independent of mean BP and potential clinical variables (P values < 0.05 on likelihood ratio tests for trend), except for SBPmax-min. Among the other BP parameters, SBPmean, SBPmax, DBPmax, and DBPmin were independently associated with END. After adjustments for potential confounders, the odds for END increased 14-21% with each increase of one standard deviation in the BP variability parameter. CONCLUSION: BP variability is independently and linearly associated with the development of neurologic deterioration in acute stage of ischemic stroke.

Trial of ORG 10172 in Acute Stroke Treatment (TOAST) classification and vascular territory of ischemic stroke lesions diagnosed by diffusion-weighted imaging.

BACKGROUND: The association between the location and the mechanism of a stroke lesion remains unclear. A diffusion-weighted imaging study may help resolve this lack of clarity. METHODS AND RESULTS: We studied a consecutive series of 2702 acute ischemic stroke patients whose stroke lesions were confirmed by diffusion-weighted imaging and who underwent a thorough etiological investigation. The vascular territory in which an ischemic lesion was situated was identified using standard anatomic maps of the dominant arterial territories. Stroke subtype was based on the Trial of ORG 10172 in Acute Stroke Treatment, or TOAST, classification. Large-artery atherosclerosis (37.3%) was the most common stroke subtype, and middle cerebral artery (49.6%) was the most frequently involved territory. Large-artery atherosclerosis was the most common subtype for anterior cerebral, middle cerebral, vertebral, and anterior and posterior inferior cerebellar artery territory infarctions. Small vessel occlusion was the leading subtype in basilar and posterior cerebral artery territories. Cardioembolism was the leading cause in superior cerebellar artery territory. Compared with carotid territory stroke, vertebrobasilar territory stroke was more likely to be caused by small vessel occlusion (21.4% versus 30.1%, P<0.001) and less likely to be caused by cardioembolism (23.2% versus 13.8%, P<0.001). Multiple-vascular-territory infarction was frequently caused by cardioembolism (44.2%) in carotid territory and by large-artery atherosclerosis (52.1%) in vertebrobasilar territory. CONCLUSIONS: Information on vascular territory of a stroke lesion may be helpful in timely investigation and accurate diagnosis of stroke etiology.

Symptomatic steno-occlusion in patients with acute cerebral infarction: prevalence, distribution, and functional outcome.

BACKGROUND AND PURPOSE: Symptomatic steno-occlusion (SYSO) in acute ischemic stroke has a significant impact on treatment options and prognosis. However, the prevalence, distribution, clinical characteristics, and outcome of SYSO are not well known. METHODS: We retrospectively identified 3,451 patients hospitalized because of ischemic stroke within 24 hours of symptom onset at 9 stroke centers in South Korea. Patients who did not undergo magnetic resonance imaging were excluded. SYSO was defined as stenosis or occlusion of cerebral arteries with relevant ischemic lesions in the corresponding arterial territory. The number, location, and severity of SYSOs and their effects on functional outcome were analyzed. RESULTS: In total, 1,929 of 3,057 subjects (63.1%) had SYSO. The most frequently affected vessels were the middle cerebral artery (34.6%), extracranial internal carotid artery (14%), vertebral artery (12.4%), and basilar artery (8.7%). SYSO predicted poor outcome on the modified Rankin Scale 3-6 (odds ratio, 1.77; 95% confidence interval, 1.46-2.15) with adjustments. Involvement of 2 or more vessels was observed in 30.6% of patients with SYSO and independently increased the risk of poor outcome (odds ratio, 2.76; 95% confidence interval, 2.12-3.59). The severity of SYSO was associated with outcome and showed a significant dose-response trend (P<0.001). The effect of SYSO on outcome did not significantly differ by individual arterial location (P for contrast=0.21). CONCLUSIONS: Approximately 60% of patients with acute ischemic stroke had SYSO, and the severity and number were inversely correlated with outcome. The results suggest that SYSO could predict stroke outcome.

Current status of acute stroke management in Korea: a report on a multicenter, comprehensive acute stroke registry.

There are limited data on the utilization of diagnostics and the variation of treatments at the national level in acute stroke care. Clinical Research Center for Stroke--5th division stroke registry aimed to describe stroke statistics and quality of care in Korea and to implement quality indicators. Clinical Research Center for Stroke--5th division registry was established in April 2008 and covers pretreatment demographics, medical and stroke severity measures, diagnostic evaluation, hyperacute revascularization, in-hospital management, discharge disposition, quality indicators, and long-term functional outcomes. Consecutive stroke cases from 12 participating centers are registered to a web-based database. Meticulous data management and auditing policy were applied. A total of 14,792 ischemic stroke cases were enrolled from April 2008 to January 2012. The median National Institutes of Health Stroke Scale score was 4 at admission, with median delay of onset to arrival of 14 h. Rate of risk factor management before stroke exceeds more than 80% for hypertension and diabetes. Revascularization procedures were performed in 1736 subjects (12%), and 34% were endovascular (n = 598). Substantial variability was noted in the preferred modality of hyperacute revascularization (range of endovascular recanalization = 6-60%), use of computed tomography (30-93%), and perfusion imaging (2-96%). The Clinical Research Center for Stroke--5th division registry documented that the current practice of acute stroke care in South Korea largely met the standard of guidelines, but variability of practice still remains. The registry would provide an opportunity to evaluate the quality of stroke care across South Korea and compare it with that of other countries.