Temporal Changes in Cognitive Function in Early Recovery Phase of the Stroke.

OBJECTIVES: Only a few studies longitudinally evaluated all cognitive domains after acute stroke. The purpose was to study the changes in cognitive function after acute stroke. MATERIALS AND METHODS: Cognitive assessment, using Thai mental state examination (TMSE) and Montreal Cognitive Assessment (MOCA), was performed at the acute stroke, and at 3 and 6 months after stroke. Cognitive domains were evaluated by MOCA subcategory score. TMSE and MOCA were compared at different stages of stroke and in among those with normal cognition (NC), vascular mild cognitive impairment (VMCI) and vascular dementia (VAD). RESULTS: 138 patients were included. At 6 months, 32 patients (23%) had NC. VMCI and VAD were diagnosed in 76 patients (55%), and 30 patients (22%), respectively. Total scores of TMSE and MOCA were higher at 3 months as compared to at the acute stroke (TMSE; 24.85 vs 23.01, p-value <0.001, MOCA; 19.30 vs 16.49, p-value <0.001), and higher TMSE, but not MOCA, at 6 months as compared to at 3 months (TMSE; 25.35 vs 24.85, p-value= 0.021, MOCA; 19.04 vs 19.30, p-value= 0.058). Changes in total scores at early stroke were highest in NC. VMCI and VAD patients had cognitive impairment in all cognitive domains. CONCLUSIONS: Cognitive impairment was highest at the acute stroke and improved during early recovery. The greatest rate of improvement occurred within 3 months. Improvement was found in all cognitive domains.

Incidence and risk factors of vascular dementia in Thai stroke patients.

BACKGROUND: Besides disability in stroke survivors, vascular cognitive impairment (VCI) can prevent these patients from living independently. The purpose of this study is to look for the incidence and risk factors of vascular dementia in Thai patients with stroke. METHODS: Adults patients with ischemic stroke were prospectively included. Cognitive assessment was performed at 3-6 months after stroke onset. Montreal Cognitive Assessment (MOCA)- Thai version was used to evaluate cognitive function, with the cutoff point of 24/25 of MOCA to define cognitive impairment/normal cognition. Vascular mild cognitive impairment (VMCI) and vascular dementia (VAD) were diagnosed in those with cognitive impairment. Epidemiologic data, Apolipoprotein E (ApoE) status, and stroke characteristics were compared between patients with and without VAD. RESULTS: There were 180 patients with the mean age of 65 years. Median time after stroke onset to have cognitive assessment was 6 months. Ninety patients (50%) had VMCI. VAD was diagnosed in 49 patients (27%). Mean Thai version of mental state examination (TMSE) and MOCA scores in patients with VAD were 20 and 12, respectively. Multivariate analysis showed that older age (OR 4.994, 95%CI 1.602-15.565, p-value = 0.006), lower education (OR 10.306, 95%CI 3.162-33.586, p-value < 0.001), history of stroke (OR 4.959, 95%CI 1.036-23.741, p-value = 0.045) and moderate to severe cerebral white matter lesions (OR 5.555, 95%CI 1.710-18.041, p-value = 0.004) were associated with VAD. ApoE 4 allele was found in 25% of the patients, but the presence did not show any association with the increased risk of VAD. CONCLUSIONS: VAD occurred in 27% of the stroke patients. Older age, low education level, history of stroke, and the presence of moderate to severe white matter lesions were associated with the increased risk of VAD.

Accuracy of Carotid Duplex Criteria in Diagnosis of Significant Carotid Stenosis in Asian Patients.

BACKGROUND: Extracranial carotid stenosis can be diagnosed by velocity criteria of carotid duplex. Whether they are accurately applied to define severity of internal carotid artery (ICA) stenosis in Asian patients needs to be proved. The purpose of this study was to evaluate the accuracy of 2 carotid duplex velocity criteria in defining significant carotid stenosis. METHODS: Carotid duplex studies and magnetic resonance angiography were reviewed. Criteria 1 was recommended by the Society of Radiologists in Ultrasound; moderate stenosis (50%-69%): peak systolic velocity (PSV) 125-230 cm/s, diastolic velocity (DV) 40-100 cm/s; severe stenosis (>70%): PSV greater than 230 cm/s, DV greater than 100 cm/s. Criteria 2 used PSV greater than 140 cm/s, DV less than 110 cm/s to define moderate stenosis (50%-75%) and PSV greater than 140 cm/s, DV greater than 110 cm/s for severe stenosis (76%-95%). RESULTS: A total of 854 ICA segments were reviewed. There was moderate stenosis in 72 ICAs, severe stenosis in 50 ICAs, and occlusion in 78 ICAs. Criteria 2 had slightly lower sensitivity, whereas higher specificity and accuracy than criteria 1 were observed in detecting moderate stenosis (criteria 1: sensitivity 95%, specificity 83%, accuracy 84%; criteria 2: sensitivity 92%, specificity 92%, and accuracy 92%). However, in detection of severe ICA stenosis, no significant difference in sensitivity, specificity, and accuracy was found (criteria 1: sensitivity 82%, specificity 99.57%, accuracy 98%; criteria 2: sensitivity 86%, specificity 99.68%, and accuracy 99%). CONCLUSIONS: In the subgroup of moderate stenosis, the criteria using ICA PSV greater than 140 cm/s had higher specificity and accuracy than the criteria using ICA PSV 125-230 cm/s. However, there was no significant difference in detection of severe stenosis or occlusion of ICA.

Clinical course, prognostic factors, and long-term outcomes of malignant middle cerebral artery infarction patients in the modern era.

BACKGROUND: Recanalization therapies have been increasingly applied in clinical practice, which might change the outcomes of patients with large middle cerebral artery (MCA) infarction. The purpose of this study was to study the clinical course, prognostic factors, and long-term outcomes of patients with an acute large MCA infarction. METHODS: Patients with an acute large MCA infarction who were treated between January, 2011 - March, 2014 were studied. The demographics and vascular risk factors were compared between patients with and without clinical outcomes of interest, favorable outcome and death. RESULTS: From a total of 1538 patients, 200 patients with large MCA infarction were included. The mean age was 67 years. The mean National Institute of Health Stroke Scale score was 20. The mean time from onset to the hospital was 289 min. Intravenous recombinant-tissue-plasminogen activator (rtPA) was given in 50 patients (25%). The mean follow-up time was 13 months. 51 patients (51/191, 27%) had a favorable outcome (modified Rankin Scale 0-2) at the final follow-up. 81 patients (81/191, 42%) died. A younger age, less severe stroke, rtPA treatment, and large-artery atherosclerosis stroke subtype were related to a favorable outcome. Older age and presence of coronary artery disease were associated with death and rtPA treatment was inversely related to death. CONCLUSIONS: Prognosis of patients with a large MCA infarction is still poor. Favorable outcomes were found in only a fourth of the total patients, and a high mortality rate was still present. Intravenous rtPA treatment seemed to be related to a favorable outcome.

Comparison of aspirin response measured by urinary 11-dehydrothromboxane B2 and VerifyNow aspirin assay in patients with ischemic stroke.

BACKGROUND: We looked for the prevalence of aspirin nonresponders, compared the results of 2 tests assessing aspirin responses-measurement of urinary 11-dehydrothromboxane B2 (dTXB2) and VerifyNow Aspirin assay-in patients with ischemic stroke, and examined the relationship of aspirin nonresponse and the outcomes of the patients. METHODS: One hundred one patients with ischemic stroke were prospectively included. Aspirin response was assessed by urinary dTXB2 measurement and VerifyNow Aspirin assay. The Spearman correlation coefficients and kappa statistics were calculated to assess correlation and agreement between the 2 tests. The measured outcome was the occurrence of cardiovascular events and death. RESULTS: Prevalence of aspirin nonresponders was 40% and 6%, if they were measured by urinary dTXB2 and VerifyNow Aspirin assay, respectively. Poor correlation in the results between the 2 tests was found (r = .135, P = .190). The degree of agreement between the 2 tests in relation to resistance status was weak (kappa = .032, P = .590). With a mean follow-up time of 17 months, the outcomes occurred significantly higher in aspirin nonresponders who were diagnosed by urinary dTXB2 measurement as compared with patients with aspirin response (18% versus 2%, odds ratio 8.8, 95% confidence interval 1.18-65.4, P = .037). CONCLUSIONS: Our research confirmed poor correlation and lack of agreement between the 2 tests. Only aspirin nonresponders who were diagnosed by dTXB2 measurement were related to having cardiovascular events and death. Further research is still needed to identify the best method of diagnosis of aspirin nonresponders.

Functional recovery at 3 months in stroke patients not receiving thrombolytic therapy: the comparison between patients arriving earlier and later than 4.5 hours.

BACKGROUND: We aim to study the recovery of functional abilities of stroke patients who did not receive recombinant tissue plasminogen activator (rtPA) after treatment for 3 months comparing patients who arrived at a hospital within 4.5 hours and those who arrived after 4.5 hours of symptom onset. Also, we investigated the predictors of the functional recovery and the quality of life (QOL) at 3 months after stroke. MATERIAL AND METHOD: Data were collected by interviewing the stroke patients and caregivers twice on Day 1 and at 3 months after the stroke onset. We collected the demographic data, Modified Rankin Scale (mRS), Barthel Index, National Institutes of Health Stroke Scale (NIHSS), Glasgow Coma Scale (GCS), and World Health Organization Quality of Life-Bref-Thai (WHOQOL-Bref-Thai). RESULTS: Eighty-eight and 85 patients arrived at a hospital within 4.5 and after 4.5 hours respectively. At 3 months after treatment, the recovery of stroke patients as assessed by mRS, Barthel Index, and the QOL in both groups did not differ significantly (P > .05). Approximately 80% in both groups had good QOL. Both groups of patients had a similar low stroke awareness and knowledge in terms of risk factors (P = .825) and care of stroke patients (P = .562). Four variables that significantly predicted the improvement of the mRS score at 3 months after treatment were age 60 years and younger, premorbid self-care ability, the NIHSS score of 14 or less and Day 1 mRS score. CONCLUSION: Stroke patients arriving at the hospital within and after 4.5 hours of the onset who did not receive the rtPA did not have significant differences in the functional outcomes and quality of life at 3 months. However, the eligibility for rtPA is not known before arriving at the hospital so that the necessity of seeking medical treatment as quickly as possible is still warranted. Increasing effective public awareness regarding stroke risk factors and care should be implemented.

Atrial fibrillation and paroxysmal atrial fibrillation detection in patients with acute ischemic stroke.

BACKGROUND: Studies about continuous electrocardiographic (ECG) monitoring in detection of paroxysmal atrial fibrillation (PAF) in Asian patients with acute ischemic stroke are very limited. We looked for the prevalence and associated factors of atrial fibrillation (AF) and PAF in Thai patients with acute ischemic stroke. METHODS: In all, 204 patients with acute ischemic stroke were prospectively included. Snapshot 12-lead ECG and continuous ECG monitoring for at least the first 24 hours were performed. Multivariate analyses were performed to find out the associated factors of AF and PAF. RESULTS: AF was diagnosed in 31 patients (15%) and PAF in 15 patients (7%). Twelve and 3 patients with PAF were diagnosed by continuous ECG monitoring and snapshot 12-lead ECG, respectively. Mean duration of continuous ECG monitoring and mean time to detect PAF were 55 and 23 hours, respectively. Multivariate analysis revealed that age of 70 years or older (odds ratio [OR] 3.52, 95% confidence interval [CI] 1.68-7.35, P = .001) and heart diseases (OR 4.26, 95% CI 1.14-15.95, P = .031) were associated with AF and PAF. CONCLUSIONS: AF/PAF was one of the common causes of ischemic stroke in Thai patients. Most PAF was detected by continuous ECG monitoring. Snapshot 12-lead ECG and continuous ECG monitoring should be recommended in all patients with acute ischemic stroke.

Intravenous thrombolysis in Thai patients with acute ischemic stroke: role of aging.

BACKGROUND: Intravenous thrombolysis is a standard treatment in eligible acute ischemic stroke (AIS) patients. However, the advisability of treating patients >80 years of age is still debated. The aim of this study was to evaluate the role of aging on the outcomes in Thai patients treated with intravenous thrombolysis. METHODS: Patients with AIS treated with intravenous recombinant tissue-plasminogen activator (rtPA) between June 2007 and November 2010 were included. The demographics and measured outcome variables were compared between patients ≤70 and >70 years of age. Patients were also classified into 4 subgroups by the age ranges: ≤60 years, 61 to 70 years, 71 to 80 years, and ≥81 years of age. RESULTS: Two hundred sixty-one patients were included. Seventeen patients (6.5%) were >80 years old. Higher mortality (20.2% vs 5.1%; P < .001) and symptomatic intracerebral hemorrhage (7.7% vs 1.2%; P = .004) were found in the patients >70 years of age when compared with younger patients, and the rate of favorable outcome was lower (38.1% vs 55.4%; P = .010). Higher mortality rates were seen with increasing age: 3%, 8%, 20%, and 21% in patients aged ≤60, 61 to 70, 71 to 80, and ≥81 years of age, respectively. CONCLUSIONS: Thai stroke patients >70 years of age may carry a higher risk of mortality when treated with intravenous rtPA compared to patients ≤70 years of age.

Outcomes of intravenous thrombolytic therapy for acute ischemic stroke with an integrated acute stroke referral network: initial experience of a community-based hospital in a developing country.

Some of the literature encourages the use of intravenous (IV) thrombolytic therapy for acute ischemic stroke (AIS) in centers with no previous experience with this therapy. The benefits of an acute stroke referral network for IV thrombolytic therapy remain controversial, however. We present outcomes of IV thrombolytic therapy for AIS with an integrated acute stroke referral network at an institution with no previous experience in stroke thrombolysis and compare the results with previously published data. A total of 458 patients with AIS or transient ischemic attack (TIA), referred from a hospital in the acute stroke referral network or walk-ins, admitted to the stroke unit of Thammasat Hospital between October 2007 and January 2009 (16 months) were prospectively assessed. The main outcome measures were IV thrombolytic treatment rate, initial National Institutes of Health Stroke Scale (NIHSS) score, door-to-needle time, onset-to-treatment time (OTT), intracerebral hemorrhage, and morbidity and mortality at 3 months after onset. A total of 100 patients (59 from hospitals in the stroke referral network) received IV recombinant tissue plasminogen activator (rt-PA) therapy (21% of the admissions with AIS and TIA); 41% of the patients referred from a hospital in the network received IV rt-PA. The median NIHSS score before thrombolysis was 15 (range, 3-34). Mean door-to-needle time was 54 minutes (range, 15-125 minutes), and mean OTT was 160 minutes (range, 60-270 minutes). There were 13 asymptomatic intracerebral hemorrhages and 2 symptomatic intracerebral hemorrhages (1 fatal). By 3 months, 42 patients had achieved excellent recovery (modified Rankin Scale score of 0-1), and 14 had died. These outcomes are comparable to data from the National Institute of Neurological Disorders and Stroke and previous studies of IV rt-PA therapy in Thailand. Our findings indicate that integrating an acute stroke referral network into IV thrombolytic therapy for AIS in a community-based setting is safe and feasible and should help increase the rate of thrombolytic therapy. Previously inexperienced community-based centers can reproduce the experience and outcome measures reported by clinical trials and in the landmark literature of IV thrombolytic therapy in patients with stroke.

Clinical Risk Score for Predicting Vascular Dementia after Ischemic Stroke in Thailand.

Background: Poststroke dementia is an important consequence of stroke and warrants early prevention, detection, and management. The objective of the study was to develop a simple clinical risk score for predicting risk of vascular dementia in patients with ischemic stroke. Methods: The design was a prospective cohort study with 177 ischemic stroke survivors. A standard stroke evaluation was performed at admission, and dementia evaluation was conducted at six months after stroke. The significant predictors were used to develop a risk score using a multivariable logistic regression model. Results: Six months after stroke, 27.1% of the patients were diagnosed with vascular dementia. Five predictors were used in the risk score: age, education, history of stroke, white matter hyperintensities, and stroke subtype. The risk score had an area under receiver operating characteristic curve (AuROC) of 0.76, 72.9% sensitivity, and 79.1% specificity in predicting risk of vascular dementia. The predicted probability of vascular dementia for each risk score point was also reported. Conclusion: The clinical risk score had an acceptable accuracy in predicting vascular dementia in ischemic stroke survivors. It can be used for identifying those who are at a high risk of developing vascular dementia.

Outcomes of Mild Stroke and High-Risk Transient Ischemic Attack in Current Clinical Practice.

INTRODUCTION: Early assessment and management of patients with mild stroke and transient ischemic attack (TIA) by specialists were recommended. This study aimed to evaluate the outcomes of these patients and identify the predictive factors of clinical progression, unfavorable outcomes, and recurrent stroke. METHODS: Patients with mild ischemic stroke (NIHSS ≤5) and high-risk TIA were studied. All patients were managed by stroke specialists within 24 h of stroke onset. The outcomes of the patients at 3 months and final follow-up were studied. Predictive factors of clinical progression, unfavorable outcomes, and recurrent stroke were analyzed. RESULTS: 254 patients were studied. Thirty-eight patients (15%) had clinical progression during admission. Large artery atherosclerosis (OR 2.49, 95% CI: 1.06-5.81), cardioembolism (OR 3.34, 95% CI: 1.26-8.87), and brainstem stroke (OR 2.78, 95% CI: 1.28-6.01) were associated with clinical progression. At the final follow-up, median 22 months, 81 patients (32%) had unfavorable outcomes. Previous disability (OR 1.81, 95% CI: 3.31-100), moderate to severe white matter lesions (OR 2.90, 95% CI: 1.44-5.84), clinical progression (OR 12.5, 95% CI: 5.08-31.25), and recurrent stroke (OR 8.47, 95% CI: 3.21-22.72) were related to unfavorable outcomes. Eleven patients (4%) had recurrent stroke within 3 months and 31 patients (12%) at the final follow-up. Older age (OR 6.68, 95% CI: 2.35-19.02), diabetes mellitus (OR 2.59, 95% CI: 1.07-6.27), and smoking (OR 4.26, 95% CI: 1.52-11.95) were related to recurrent stroke. CONCLUSION: Implementation of the up-to-date standard care in clinical practice would bring good clinical outcomes to the patients with mild stroke and high-risk TIA.

The differences in clinical characteristics and natural history between essential tremor and essential tremor plus.

The diverse clinical manifestation of essential tremor (ET) has led to the question whether the different phenotypes may affect the clinical outcome and progression. This study aimed to estimate the clinical characteristics and natural history of ET and ET-plus. A total of 221 patients with ET were included, 117 (52.9%) reclassified as ET and 104 (47.1%) as ET-plus. Patients with ET-plus were significantly older in age at onset (P < 0.001); had a higher frequency of cranial tremors (P < 0.001), neurological comorbidities (P < 0.001) and psychiatric comorbidities (P = 0.025); more tremor progression (P < 0.001); and poorer response to medical treatment (P < 0.001) compared to ET patients. Regression analysis revealed that late-onset tremor (OR 11.02, 95% CI 2.79-43.53), neurological comorbidities (OR 3.38, 95% CI 1.56-7.31), psychiatric comorbidities (OR 4.29, 95% CI 1.48-12.44), cranial tremors (OR 2.10, 95% CI 1.02-4.30), and poor response to medical treatment (OR 3.67, 95% CI 1.87-7.19) were associated with ET-plus diagnosis. ET and ET-plus differ in the age of onset, tremor distribution, comorbidities, treatment response rate, and progression. Identifying the ET phenotypes may increase the clinical value in therapeutic strategies and clinical research in the future.

Causes of ischemic stroke in young adults in Thailand: a pilot study.

There is scarce information about ischemic stroke in young adults in Thailand. The purpose of this study was to explore the causes of ischemic stroke in Thai adults age 16-50 years. All ischemic strokes treated in persons in this age range between August 2006 and December 2008 were prospectively included. Stroke subtypes were classified according to Trial of ORG 10172 in Acute Stroke Treatment criteria as large-artery atherosclerosis (LAA), cardioembolism (CE), small-artery occlusion (SAO), stroke of other determined cause (OC), or stroke of undetermined cause (UND). The study group comprised 99 patients, with a mean age of 40 years and a mean National Institutes of Health Stroke Scale score of 8. In patients age <41 years, UND (32%; P = .0652) and OC (30%; P = .0167) were the most common stroke subtypes. In patients age 41-50 years, SAO (29%; P = .0947) and UND (21%) were the most common subtypes. Antiphospholipid syndrome (6%) and neurosyphilis (4%) were the leading causes of the OC subtype. Hyperlipidemia, smoking, and hypertension were common risk factors. Although the distribution of stroke subtypes was comparable with that found in previous studies from other countries, the identified causes were different.

Low vs standard dose of recombinant tissue plasminogen activator in treating East Asian patients with acute ischemic stroke.

BACKGROUND: Intravenous recombinant tissue plasminogen activator (rtPA) has been approved to treat eligible patients with acute ischemic stroke within 4.5 hours of onset. The rationale for using a lower dose in Asian patients came from concerns about intracerebral hemorrhage because of the racial differences in blood coagulation-fibrinolysis factors. AIM: The aim of this systemic review was to compare the data from previous studies to address the efficacy and safety of using low-dose vs standard-dose rtPA in treating patients with acute ischemic stroke. MATERIAL AND METHODS: Previous studies were searched and analyzed. The confidence interval was calculated at 95%. Baseline characteristics and outcomes of the patients were compared between two doses of rtPA (0.6 vs 0.9 mg/kg), using Z test for two independent proportions. RESULTS: Patients who received standard-dose rtPA had significantly higher favorable outcome at 3 months (33.1 vs 47.2%, P<0.0001), without significant difference in the rates of symptomatic intracerebral hemorrhage (3.5 vs 4.3%, P = 0.42) and mortality (13.1 vs 11.7%, P = 0.56). However, patients in the low-dose group were older and had more severe stroke. CONCLUSIONS: Patients receiving standard-dose rtPA seem to have higher rates of favorable outcome. However, there were significant differences in baseline characteristics between the two groups. A further, well-designed, randomized study in the same population is still needed to clarify the suspected benefit of the standard dose for East Asian patients.

Early outcome after intravenous thrombolysis in patients with acute ischemic stroke.

BACKGROUND: Patients with acute ischemic stroke who had early neurological improvement had better functional outcome. The purpose of this study was to determine factors associated with early clinical improvement and early worsening in patients with acute ischemic stroke treated with intravenous thrombolysis. PATIENTS AND METHODS: Patients treated with intravenous recombinant tissue plasminogen activator (rtPA) between August 2008 and November 2010 were the subjects of this study. Early improvement was defined by marked, clinical improvement or complete recovery at 24 h (National Institutes of Health Stroke Scale (NIHSS) 0-4 at 24 h). Early worsening was defined by an increase in NIHSS ≥1 from baseline. The baseline characteristics were compared between patients with and without outcome of interest. RESULTS: Of the 203 patients studied, 19 (9.4%) patients had complete recovery and 68 (33.5%) patients had marked clinical improvement (NIHSS 1-4) at 24 h. Most patients with early clinical improvement (86%) had favorable outcome at three months. Of the 22 (10.8%) patients who had early clinical worsening, only three (14%) patients achieved favorable outcome at three months and six (29%) patients died. Multivariate analysis revealed that older age (≥70 years old) (odd ratio (OR) 0.498, P = 0.049), severe stroke (NIHSS ≥15) (OR 0.154, P < 0.0001) and having intracerebral hemorrhage (ICH) (OR 0.364, P = 0.032) were inversely associated with early improvement. History of transient ischemic attack (TIA) (OR 7.724, P = 0.043) and ICH (OR 4.477, P = 0.008) were related to early worsening. CONCLUSIONS: The presence of early clinical improvement or worsening within 24 h after treatment with rtPA had major impact on the outcome at three months.

Etiology of Dementia in Thai Patients.

INTRODUCTION: Molecular imaging has been developed and validated in Thai patients, comprising a portion of patients in the dementia registry. This should provide a more accurate diagnosis of the etiology of dementia, which was the focus of this study. METHODS: This was a multicenter dementia study. The baseline characteristics, main presenting symptoms, and results of investigations and cognitive tests of the patients were electronically collected in the registry. Functional imaging and/or molecular imaging were performed in patients with an equivocal diagnosis of the causes of dementia, especially in atypical dementia or young onset dementia (YOD). RESULTS: There were 454 patients in the study. The mean age of the patients was 78 years, with 60% female. Functional imaging and/or molecular imaging were performed in 57 patients (57/454 patients, 13%). The most common cause of dementia was Alzheimer's disease (AD; 50%), followed by vascular dementia (VAD; 24%), dementia with Lewy bodies (6%), Parkinson's disease dementia (6%), frontotemporal dementia (FTD; 2.6%), progressive supranuclear palsy (2%), multiple system atrophy (0.8%), and corticobasal syndrome (0.4%). YOD accounted for 17% (77/454 patients), with a mean age of 58 years. The causes of YOD were early onset amnestic AD (44%), VAD (16%), behavioral variant FTD (8%), posterior cortical atrophy (6.5%), and logopenic variant primary progressive aphasia (5.2%). CONCLUSION: AD was the most common cause of dementia in Thai patients and the distribution of other types of dementia and main presenting symptoms were similar to previous reports in Western patients; however, the proportion of YOD was higher.

Implementation of Telemedicine and Stroke Network in thrombolytic administration: comparison between walk-in and referred patients.

BACKGROUND: The purpose of this study was to evaluate the efficacy and safety of implementation of telemedicine and the Thammasat Stroke Network model in treating acute ischemic stroke patients with intravenous thrombolysis. METHODS: Telemedicine (telephone consultation and tele-radiology) has been used in acute ischemic stroke management since June, 2007. The Thammasat Stroke Network (TSN) was effectively organized in March, 2008. Thammasat Hospital served as a "hub" hospital, with 25 "spoke" hospitals in the TSN. The main outcome measures included favorable outcome of the patients treated with intravenous tissue plasminogen activator (tPA) at 3 months and symptomatic intracerebral hemorrhage by comparison between walk-in patients and the patients who were referred by the TSN. RESULTS: There were 14 patients (14 out of 170 acute ischemic stroke patients, 8%) and 110 patients (110 out of 406 patients, 27%) receiving tPA, before and after implementation of TSN, respectively. Walk-in patients (66 patients) had significant shorter onset-to-treatment duration as compared with referred patients (58 patients) (130 vs. 170 min, P < 0.0001). However, there was no significant difference in favorable outcome (48 vs. 42%, P = 0.538) and rate of symptomatic intracerebral hemorrhage (3 vs. 2%, P = 0.637). CONCLUSION: Implementation of telemedicine and TSN markedly increased tPA administrations, without compromising favorable and safety outcomes.

Feasibility and safety of remote radiology interpretation with telephone consultation for acute stroke in Thailand.

"Telestroke" is emerging as a potential timesaving, efficient means for evaluating patients experiencing acute ischemic stroke. It provides an opportunity for administration of thrombolytic drugs within the short therapeutic time window associated with AIS. We describe our experiences of the feasibility and safety of remote radiology interpretation with telephone consultation. Thammasat Stroke Center employs a computed tomography-digital imaging and communication in medicine (CT-DICOM) image transfer by PACS (SYNAPSE-Fujifilm), providing a real-time CT image transferred directly to the stroke consultants. The patient data are communicated by traditional telephone conversation. Here, we assessed patients who received intravenous rt-PA treatment for ASI between October 2007 and January 2009. A total of 458 patients with AIS and transient ischemic attack (TIA) were admitted to a stroke unit during the study period. One hundred patients received intravenous rt-PA (21%). Median NIHSS before thrombolysis was 15 (3-34). Mean door-to-needle time was 54 minutes (15-125). Mean onset-to-treatment time OTT was 160 minutes (60-270). There were 13 asymptomatic intracerebral hemorrhages and two (one fatal) symptomatic intracerebral hemorrhages. At 3 months, 42 patients had achieved excellent recovery (mRS, 0-1) and 14 had died. Administration of rt-PA for AIS with remote radiology interpretation with telephone consultation was feasible and safe, and the system was well received. Further studies are needed to determine the benefit of this method as compared to the conventional telephone consultation alone.

Meralgia paresthetica-like syndrome may be caused by transient lumbar nerve root injury without definite compression: a case report.

Meralgia paresthetica is a well-known sensory syndrome describing paresthesia and/or anesthesia in the anterolateral aspect of the thigh that is supplied by the lateral femoral cutaneous nerve. Compression of the nerve usually occurs at the point where it passes between the anterior superior iliac spine and the inguinal ligament. Proximal lesions such as lumbar radiculopathy, lumbar disc herniation, and spinal stenosis have been reported to cause meralgia paresthetica-like syndrome. These proximal lesions directly injure L2 and L3 spinal nerve roots and cause a constant compression of the nerve roots. The presented paper introduces a hypothesis that this syndrome can be caused by transient injury to the L2 and L3 nerve roots by the upper adjacent disc bulge without definite compression. This hypothesis is supported by lumbar spine magnetic resonance imaging of a patient presenting with a meralgia paresthetica-like symptom during bending forward and twisting of the body, showing no L2/L3 herniated disc but mildly posterior bulging of T12/L1 disc. This hypothesis emphasizes an importance of appropriate postures in patients with meralgia paresthetica-like symptoms in order to prevent long-term morbidity.

Fetal origin of posterior cerebral artery related to poor collaterals in patients with acute ischemic stroke.

The anatomic variation of Circle of Willis (CW) has been shown to have a great impact on its compensatory capacity during acute ischemic stroke. The purpose of the study was to evaluate the effect of variations in CW on collateral circulation in patients with acute ischemic stroke who had major artery occlusion. Patients with acute ischemic stroke within 4.5 h of stroke onset who had at least moderate severity of stroke (NIHSS ≥ 6), caused by major artery occlusion were included. Multiphase computed tomography angiography (CTA) was performed. Variations in CW on each patient were recorded and compared between those with poor collateral and intermediate-good collateral circulation. There were 66 patients. Mean NIHSS was 15. Forty patients had poor collateral circulation and 26 patients had intermediate-good collateral circulation. There were variations in CW: no visualized posterior communicating artery (PCOM) (31/66, 47%), fetal origin of posterior cerebral artery (25/66, 38%), one anterior cerebral artery, segment A1 (A1) hypoplasia or atresia (16/66, 24%), one PCOM (8/66, 12%), and complete CW (3/66, 5%). Fetal origin of posterior cerebral artery (PCA) was associated with poor collateral circulation (48% vs 23%, p-value = 0.046). This pilot study showed that the presence of fetal origin of PCA was associated with poor collateral circulation in patients with acute ischemic stroke caused by major artery occlusion.