Modified CAVE score for predicting late seizures after intracerebral hemorrhage.

BACKGROUND AND PURPOSE: Seizures commonly occur in patients with intracerebral hemorrhage (ICH). Anticonvulsants are commonly used for preventing seizures in patients with ICH. Thus, patients with ICH at high risk of seizures must be identified. The study aims to elucidate whether double the score of cortex involvement in ICH patients can increase accuracy of CAVE score for predicting late seizures. METHOD: This retrospective analysis of the medical records of surviving patients admitted between June 1, 2013, and December 31, 2019. Validated the CAVE score and modified it (CAVE2). The main outcome of patients with ICH was seizures. The first seizures occurring within 7 days after a stroke were defined as early seizures. Seizures occurring after 1 week of stroke onset, including patients who had experienced early seizures or patients who had not, were defined as late seizures. CAVE and CAVE2 scores were validated using the cohort. The accuracy and discrimination of those two scores were accessed by the area under the operating characteristic curve. Akaike information criterion, integrated discrimination improvement, and continuous net reclassification improvement were used to assess the performance of the CAVE and CAVE2 scores. RESULTS: In the cohort showed that late seizures occurred in 12.7% (52/408) of patients with ICH. Male sex, age > 65 years, cortex involvement, and early seizures were associated with the occurrence of late seizures, with odds ratios of 2.09, 2.04, 4.12, and 3.78, respectively. The risk rate of late seizures was 6.66% (17/255), 14.8% (17/115), and 47.4% (18/38) for CAVE scores ≤ 1, 2, and ≥ 3, and 4.6% (12/258), 18.3% (13/71), and 54.4 (20/37) for CAVE2 scores ≤ 1, 2, and ≥ 3 respectively. The C-statistics for the CAVE and CAVE2 scores were 0.73 and 0.74 respectively. CONCLUSION: The CAVE score can identify patients with ICH and high risk for late seizures. The CAVE can be modified by changing the score of cortex involvement to 2 points to improve accuracy in predicting late seizures in patients with ICH.

Discontinuation of preventive antiepileptic drugs in patients with intracerebral hemorrhage.

BACKGROUND: The risk factors for seizures in patients with intracerebral hemorrhage (ICH) stroke and the effect of seizure prevention by anticonvulsant are not well understood. Limited studies have investigated the risk of seizure after discontinuing antiepileptic drugs in patients with ICH. This study aimed to investigate the role of valproic acid (VA) for seizure prevention and to access the risk of seizure after anticonvulsant withdrawal in patients with spontaneous ICH. METHODS: Between 2013 and 2015, 177 patients with ICH were enrolled in this 3-year retrospective study. Seizures were classified as early seizure (first seizure within 1 week of ICH), delayed seizure (first seizure after 1 week), and late seizure (any seizure after 1 week). Binary logistic regression was used to evaluate the relationship between baseline clinical factors and late seizures between study periods. VA was prescribed or discontinued based on the decision of the physician in charge. RESULTS: Seizures occurred in 24 patients, including early seizure in 6.78% (12/177) of the patients, delayed seizure in 7.27% (12/165) of the patients without early seizure, and late seizure in 9.60% (17/177) of the patients. Most seizures occurred within the first year. Binary logistic regression analysis showed ICH with cortex involvement as the independent risk factor for seizures. VA did not decrease the risk of seizures. Patients with ICH with cortical involvement using anticonvulsants for longer than 3 months did not have a decreased risk of seizures (odds ratio 1.86, 95% CI: 0.43-8.05). CONCLUSIONS: Spontaneous ICH with cortex involvement is the risk factor for seizure. Most seizures occurred within 1 year after stroke onset over a 3-year follow up. Discontinuation of antiepileptic drug within 3 months in patients does not increase the risk of seizure.

Clinical Profile and Outcome of Myasthenic Crisis In Central Taiwan.

BACKGROUND: Myasthenia gravis (MG) is an autoimmune disease caused by antibodies to acetylcholine receptors of the skeletal muscle. Myasthenic crisis (MC) is a complication observed during both early and late stage MG cases. In this study, we examined current treatments and three years outcomes in patients with MG and MC. We also investigated the impact of thymectomy and systemic lupus erythematosus (SLE) in patients with MG and MC. METHODS: In this retrospective study, we reviewed the medical records of all patients admitted to one teaching hospital between January 2006 and December 2014 and identified those for whom discharge diagnosis included the International Classification of Diseases, ninth revision (ICD-9) codes corresponding to MG (358.X, all extensions and all positions). RESULTS: We identified 29 patients and 49 hospitalizations. Among these patients, the cause for initial hospitalization was MG in 16 cases and MC in 13 cases. Six out of the 16 MG patients were readmitted within 3 years; with 2 of the cases due to MC. Eight of the initial 13 MC patients were readmitted within 3 years, and 6 of the cases due to MC. Among these 15 MC patients, 14 were admitted to the intensive care unit (ICU), and 8 were intubation and put on mechanical ventilators. The median ICU stay was 7 days (3-45). Both MG patients who were also diagnosed with SLE experienced MC. One patient died during the first-time hospitalization, and one patient died during re-hospitalization within 2 years. CONCLUSION: Plasma exchange (PE) is the main treatment modality of MC, and most patients in our cohort had a good response. Infection is the most common trigger of MC and a significant cause of death. Despite significant morbidity and mortality in patients with MC, a favorable long-term outcome is possible with intensive treatment. Key Words: myathenia gravis, myasthenic crisis, systemic lupus erythematosus, outcome.

Underestimated Rate of Status Epilepticus according to the Traditional Definition of Status Epilepticus.

PURPOSE: Status epilepticus (SE) is an important neurological emergency. Early diagnosis could improve outcomes. Traditionally, SE is defined as seizures lasting at least 30 min or repeated seizures over 30 min without recovery of consciousness. Some specialists argued that the duration of seizures qualifying as SE should be shorter and the operational definition of SE was suggested. It is unclear whether physicians follow the operational definition. The objective of this study was to investigate whether the incidence of SE was underestimated and to investigate the underestimate rate. METHODS: This retrospective study evaluates the difference in diagnosis of SE between operational definition and traditional definition of status epilepticus. Between July 1, 2012, and June 30, 2014, patients discharged with ICD-9 codes for epilepsy (345.X) in Chia-Yi Christian Hospital were included in the study. A seizure lasting at least 30 min or repeated seizures over 30 min without recovery of consciousness were considered SE according to the traditional definition of SE (TDSE). A seizure lasting between 5 and 30 min was considered SE according to the operational definition of SE (ODSE); it was defined as underestimated status epilepticus (UESE). RESULTS: During a 2-year period, there were 256 episodes of seizures requiring hospital admission. Among the 256 episodes, 99 episodes lasted longer than 5 min, out of which 61 (61.6%) episodes persisted over 30 min (TDSE) and 38 (38.4%) episodes continued between 5 and 30 min (UESE). In the 38 episodes of seizure lasting 5 to 30 minutes, only one episode was previously discharged as SE (ICD-9-CM 345.3). Conclusion. We underestimated 37.4% of SE. Continuing education regarding the diagnosis and treatment of epilepsy is important for physicians.

Serotonin Syndrome Induced by Combined Use of Mirtazapine and Olanzapine Complicated with Rhabdomyolysis, Acute Renal Failure, and Acute Pulmonary Edema-A Case Report.

PURPOSE: Serotonin syndrome is a potentially life-threatening complication of serotonergic agents. Although mirtazapine is a relatively safe antidepressant and has a comparatively low incidence of side effects, it still could induce serotonin syndrome. CASE REPORT: We described a 34-year-old man with schizophrenic disorder who presented with acute consciousness disturbance, extremely high fever, rigidity, and spontaneous clonus in lower limbs. Two days before entry, oral mirtazapine was added to his regular medication of olanzapine. The serotonin-related symptoms resolved soon after withdrawal of mirtazapine and olanzapine combined with treatment with intravenous benzodiazepine and oral cyproheptadine. However, the clinical course was complicated by rhabdomyolysis, acute renal failure, and acute pulmonary edema. After receiving mechanical ventilation, hemodialysis, and appropriate supportive treatment, his general condition recovered and he was discharged without any neurological sequelae. CONCLUSION: With the increasing use of serotonergic agents, awareness of serotonin syndrome is important. Early diagnosis and timely discontinuation of the offending agent(s) are imperative to prevent morbidity and mortality.

Oxfordshire Community Stroke Project classification improves prediction of post-thrombolysis symptomatic intracerebral hemorrhage.

BACKGROUND: The Oxfordshire Community Stroke Project (OCSP) classification is a simple stroke classification system with value in predicting clinical outcomes. We investigated whether and how the addition of OCSP classification to the Safe Implementation of Thrombolysis in Stroke (SITS) symptomatic intracerebral hemorrhage (SICH) risk score improved the predictive performance. METHODS: We constructed an extended risk score by adding an OCSP component, which assigns 3 points for total anterior circulation infarcts, 0 point for partial anterior circulation infarcts or lacunar infarcts. Patients with posterior circulation infarcts were assigned an extended risk score of zero. We analyzed prospectively collected data from 4 hospitals to compare the predictive performance between the original and the extended scores, using area under the receiver operating characteristic curve (AUC) and net reclassification improvement (NRI). RESULTS: In a total of 548 patients, the rates of SICH were 7.3% per the National Institute of Neurological Diseases and Stroke (NINDS) definition, 5.3% per the European-Australasian Cooperative Acute Stroke Study (ECASS) II, and 3.5% per the SITS-Monitoring Study (SITS-MOST). Both scores effectively predicted SICH across all three definitions. The extended score had a higher AUC for SICH per NINDS (0.704 versus 0.624, P = 0.015) and per ECASS II (0.703 versus 0.612, P = 0.016) compared with the SITS SICH risk score. NRI for the extended risk score was 22.3% (P = 0.011) for SICH per NINDS, 21.2% (P = 0.018) per ECASS II, and 24.5% (P = 0.024) per SITS-MOST. CONCLUSIONS: Incorporation of the OCSP classification into the SITS SICH risk score improves risk prediction for post-thrombolysis SICH.

Association Between Abnormal Course of Carotid Artery and Cerebrovascular Disease.

PURPOSE: Abnormal course of the carotid artery (ABCA) is commonly identified during carotid sonography studies. Whether ABCA is related to the risk of stroke and stroke risk factors remains unclear. The purpose of the study is to investigate the prevalence of ABCA and the relationship with stroke and the risk factors of stroke. METHODS: Color duplex ultrasound scanning of carotid arteries was performed on 615 subjects (between January 1, 2012 and March 31, 2012). ABCA and intimal thickness were recorded. Risk factors of stroke such as hypertension, diabetes mellitus, dyslipidemia, atherosclerosis, stroke history, and heart disease were recorded. The prevalence of ABCA was analyzed and its relationship with stroke and stroke risk factors was evaluated. RESULTS: ABCA was found in 4.1% (25/615) patients, 6.29% (19/302) in women, and 1.91% (6/313) in men. ABCA in 1 vessel was noted in 18 patients, 2 vessels in 3 patients, 3 vessels in 3 patients, and 4 vessels in 1 patient. The frequency of ABCA was significantly higher in women than in men (6.3% vs 1.9%, p = 0.01). There was no difference in the prevalence of ABCA between stroke patients and nonstroke subjects ( p = 0.60). ABCA was more frequent in patients older than 65 years. (5.91% (22/372) vs. 1.23% (3/243) p = 0.01). Logistic regression analysis did not reveal associations between ABCA and stroke risk factors (hypertension, diabetes mellitus, dyslipidemia, stroke history, heart disease and atherosclerosis). During 1 year follow-up, 2.88% (17/590) of non-ABCA patients and 4.0% (1/25) of ABCA patients had event of stroke or transient ischemic attack (TIA) ( p =0.08). CONCLUSION: The prevalence of ABCA in the present study is significantly lower than that in previous studies (Togay-Isikay et al., 24.6%, Del Corso et al., 58%). ABCA is more frequent in women and older patients. ABCA is not related to stroke and stroke risk factors. From our results, we suggest that patients with ABCA be placed under observation unless they exhibit neurological symptoms.

Brain biopsy-proven intravascular lymphomatosis presenting as rapidly recurrent strokes-two case reports.

PURPOSE: Intravascular lymphomatosis (IVL) is rare and usually goes undiagnosed until the time of autopsy because of its protean neurological manifestations. CASE REPORT: In this report, we describe two women who developed rapidly recurrent strokes within one to two months. In both cases, brain magnetic resonance imaging showed progression of bilateral cerebral infarcts, and histopathology from brain biopsy confirmed the diagnosis of IVL. The first case did not receive chemotherapy and died of septic shock one month after diagnosis. The second case received whole brain radiotherapy followed by rituximab-containing chemotherapy, and experienced partial improvement of neurological deficits. However, she began to deteriorate in consciousness at 8 months and became stuporous at 10 months after the onset of symptoms. CONCLUSION: IVL should be considered as a possible etiology if multiple strokes occur in a short period of time.

Epidermoid cyst presenting as isolated trigeminal neuralgia - two case reports.

PURPOSE: Symptomatic TN accounts for up to 15% of all TN. Though there are many established "red flag" signs, it is still sometimes difficult to sift symptomatic from classic TN. We herein report two cases of isolated TN with normal neurologic examinations and then tissue proved as epidermoid cyst. CASE 1: A 17-year-old girl presented with paroxysmal intense pain mixed dull background pain at right mandibular region for one month. The blink reflex demonstrated brainstem lesion and brain magnetic resonance imaging (MRI) revealed a huge lobulated tumor in right cerebellopontine angle (CPA) with obvious brainstem compression. Her right facial pain was nearly completely disappeared postoperatively. CASE 2: The 48-year-old woman had chronic paroxysmal electric-like and burning pain in left V3 region for more than 5 years. Because of refractory pain, brain MRI was arranged and showed a non-enhancing cystic lesion at left CPA. Post operative complications occurred as left multiple lower cranial nerve palsies and Horner syndrome, and truncal ataxia. Her facial pain was completely free after 1 month follow up. CONCLUSION: In the first patient, teenage onset, abnormal trigeminal reflex, and early developing background pain struck us directly to symptomatic TN. In the second case, we suspected symptomatic TN with uncertainty before image study. TN could be the isolated initial symptom of CPA epidermoid cysts. In consideration about pretty high prevalence of symptomatic TN, physicians should be more alert and straightforward arrange neuroimage when facing TN patients with atypical presentation.

Idiopathic hypertrophic pachymeningitis with anticardiolipin antibody: A case report.

RATIONALE: Idiopathic hypertrophic pachymeningitis (IHP) is a rare neurological disorder without a definite etiology. Diagnosis is mainly based on exclusion of other etiologies. PATIENT CONCERNS: A 41-year-old male patient presented with insidious onset headache of 3-month duration. DIAGNOSES: Contrast-enhanced brain magnetic resonance imaging (MRI) revealed diffuse pachymeningeal enhancement over bilateral cerebral hemispheres and the tentorium cerebelli. Lumbar puncture showed increased pressure, lymphocytic pleocytosis, and elevated protein level with normal glucose concentration. Blood tests detected elevated erythrocyte sedimentation rate (ESR) and C-reactive protein. Pathological examination of the dura mater from the right frontal convexity disclosed coarse collagenous deposition with focal lymphoid aggregation. After malignancy and infectious etiologies were excluded, a diagnosis of IHP was made. INTERVENTIONS: Oral prednisolone and azathioprine followed by methotrexate were administered. OUTCOMES: During the 7-year follow-up period, although the patient was not totally headache-free, medical therapy significantly reduced the severity of headache. Follow-up MRI studies showed a reduction in meningeal enhancement and serial ESR measurements revealed a trend of improvement. LESSONS: Methotrexate therapy may be considered in cases of steroid-resistant IHP. In addition to clinical evaluation, serial ESR testing may be considered to guide the treatment strategy and assess the response to therapy.

Increased use of thrombolytic therapy and shortening of in-hospital delays following acute ischemic stroke: experience on the establishment of a primary stroke center at a community hospital.

PURPOSE: To improve and standardize stroke care, the establishment of primary stroke centers (PSCs) has been advised. Thrombolytic therapy has been proved to improve the outcome of acute ischemic stroke (AIS). We assessed the use of thrombolytic therapy before and after setting up a PSC at a community hospital. METHODS: In November 2007, a PSC was established at our hospital. Following guidelines based on national recommendations, we administered intravenous tissue plasminogen activator (tPA) to patients who met the criteria. To study the effects of the establishment of the PSC on tPA treatment rates, we examined our database of stroke patients dating back to January 2004. RESULTS: Before the establishment of the PSC, there have been 2,420 patients admitted to our hospital diagnosed with AIS. Only 1.2% of these patients were treated with intravenous tPA. Following the establishment of the PSC, 2.8% of 1151 AIS patients were treated with tPA. Time of patient arrival to patient treatment was also diminished. CONCLUSION: The establishment of the PSC significantly increases the usage of tPA treatment. Furthermore, response time to patient cases was also quicker. However, for maximum effectiveness, the public still needs to be made more aware of the risks of stroke and the importance of seeking medical care at the first signs of stroke.

The Impact of Loading Dose on Outcome in Stroke Patients Receiving Low-Dose Tissue Plasminogen Activator Thrombolytic Therapy.

BACKGROUND: Intravenous tissue plasminogen activator (tPA) (0.9 mg/kg, maximum 90 mg) with a bolus of 10% of the total dose given within 1-2 mins is the standard therapy for patients receiving thrombolytic therapy. Low-dose (0.6 mg/kg) tPA is also approved for thrombolytic therapy for ischemic stroke patients. Low-dose tPA is associated with a low bolus dose. It is unknown whether increasing the bolus dose in patients receiving low-dose tPA thrombolysis may improve outcomes or increase the risk of hemorrhagic transformation (HT). AIM: This study investigated the impact of the bolus dose on the outcome in ischemic stroke patients receiving low-dose tPA thrombolytic therapy. METHODS: In this retrospective, observational study, we enrolled 214 ischemic stroke patients receiving low-dose tPA thrombolytic therapy. Of these 214 patients, 107 patients received 10% of the total dose as a bolus dose, and 107 patients received 15% of the total dose as a bolus dose. The National Institutes of Health Stroke Score (NIHSS) were evaluated before tPA infusion, 24 h after thrombolytic therapy, and at discharge. Stroke severity was categorized as mild (0-5), moderate (6-14), severe (15-24), or very severe (≥25). Neurological improvement (NI) was defined as an improvement of 6 or more points in the NIHSS, and no response (NR) was defined as an increase in the NIHSS of ≤4 points or a decrease ≤6 points. Neurological deterioration (ND) was defined as an increase in the NIHSS >4 points. A good outcome was defined as a modified Ranking Score (mRS) of 0 or 1. We compared the NI, NR, and ND rates at 24 hrs after thrombolytic therapy and discharge between the 15% and 10% bolus dose groups. RESULTS: In patients with mild and moderate stroke, there was no significant difference in the NI, NR, ND, and HT rates and 6-month outcomes between the 15% and 10% bolus groups. In patients with severe and very severe stroke, outcomes at 6 months were significantly better in the 15% bolus group than in the 10% bolus group. The factors affecting the outcomes of severe and very severe stroke patients are hypertension and bolus dose. CONCLUSION: In severe and very severe stroke patients receiving low-dose tPA thrombolytic therapy, a bolus dose of 15% of the total dose can improve outcomes.

Impact of silent infarction on the outcome of stroke patients.

BACKGROUND/PURPOSE: Silent infarcts (SIs) are commonly found on brain computed tomography (CT) or magnetic resonance imaging (MRI) among elderly subjects, but their risk factors and impact on outcome in stroke patients are unknown. We evaluated the prevalence, risk factors and impact of SIs on the outcome of patients admitted with first-ever ischemic stroke or transient ischemic attack (TIA). METHODS: A prospective study of 446 patients admitted consecutively to the neurology service with a diagnosis of TIA or stroke between July 2003 and June 2005, including 226 without any history of prior TIA or stroke. All patients underwent brain CT on the day of admission to the hospital. Risk factors analyzed included age, history of hypertension, diabetes mellitus, cardiovascular disease or stroke, smoking habit and alcohol use. Cholesterol and triglyceride levels were measured on the second day of admission. We monitored these patients for 24 months after stroke onset. RESULTS: The frequency of SIs among the 226 patients with first-ever stroke or TIA was 20%. Most of the SIs were small and deep. Small-artery disease was more frequently observed in patients with SIs. Age, hypertension, diabetes mellitus, hypercholesterolemia, hypertriglyceridemia, alcohol use, smoking habits and atrial fibrillation did not significantly differ between patients with SIs and those without SIs. During the 24-month follow-up period, the frequency of recurrent stroke was higher in patients with SIs than those without SIs. The mortality rate was higher in patients without SIs than those with SIs. The interval from stroke onset to rehospitalization was shorter in patients without SIs than in those with SIs. CONCLUSION: The study showed a higher frequency of small artery disease in patients with SIs. First-ever stroke patients with SIs should be considered at high risk for recurrent stroke.

Intravenous thrombolytic therapy for acute ischemic stroke: the experience of a community hospital.

BACKGROUND AND PURPOSE: Tissue plasminogen activator (tPA) is a standard therapy for acute ischemic stroke (AIS) but only limited data are noted in Taiwan. The purpose of this study was to assess the safety, feasibility, and efficacy of treatment in a community hospital setting. METHODS: We retrospectively reviewed the medical records of all patients who had received intravenous tPA therapy from 1998 to 2007 in our hospital. We compared the characteristics, complications, and outcomes in our patients with those of patients in the National Institute of Neurological Disorders and Stroke (NINDS) trial. RESULTS: A total of 43 patients were reviewed with a mean age of 63 years and a male predominance (64%). The median pretreatment National Institutes of Health Stroke Scale score was 18. In our patients, cardioembolism was the leading course of the strokes. The mean time from stroke onset to treatment was 134 minutes, and the mean door-to-computed tomography-time was 34 minutes while the mean door-to-needle time was 93 minutes. Within 36 hours symptomatic intracerebral hemorrhage occurred in two patients (4.7%). Four patients (9.3%) developed brain herniation with fatality. At follow-up, fourteen patients (33%) had a favorable outcome on the modified Rankin Scale (0-1). Patient outcome was not significantly different from that in the NINDS trial. CONCLUSION: Although the number of patients with AIS receiving tPA in this study was small, thrombolytic therapy can be performed safely and effectively by physicians in the community hospital setting.

Ethic issue in ischemic stroke patients wit thrombolytic therapy.

OBJECTIVE: To discuss the ethical challenge in thrombolytic therapy. BACKGROUND: Thrombolytic therapy with recombinant tissue-type plasminogen activator (rt-Pa) has been found to be beneficial to the outcome of patients who had a stroke. However, the ethic issue that is related to intravenous rt-Pa infusion has not been discussed. PATIENTS: Four patients with a middle cerebral artery (MCA) infarct arrived at the emergency department (ER) of our hospital within 3 hours of stroke onset. All of them violated the guidelines of thrombolytic therapy for patients. The families of three patients insisted on the thrombolytic therapy. Two patients received rt-Pa infusion and two did not. RESULTS: Two patients who received rt-Pa infusion experienced hemorrhagic transformation. One died on the fifth day after stroke, and the other one had a poor outcome with a modified ranking scale (mRS) of 5. One of the two patients who did not receive rt-Pa infusion suffered from hemorrhagic transformation and died on the third day after stroke, and the other one had a poor outcome with mRS of 5. CONCLUSIONS: These 4 cases highlight the complexity of thrombolytic therapy in patients who violate the guidelines because the families insisted on thrombolytic therapy. No one is sure that the family's decision was the patient's wish. When a stroke patient violates the guidelines of thrombolytic therapy and the family of the patient insists on the thrombolytic therapy, a conversation between patients, patients' families and clinicians is necessary. Physician should tell patient and their families about the high risk of hemorrhagic transformation and mortality. If the family wants to make a decision, physician should request patient or patient's families to sign an against medical advice form and follow the patient's or their family's decision for the outcome.

Progression of Mild to Moderate Stenosis in the Internal Carotid Arteries of Patients With Ischemic Stroke.

Background and purpose: Severe stenosis in the internal carotid artery may increase the risk of ischemic stroke. The factors that affect the progression of carotid artery stenosis in patients with ischemic stroke are poorly studied. No guidelines for the duration of follow-up of patients with ischemic stroke through carotid ultrasonography exist. Methods: In this retrospective study, 179 patients (108 men; mean age, 68 years) with ischemic stroke and mild to moderate stenosis in the internal carotid artery (ICA) were recruited. Carotid artery ultrasonography was performed over the period of January 2013 to June 2016 with a median follow-up of 36 months (mean 36.5 ± 3.5 months). The severity of carotid artery stenosis was estimated with the following equation: 1- (narrowest ICA diameter/total lumen diameter at the narrowest site). The severity of stenosis was categorized into grades I (0-29%), II (30-49%), III (50-59%), and IV (60-69%). The patient's stenosis grade was defined on the basis of the stenosis rate of the ICA side with most severe stenosis. Results: Stenosis progressed in 17.9% (64/358) of the vessels in 30.7% (55/179) of patients. The risk of stenosis progression increased as the severity of ICA stenosis increased. Patients with stenosis rates of above 50% are at a higher risk of stenosis progression than those with stenosis rate of < 50%. Relative to the patient group with an ICA stenosis rate of 0-29%, the adjusted odds ratios of stenosis progression were 2.33 (p = 0.03; 95% CI: 1.05~5.17), 3.50 (p = 0.09; 95% CI: 0.81~15.84), and 6.61 (p = 0.03; 95% CI: 1.01~39.61) in patient groups with ICA stenosis rates of 30-49%, 50-59%, and 60-69%, respectively. Hyper-LDL-cholesterolemia (Hyper-LDL-c) also increased the risk of stenosis progression, with an adjusted odds ratio of 2.22 (p = 0.03; 95% CI: 1.05~4.71). Conclusion: The rate of ICA stenosis progression increases with stenosis grade. Patients with ICA stenosis severity >50% and Hyper-LDL-c have high rates of stenosis progression. For the patients with stroke and ICA stenosis severity >50%, annual follow up through carotid artery ultrasonography may be necessary.

Neurological deterioration in patients with first-ever ischemic stroke.

A study was conducted for 121 patients (55 female, 66 male; age 68.7 +/- 10.4 years) with first-ever ischemic stroke to investigate the frequency and risk factors of early neurological deterioration (ND). The initial evaluation was carried out within 24 hours of stroke onset. National Institutes of Health Stroke Scale score and Barthel index were used to evaluate patients for a period of 2 months. Thirty-eight patients (31.4%) showed early ND and 83 patients (68.6%) were stable or improved. Among the 38 patients with ND, 25 (65.8%) patients occurred within 48 hours after initial evaluation. In most patients, ND began on the first day and ceased on the third day after stroke onset. Neurological function started to improve after ND reaching the nadir. The mortality rate was 13.2% (5/38) for patients with ND and 1.2% (1/83) for patients without deterioration. At the end of the study, the functional ability and motility of patients were lower in the progressive group than in the non-progressive/stable group. Results of this study seem to indicate that an elevated C-reactive protein level and total anterior circulation infarction are risk factors for ND. The results also suggest that more aggressive and early treatments are needed for stroke patients to prevent disease progression.

Silent infarction in patients with first-ever stroke.

BACKGROUND/PURPOSE: Silent infarcts (SIs) are commonly found in brain computed tomography (CT) or magnetic resonance imaging (MRI) of elderly subjects. However, the prevalence of this silent infarction (SI) and risk factors for this entity are not entirely known. This study was aimed to evaluate the prevalence of silent infarcts in brain CT and risk factors in patients admitted with first-ever ischemic stroke or transient ischemic attack (TIA). METHODS: From July 2003 to May 2005, a prospective study was performed for 446 patients admitted to our neurology service with a diagnosis of TIA or stroke. Two hundred and twenty-six patients did not have a history of stroke or TIA prior to the event. All patients received a brain CT on the day when they arrived at the hospital. Risk factors that are monitored included age, history of hypertension, diabetes mellitus, cardiovascular disease, stroke, smoking and alcohol use. Cholesterol and triglyceride levels were measured on the second day of admission. RESULTS: The results showed that the frequency of SI among 226 patients with first-ever stroke or TIA was 20%. Most of the SIs were small and deep. Small-artery disease was more frequently observed in patients with silent infarction. Age, hypertension, diabetes mellitus, hypercholesterolemia, hypertriglyceridemia, alcohol habit, smoking and atrial fibrillation were not significantly different between patients with silent infarct and patients without silent infarct. CONCLUSIONS: The study shows small-artery disease is more frequent in patients with silent infarction. The clinical significance of silent infarct needs further study.

Outcome of stroke patients receiving different doses of recombinant tissue plasminogen activator.

BACKGROUND AND PURPOSE: Intravenous recombinant tissue plasminogen activator (tPA) at a dose of 0.9 mg/kg body weight is associated with a high hemorrhagic transformation (HT) rate. Low-dose tPA (0.6 mg/kg) may have a lower hemorrhage rate but the mortality and disability rates at 90 days cannot be confirmed as non-inferior to standard-dose tPA. Whether the doses 0.7 and 0.8 mg/kg have better efficacy and safety needs further investigation. Therefore, this study is to compare the efficacy and safety of each dose of tPA (0.6, 0.7, 0.8, and 0.9 mg/kg body weight) and to investigate the factors affecting early neurological improvement (ENI) and early neurological deterioration (END). METHODS: For this observational study, data were obtained from 274 patients who received tPA thrombolytic therapy in Chia-Yi Christian Hospital stroke unit. The tPA dose was given at the discretion of each physician. The definition of ENI was a >8 point improvement (compared with baseline) at 24 h following thrombolytic therapy or an improvement in the National Institutes of Health Stroke Score (NIHSS) to 0 or 1 toward the end of tPA infusion. The definition of END was a >4 point increase in NIHSS (compared with baseline) within 24 h of tPA infusion. The primary objective was to investigate whether 0.7 and 0.8 mg/kg of tPA have higher ENI rate, lower END rate, and better outcome at 6 months. Poor outcome was defined as having a modified Rankin Scale of 3 to 6 (range, 0 [no symptoms] to 6 [death]). The secondary objective was to investigate whether low-dose tPA has a lower risk of intracerebral HT than that with standard-dose tPA. We also investigated the factors affecting ENI, END, HT, and 6-month outcome. RESULTS: A total of 274 patients were included during the study period, of whom 260 were followed up for >6 months. There was a trend for the HT rate to increase as the dose increased (P=0.02). The symptomatic HT rate was not significantly different among the low-dose and standard-dose groups. The ENI and END (P=0.52) were not significantly different among the four dosage groups. The clinical functional outcome at 6 months after stroke onset was poorer in the standard-dose group (P=0.02). Stroke severity (P<0.01), stroke type (P=0.03), and diabetes mellitus (P=0.04) affected the functional outcome at 6 months. CONCLUSION: Among the 274 patients receiving tPA thrombolytic therapy, the HT rate increased as dose increased. The symptomatic HT, ENI and END rates were not significantly different among the low-dose (0.6, 0.7, and 0.8 mg/kg) and standard-dose groups. Stroke severity (NIHSS >12), stroke type (cardioembolism and large artery atherosclerosis) and diabetes mellitus were associated with poor outcome at 6 months.

Sex-related differences in the risk factors for in-hospital mortality and outcomes of ischemic stroke patients in rural areas of Taiwan.

BACKGROUND AND PURPOSE: Sex-related differences in the clinical presentation and outcomes of stroke patients are issues that have attracted increased interest from the scientific community. The present study aimed to investigate sex-related differences in the risk factors for in-hospital mortality and outcome in ischemic stroke patients. METHODS: A total of 4278 acute ischemic stroke patients admitted to a stroke unit between January 1, 2007 and December 31, 2014 were included in the study. We considered demographic characteristics, clinical characteristics, co-morbidities, and complications, among others, as factors that may affect clinical presentation and in-hospital mortality. Good and poor outcomes were defined as modified Ranking Score (mRS)≦2 and mRS>2. Neurological deterioration (ND) was defined as an increase of National Institutes of Health Stroke Score (NIHSS) ≥ 4 points. Hemorrhagic transformation (HT) was defined as signs of hemorrhage in cranial CT or MRI scans. Transtentorial herniation was defined by brain edema, as seen in cranial CT or MRI scans, associated with the onset of acute unilateral or bilateral papillary dilation, loss of reactivity to light, and decline of ≥ 2 points in the Glasgow coma scale score. RESULTS: Of 4278 ischemic stroke patients (women 1757, 41.1%), 269 (6.3%) received thrombolytic therapy. The in hospital mortality rate was 3.35% (139/4278) [4.45% (80/1757) for women and 2.34% (59/2521) for men, p < 0.01]. At discharge, 41.2% (1761/4278) of the patients showed good outcomes [35.4% (622/1757) for women and 45.2% (1139/2521) for men]. Six months after stroke, 56.1% (1813/3231) showed good outcomes [47.4% (629/1328) for women and 62.2% (1184/1903) for men, p < 0.01]. Atrial fibrillation (AF), diabetes mellitus, stroke history, and old age were factors contributing to poor outcomes in men and women. Hypertension was associated with poor outcomes in women but not in men in comparison with patients without hypertension. Stroke severity and increased intracranial pressure were associated with increased in-hospital mortality in men and women. AF was associated with increased in-hospital mortality in women but not in men compared with patients without AF. CONCLUSION: The in-hospital mortality rate was not significantly different between women and men. Functional outcomes at discharge and six months after stroke were poorer in women than in men. Hypertension is an independent factor causing poorer outcomes in women than in men. AF is an independent factor affecting sex differences in hospital mortality in women.