Triglyceride-Related Parameters and Symptomatic Atherosclerotic Lesions in Patients With Ischemic Stroke.

Objective: Recently, evidence has suggested that the pathophysiology and risk factors of intracranial atherosclerosis (ICAS) differs from those of extracranial atherosclerosis (ECAS). In addition, novel parameters reflecting metabolic conditions, such as insulin resistance or atherogenic dyslipidemia, based on triglycerides (TG) and other biomarkers, have emerged. In this study, we evaluated the association between TG-related parameters and symptomatic cerebral atherosclerosis in patients with acute ischemic stroke resulting from large artery atherosclerosis (LAA). Methods: We assessed consecutive acute LAA-stroke patients between January 2010 and December 2020. Based on the radiological findings, we classified the relevant symptomatic arteries that caused the index stroke into LAA-ICAS and LAA-ECAS. As TG-related parameters, the atherogenic index of plasma (AIP) and TG-glucose (TyG) index were calculated according to the following formulas: AIP = log10 (TG Level/High-density Lipoprotein Cholesterol Level), TyG Index = Ln (TG Level × Glucose Level/2). Results: A total of 519 patients with LAA-stroke were evaluated. In multivariable logistic regression analysis to identify predictors of LAA-ICAS, AIP was significantly associated with LAA-ICAS (adjusted odds ratio [aOR], 3.60; 95% confidence interval [CI], 1.60-8.06). TyG index also showed a statistically significant relationship with LAA-ICAS (aOR, 1.60; 95% CI, 1.11-2.32). However, TG per se did not show a statistical association with LAA-ECAS. Conclusion: TG-related parameters were more closely associated with stroke by ICAS than by ECAS. The metabolic conditions reflected by the AIP or TyG index, rather than hypertriglyceridemia itself, may play a greater role in determining the relevant vessel causally involved in a stroke.

Outcomes of non-vitamin K oral anticoagulants for secondary prevention in ischemic stroke with atrial fibrillation.

Previous studies have rarely investigated the role of non-vitamin K oral anticoagulants (NOAC) and warfarin in the secondary prevention of ischemic stroke patients with nonvalvular atrial fibrillation (NVAF). In this study, we compared the effectiveness and safety of NOAC and warfarin for secondary prevention in Korean ischemic stroke patients with NVAF. Based on the Korean National Health Insurance Service Database, this study included 21,064 oral anticoagulants-naïve acute ischemic stroke patients with NVAF between July 2015 and June 2019. The main study outcomes included ischemic stroke, systemic embolism, major bleeding, and death. During the observational periods, NOAC users had a significantly decreased risk of ischemic stroke + systemic embolism (adjusted hazard ratio [aHR] 0.86; 95% confidence interval [CI] 0.78-0.95), ischemic stroke (aHR 0.89; 95% CI 0.81-0.99), major bleeding (aHR 0.78; 95% CI 0.68-0.89), and all-cause death (aHR 0.87; 95% CI 0.81-0.93). Standard-dose NOAC users had a lower risk of ischemic stroke, systemic embolism, and major bleeding events than warfarin users. In contrast, low-dose NOAC users did not differ in risk from warfarin users for all outcomes. In conclusion, NOACs were associated with a lower risk of secondary thromboembolic events and bleeding complications in Korean ischemic stroke patients with NVAF than warfarin.

Blood urea nitrogen to albumin ratio is associated with cerebral small vessel diseases.

Blood urea nitrogen (BUN) to albumin ratio (BAR) is a comprehensive parameter that reflects renal, inflammatory, nutritional, and endothelial functions. BAR has been shown to be associated with various cancers, pneumonia, sepsis, and pulmonary and cardiovascular diseases; however, few studies have been conducted on its association with cerebrovascular diseases. In this study, we evaluated the association between BAR and cerebral small vessel disease (cSVD) in health check-up participants. We assessed consecutive health check-up participants between January 2006 and December 2013. For the cSVD subtype, we quantitatively measured the volume of white matter hyperintensity (WMH) and qualitatively measured the presence of lacune and cerebral microbleeds (CMBs). The BAR was calculated by dividing BUN by albumin as follows: BAR = BUN (mg/dl)/albumin (g/dl). A total of 3012 participants were evaluated. In multivariable linear regression analysis, BAR showed a statistically significant association with WMH volume after adjusting for confounders [ß = 0.076, 95% confidence interval (CI): 0.027-0.125]. In multivariable logistic regression analyses, BAR was significantly associated with lacunes [adjusted odds ratio (aOR) = 1.20, 95% CI: 1.00-1.44] and CMBs (aOR = 1.28, 95% CI: 1.06-1.55). BAR was associated with all types of cSVD in the health check-up participants.

Monocyte to high-density lipoprotein cholesterol ratio is associated with cerebral small vessel diseases.

BACKGROUND: Inflammation is a major pathological mechanism underlying cerebrovascular disease. Recently, a new inflammatory marker based on the ratio between monocyte count and high-density lipoprotein (HDL) cholesterol has been proposed. In this study, we evaluated the relationship between monocyte-to-HDL cholesterol ratio (MHR) and cerebral small vessel disease (cSVD) lesions in health check-up participants. METHODS: This study was a retrospective cross-sectional study based on a registry that prospectively collected health check-up participants between 2006 and 2013. Three cSVD subtypes were measured on brain magnetic resonance imaging. White matter hyperintensity (WMH) volume, and lacunes and cerebral microbleeds (CMBs) were quantitatively and qualitatively measured, respectively. The MHR was calculated according to the following formula: MHR = monocyte counts (× 103/µL) / HDL cholesterol (mmol/L). RESULTS: In total, 3,144 participants were evaluated (mean age: 56 years, male sex: 53.9%). In multivariable analyzes adjusting for confounders, MHR was significantly associated with WMH volume [ß = 0.099, 95% confidence interval (CI) = 0.025 to 0.174], lacune [adjusted odds ratio (aOR) = 1.43, 95% CI = 1.07-1.91], and CMB (aOR = 1.51, 95% CI = 1.03-2.19). In addition, MHR showed a positive quantitative relationship with cSVD burden across all three subtypes: WMH (P < 0.001), lacunes (P < 0.001), and CMBs (P < 0.001). CONCLUSIONS: High MHR was closely associated with cSVD in health check-up participants. Because these associations appear across all cSVD subtypes, inflammation appears to be a major pathological mechanism in the development of various cSVDs.

Clinical significance of D-dimer levels during acute period in ischemic stroke.

BACKGROUND: Initial D-dimer level is a well-known prognostic parameter in patients with acute ischemic stroke (AIS). However, there have been no studies on the clinical significance of follow-up D-dimer levels. In this study, we evaluated the association between initial and follow-up D-dimer levels and early neurological deterioration (END) in patients with AIS. METHODS: We included consecutive patients with AIS who had a positive initial D-dimer test (> 0.55 mg/L) between March 2021 and November 2022. The follow-up D-dimer test was performed on the 7th day after hospitalization and on the day of discharge if discharged earlier. END was defined as an increase of ≥ 2 in the total NIHSS score, or ≥ 1 in the motor NIHSS score within the first 7 days of admission. As medical conditions closely associated with the initial and follow-up D-dimer levels in AIS patients, we also evaluated the history of cancer, active cancer, and venous thromboembolism (VTE) that occurred during hospitalization together. RESULTS: A total of 246 patients with AIS were evaluated (median age: 87 years, male: 56.5%). In multivariable logistic regression analysis, the initial D-dimer level was closely associated with END after adjusting for confounders (adjusted odds ratio [aOR]: 1.48, 95% CI: 1.06-2.05). The follow-up D-dimer level also showed a close correlation with END (aOR: 1.60, 95% CI: 1.16-2.20). Regarding the analysis of the association between D-dimer levels and underlying cancer or VTE, the initial D-dimer level showed a statistically significant positive relationship only with active cancer (P = 0.024). On the other hand, the follow-up D-dimer level was found to be statistically significantly associated with a history of cancer (P = 0.024), active cancer (P = 0.001), and VTE (P = 0.001). CONCLUSIONS: Initial and follow-up D-dimer levels were associated with END in AIS patients. Particularly, the follow-up D-dimer level showed a clear correlation not only with END but also with the underlying cancer or the occurrence of VTE during the acute period.

Effectiveness and safety of secondary prevention of non-vitamin K oral anticoagulants use by drug type in Asian patients.

BACKGROUND: Although widely used in clinical fields, real-world data on the role of warfarin and non-vitamin K oral anticoagulants (NOACs) for the secondary prevention of thromboembolic complications in ischemic stroke patients with nonvalvular atrial fibrillation (NVAF) are scarce. AIMS: This retrospective cohort study compared the effectiveness and safety of secondary prevention of NOAC and warfarin in ischemic stroke patients with NVAF. METHODS: From the Korean National Health Insurance Service Database, we included 16,762 oral anticoagulants-naive acute ischemic stroke patients with NVAF between July 2016 and June 2019. The main outcomes included ischemic stroke, systemic embolism, major bleeding, and all-cause of death. RESULTS: In total, 1717 warfarin and 15,025 NOAC users were included in the analysis. After 1:8 propensity score matching, during the observation period, all types of NOACs had a significantly lower risk of ischemic stroke and systemic embolism than warfarin (edoxaban: adjusted hazard ratio [aHR], 0.80; 95% confidence interval [CI], 0.68-0.93, rivaroxaban: aHR, 0.82; 95% CI, 0.70-0.96, apixaban: aHR, 0.79; 95% CI, 0.69-0.91, and dabigatran: aHR, 0.82; 95% CI, 0.69-0.97). Edoxaban (aHR, 0.77; 95% CI, 0.62-0.96), apixaban (aHR, 0.73; 95% CI, 0.60-0.90), and dabigatran (aHR, 0.66; 95% CI, 0.51-0.86) had lower risks of major bleeding and all-cause of death. CONCLUSIONS: All NOACs were more effective than warfarin in the secondary prevention of thromboembolic complications in ischemic stroke patients with NVAF. Except for rivaroxaban, most NOACs demonstrated a lower risk of major bleeding and all-cause of death than warfarin.

Infarct growth velocity predicts early neurological outcomes in single subcortical infarction.

In single subcortical infarction (SSI), changes in lesion size are a major determinant of early neurological deterioration. We evaluated the association between END and infarct growth velocity (IGV) in patients with SSI. We included consecutive patients with SSI who underwent MRI within 24 h of symptom onset between 2010 and 2020. END was defined as an increase of ≥ 2 in the total National Institutes of Health Stroke Scale (NIHSS) score or ≥ 1 in the motor NIHSS score. IGV was calculated using the following formula: IGV (mL/h) = diffusion-weighted imaging volume (mL)/time to MRI (h). A total of 604 patients with SSI were evaluated. Multivariable logistic regression analysis showed that IGV remained significant after adjusting for confounders (aOR = 1.34, 95% CI 1.12-1.61). In a subgroup analysis based on the type of SSI, only patients with distal SSI showed an association between IGV and END (aOR = 1.64, 95% CI 1.24-2.16). In patients with proximal SSI, IGV did not show any statistical association with END. In conclusion, IGV was positively associated with END in patients with SSI. IGV should be interpreted differently in clinical settings depending on the location of the SSI lesion.

Long Sleep Duration and Dissatisfaction with Sleep Quality Are Associated with Ischemic Stroke in Young Patients.

INTRODUCTION: Suboptimal sleep duration and poor sleep quality have been proposed to increase stroke risk. However, their significance in young ischemic stroke is unclear. We aimed to investigate the importance of sleep duration and quality on young ischemic stroke patients. METHODS: A multicenter matched case-control study was performed to evaluate under-recognized risk factors in young (<45 years) ischemic stroke patients in 8 tertiary hospitals in Korea. A total of 225 patients and 225 age- and sex-matched controls were enrolled in the same period. Detailed information about patients' demographics, socioeconomic state, and traditional and nontraditional risk factors including sleep-related factors were obtained using structured questionnaires. Risk of ischemic stroke was estimated using conditional logistic regression analysis. RESULTS: Although average sleep duration was similar in patients and controls, patients were more likely to have long (≥9 h) or extremely short (<5 h) sleep durations. In addition, the proportion of subjects with dissatisfaction with sleep quality was higher in patients than controls (66.2 vs. 49.3%, p < 0.001). In multivariable conditional logistic regression analysis, long sleep duration (OR: 11.076, 95% CI: 1.819-67.446, p = 0.009) and dissatisfaction with sleep quality (OR: 2.116, 95% CI: 1.168-3.833, p = 0.013) were independently associated with risk of ischemic stroke. CONCLUSIONS: Long sleep duration and dissatisfaction with sleep quality may be associated with increased risk of ischemic stroke in young adults. Improving sleep habit or quality could be important for reducing the risk of ischemic stroke.

Association of Body Shape Index with Cerebral Small Vessel Disease.

INTRODUCTION: A body shape index (ABSI) is an anthropometric index designed to reflect the influence of visceral fat. ABSI has been previously associated with various atherosclerosis, metabolic diseases, and cardiovascular diseases; however, relatively few studies have been conducted on cerebrovascular disease. In this study, we evaluated the association between ABSI and cerebral small vessel disease (cSVD) in health check-up participants. METHODS: We evaluated consecutive health check-up participants between January 2006 and December 2013. As subtypes of cSVD, we quantitatively measured the volume of white matter hyperintensity (WMH) and qualitatively measured the presence of silent brain infarct (SBI) and cerebral microbleed (CMB). ABSI was calculated according to the following formula: ABSI (m11/6/kg-2/3) = waist circumference (m)/(body mass index [kg/m2]2/3 × height [m]1/2). RESULTS: A total of 3,219 health check-up participants were assessed (median age, 56 years; male sex, 54.0%). In the multivariable analysis, ABSI was significantly associated with WMH volume (ß = 0.107, 95% confidence interval [CI] = 0.013-0.200), SBI (adjusted odds ratio [aOR] = 1.62, 95% CI = 1.14-2.31), and CMB (aOR = 1.64, 95% CI = 1.16-2.33) after adjusting for confounders (per 100 m11/6/kg-2/3). Furthermore, ABSI showed a dose-response relationship with the burden of each cSVD pathology. CONCLUSIONS: High ABSI was associated with a higher burden of cSVD in health check-up participants. As ABSI showed close associations with all subtypes of cSVD, visceral fat may be a common risk factor penetrating cSVD pathologies.

Annual exposure to PM10 is related to cerebral small vessel disease in general adult population.

Ambient air pollution is one of the most important global health issues. Although several studies have been reported the associations between air pollution and brain function or structure, impact of the air pollution on cerebral small vessel disease (cSVD) have rarely been explored in Asian adult population. We evaluated the association between exposure to air pollutants and cSVD in Korean asymptomatic adults. This cross-sectional study included 3257 participants of a health screening program from January 2006 to December 2013. All participants performed brain magnetic resonance imaging. To assess the cSVD, we considered three features such as white matter hyperintensities (WMH), silent lacunar infarction (SLI), and cerebral microbleeds (CMBs). The annual average exposure to air pollutants [particulate matter ≤ 10 µm in aerodynamic diameter (PM10), nitrogen dioxide (NO2), sulfur dioxide (SO2), and carbon monoxide (CO)] was generated. The mean [standard deviation (SD)] age of the total 3257 participants was 56.5 (9.5) years, and 54.0% of them were male. Among all the included participants, 273 (8.4%) had SLI and 135 (4.1%) had CMBs. The mean volume (± SD) of WMH was 2.72 ± 6.57 mL. In result of linear regression analysis, the volume of WMH was associated with various potential factors including age, height, weight, smoking and alcohol consumption status, blood pressure (BP), hypertension, and diabetes mellitus. SLI-positive group, compared to the SLI-negative group, was older, shorter, and had higher BP as well as higher frequency of hypertension and diabetes mellitus. After adjusting for covariates, the annual average concentration of PM10 was significantly associated with the volume of WMH [ß (95% CI) for Model 1 = 0.082 (0.038- 0.125), p < 0.001; ß (95% CI) for Model 2 = 0.060 (0.013, 0.107), p = 0.013]. CMBs were not associated with the annual average concentration of PM10. No significant associations of NO2, SO2, and CO with cSVD were observed. In conclusion, PM10 exposure is associated with significant increases in brain WMH' volume and silent lacunar infarcts in asymptomatic adults.

The Atherogenic Index of Plasma is Associated With Cerebral Small Vessel Disease: A Cross-Sectional Study.

Objective: Recently, the lipid profile of atherogenic dyslipidemia has become important in cerebrovascular diseases. Atherogenic index of plasma (AIP), an index that reflects this lipid profile as a single number, has been proposed, but there are still few related studies in cerebrovascular disease. In this study, we evaluated the relationship between AIP and cerebral small vessel disease (cSVD) in health check-up participants. Methods: We assessed consecutive health check-ups participants between 2006 and 2013. cSVD was measured including the following three subtypes: white matter hyperintensity (WMH), lacuens, and cerebral microbleeds (CMBs). WMH quantitatively measured the volume, and lacunes and CMBs qualitatively evaluated the presence. AIP was calculated according to the following formula based on blood test results: AIP=log [triglyceride (mg/dL)/high-density lipoprotein cholesterol (mg/dL)]. Results: A total of 3,170 participants were evaluated (mean age: 56.5 years, male sex: 53.8%). In multivariable linear regression analysis, AIP (ß=0.129, 95% confidence interval [CI]=0.003-0.255) was associated with WMH. Age, hypertension, diabetes, lipid-lowering agents, and intracranial atherosclerosis were also associated with WMH volume. In multivariable logistic regression analysis, AIP (adjusted odds ratio=1.72 1.79, 95% CI=1.03-2.90) showed close association with lacunes. Age and intracranial atherosclerosis were also related to lacunes. CMBs did not show a statistically significant association with AIP. Conclusion: High AIP was associated with cSVD in health check-up participants. Since this close relationship was only seen in WMH and lacunes, these subtypes may have arisen from a more atherosclerosis-related pathology.

Systemic immune-inflammation index is associated with white matter hyperintensity volume.

Systemic immune-inflammation index (SII) is a novel inflammatory marker based on the composition ratio of blood cell counts. In this study, we evaluated the association between the SII and cerebral small vessel disease (cSVD) in health check-up participants. We evaluated participants from our health check-up registry between 2006 and 2013. The SII was calculated using the following formula: SII = (platelet count × neutrophil count)/lymphocyte count. cSVD was assessed by considering white matter hyperintensity (WMH) volume, lacunes, and cerebral microbleeds (CMBs). A total of 3187 participants were assessed. In multivariable linear regression analysis, the SII was significantly related to WMH volume [ß = 0.120, 95% confidence interval (CI) 0.050-0.189]. However, lacunes and CMBs showed no statistical significance with the SII. In the subgroup analysis by age, the SII was significantly associated with WMH volume only in participants aged ≥ 60 years (ß = 0.225, 95% CI 0.068-0.381). In conclusion, a high SII was associated with cSVD. Since this association was more pronounced in WMH than in lacunes or CMBs, WMH might be closer to the inflammation-related pathological mechanisms.

Cardiovascular risk scores in asymptomatic carotid stenosis: A validation study with ultrasonographic parameters.

We evaluated the feasibility of the Framingham stroke risk score (FSRS) and atherosclerotic cardiovascular disease (ASCVD) risk scores for asymptomatic carotid stenosis (ACS). In addition, we developed novel risk prediction models for ischemic stroke and composite outcomes by combining ultrasonographic parameters and conventional cardiovascular risk scores. We retrospectively enrolled 612 patients with ACS greater than 50% over 7 years and evaluated them using transcranial Doppler and carotid duplex ultrasonography. In total, 150 patients were included in the analysis. During the mean 5-year follow-up, 6 ischemic strokes and 25 composite events were detected. Among all ultrasonographic parameters, only a higher peak-systolic velocity/end-diastolic velocity ratio was detected and significantly associated with an increased risk of relevant ischemic stroke (hazard ratio: 1.502, 95% confidence interval: 1.036-1.968). The C-statistics of the FSRS and ASCVD risk scores were 0.646 and 0.649, respectively, for relevant ischemic stroke, and 0.612 and 0.649, respectively, for composite outcomes. C-statistics of the FSRS and ASCVD risk scores combined with ultrasonographic parameters increased to 0.937 and 0.941, respectively, for ischemic stroke, and 0.856 and 0.886, respectively, for composite outcomes. The study suggests that inclusion of ultrasonographic parameters in conventional cardiovascular scores helps identify the risk of further vascular events in ACS patients.

Effects of intracranial atherosclerosis and atrial fibrillation on the prognosis of ischemic stroke with active cancer.

BACKGROUND: In ischemic stroke patients with active cancer, cryptogenic stroke has worse prognosis than stroke by conventional mechanisms. However, the individual effects of intracranial atherosclerosis (ICAS) or atrial fibrillation (AF) on the prognosis of these patients have not been studied. AIMS: Therefore, we aimed to investigate the effects of ICAS and AF on the prognosis of ischemic stroke patients with active cancer. METHODS: We included ischemic stroke patients with active cancer between 2010 and 2020. Early neurological deterioration (END) was defined as an increase of ≥ 1 in the motor NIHSS score, or ≥ 2 in the total NIHSS score within 72 hours of admission. Unfavorable outcomes were defined as a score of ≥ 3 on the 3-month modified Rankin Scale. RESULTS: In total, 116 ischemic stroke patients with active cancer were evaluated. In multivariable analysis, ICAS was positively associated with END (adjusted odds ratio [aOR] = 4.56, 95% confidence interval [CI]: 1.52-13.70), and this association showed a quantitative relationship according to the degree of stenosis of ICAS (stenosis group: aOR = 4.24, 95% CI: 1.31-13.72; occlusion group, aOR = 5.74, 95% CI: 1.05-31.30). ICAS was also closely related to unfavorable outcomes (aOR = 6.33, 95% CI: 1.15-34.79). In contrast, AF showed no significant association with END or unfavorable outcomes. Our data showed that patients with ICAS had larger and more severe initial stroke lesions, and poorer prognosis than those without. CONCLUSIONS: ICAS, but not AF, was closely associated with poor prognosis in ischemic stroke patients with active cancer.

Effects of cerebral small vessel disease on the outcomes in cryptogenic stroke with active cancer.

Cerebral small vessel diseases (cSVDs) affect the prognosis of various types of ischemic stroke. Therefore, we evaluated the association between cSVD and the prognosis of cryptogenic stroke patients with active cancer. We enrolled patients diagnosed with cryptogenic stroke and active cancer from 2010 to 2016. Early neurological deterioration (END) was defined as a ≥ 2-point increase in the total NIHSS score or a ≥ 1-point increase in the motor NIHSS score within the first 72 h. We defined an unfavorable outcome as the modified Rankin Scale (mRS) score ≥ 3 points. We analyzed cSVD separately for each subtype including white matter hyperintensity (WMH), silent brain infarct (SBI), and cerebral microbleed (CMB). A total of 179 cryptogenic stroke patients with active cancer were evaluated. In the multivariable analysis, SBI was significantly associated with END (adjusted odds ratio = 3.97, 95% confidence interval: 1.53-10.33). This close relationship between SBI and END increased proportionally with an increase in SBI burden. However, WMH and CMB showed no significant association with END. None of the cSVD subtypes showed a statistically significant relationship with the 3-month unfavorable outcome. SBI was the only parameter closely associated with END in cryptogenic stroke patients with active cancer.

High triglyceride-glucose index is associated with early recurrent ischemic lesion in acute ischemic stroke.

The triglyceride-glucose (TyG) index has been associated with various metabolic, cardiovascular, and cerebrovascular diseases. We evaluated the association between the TyG index and early recurrent ischemic lesions (ERILs) in patients with acute ischemic stroke (AIS). We included consecutive patients diagnosed with AIS between 2010 and 2016. ERILs were defined as new diffusion-weighted imaging lesions outside the initial symptomatic lesion area. The TyG index was calculated using the following formula: log scale of fasting triglyceride × fasting glucose/2. A total of 176 patients with AIS were evaluated. In the multivariable analysis, the TyG index remained significant (adjusted odds ratio [aOR] 2.63, 95% confidence interval [CI] 1.34-5.15). This close correlation between the TyG index and ERIL was pronounced in ERIL-same group (aOR 2.84, 95% CI 1.40-5.78), but not in ERIL-different group. When comparing the relationship between the TyG index and ERIL by stroke mechanisms, only the intracranial- and extracranial-large artery atherosclerosis groups showed significantly higher TyG index values in patients with ERIL than those without. In conclusion, a higher TyG index was associated with ERIL, especially ERIL-same, in patients with AIS. The TyG index appears to be involved in ERIL occurrence by a mechanism related to atherosclerosis.

Different Predictive Factors for Early Neurological Deterioration Based on the Location of Single Subcortical Infarction: Early Prognosis in Single Subcortical Infarction.

Background and Purpose: Patients with single subcortical infarctions (SSIs) have relatively a favorable prognosis, but they often experience early neurological deterioration (END). In this study, we compared the predictors for END in patients with SSI according to the location of the lesion. Methods: We included consecutive patients with SSIs within 72 hours of symptom onset presenting between 2010 and 2016. END was defined as an increase of ≥2 in the total National Institutes of Health Stroke Scale (NIHSS) score or ≥1 in the motor NIHSS score within the first 72 hours of admission. Along with the analysis of all patients with SSI, we also analyzed the predictors for END in proximal/distal SSI patients and anterior/posterior circulation SSI patients. Results: A total of 438 patients with SSI were evaluated. In multivariable analysis, initial NIHSS score (adjusted odds ratio, 1.36 [95% CI, 1.15­1.60]), pulsatility index (adjusted odds ratio, 1.25 [95% CI, 1.03­1.52]), parent artery disease (adjusted odds ratio, 2.14 [95% CI, 1.06­4.33]), and neutrophil-to-lymphocyte ratio (adjusted odds ratio, 1.24 [95% CI, 1.04­1.49]) were positively associated with END. In patients with proximal SSI, initial NIHSS score, pulsatility index, parent artery disease, and neutrophil-to-lymphocyte ratio showed positive associations with END. Meanwhile, no variable related to END was found in the distal SSI group. When we compared the predictors for END based on the involved vascular territory, higher initial NIHSS score and neutrophil-to-lymphocyte ratio were significantly associated with END in patients with anterior circulation SSIs. On the contrary, higher pulsatility index values and the presence of parent artery disease were independent predictors for END in patients with SSIs in the posterior circulation. Conclusions: Initial NIHSS score, pulsatility index, parent artery disease, and neutrophil-to-lymphocyte ratio are associated with END in patients with SSIs. The frequency and predictors for END differ depending on the location of the SSI.

Causes, Risk Factors, and Clinical Outcomes of Stroke in Korean Young Adults: Systemic Lupus Erythematosus is Associated with Unfavorable Outcomes.

BACKGROUND AND PURPOSE: The incidence of ischemic stroke (IS) in young adults is increasing, and the associated large socioeconomic impact makes understanding IS in young adults important. We investigated the causes of and risk factors for IS in young adults, and their impact on outcomes. METHODS: The Stroke in Korean Young Adults (SKY) study is a standardized multicenter prospective study involving eight medical centers of the Republic of Korea. First-ever IS patients aged 18 years to 44 years were prospectively included in this study within 7 days of stroke onset. Their outcomes at 3 months were analyzed. RESULTS: This study enrolled 270 patients from April 2014 to December 2018, most (67.8%) of whom were male. About 41.5% of the patients had one or more vascular risk factors from among hypertension, diabetes mellitus, and dyslipidemia. However, only half of them had received regular treatment. Arterial dissection was more common in males, and systemic lupus erythematosus (SLE) and Moyamoya disease were more common in females. The outcome was favorable (modified Rankin Scale score of 0 or 1) in 81.9% of the patients at 3 months after stroke onset. More severe initial symptoms, higher initial glucose level, and SLE as a comorbidity were associated with unfavorable outcomes. CONCLUSIONS: Young adult IS patients in Korea exhibit low awareness and poor management of their risk factors. Although the short-term outcome was relatively favorable in those patients, having SLE was associated with unfavorable outcomes. More attention needs to be paid for improving awareness and controlling risk factors in this population.

Visceral adiposity index is associated with silent brain infarct in a healthy population.

Visceral adiposity index (VAI) has been associated with various cardio-metabolic diseases; however, there is limited information about its association with cerebrovascular diseases. In this study, we evaluated the relationship between VAI and silent brain infarct (SBI). We evaluated a consecutive series of healthy volunteers over the age of 40 between January 2006 and December 2013. SBI was defined as an asymptomatic, well-defined lesion with a diameter ≥ 3 mm with the same signal characteristics as the cerebrospinal fluid. VAI was calculated using sex-specific equations as described in previous studies. A total of 2596 subjects were evaluated, and SBI was found in 218 (8%) participants. In multivariable analysis, VAI (adjusted odds ratio [aOR] = 1.30; 95% confidence interval [CI] 1.03-1.66; P = 0.030) remained a significant predictor of SBI after adjustment for confounders. The close relationship between VAI and SBI was prominent only in females (aOR = 1.44; 95% CI 1.00-2.07; P = 0.048). In the evaluation between VAI and the burden of SBI, VAI showed a positive dose-response relationship with the number of SBI lesions (P for trend = 0.037). High VAI was associated with a higher prevalence and burden of SBI in a neurologically healthy population.