Radiotherapy Is Associated with an Accelerated Risk of Carotid Atherosclerosis in Patients with Nasopharyngeal Carcinoma: A Nine-Year Prospective Follow-Up Study.

Radiation-related extracranial vasculopathy is a common late effect after radiation in patients with nasopharyngeal carcinoma (NPC). We proposed the hypothesis that radiation-related extracranial vasculopathy is a progressive process that can begin immediately after radiotherapy and persist for a longer period, and inflammation and oxidative stress may play a pivotal role in this process. Thirty-six newly diagnosed NPC patients were assessed with B-mode ultrasound for the common carotid artery (CCA) intima media thickness (IMT) measurement as well as surrogate markers at three different stages (baseline, immediately after concurrent chemoradiation therapy (CCRT), and 9 years after enrollment). A healthy control group was also recruited for comparison. Surrogate markers including a lipid profile, HbA1c, inflammation, oxidative stress, and platelet activation markers were assessed. The mean CCA IMT in the NPC group were increased immediately after CCRT (p = 0.043). The mean CCA IMT value after a 9-year follow-up also showed a significant increase in NPC and control group, respectively (p < 0.0001 and p < 0.0001, paired t test). The annual increase mean CCA IMT (mm) was 0.053 ± 0.025 and 0.014 ± 0.013 in NPC and control group, respectively (p < 0.0001). The baseline high sensitivity CRP (hs-CRP), thiol, TBARS, and CD63 level were significantly higher in the NPC group (hs-CRP, p = 0.001, thiol, p < 0.0001, TBARS, p = 0.05, and CD63 level, p = 0.04). The thiol and TBARS levels were significantly lower in NPC patients immediately after CCRT (thiol, p < 0.0001, and TBARS, p = 0.043). The CD62P level was significantly higher while the thiol level was significantly lower in the NPC group after a 9-year follow-up (CD62P level, p = 0.007; and thiol level, p = 0.004). Radiation-related extracranial vasculopathy is a progressive process that begins immediately after radiotherapy with significantly increased carotid IMT compared to the control group during the 9-year follow-up. Chronic inflammation and oxidative stress might serve to drive the process and also contribute to increased platelet activation.

Autonomic Dysfunction Contributes to Impairment of Cerebral Autoregulation in Patients with Epilepsy.

Patients with epilepsy frequently experience autonomic dysfunction and impaired cerebral autoregulation. The present study investigates autonomic function and cerebral autoregulation in patients with epilepsy to determine whether these factors contribute to impaired autoregulation. A total of 81 patients with epilepsy and 45 healthy controls were evaluated, assessing their sudomotor, cardiovagal, and adrenergic functions using a battery of autonomic nervous system (ANS) function tests, including the deep breathing, Valsalva maneuver, head-up tilting, and Q-sweat tests. Cerebral autoregulation was measured by transcranial Doppler examination during the breath-holding test, the Valsalva maneuver, and the head-up tilting test. Autonomic functions were impaired during the interictal period in patients with epilepsy compared to healthy controls. The three indices of cerebral autoregulation-the breath-holding index (BHI), an autoregulation index calculated in phase II of the Valsalva maneuver (ASI), and cerebrovascular resistance measured in the second minute during the head-up tilting test (CVR2-min)-all decreased in patients with epilepsy. ANS dysfunction correlated significantly with impairment of cerebral autoregulation (measured by BHI, ASI, and CVR2-min), suggesting that the increased autonomic dysfunction in patients with epilepsy may augment the dysregulation of cerebral blood flow. Long-term epilepsy, a high frequency of seizures, and refractory epilepsy, particularly temporal lobe epilepsy, may contribute to advanced autonomic dysfunction and impaired cerebral autoregulation. These results have implications for therapeutic interventions that aim to correct central autonomic dysfunction and impairment of cerebral autoregulation, particularly in patients at high risk for sudden, unexplained death in epilepsy.

Impact of estimated-weight-base dose of alteplase in acute stroke treatment on clinical outcome.

Dosing of recombinant tissue plasminogen activator (rt-PA) for acute ischemic stroke treatment is often based on estimated body weight (BW) worldwide in routine clinical practice due to infeasible of accurate BW measurement. The aim of our study is to explore the impact of estimated BW when dosing rt-PA in acute ischemic stroke treatment on clinical outcome. Between January 2013 to May 2018, 126 acute ischemic stroke patients received intravenous rt-PA treatment based on estimated BW dosage were recruited. All patients had actual BW measured in ward after treatment. Based on the dosage of rt-PA given, patients were categorized into three groups, standard dose (0.8-1.0 mg/kg), overdose (>1.0 mg/kg), and underdose (<0.8 mg/kg). Among all 126 patients, 101 (80.2%) patients were treated with standard dose, 12 (9.5%) patients with overdose, and 13 (10.3%) patients with underdose of rt-PA respectively. There was no significant difference between demographic characteristics, pre-morbid risk factors, National Institutes of Health Stroke Scale (NIHSS) score at 24 h, NIHSS score at discharge, modified Rankin scale (mRS) within 0 to 2 in discharge or in 3 months after the event within the three groups. There was also no significant difference in hemorrhagic transformation and symptomatic intracranial hemorrhage (SICH). In conclusion, calculation of the dose of rt-PA based upon the estimated BW to treat acute ischemic stroke patients had no negative impact on the clinical outcome in our study.

Association of carotid intima-media thickness with the risk of sudden sensorineural hearing loss.

Cardiovascular factors are associated with the pathophysiological features and risk of sudden sensorineural hearing loss (SSNHL). However, little is known about the link between carotid intima-media thickness (IMT), SSNHL risk, and their respective treatment outcomes. In this study, we retrospectively reviewed 47 SSNHL cases and 33 control subjects from a single medical center and compared their demographic data and clinical characteristics, including their carotid IMT and audiological data. Of the 80 enrolled subjects, the proportion of those with high carotid IMT was greater in the SSNHL group (53.2%) than in the control group (21.2%), with an odds ratio (OR) of 4.22 (95% confidence interval (CI) [1.53-11.61], P = 0.004). Notably, high carotid IMT was more common in female SSNHL patients than females in the control group (54.2% vs. 12.5%; OR, 8.27 (95% CI [1.53-44.62]), P = 0.008), particularly in female patients ≥50 years of age (75% vs. 25%; OR, 9.0 (95% CI [1.27-63.9]), P = 0.032). The multivariate regression analyses showed the association between high carotid IMT and SSNHL with an adjusted OR of 4.655 (95% CI [1.348-16.076], P = 0.015), particularly in female SSNHL patients (adjusted OR, 9.818 (95% CI [1.064-90.587], P = 0.044). The carotid IMT was not associated with the treatment outcomes of SSNHL. Our results indicate that early-stage atherosclerosis may be associated with SSNHL, particularly in female patients more than 50 years old.

Serum Levels of Brain-Derived Neurotrophic Factor and Insulin-Like Growth Factor 1 Are Associated With Autonomic Dysfunction and Impaired Cerebral Autoregulation in Patients With Epilepsy.

Background: Brain-derived neurotrophic factor (BDNF) and insulin-like growth factor 1 (IGF-1) may regulate the autonomic nervous system (ANS) in epilepsy. The present study investigated the role of IGF-1 and BDNF in the regulation of autonomic functions and cerebral autoregulation in patients with epilepsy. Methods: A total of 57 patients with focal epilepsy and 35 healthy controls were evaluated and their sudomotor, cardiovagal, and adrenergic functions were assessed using a battery of ANS function tests, including the deep breathing, Valsalva maneuver, head-up tilting, and Q-sweat tests. Cerebral autoregulation was measured by transcranial doppler during the breath-holding test and the Valsalva maneuver. Interictal serum levels of BDNF and IGF-1 were measured with enzyme-linked immunosorbent assay kits. Results: During interictal period, reduced serum levels of BDNF and IGF-1, impaired autonomic functions, and decreased cerebral autoregulation were noted in patients with epilepsy compared with healthy controls. Reduced serum levels of BDNF correlated with age, adrenergic and sudomotor function, overall autonomic dysfunction, and the autoregulation index calculated in Phase II of the Valsalva maneuver, and showed associations with focal to bilateral tonic-clonic seizures. Reduced serum levels of IGF-1 were found to correlate with age and cardiovagal function, a parameter of cerebral autoregulation (the breath-hold index). Patients with a longer history of epilepsy, higher seizure frequency, and temporal lobe epilepsy had lower serum levels of IGF-1. Conclusions: Long-term epilepsy and severe epilepsy, particularly temporal lobe epilepsy, may perturb BDNF and IGF-1 signaling in the central autonomic system, contributing to the autonomic dysfunction and impaired cerebral autoregulation observed in patients with focal epilepsy.

Do NOACs Improve Antithrombotic Therapy in Secondary Stroke Prevention in Nonvalvular Atrial Fibrillation?

Guidelines recommended oral anticoagulant (OAC) for ischemic stroke patients related to atrial fibrillation (AF). But, underprescription or underdose of warfarin was observed worldwide. We aimed to explore if the use of antithrombotic therapy in nonvalvular AF (NVAF) ischemic stroke patients improved after novel oral anticoagulants (NOACs) became available. Between January 2011 to December 2013, 360 acute ischemic stroke patients related to NVAF were recruited. Patients were categorized into 2 groups based on the date (July 2012) of NOACs' availability. There were 184 patients recruited before July 2012, and whereas 176 patients after July 2012. Demographic data, interested factors, and the percentage of patient on OAC were compared. One month after discharge, percentage of OAC utilization was significantly higher (29% versus 41%; P = 0.022) as well as effective anticoagulation (22.2% versus 80.6%; P < 0.001); warfarin utilization was significantly less (28.3% versus 11%; P < 0.001) after NOACs became available. Antiplatelet agent utilization was high in 2 groups (57% versus 52%; P = 0.36). Age (odd ratios [OR] 0.947; 95% confidence intervals [CI] 0.912-0.984; P = 0.005), Barthel index (OR 1.012; 95% CI 1.000-1.025; P = 0.05), and NOACs' availability (OR 1.857; 95% CI 1.086-3.175; P = 0.024) were the significant factors affecting the use of OAC. A higher percentage of NVAF ischemic stroke patients returning for their 1-month follow-up were treated with NOACs than with warfarin. The use of antithrombotic therapy improved after NOACs became available. But, the majority of the patients were still received antiplatelet agent for emboli stroke prevention.

Favorable circulatory system outcomes as adjuvant traditional Chinese medicine (TCM) treatment for cerebrovascular diseases in Taiwan.

BACKGROUND: This study searches the National Health Insurance Research Database (NHIRD) used in a previous project, aiming for reconstructing possible cerebrovascular disease-related groups (DRG),and estimating the costs between cerebrovascular disease and related diseases. METHODS AND MATERIALS: We conducted a nationwide retrospective cohort study in stroke inpatients, we examined the overall costs in 3 municipalities in Taiwan, by evaluating the possible costs of the expecting diagnosis related group (DRG) by using the international classification of diseases version-9 (ICD-9) system, and the overall analysis of the re-admission population that received traditional Chinese medicine (TCM) treatment and those who did not. RESULTS: The trend demonstrated that the non-participant costs were consistent with the ICD-9 categories (430 to 437) because similarities existed between years 2006 to 2007. Among the TCM patients, a wide variation and additional costs were found compared to non-TCM patients during these 2 years. The average re-admission duration was significantly shorter for TCM patients, especially those initially diagnosed with ICD 434 during the first admission. In addition, TCM patients demonstrated more severe general symptoms, which incurred high conventional treatment costs, and could result in re-admission for numerous reasons. However, in Disease 7 of ICD-9 category, representing the circulatory system was most prevalent in non-TCM inpatients, which was the leading cause of re-admission. CONCLUSION: We concluded that favorable circulatory system outcomes were in adjuvant TCM treatment inpatients, there were less re-admission for circulatory system events and a two-third reduction of re-admission within ICD-9 code 430 to 437, compared to non-TCM ones. However, there were shorter re-admission duration other than circulatory system events by means of unfavorable baseline condition.

Long-term effects on carotid intima-media thickness after radiotherapy in patients with nasopharyngeal carcinoma.

BACKGROUND: Vascular abnormalities are the predominant histologic changes associated with radiation in nasopharyngeal carcinoma (NPC). This study examined if the duration after radiotherapy correlates with the progression of carotid intima-media thickness (IMT) and investigated its relationship with inflammatory markers. METHODS: One hundred and five NPC patients post-radiotherapy for more than one year and 25 healthy control subjects were examined by B-mode ultrasound for IMT measurement at the far wall of the common carotid artery (CCA). Surrogate markers including lipid profile, HbA1c, and high sensitive C-reactive protein (hs-CRP) were assessed. RESULTS: The IMT of CCA was significantly increased in NPC patients and carotid plaque was detected in 38 NPC patients (38/105, 36.2%). Significant risk factors for carotid plaques included age, duration after radiotherapy, and HbA1c levels. Age, duration after radiotherapy, hs-CRP, HbA1c, and platelet count positively correlated with IMT. The cut-off value of age and duration after radiotherapy for the presence of plaque was 52.5 years and 42.5 months, respectively. In NPC subjects, multiple linear regression analysis revealed that age, gender, duration after radiotherapy and platelet counts were independently associated with CCA IMT. After adjustments for age, gender and platelet counts, IMT increased in a linear manner with duration after radiotherapy. CONCLUSIONS: Radiation-induced vasculopathy is a dynamic and progressive process due to late radiation effects. Extra-cranial color-coded duplex sonography can be part of routine follow-up in NPC patients aged ≥50 years at 40 months post-radiotherapy.

The effect of decreasing statin's dosage on LDL-C levels after target levels achieved.

OBJECTIVE: Evidences from clinical trials had demonstrated that statins reduce the risk of cardio-cerebral vascular events. But lipid lowering therapy (LLT) was suboptimal in stroke patients and clinically, observation of reducing the dosage of statins is common when target low density lipoprotein cholesterol (LDL-C) level achieved. We aim to explore the changes in lipid profile after reducing statin's dosage when target LDL-C level achieved. METHODS: One hundred and three consecutive stroke patients follow up at out-patient clinic (44 women, 59 men) were recruited. Twenty two patients had their statin's dosage decreased to half while eighty one patients had their initial statin's dosage maintained after target LDL-C (less than 100mg/dL) level achieved. Lipid profile before and after LLT adjustment were compared. RESULTS: The follow-up LDL-C level was significant higher while the percentage of patients with LDL-C level less than 100 mg/dL was significant lower in patients with statin's dosage decreased. For all patients, regardless the adjustment of LLT, the percentage of patients with LDL-C level less than 100 mg/dL was significant lower in follow- up lipid profile comparing with the baseline, but only the follow-up total cholesterol and LDL-C level were significant higher in the patients group with reduced statin's dosage. No significant change was found in follow-up high density-lipoprotein cholesterol and triglyceride level in either group. CONCLUSION: More patients had LDL-C level more than 100 mg/dL after dosage of statins decreased. We suggested that only for absolute contraindication or adverse effects of statins should we adjust LLT, it is better to maintain the dosage of statins after target level achieved. The impact of lipid profile changed after LLT adjustment on clinical outcomes needs further studied.

Long-term Outcomes of Carotid Artery Stenting for Radiation-Associated Stenosis.

BACKGROUND: In Taiwan, the prevalence of head and neck cancer is relatively high. Because radiation-associated carotid stenosis is a significant risk factor for stroke, carotid artery stenting (CAS), instead of carotid endarterectomy, is indicated in patients with radiation-associated carotid stenosis. We sought to evaluate the effect of neck radiotherapy (XRT) on the long-term outcome of patients undergoing CAS. METHODS: From March 2001 to November 2011, 147 CAS procedures were performed on 129 patients (n = 43 for XRT, n = 86 for non-XRT). Mean follow-up was 42.7 ± 20.5 months (median: 52 months; range: 1-60 months). Duplex velocity criterion for > 50% restenosis after CAS was defined as peak systolic velocity > 175 cm/s. Endpoints included 5-year freedom from mortality, ipsilateral recurrent stroke, and major adverse cardiovascular events (MACE). RESULTS: The mean age of XRT patients was significantly lesser than that of non-XRT patients (61 ± 8 vs. 71 ± 8, p < 0.001). There was significantly less coronary artery disease and other cardiovascular co-morbidities in XRT patients. No significant differences were noted in the composite 30-day ipsilateral stroke/myocardial infarction/mortality (XRT: 8.6% vs. non-XRT: 6%, p > 0.05) and 5-year freedom from mortality, ipsilateral recurrent stroke, and MACE (p > 0.05) between the two groups. Intra-stent carotid restenosis > 50% was significantly higher in the XRT group on follow-up. CONCLUSION: Long-term outcomes of CAS for radiation-associated stenosis were not altered by a history of neck XRT, except for asymptomatic carotid restenosis.

Long-term effects of neck irradiation on cardiovascular autonomic function: a study in nasopharyngeal carcinoma patients after radiotherapy.

INTRODUCTION: Baroreflex failure has been reported as a late sequalum of neck radiotherapy. In this study we investigated cardiovascular autonomic function in patients after neck radiotherapy to determine predictive factors associated with outcome. METHODS: Eighty-nine patients with nasopharyngeal carcinoma were evaluated ≥6 months after radiotherapy for cardiovascular autonomic function and compared with 48 control subjects. Inflammatory markers and carotid intima-media thickness were also assessed. RESULTS: Autonomic parameters of heart rate response to deep breathing and Valsalva ratio were significantly lower in the patient group. Cardiovascular autonomic impairment was generally mild with relative sparing of the efferent cardiovagal pathway. By univariate and multivariate analyses, the time after radiotherapy and C-reactive protein level were significantly associated with the degree of cardiovascular autonomic dysfunction. CONCLUSIONS: Radiation-induced cardiovascular autonomic impairment is a dynamic and progressive process that occurs long after radiotherapy. Chronic inflammation plays a major role in this process.

Factors associated with increased carotid intima-media thickness in obstructive sleep apnea/hypopnea syndrome.

BACKGROUND: Obstructive sleep apnea/hypopnea syndrome (OSAHS) is strongly associated with the increase of cardiovascular and cerebrovascular disorders. Carotid intima-media thickness (IMT) is used as a surrogate marker for subclinical or early atherosclerosis. Knowledge regarding early atherosclerosis in patients with OSAHS is scarce, and factors predicting carotid IMT have not been well studied. OBJECTIVE: To compare IMT in patients with OSAHS versus controls and explore the factors associated with increased IMT in OSAHS. METHODS: One hundred fifty-six OSAHS patients and 35 controls without history of vascular events, hypertension, and diabetes mellitus who underwent polysomnography were consecutively enrolled. Carotid IMT was measured using B-mode ultrasonography. Body mass index, waist circumference, hip circumference, waist-to-hip circumference ratio, Epworth Sleepiness Scale, and polysomnographic variables including arousal index, apnea/hypopnea index, mean oxygen saturation, and lowest oxygen saturation were assessed. Fasting plasma glucose, blood lipid profile, and high-sensitivity C-reactive protein were measured. RESULTS: Average carotid IMT of OSAHS patients was significantly thicker than controls (0.66 vs. 0.58 mm, P=0.002) and multivariable logistic regression analysis revealed that arousal index [odds ratio (OR), 0.77; confidence interval (CI), 0.63-0.95; P=0.01] and lowest oxygen saturation (OR, 1.91; CI, 1.24-2.95; P=0.003) were significantly associated with OSAHS patients. Among the OSAHS patients, age (OR, 1.16; CI, 1.10-1.22; P<0.0001), fasting plasma glucose (OR, 1.05; CI, 1.01-1.10; P=0.04), low-density lipoprotein cholesterol (OR, 1.03; CI, 1.02-1.05; P<0.0001), and high-sensitivity C-reactive protein (OR, 1.48; CI, 1.13-1.95; P=0.005) were significantly associated with patients with IMT≥0.65 mm. CONCLUSIONS: IMT was thicker in OSAHS patients without history of vascular events, hypertension, and diabetes mellitus. This study demonstrates that early atherosclerosis exists in this group of patients.

Effects of long-term antiepileptic drug monotherapy on vascular risk factors and atherosclerosis.

PURPOSE: Long-term therapy with antiepileptic drugs (AEDs) has been associated with metabolic consequences that lead to an increase in risk of atherosclerosis in patients with epilepsy. We compared the long-term effects of monotherapy using different categories of AEDs on markers of vascular risk and the atherosclerotic process. METHODS: One hundred sixty adult patients who were receiving AED monotherapy, including two enzyme-inducers (carbamazepine, CBZ; and phenytoin, PHT), an enzyme-inhibitor (valproic acid, VPA), and a noninducer (lamotrigine, LTG) for more than 2 years, and 60 controls were enrolled in this study. All study participants received measurement of common carotid artery (CCA) intima media thickness (IMT) by B-mode ultrasonography to assess the extent of atherosclerosis. Other measurements included body mass index, and serum lipid profile or levels of total homocysteine (tHcy), folate, uric acid, fasting blood sugar, high sensitivity C-reactive protein (hs-CRP), or thiobarbituric acid reactive substances (TBARS). KEY FINDINGS: Long-term monotherapy with older-generation AEDs, including CBZ, PHT, and VPA, caused significantly increased CCA IMT in patients with epilepsy. After adjustment for the confounding effects of age and gender, the CCA IMT was found to be positively correlated with the duration of AED therapy. Patients with epilepsy who were taking enzyme-inducing AED monotherapy (CBZ, PHT) manifested disturbances of cholesterol, tHcy or folate metabolism, and elevation of the inflammation marker, hs-CRP. On the other hand, patients on enzyme-inhibiting AED monotherapy (VPA) exhibited an increase in the levels of uric acid and tHcy, and elevation of the oxidative marker, TBARS. However, no significant alterations in the markers of vascular risk or CCA IMT were observed in patients who received long-term LTG monotherapy. SIGNIFICANCE: Patients with epilepsy who were receiving long-term monotherapy with CBZ, PHT, or VPA exhibited altered circulatory markers of vascular risk that may contribute to the acceleration of the atherosclerotic process, which is significantly associated the duration of AED monotherapy. This information offers a guide for the choice of drug in patients with epilepsy who require long-term AED therapy, particularly in aged and high-risk individuals.

Acute/subacute cerebral infarction (ASCI) in HIV-negative adults with cryptococcal meningoencephalitis (CM): a MRI-based follow-up study and a clinical comparison to HIV-negative CM adults without ASCI.

BACKGROUND: Acute/subacute cerebral infarction (ASCI) in HIV-negative cryptococcal meningoencephalitis (CM) adults has rarely been examined by a series of MRI-based follow-up study. We studied a series of MRI follow-up study of CM adults and compared the clinical characters of those with ASCI and those without ASCI. METHODS: The clinical characteristics and a series of brain MRI findings of seven CM adults with ASCI were enrolled for analysis. The clinical characteristics of another 30 HIV-negative CM adults who did not have ASCI were also included for a comparative analysis. RESULTS: The seven HIV-negative CM adults with ASCI were four men and three women, aged 46-78 years. Lacunar infarction was the type of ASCI, and 86% (6/7) of the ACSI were multiple infarctions distributed in both the anterior and posterior cerebrovascular territories. The seven CM patients with ASCI were significantly older and had a higher rate of DM and previous stroke than the other 30 CM adults without ASCI. They also had a higher incidence of consciousness disturbance at presentation and had a poor prognosis. CONCLUSION: ASCI was found in 18.9% (7/37) of HIV-negative CM adults. Serial MRI follow-up studies may allow a better delineation of ASCI in this specific group of infectious disease and multiple lacunar infarctions was the most common type. Older in age and presence of DM and previous stroke were the significant underlying conditions. CM patients with ASCI also had a poor therapeutic outcome.

Effect of erythropoietin on level of circulating endothelial progenitor cells and outcome in patients after acute ischemic stroke.

INTRODUCTION: Erythropoietin (EPO) enhances the circulating level of endothelial progenitor cells (EPCs), which has been reported to be associated with prognostic outcome in ischemic stroke (IS) patients. The aim of this study was to evaluate the time course of circulating EPC level and the impact of EPO therapy on EPC level and clinical outcome in patients after acute IS. METHODS: In total, 167 patients were prospectively randomized to receive either EPO therapy (group 1) (5,000 IU each time, subcutaneously) at 48 h and 72 h after acute IS, or serve as placebo (group 2). The circulating level of EPCs (double-stained markers: CD31/CD34 (E1), CD62E/CD34 (E2) and KDR/CD34 (E3)) was determined using flow cytometry at 48 h and on days 7 and 21 after IS. EPC level was also evaluated once in 60 healthy volunteers. RESULTS: Circulating EPC (E1 to E3) level at 48 h after IS was remarkably higher in patients than in control subjects (P < 0.02). At 48 h and on Day 7 after IS, EPC (E1 to E3) level did not differ between groups 1 and 2 (all P > 0.1). However, by Day 21, EPC (E1 to E3) level was significantly higher in group 1 than in group 2 (all P < 0.03). Additionally, 90-day recurrent stroke rate was notably lower in group 1 compared with group 2 (P = 0.022). Multivariate analysis demonstrated that EPO therapy (95% confidence interval (CI), 0.153 to 0.730; P = 0.006) and EPC (E3) (95% CI, 0.341 to 0.997; P = 0.049) levels were significantly and independently predictive of a reduced 90-day major adverse neurological event (MANE) (defined as recurrent stroke, National Institutes of Health Stroke scale ≥8, or death). CONCLUSIONS: EPO therapy significantly improved circulating EPC level and 90-day MANE. TRIAL REGISTRATION NUMBER: ISRCTN: ISRCTN96340690.

Comparison of carotid artery stenting performance between cardiologists and neuroradiologists: one medical center's experience.

PURPOSE: To report the experience of carotid artery angioplasty with stenting (CAS) by cardiologists (CV) and neuroradiologists (NR) in an area with less incidence of extracranial artery stenosis. METHODS: From 1999 to 2008, 210 patients with 231 stents were collected by claim records from the administrative office and reviewed by one independent neurologist. Outcome measures were peri-procedural adverse events (AE), restenosis and recurrent ipsilateral stroke (RS) rate, categorized into treatment groups by either CV or NR. RESULTS: The average age was 69.0 years and 82.9 % of the patients were men. 63.8% of the patients with 62.8% stents were treated by CV and the remaining 36.2% of patients with 37.2% stents were done by NR. Symptomatic CAS was evident in 70.1% of the CV cases and 83.0% in NR treated patients (P = 0.017). The peri-procedural AE rate was 31.6%; 35.9% in CV group and 24.4% in the NR group (P = 0.071). RS rate was 4.8% in 663.3 days; 4.1% in 920.8 days in the CV group and 5.8% in 354.2 days in the NR group (P = 0.865). The restenosis rate was 10.9% in 630.5 days; 5.4% in the CV group in 224.8 days and 20.6% in the NR group in 817.8 days (P = 0.007). CONCLUSIONS: The restenosis and recurrent stroke rates after carotid artery stenting in Taiwan appears to be consistent with other published and well organized trials. Measures to minimize peri-procedural AR rates are definitely warranted.

Long-term effects of baroreflex function after stenting in patients with carotid artery stenosis.

Baroreflex sensitivity is recognized for its prognostic relevance to cardio-vascular and cerebro-vascular risks. However, little is known about the long-term outcome of baroreflex function in patients with carotid stenosis undergoing carotid stenting. Heart rate variability and cardio-vascular autonomic function, including baroreflex sensitivity, were examined using non-invasive methods in 22 adult patients who underwent carotid stenting. They were compared with the normal control group with 22 sex- and age-matched normal volunteers and the risk control group with 10 adult patients with severe stenosis or even total occlusion of the carotid artery without stenting. The groups of patients with stenting and risk controls had significantly reduced valsalva ratio and baroreflex sensitivity measured by the valsalva method compared to normal controls. However, there was no significant difference between patients with stenting and risk controls. There was significant decrease in heart rate response to deep breathing and to head-up tilt in patients with carotid stenting compared to normal controls. Other parameters of cardio-vascular autonomic function showed no difference among the three groups. Reduced baroreceptor function in patients with carotid stenting may be due to underlying diseases rather than the stenting itself. There was no short-term parasympathetic hyperactivity after the stenting, suggesting that the effect is transient rather than permanent.

Extracranial carotid artery disease in nasopharyngeal carcinoma patients with post-irradiation ischemic stroke.

OBJECTIVE: Irradiation induced extracranial carotid occlusive disease has been recognized as a potential cause of post-irradiation stroke in nasopharyngeal carcinoma (NPC) patients. Our study aims to investigate the prevalence of extracranial CA disease in post-irradiated Taiwanese NPC ischemic stroke patients. METHODS: Forty-three NPC patients with ischemic stroke were retrospectively selected from the stroke registration of the study hospital and compared with 276 first-ever ischemic stroke patients from the same database, of which 31 patients underwent carotid duplex sonography (CDS). Significant atherosclerotic lesions of the carotid arteries were defined as a >50% stenosis or an occlusion according to CDS. RESULTS: Significant carotid lesions occurred in 13 of 31 (42%) NPC patients. Stroke was more frequently caused by large artery disease (44% versus 23%; p<0.01) in NPC patients than in first-ever stroke patients without NPC. Carotid artery disease (odds ratio 7.22, 95% confidence interval 2.51-20.77; p<0.0001) and absence of diabetes mellitus (odds ratio 0.26, 95% confidence interval 0.07-0.93; p=0.039) were the strongest independent discriminators between NPC stroke patients and non-NPC stroke patients in a multivariate logistic regression analysis. CONCLUSION: Patients who received neck irradiation are at risk for the delayed development of diffused atherosclerosis but also for carotid occlusion within years, although the mechanism remains elusive and probably multifactorial.

The effectiveness of interactive computer assisted instruction compared to videotaped instruction for teaching nurses to assess neurological function of stroke patients: a randomized controlled trial.

BACKGROUND: Teaching inexperienced nurses to assess neurologic function of acute ischemic stroke patients poses challenges to educators in Taiwan. OBJECTIVES: The purpose of this study was to examine the effectiveness of two programs that teach nurses the use of the Chinese version of the National Institute of Health Stroke Scale (C-NIHSS), and to evaluate the level of learner satisfaction with these teaching programs. DESIGN: An experimental research design with two groups, one pre-test and two post-tests was utilized. SETTING: Six neurology and neurosurgery wards at two hospitals in southern Taiwan. PARTICIPANTS: Participating nurses were stratified based on their clinical level of experience and prior training on the National Institute of Health Stroke Scale (NIHSS). They were randomly assigned to either the experimental C-NIHSS interactive computer assisted instruction (ICAI) group (n=44) or the Instructor-led videotape learning program (IVLP) group (n=40) to learn the C-NIHSS. METHODS: The measurement tools included the score verification unit (SVU) (score range from 0 to 45, content validity index, CVI=0.96, percentage agreement=84%) and the learner satisfaction scale (CVI=0.92, Cronbach's alpha=0.97). RESULTS: Both groups' scores on the assessment of correctness significantly increased (F=35.50, p=0.00) after intervention. However, there was an insignificant difference between the changes in the two groups (F=0.02, p=0.89). After using one-way ANCOVA analysis, and adjusting for the length of experience in neurological nursing, the results showed that in the second post-test, the ICAI group's score was significantly higher than that of the IVLP group (F=4.81, p=0.03). There was a positive correlation between assessment correctness on the second post-test and length of experience in neurological nursing (r=0.35, p<0.05). It was concluded that nurses with less experience in neurological nursing, who receive ICAI will perform a better assessment of stroke patients than those who received IVLP. CONCLUSION: The C-NIHSS ICAI teaching program contributed to better assessment correctness after adjusting for the length of experience in neurological nursing, and to some extent increased satisfaction for the participating nurses. Therefore it is worth promoting the use of ICAI for in-service education of nurses, especially for nurses with less experience in neurological nursing, in order to enhance long-term effects of learning.

Long-term antiepileptic drug therapy contributes to the acceleration of atherosclerosis.

PURPOSE: Long-term antiepileptic drug (AED) therapy has been associated with an increase in risk of atherosclerosis. At issue is whether this risk is related to the duration of AED therapy. We evaluated the hypothesis that the cumulative effect of long-term exposure to AEDs plays a pivotal role in the pathogenesis of atherosclerosis in patients with epilepsy. METHODS: One hundred ninety-five patients under long-term AED therapy and 195 healthy age- and sex-matched control subjects received measurement of intima media thickness (IMT) at the far wall of the common carotid artery (CCA) by B-mode ultrasonography to assess the extent of atherosclerosis. Other measurements included body mass index (BMI) and blood lipid profile or homocysteine, folic acid, uric acid, fasting blood sugar, high sensitivity C-reactive protein (hs-CRP), thiobarbituric acid reactive substances (TBARS), and total reduced thiols. RESULTS: CCA IMT was significantly increased in patients with epilepsy, with male subjects exhibiting thicker IMT than their female counterparts. Whereas BMI, homocysteine, hs-CRP, and TBARS were significantly elevated, folic acid and thiols were significantly reduced in patients with epilepsy. Multiple linear regression analysis further revealed that duration of AED therapy, age, gender, and TBARS level (index for oxidative stress) were independently associated with CCA IMT. In addition, the log-transformed CCA IMT increased linearly with duration of AED therapy after adjustments for age, gender, and TBARS level. DISCUSSION: The duration of AED therapy is significantly associated with the acceleration of atherosclerosis in patients with epilepsy, alongside independent contributions of age, gender, and oxidative stress to the atherosclerotic process.