Incidence of recurrent ischemic stroke and its associated factors in a tertiary care center in Thailand: a retrospective cohort study.

BACKGROUND: Ischemic stroke (IS) is one of the leading causes of death among non-communicable diseases in Thailand. Patients who have survived an IS are at an increased risk of developing recurrent IS, which can result in worse outcomes and post-stroke complications. OBJECTIVES: The study aimed to investigate the incidence of recurrent IS among patients with first-ever IS during a one-year follow-up period and to determine its associated risk factors. METHODS: Adult patients (aged ≥ 18 years) who were hospitalized at the Stroke Center, King Chulalongkorn Memorial Hospital (KCMH) in Bangkok, Thailand, due to first-ever IS between January and December 2019 and had at least one follow-up visit during the one-year follow-up period were included in this retrospective cohort study. IS diagnosis was confirmed by neurologists and imaging. The log-rank test was used to determine the event-free survival probabilities of recurrent IS in each risk factor. RESULTS: Of 418 patients hospitalized due to first-ever IS in 2019, 366 (87.6%) were included in the analysis. During a total of 327.2 person-years of follow-up, 25 (6.8%) patients developed recurrent IS, accounting for an incidence rate of 7.7 per 100 person-year (95% confidence interval [CI] 5.2-11.3). The median (interquartile range) time of recurrence was 35 (16-73) days. None of the 47 patients with atrial fibrillation developed recurrent IS. The highest incidence rate of recurrent IS occurred within 1 month after the first episode (34 per 100 person-years) compared to other follow-up periods. Patients with small vessel occlusion and large-artery atherosclerosis (LAA) constituted the majority of patients in the recurrent IS episode (48% and 40%, respectively), with LAA exhibiting a higher recurrence rate (13.5%). Additionally, smoking status was found to be associated with an increased risk of recurrence. CONCLUSION: The incidence rate of the recurrence was moderate in our tertiary care setting, with a decreasing trend over time after the first episode. The various subtypes of IS and smoking status can lead to differences in event-free survival probabilities.

Brain perfusion single photon emission computed tomography abnormality in MRI-negative stroke-like patients post COVID-19 vaccination.

Stroke-like symptoms after COVID-19 vaccination was thought to be functional if there was no anatomical image abnormality. We aimed to analyze brain perfusion changes in these patients. A case-control study of brain perfusion single photon emission computed tomography (SPECT) of 12 vaccinated patients with left-sided stroke-like symptoms were compared with 12 age- and gender-matched normal interictal brain SPECTs using voxel-based analysis. Significant hyperperfusion was seen on the right side in postcentral, inferior parietal, mid temporal, parahippocampal, and caudate regions, and on the left side in the thalamus, hippocampus, and mid temporal areas. In addition, there were hypoperfused bilateral superior frontal gyri and right mid/posterior cingulate cortex (Family-wise-error corrected p-values  < .05). Both hypoperfusion and hyperperfusion in the brain are demonstrated. We hypothesize that these findings might be the result of the functional neurological disorder. However, based on other previous studies, circulating spike protein in the patients' plasma early after vaccination might also be the cause.

Predictors of Recurrent Stroke After Embolic Stroke of Undetermined Source in the RE-SPECT ESUS Trial.

Background We sought to determine recurrent stroke predictors among patients with embolic strokes of undetermined source (ESUS). Methods and Results We applied Cox proportional hazards models to identify clinical features associated with recurrent stroke among participants enrolled in RE-SPECT ESUS (Randomized, Double-Blind, Evaluation in Secondary Stroke Prevention Comparing the Efficacy and Safety of the Oral Thrombin Inhibitor Dabigatran Etexilate Versus Acetylsalicylic Acid in Patients With Embolic Stroke of Undetermined Source) trial, an international clinical trial evaluating dabigatran versus aspirin for patients with ESUS. During a median follow-up of 19 months, 384 of 5390 participants had recurrent stroke (annual rate, 4.5%). Multivariable models revealed that stroke or transient ischemic attack before the index event (hazard ratio [HR], 2.27 [95% CI, 1.83-2.82]), creatinine clearance <50 mL/min (HR, 1.69 [95% CI, 1.23-2.32]), male sex (HR, 1.60 [95% CI, 1.27-2.02]), and CHA2DS2-VASc ≥4 (HR, 1.55 [95% CI, 1.15-2.08] and HR, 1.66 [95% CI, 1.21-2.26] for scores of 4 and ≥5, respectively) versus CHA2DS2-VASc of 2 to 3, were independent predictors for recurrent stroke. Conclusions In RE-SPECT ESUS trial, expected risk factors previously linked to other common stroke causes were associated with stroke recurrence. These data help define high-risk groups for subsequent stroke that may be useful for clinicians and for researchers designing trials among patients with ESUS. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT02239120.

Depressive symptoms due to stroke are strongly predicted by the volume and location of the cerebral infarction, white matter hyperintensities, hypertension, and age: A precision nomothetic psychiatry analysis.

OBJECTIVES: To delineate the effects of white matter hyperintensities (WMHs) as measured by Fluid-attenuated inversion recovery (FLAIR) and infarction volume as measured by Diffusion-weighted imaging (DWI) on post-stroke depression symptoms. METHODS: Baseline National Institutes of Health Stroke Score (NIHSS) and Modified Rankin Scale (mRS) scores, and FLAIR and DWI MRIs to assess WMHs and acute infarct volumes, respectively, were assessed in 47 patients (≥55 years) with acute ischemic stroke and 17 normal controls. The Montgomery-Åsberg Depression Rating Scale (MDRS) was assessed three months after the stroke. RESULTS: The MADRS score was significantly increased in stroke patients as compared with normal controls. The MADRS scale is not unidimensional and cannot be used as an accurate indicator of depression severity in stroke patients. Three months after stroke, key depressive (sadness and inability to feel) and concentration-tension symptoms, and lassitude are significantly predicted by the infarct volume. Right side infarction strongly predicts key depressive symptoms and left side infarction strongly predicts concentration-tension and lassitude scores. Total WMHs significantly predict key depressive and concentration-tension symptoms, and lassitude, with these effects being mediated by right and left DWI stroke volumes and associated disabilities. CONCLUSIONS: Interactions between age, hypertension, a chronic atherosclerotic process, and acute stroke account for the onset of key depressive symptoms three months after the acute infarct. Chronic and acute neuro-immune and neuro-oxidative stress pathways associated with the formation of WMHs and acute stroke may explain the incidence of post-stroke key depressive and concentration-tension symptoms, and lassitude.

A Prospective Study of Azilsartan Medoxomil in the Treatment of Patients with Essential Hypertension and Type 2 Diabetes in Asia.

This phase 4 study evaluated the efficacy and safety of azilsartan medoxomil (AZL-M) in patients with essential hypertension and type 2 diabetes mellitus (T2DM) in Hong Kong, Taiwan, and Thailand. This was a prospective, multicenter, single-arm, open-label study with patients aged 18-75 years with T2DM and essential hypertension and on stable treatment for T2DM. Patients with uncontrolled hypertension were treated with AZL-M 40 mg daily, with the option to uptitrate to 80 mg at 6 weeks. In all, 380 of the 478 patients screened in Hong Kong, Taiwan, and Thailand were enrolled. At week 6, 97 patients (25.5%) were titrated up to AZL-M 80 mg based on BP readings. At 12 weeks, 54.8% of patients reached the blood pressure (BP) goal of <140/85 mm Hg by trough sitting clinic BP (primary endpoint), and 62.8% and 27.0% achieved a BP of <140/90 mm Hg and <130/80 mm Hg, respectively. The efficacy of AZL-M over 12 weeks was also seen in different age and body mass index groups. The incidence of treatment emergent adverse events (TEAEs) was 12.9% before 6 weeks and 16.1% after 6 weeks, and they were mostly mild in severity. The most frequent TEAE was dizziness (4.7%). The incidence of TEAEs leading to study drug discontinuation (4.5%) and drug-related TEAEs (5.0% before 6 weeks; 3.9% after 6 weeks) was low. In patients with essential hypertension and T2DM in Asia, treatment with AZL-M indicated a favorable efficacy and safety profile in achieving target BP.

Prolonged migraine aura resembling ischemic stroke following CoronaVac vaccination: an extended case series.

BACKGROUND: After the initiation of the COVID-19 vaccination program in Thailand, thousands of patients have experienced unusual focal neurological symptoms. We report 8 patients with focal neurological symptoms after receiving inactivated virus vaccine, CoronaVac. CASE SERIES: Patients were aged 24-48 years and 75% were female. Acute onset of focal neurological symptoms occurred within the first 24 h after vaccination in 75% and between 1-7d in 25%. All presented with lateralized sensory deficits, motor deficits, or both, of 2-14 day duration. Migraine headache occurred in half of the patients. Magnetic resonance imaging of the brain during and after the attacks did not demonstrate any abnormalities suggesting ischemic stroke. All patients showed moderately large regions of hypoperfusion and concurrent smaller regions of hyperperfusion on SPECT imaging while symptomatic. None developed permanent deficits or structural brain injury. DISCUSSIONS: Here, we present a case series of transient focal neurological syndrome following Coronavac vaccination. The characteristic sensory symptoms, history of migraine, female predominant, and abnormal functional brain imaging without structural changes suggest migraine aura as pathophysiology. We propose that pain related to vaccine injection, component of vaccine, such as aluminum, or inflammation related to vaccination might trigger migraine aura in susceptible patients.

Short Communication: Incidence and Risk Factors of Ischemic Stroke and Transient Ischemic Attack Among People Living with HIV: A Longitudinal Cohort Study.

People living with HIV (PLWH) have higher ischemic cerebrovascular disease rates than HIV-negative individuals. We aimed to determine the incidence and risk factors of ischemic stroke (IS) and transient ischemic attack (TIA) among Thai PLWH. Data from adults living with HIV who were enrolled in a prospective HIV-NAT 006 cohort in Bangkok, Thailand, from 1996 to 2020 were included in the analysis. The primary endpoint was first-ever IS or TIA. Among 2020 PLWH included in the analysis, 16 (0.8%) developed first-ever IS/TIA over 23,579 person-years (incidence: 0.7 per 1,000 person-years [95% confidence interval {CI} 0.4-1.1]). Median CD4 cell counts before developing IS/TIA was 480 cells/mL and 87.5% were virologically suppressed. In multivariate models, hypertension was the only factor significantly associated with IS/TIA incidence (adjusted subhazard ratio 4.4; 95% CI 1.2-15.6, p = .02). The incidence of IS/TIA was low among well-suppressed Thai PLWH. Traditional risk factors, particularly hypertension, still play an essential role in developing IS/TIA.

Patient perception and treatment convenience of dabigatran versus vitamin K antagonist when used for stroke prophylaxis in atrial fibrillation: Real-world Evaluation of Long-term Anticoagulant Treatment Experience (RE-LATE) study.

PURPOSE: Dabigatran is a direct thrombin inhibitor approved for stroke prophylaxis in patients with non-valvular atrial fibrillation (NVAF). Real-world data about patient preference, satisfaction and convenience in patients in Asia are not available. The study aimed to explore the perception of patients with newly diagnosed NVAF regarding dabigatran versus vitamin K antagonists (VKAs), when used for stroke prevention. PATIENTS AND METHODS: This was a multinational, multicentre, non-interventional study involving 49 sites across 5 countries in South East Asia and South Korea where 934 patients newly diagnosed with NVAF were initiated on either dabigatran (N=591) or VKA (N=343). Data were collected at baseline and over two follow-up visits across 6 months. Treatment satisfaction and patient convenience were evaluated using the Perception on Anticoagulant Treatment Questionnaire-2 (PACT-Q2). RESULTS: The mean age of the patients was 65.9±10.4 years, and 64.2% were male. Mean CHA2DS2-VASc score was 2.4±1.5, and mean HAS-BLED score was 1.2±0.9. At baseline, patients initiated on dabigatran had higher stroke risk, bleeding risk, creatinine clearance and proportion of patients with concomitant illnesses compared with patients initiated on VKAs. Treatment convenience was perceived to be significantly better with dabigatran versus VKAs at visits 2 and 3 (p=0.0423 and 0.0287, respectively). Treatment satisfaction was significantly better with dabigatran compared with VKAs at visit 3 (p=0.0300). CONCLUSION: In this study, dabigatran is associated with better patient perception in terms of treatment convenience and satisfaction compared with VKAs when used for stroke prevention in newly diagnosed NVAF patients from South East Asia and South Korea. TRIAL REGISTRATION NUMBER: NCT02849509. PLAIN LANGUAGE SUMMARY: Patient satisfaction with dabigatran versus VKAs in South East Asia. Patients with atrial fibrillation are at high risk of stroke and require anticoagulants for stroke prevention. Two such anticoagulants are dabigatran and VKAs. We wanted to compare the extent of satisfaction and treatment convenience among newly diagnosed patients with atrial fibrillation from the South East Asian region when they were given either dabigatran or VKAs. Consenting patients filled out a standardised questionnaire called the PACT-Q2 over three visits after they were started on either dabigatran (591 patients) or VKAs (343 patients). We found that satisfaction and convenience were significantly higher when patients received dabigatran than when they received VKAs.

Acute prolonged motor aura resembling ischemic stroke after COVID - 19 vaccination (CoronaVac): the first case report.

BACKGROUND: We report the first case of a patient who suffered transient focal neurological deficit mimicking stroke following CoronaVac vaccination. However, instead of an ischemic stroke, motor aura was suspected. CASE PRESENTATIONS: A 24 year-old Thai female presented with left hemiparesis fifteen minutes after receiving CoronaVac. She also had numbness of her left arm and legs, flashing lights, and headaches. On physical examination, her BMI was 32.8. Her vital signs were normal. She had moderate left hemiparesis (MRC grade III), numbness on her left face, arms, and legs. Her weakness continued for 5 days. A brain CT scan was done showing no evidence of acute infarction. Acute treatment with aspirin was given. MRI in conjunction with MRA was performed in which no restricted diffusion was seen. A SPECT was performed to evaluate the function of the brain showing significant hypoperfusion of the right hemisphere. The patient gradually improved and was discharged. DISCUSSIONS: In this study, we present the first case of stroke mimic after CoronaVac vaccination. After negative imaging studies had been performed repeatedly, we reach a conclusion that stroke is unlikely to be the cause. Presumably, this phenomenon could possibly have abnormal functional imaging study. Therefore, we believed that it might be due to cortical spreading depression, like migraine aura, which we had conducted a literature review.

Short Communication: Ischemic Stroke Subtypes Among Thai HIV-Infected Patients: A 12-Year Retrospective Study.

Traditional vascular risk factors and HIV-related factors can contribute to higher prevalence of ischemic stroke (IS) among HIV-infected patients. Understanding the underlying mechanism of IS could lead to proper management and prognosis. We aimed to determine the prevalence of IS subtypes among HIV-infected patients who were hospitalized due to IS. Medical records of patients who were hospitalized at the King Chulalongkorn Memorial Hospital, Bangkok, Thailand, between 2008 and 2019 due to first-ever IS with documented HIV infection were retrospectively analyzed. IS subtypes were classified according to the Trial of Org 10172 in Acute Stroke Treatment (TOAST) classification. Among 6,952 patients who were hospitalized due to IS, 50 [0.7% (95% confidence interval: 0.5-1.0)] were HIV-infected patients and were included in the analysis. Common traditional stroke risk factors were dyslipidemia (62%), smoking (55.3%), hypertension (52%), and alcohol consumption (45%). The median (interquartile range) CD4 cell count was 294.5 (186-485) cells/mL and 74% were on antiretroviral therapy. The most common etiology of IS was small vessel occlusion (SVO) (48%), followed by stroke of undetermined etiology (UD) (26%), and stroke of other determined etiology (OD) (14%). Among patients with OD, 5 of 7 were from infectious-related cause. Virologically unsuppressed group had significantly higher proportion of OD (33.3% vs. 3.6%), UD (38.9% vs. 17.9%), and lower proportion of SVO (22.2% vs. 60.7%) based on TOAST classification compared with virologically suppressed group (p = .01). SVO was the most common cause of IS among HIV-infected patients and was more likely to occur among virologically suppressed group, suggesting that traditional vascular risk factors may play a larger role in developing IS. OD was more likely to occur among virologically unsuppressed group, most of which were infectious-related cause.

Dabigatran or Aspirin After Embolic Stroke of Undetermined Source in Patients With Patent Foramen Ovale: Results From RE-SPECT ESUS.

BACKGROUND AND PURPOSE: Patent foramen ovale (PFO) may increase the risk of embolic stroke of undetermined source (ESUS). Guidelines suggest anticoagulation may be more effective than antiplatelets in preventing stroke in patients with ESUS and PFO when interventional closure is not performed. METHODS: Patients with ESUS randomized to dabigatran (150/110 mg BID) or aspirin (100 mg QD) from the RE-SPECT ESUS study (Randomized, Double-Blind, Evaluation in Secondary Stroke Prevention Comparing the Efficacy and Safety of the Oral Thrombin Inhibitor Dabigatran Etexilate Versus Acetylsalicylic Acid in Patients With Embolic Stroke of Undetermined Source) were included. The rate of recurrent stroke (primary end point) and ischemic stroke was reported for patients with and without baseline PFO. A meta-analysis comparing the effects of anticoagulant and antiplatelet therapy on ischemic stroke in patients with PFO was updated to include RE-SPECT ESUS. RESULTS: PFO was present in 680 of 5388 (12.6%) patients with documented PFO status. The risk of recurrent stroke with dabigatran versus aspirin was similar in patients with and without PFO (P for interaction, 0.8290). In patients with PFO, the meta-analysis found no statistically significant difference between anticoagulant and antiplatelet therapy (odds ratio, 0.70 [95% CI, 0.43-1.14]) for ischemic stroke. CONCLUSIONS: There is insufficient evidence to recommend anticoagulation over antiplatelet therapy for patients with ESUS and a PFO. More data are needed to guide antithrombotic therapy in this population. Registration: URL: https://www.clinicaltrials.gov. Unique identifier: NCT02239120.

Atrial fibrillation prevalence and risk profile from novel community-based screening in Thailand: A prospective multi-centre study.

BACKGROUND: In Thailand, almost one-quarter of strokes are related to atrial fibrillation (AF), and many could be prevented if AF were diagnosed and treated prior to the stroke. Therefore, we tested a novel strategy to screen large numbers of community residents using village health volunteers and primary care nurses. METHODS: Local primary care nurses and village health volunteers in Phetchaburi and Lopburi provinces, Thailand were trained to perform AF screening using a blood pressure device with AF algorithm (Microlife A200 AFib). 10% of residents aged ≥ 65 years were randomly selected for screening during home-visits. Participants with possible AF were given follow-up appointments for further testing, including 12-lead ECG and echocardiogram. RESULTS: Over two-months, 9.7% (13,864/143,478) of the target population were screened: mean age 73.2 ± 6.4 years, 32.4% male. The estimated AF prevalence (detected by Microlife A200 AFib) was 2.8% (95% CI, 2.6-3.1%) for age ≥ 65 years (i.e. 393/13,864 participants). Prevalence increased with age from 1.9% (65-69 years) to 5.0% (≥85 years) (p < 0.001). Only 58% (226/393) of participants with suspected AF attended the follow-up appointment (1-3 months after initial screen): mean CHA2DS2-VASc score 3.2 ± 1.2; 86.3% (195/226) had Class-1 oral anticoagulation recommendation, and 33% (75/226) had AF on 12-lead ECG. CONCLUSIONS: In Thailand, large-scale AF screening in the community is feasible using trained volunteer health workers, allowing screening of large numbers in a short time-period. Further investigation of this strategy is warranted, ensuring mechanisms to obtain a timely rhythm strip or 12-lead ECG locally, and a designated pathway to treatment.

Real-world evaluation of perception, convenience and anticoagulant treatment satisfaction of patients with atrial fibrillation switched from long-term vitamin K antagonist treatment to dabigatran.

BACKGROUND AND PURPOSE: Real-world data about treatment convenience and satisfaction in Asian non-valvular atrial fibrillation (NVAF) patients after switching from vitamin K antagonists (VKAs) to non-VKA oral anticoagulants were evaluated. METHODS: In this non-interventional study involving 49 sites across five countries in Southeast Asia and South Korea, 379 stable NVAF patients who switched from VKA therapy to dabigatran during routine clinical practice were recruited and followed up for 6 months. Treatment convenience and satisfaction were evaluated using Perception on Anticoagulant Treatment Questionnaire-2 (PACT-Q2). Through post hoc analysis, factors associated with improved treatment convenience scores at visit 2 were described. RESULTS: Treatment convenience and satisfaction significantly improved after switching from VKAs to dabigatran at visit 2 and visit 3 (convenience: p<0.001 each vs baseline; satisfaction: p=0.0174 (visit 2), p=0.0004 (visit 3) compared with baseline). Factors predictive of higher (>80th percentile) response on treatment convenience were female sex, younger age (<75 years), higher baseline stroke risk, higher creatinine clearance and absence of concomitant hypertension, stroke or gastrointestinal diseases. CONCLUSION: Dabigatran was associated with a significant improvement in treatment convenience and satisfaction after switching from VKAs when used for stroke prevention in NVAF patients from Southeast Asia and South Korea.

Serum miRNA125a-5p, miR-125b-5p, and miR-433-5p as biomarkers to differentiate between posterior circulation stroke and peripheral vertigo.

BACKGROUND: Acute vertigo is a common presentation of inner ear disease. However, it can also be caused by more serious conditions, especially posterior circulation stroke. Differentiating between these two conditions by clinical presentations and imaging studies during the acute phase can be challenging. This study aimed to identify serum microRNA (miRNA) candidates that could differentiate between posterior circulation stroke and peripheral vertigo, among patients presenting with acute vertigo. METHODS: Serum levels of six miRNAs including miR-125a-5p, miR-125b-5p, miR-143-3p, miR-342-3p, miR-376a-3p, and miR-433-5p were evaluated. Using quantitative reverse-transcription polymerase chain reaction (RT-qPCR), the serum miRNAs were assessed in the acute phase and at a 90 day follow-up visit. RESULTS: A total of 58 patients with posterior circulation stroke (n = 23) and peripheral vertigo (n = 35) were included in the study. Serum miR-125a-5p (P = 0.001), miR-125b-5p (P <  0.001), miR-143-3p (P = 0.014) and miR-433-5p (P = 0.0056) were present at significantly higher levels in the acute phase, in the patients with posterior circulation infarction. Based on the area under the receiver operating characteristic curve (AUROC) only miR-125a-5p (0.75), miR-125b-5p(0.77), and miR-433-5p (0.71) had an acceptable discriminative ability to differentiate between the central and peripheral vertigo. A combination of miRNAs revealed no significant improvement of AUROC when compared to single miRNAs. CONCLUSION: This study demonstrated the potential of serum miR-125a-5p, miR-125b-5p, and miR-433-5p as biomarkers to assist in the diagnosis of posterior circulation infarction among patients presenting with acute vertigo.

Incidence and Risk Factors of Postcontrast Acute Kidney Injury in Patients with Acute Ischemic Stroke.

BACKGROUND: Multimodal computed tomography (CT) guides decision-making regarding use of thrombolytic agents in acute ischemic stroke patients. However, postcontrast acute kidney injury (PC-AKI) is a potential adverse effect of the contrast media used, which may require hemodialysis and cause a longer hospital stay. The incidence and risk factors of PC-AKI in acute ischemic stroke patients, particularly in Thailand, remain unclear. Goal. We aimed at determining the incidence and risk factors of PC-AKI in patients with acute ischemic stroke undergoing multimodal CT. METHODS: We conducted a retrospective review of Thai acute ischemic stroke patients admitted to the King Chulalongkorn Memorial Hospital between January 2014 and December 2017 who received multimodal CT and thrombolytic treatment with alteplase. RESULT: Overall, 109 patients were included for analysis; eight patients (7.3%) developed PC-AKI. Estimated glomerular filtration rate (eGFR) ≤ 30 mL/min and mechanical thrombectomy were risk factors significantly associated with PC-AKI. CONCLUSION: The incidence of PC-AKI in a real practice setting did not differ from previous reports. Two factors were associated with PC-AKI, eGFR ≤ 30 mL/min and mechanical thrombectomy. Patients without these risk factors may not need to wait for the results of renal function testing prior to multimodal CT.

Outcomes of thrombolytic therapy in acute ischemic stroke: mothership, drip-and-ship, and ship-and-drip paradigms.

BACKGROUND: Chulalongkorn Stroke Center is a comprehensive stroke center (CSC) located in Bangkok, Thailand. Our stroke network consists of different levels of spoke hospitals, ranging from community hospitals where thrombolytic treatment is not available, to those capable of onsite thrombolytic therapy. This study aimed to assess the time to treatment and outcomes among acute ischemic stroke patients who received thrombolytic treatment in the Chulalongkorn Stroke Network by 1.) Direct arrival at the CSC (mothership) 2.) Telestroke-assisted thrombolytic treatment with secondary transfer to the CSC (drip-and-ship) 3.) Referral from community hospital to the CSC for thrombolytic treatment (ship-and-drip). METHODS: Acute ischemic stroke patients who received thrombolytic treatment during January 2016-December 2017 in the Chulalongkorn Stroke Network were studied. Time to treatment and clinical outcomes were compared among treatment groups. RESULTS: There were 273 patients in the study including 147, 87, and 39 patients in mothership, drip-and-ship, and ship-and-drip paradigms, respectively. The door-to-needle-time (DTN) and onset-to-needle-time (OTN) times were significantly longest in ship-and-drip group (146.5 ± 62/205.03 ± 44.88 mins) compared to mothership (38 ± 23/155.2 ± 60.54 mins) and drip-and-ship (63.0 ± 44/166.09 ± 87 mins), P < 0.05. There was no significant difference regarding functional independence defined by modified Rankin Scale (mRS) ≤ 2 at 3 months (P = 0.12), in-hospital mortality (P = 0.37), mortality at 3 months (P = 0.73), and symptomatic intracerebral hemorrhage (P = 0.24) among groups. CONCLUSION: Thrombolytic treatment with drip and ship method under teleconsultation is feasible in Thailand. There was no difference of clinical outcome among the 3 treatment paradigms. However, DTN time and OTN time were longest in the ship-and-drip paradigm.

Nonbacterial Thrombotic Endocarditis Related to Adenocarcinoma of the Uterine Cervix.

We report a 66-year-old female patient who presented with acute onset of visual loss with relative afferent pupillary defect, hemineglect, hemihypesthesia, and apraxia. Magnetic resonance imaging of the brain demonstrated different stages of ischemic stroke in different vascular territories, suggesting cardiogenic embolism. Past history was significant for advanced-stage adenocarcinoma of the uterine cervix under chemoradiation treatment. On echocardiogram, vegetation at the aortic valve was observed. With the absence of evidence of infectious endocarditis, diagnosis of nonbacterial thrombotic endocarditis was made, and the patient was treated by long-term anticoagulant. This case is unique in terms of the adenocarcinoma cell type of cervical cancer, which is uncommon and has been rarely reported to be related to nonbacterial thrombotic endocarditis.

Cost-Effectiveness Analysis of Non-Vitamin K Antagonist Oral Anticoagulants Versus Warfarin in Thai Patients With Non-Valvular Atrial Fibrillation.

BACKGROUND: Non-vitamin K antagonist oral anticoagulants (NOACs) have been recommended as preferred options for stroke prevention in patients with atrial fibrillation (AF) versus warfarin by guidelines worldwide. AIM: This study aimed to evaluate the cost-effectiveness of each NOAC in a Thai health care environment, a country with upper middle-income economies based on the World Bank's classification. METHOD: A lifetime Markov model was created from a Thai societal perspective. The model consisted of 19 health states separated into two cycles: event cycle and consequence cycle. The consequences of AF included in the model were ischaemic stroke, intracranial haemorrhage, extracranial haemorrhage, and myocardial infarction. All NOACs available in Thailand (dabigatran 150 mg and 110 mg twice daily; rivaroxaban 20 mg once daily; apixaban 5 mg twice daily; edoxaban 60 mg and 30 mg once daily) were assessed using warfarin with an international normalised ratio of 2-3 as the reference. Inputs were a combination of published literature and local data when available. A willingness-to-pay of 160,000 Thai baht (THB)/quality-adjusted life year (QALY) was used as the threshold of being cost-effective. Incremental cost-effectiveness ratios and cost-effectiveness acceptability curves were estimated. RESULTS: All NOACs were not cost-effective strategies for the Thai AF population. The ranking of incremental cost-effectiveness ratios from lowest to highest were apixaban 5 mg twice daily (THB 692,136 or US$21,862) followed by edoxaban 60 mg once daily (THB 911,772 or US$28,799), edoxaban 30 mg once daily (THB 913,749 or US$28,861), dabigatran 150 mg twice daily (THB 1,102,106 or US$34,811), dabigatran 110 mg twice daily (THB 1,195,347 or US$37,756), and rivaroxaban 20 mg once daily (THB 1,347,650 or US$42,566). Cost-effectiveness acceptability curve indicated that apixaban had the highest potential to be a cost-effective strategy versus other NOACs. CONCLUSIONS: Our findings indicated that all NOACs were not cost-effective in the Thai AF population. Of the NOACs, apixaban may be the most likely to be cost-effective. These data may be useful for policymakers to perform a comprehensive evaluation of these agents for formulary decision and pricing negotiation.