Intravenous tissue plasminogen activator for acute ischemic stroke in patients with renal dysfunction.

OBJECTIVE: This study used the Taiwan Stroke Registry data to evaluate the efficacy and safety of intravenous tissue plasminogen activator (tPA) in treating acute ischemic stroke in patients with renal dysfunction. DESIGN: We identified 3525 ischemic stroke patients and classified them into two groups according to the estimated glomerular filtration rate (eGFR) at the emergency department: ≥60, and <60 ml/min/1.73 m2 or on dialysis and by the propensity score from August 2006 to May 2015. The odds ratio of poor functional outcome (modified Rankin Scale ≥2) was calculated for patients with tPA treatment (N = 705), compared to those without tPA treatment (N = 2820), by eGFR levels, at 1, 3 and 6 months after ischemic stroke. We also evaluated the risks of intracerebral hemorrhage, upper gastrointestinal bleeding, mortality, between the two groups by eGFR levels. RESULTS: Among patients with eGFR levels of <60 ml/min/1.73 m2, tPA therapy reduced the odds ratio of poor functional outcome to 0.60 (95% confidence interval = 0.42-0.87) at 6 months after ischemic stroke. The tPA therapy was not associated with increased overall risk of upper gastrointestinal bleeding, but with increased risk of intracerebral hemorrhage. The low eGFR was not a significant risk factor of intracerebral hemorrhage among ischemic stroke patients receiving tPA treatment. CONCLUSIONS: tPA for acute ischemic stroke could improve functional outcomes without increasing the risks of upper gastrointestinal bleeding for patients with or without renal dysfunction. The low eGFR was not a significant risk factor for intracerebral hemorrhage among patients receiving tPA treatment.

Antiplatelet agents for the secondary prevention of ischaemic stroke in patients with or without renal dysfunction.

BACKGROUND AND PURPOSE: Studies on using antiplatelet agents for secondary prevention in ischaemic stroke patients with renal dysfunction are limited. The Taiwan Stroke Registry database was used to compare the efficacy of antiplatelet agents. METHODS: From the Taiwan Stroke Registry data, 39 174 acute ischaemic stroke patients were identified and were classified into three groups by antiplatelet agent: aspirin, clopidogrel and dual antiplatelet therapy (DAPT) with a combination of aspirin and clopidogrel. The re-stroke incidence and 1-year mortality were stratified by estimated glomerular filtration rate (eGFR) levels at admission: ≥90, 60-89 and <60 ml/min/1.73 m2 or on dialysis. RESULTS: Compared to the aspirin group, the re-stroke differences were not statistically significant for the clopidogrel group [adjusted subhazard ratio 0.95, 95% confidence interval (CI) 0.84-1.08] and the DAPT group (adjusted subhazard ratio 1.03, 95% CI 0.77-1.39) after controlling for the competing risk of death. The mortality rate increased as the eGFR level declined. In addition, compared to patients taking aspirin, there was no statistically significant difference in overall 1-year mortality for the clopidogrel group (adjusted hazard ratio 1.11, 95% CI 0.95-1.29) and for the DAPT group (adjusted hazard ratio 1.01, 95% CI 0.67-1.54). The results were consistent in different subgroups stratified by eGFR levels. CONCLUSIONS: There was no difference in the risks of recurrent stroke and 1-year mortality amongst ischaemic stroke patients with or without renal dysfunction receiving antiplatelet agents with aspirin, clopidogrel or dual agents with a combination of aspirin and clopidogrel, regardless of their renal dysfunction status.

The association between septicemia and the risk of multiple sclerosis: a nationwide register-based retrospective cohort study in Taiwan.

BACKGROUND: Multiple sclerosis (MS) is the most common inflammatory demyelinating disease of the central nervous system. Few studies focused on the relationship between septicemia and MS. AIM: To evaluate the potential impact of septicemia on risk for MS. DESIGN: Two cohorts of patients with septicemia and without septicemia were followed up for the occurrence of MS. METHODS: Patients of 482 790 with septicemia was enrolled from the National Health Insurance Research Database between 2001 and 2011 as the study group to match the 1 892 820 individuals, as the control group, by age and gender. Incidence of MS in both groups was calculated. Cox proportional-hazards regressions were performed for investigating hazard ratios (HR) for MS between groups. RESULTS: Septicemia patients had a 3.06-fold (95% CI: 2.16-4.32, P < 0.001) greater risk of developing MS than the matched group. In addition, higher severity of septicemia was associated with higher risk of developing MS (moderate: HR = 4.03, 95% CI: 2.53-6.45, P < 0.001; severe: HR = 11.1, 95% CI: 7.01-17.7, P < 0.001). Similar results also occurred in both male and female patients with septicemia (male: HR = 4.06, 95% CI: 2.17-7.58, P < 0.001; female: HR = 2.72, 95% CI: 1.79-4.11, P < 0.001). Patients without counterpart comorbidities had a significantly higher risk of MS than the controlled group (HR = 3.02, 95% CI: 2.10-4.35, P < 0.001). CONCLUSION: The results indicated septicemia is linked to an increased risk for MS. Aggressively preventing and treating septicemia may be warranted for one of precautionary strategies of MS.

Pre-stroke physical activity is associated with fewer post-stroke complications, lower mortality and a better long-term outcome.

BACKGROUND AND PURPOSE: Physical activity is associated with a reduced incidence of first-time stroke. However, few studies have examined the effect of pre-stroke physical activity on post-stroke complications and clinical outcomes. METHODS: A total of 39 835 cases of stroke registered in the nationwide stroke registry system of Taiwan between 2006 and 2009 were analyzed according to five levels of severity as determined by National Institutes of Health Stroke Scale score upon hospital admission. Pre-stroke physical activity was defined in the Taiwan Stroke Registry as dedicated leisure-time physical activity for at least 30 min/day for 3 days/week for more than 6 months. A Cox model was used to compare complications and outcomes between active and inactive groups. RESULTS: The active and inactive groups were similar in age distribution and stroke type distribution, but the active group had better National Institutes of Health Stroke Scale scores upon admission. The active group also had significantly fewer post-stroke complications. Active patients had lower hospital mortality and better functional outcomes upon discharge as per the modified Rankin Scale. Improved functional status in the active group was significant at 1, 3 and 6 months post-stroke. CONCLUSION: Dedicated leisure-time physical activity for at least 30 min/day, at least three times per week for more than 6 months was associated with decreased stroke severity, fewer post-stroke complications, lower mortality and better outcomes.

Comparison of transcranial color-coded sonography and magnetic resonance angiography in acute ischemic stroke.

BACKGROUND AND PURPOSE: This study was designed to assess the accuracy of transcranial color-coded sonography (TCCS) as compared to magnetic resonance angiography (MRA) for detecting intracranial arterial stenosis in patients with acute cerebral ischemia. METHODS: The authors prospectively identified 120 consecutive patients admitted with acute ischemic stroke and performed both TCCS and MRA with a mean interval of 1 day. TCCS data (sampling depth, peak systolic and end diastolic angle-corrected velocity, mean angle-corrected velocity, and pulsatility index) for middle cerebral arteries (MCAs) were compared to MRA data and classified into 4 grades: normal (grade 1): normal caliber and signal; mild stenosis (grade 2): irregular lumen with reduced signal; severe stenosis (grade 3): absent signal in the stenotic segment (flow gap) and reconstituted distal signal; and possible occlusion (grade 4): absent signal. The cutoffs were chosen to maximize diagnostic accuracy. RESULTS: Interobserver agreement for MRA grading resulted in a weighted-kappa value of 0.776. The rate of poor temporal window was 37% (89/240). Doppler signals were obtained in 135 vessels, and the angle-corrected velocities (peak systolic, end diastolic, mean) were significantly different (P = .001, P = .006, and P < .001) among the MRA grades: grade 1 (100, 47, 68 cm/s), grade 2 (171, 72, 110 cm/s), grade 3 (226, 79, 134 cm/s), grade 4 (61, 26, 39 cm/s). Additionally, an angle-corrected MCA peak systolic velocity > or = 120 cm/s correlates with intracranial stenosis on MRA (grade 2 or worse) with high specificity (90.5%; 95% confidence interval = 78.5%-96.8%) and positive predictive value (93.9%) but relatively low sensitivity (66.7%; 95% confidence interval = 61.2%-69.5%) and negative predictive value (55.1%). CONCLUSION: Elevated MCA velocities on TCCS correlate with intracranial stenosis detected on MRA. An angle-corrected peak systolic velocity > or = 120 cm/s is highly specific for detecting intracranial stenosis as defined by significant MRA abnormality.

Bethlem myopathy in a Taiwanese family.

We report three cases of Bethlem myopathy from three consecutive generations of a Taiwanese family, including one woman aged 70, one man aged 40, and a boy aged 8. The clinical features of the patients included autosomal dominant inheritance, childhood or adolescent onset, mainly proximal and extensor involvement, early diffuse joint contractures, and absence of cardiac involvement. These features fulfilled the diagnostic criteria for Bethlem myopathy. Though the clinical course of the disease was once thought to be benign, our female patient became wheelchair-bound at the age of 53. This suggests that the disease process in Bethlem myopathy is slow but ongoing.

Involvement of nervous system in maternally inherited diabetes and deafness (MIDD) with the A3243G mutation of mitochondrial DNA.

OBJECTIVES: The A3243G mutation of mitochondrial DNA (mtDNA) has been associated with maternally inherited diabetes and deafness (MIDD) in a number of reports; however, the involvement of the nervous system has rarely been mentioned, prompting this exploration of the manifestation of neurological disorders in MIDD cases. MATERIAL AND METHODS: We investigated four generations of a large Taiwanese family in which MIDD is manifest. We conducted a series of clinical examinations, including computed tomography (CT) and magnetic resonance imaging (MRI) of the head, brain 99mTc-HMPAO single photon emission computed tomography (SPECT), cognitive function tests, and nerve conduction velocity (NCV) studies. Blood levels of creatine kinase (CK) and lactate, pathology of muscle biopsy samples and proportions of mutant mtDNA in blood cells, hair follicles, muscle and skin were also analyzed. Mean follow-up period was 4 years. RESULTS: The patients exhibited the clinical features of diabetes mellitus including sensorineural hearing loss, short stature, and/or histories of spontaneous abortion. No stroke-like episodes were reported. Analysis for mtDNA revealed that the A3243G mutation existed in 11 members (6 symptomatic and 5 asymptomatic members) of this MIDD-prone family, with the proportion of mutant mtDNA ranging from 21% to 47% in leukocytes. Head CT revealed diffuse brain atrophy for all 6 (100%) patients examined and bilateral basal ganglia calcification in 4 of 6 (67%) patients. Brain 99mTc-HMPAO SPECT revealed diminished uptake in the bilateral parieto-occipital or occipital regions for all 6 tested patients, cognitive function for these patients was normal. Results of head CT and SPECT were normal in one asymptomatic member of the family. One muscle biopsy revealed abundant ragged-red fibers with modified Gomori-trichrome stain. Muscle-enzyme activity and serum-lactate levels were normal. CONCLUSION: We have demonstrated that a wide spectrum of sub clinical pathologies of the central nervous system and muscle are present for this MIDD-prone family, none of whom developed typical MELAS during the 4-year period of follow-up study.