Comparison of Factors Associated With Direct Versus Transferred-in Admission to Government-Designated Regional Centers Between Acute Ischemic Stroke and Myocardial Infarction in Korea.

BACKGROUND: There has been no comparison of the determinants of admission route between acute ischemic stroke (AIS) and acute myocardial infarction (AMI). We examined whether factors associated with direct versus transferred-in admission to regional cardiocerebrovascular centers (RCVCs) differed between AIS and AMI. METHODS: Using a nationwide RCVC registry, we identified consecutive patients presenting with AMI and AIS between July 2016 and December 2018. We explored factors associated with direct admission to RCVCs in patients with AIS and AMI and examined whether those associations differed between AIS and AMI, including interaction terms between each factor and disease type in multivariable models. To explore the influence of emergency medical service (EMS) paramedics on hospital selection, stratified analyses according to use of EMS were also performed. RESULTS: Among the 17,897 and 8,927 AIS and AMI patients, 66.6% and 48.2% were directly admitted to RCVCs, respectively. Multivariable analysis showed that previous coronary heart disease, prehospital awareness, higher education level, and EMS use increased the odds of direct admission to RCVCs, but the odds ratio (OR) was different between AIS and AMI (for the first 3 factors, AMI > AIS; for EMS use, AMI < AIS). EMS use was the single most important factor for both AIS and AMI (OR, 4.72 vs. 3.90). Hypertension and hyperlipidemia increased, while living alone decreased the odds of direct admission only in AMI; additionally, age (65-74 years), previous stroke, and presentation during non-working hours increased the odds only in AIS. EMS use weakened the associations between direct admission and most factors in both AIS and AMI. CONCLUSIONS: Various patient factors were differentially associated with direct admission to RCVCs between AIS and AMI. Public education for symptom awareness and use of EMS is essential in optimizing the transportation and hospitalization of patients with AMI and AIS.

Routing to Endovascular Treatment of Ischemic Stroke in Korea: Recognition of Need for Process Improvement.

BACKGROUND: To track triage, routing, and treatment status regarding access to endovascular treatment (EVT) after acute ischemic stroke (AIS) at a national level. METHODS: From national stroke audit data, potential candidates for EVT arriving within 6 hours with National Institute of Health Stroke Scale score of ≥ 7 were identified. Acute care hospitals were classified as thrombectomy-capable hospitals (TCHs, ≥ 15 EVT cases/year) or primary stroke hospital (PSH, < 15 cases/year), and patients' initial routes and subsequent inter-hospital transfer were described. Impact of initial routing to TCHs vs. PSHs on EVT and clinical outcomes were analyzed using multilevel generalized mixed effect models. RESULTS: Out of 14,902 AIS patients, 2,180 (14.6%) were EVT candidates. Eighty-one percent of EVT candidates were transported by ambulance, but only one-third were taken initially to TCHs. Initial routing to TCHs was associated with greater chances of receiving EVT compared to initial routing to PSHs (33.3% vs 12.1%, P < 0.001; adjusted odds ratio [aOR], 2.21; 95% confidence interval [CI], 1.59-2.92) and favorable outcome (38.5% vs. 28.2%, P < 0.001; aOR, 1.52; 95% CI, 1.16-2.00). Inter-hospital transfers to TCHs occurred in 17.4% of those initially routed to a PSH and was associated with the greater chance of EVT compared to remaining at PSHs (34.8% vs. 7.5%, P < 0.001), but not with better outcomes. CONCLUSION: Two-thirds of EVT candidates were initially routed to PSHs despite greater chance of receiving EVT and having favorable outcomes if routed to a TCH in Korea. Process improvement is needed to direct appropriate patients to TCHs.

The Trend in Incidence and Case-fatality of Hospitalized Acute Myocardial Infarction Patients in Korea, 2007 to 2016.

BACKGROUND: The trend in the incidence of hospitalized acute myocardial infarction (AMI) and the difference between regions has not been reported in Korea since 2010. Thus, we aimed to inspect recent trends and regional differences in the incidence of AMI and case-fatality between 2007 and 2016. METHODS: Data from the medical utilization cohort from 2002 to 2016 were analyzed. New incidence of AMI was identified by checking the diagnosis code, duration of admission, type of test, treatment, and medication. Age-standardized incidence rate by gender, age group, and resident region was calculated from 2007 to 2016. Cumulative case-fatality rate was calculated until 3 years. RESULTS: Age-standardized incidence of hospitalized AMI decreased from 53.6 cases per 100,000 person-years in 2007 to 38.9 cases in 2011. Thereafter, the incidence gradually increased to 43.2 cases in 2016. The trend by gender and age groups was also similar to the total trend. The regional age-standardized incidence was the highest in Daegu (50.3 cases per 100,000 person-years) and the lowest in Sejong (30.2 cases), which were similar to the ischemic heart disease mortality in these regions. The 7-, 30-, and 90-days and 1- and 3-years average case-fatality over 10 years were 3.2%, 6.9%, 9.9%, 14.7%, and 22.4%, respectively. CONCLUSION: Although case-fatality continuously decreased from 2007 to 2016, hospitalized AMI incidence decreased from 2007 to 2011 and gradually increased from 2011 to 2016, with marked disparity between regions. Effective preventive strategies to decrease AMI incidence are required to decrease cardiovascular disease mortality in Korea.

Laboratory measurement of apixaban using anti-factor Xa assays in acute ischemic stroke patients with non-valvular atrial fibrillation.

Apixaban is effective and safe for preventing stroke, and its usage has increased exponentially in recent years. However, data concerning the therapeutic range of apixaban is limited. This study determined the trough and peak levels of apixaban-specific anti-factor Xa activity (AFXaA) in acute ischemic stroke patients with non-valvular atrial fibrillation (NVAF) in Korea. The study included 85 patients who received apixaban. Blood samples were taken to measure the trough and peak levels of AFXaA using a chromogenic anti-factor assay, as well as prothrombin time (PT) and activated partial thromboplastin time (aPTT). We also reviewed complications such as major bleeding of patients treated with apixaban. In patients given a 5.0-mg apixaban dose, the median trough and peak levels of AFXaA were 104.5 and 202.0 ng/mL. In patients given a 2.5-mg apixaban dose, the median trough and peak AFXaA levels were 76.0 and 151.0 ng/mL. The PT showed a positive correlation with increased AFXaA activity at both levels (Trough R = 0.486, Peak R = 0.592), but the aPTT had no relationship with AFXaA activity at both levels (Trough R = 0.181, Peak R = 0.129). Two cases with intracranial bleeding belonged to the highest AFXaA quartile (Trough, p = 0.176; Peak, p = 0.053). In conclusion, we determined the trough and peak levels of AFXaA in patients with NVAF while being treated with the apixaban in Korea. Our results could be used as a starting point when setting the reference ranges for laboratories using anti-Xa assay. Large-scale studies are needed to establish the reference range for AFXaA in patients with NVAF.

Atorvastatin pretreatment attenuates kainic acid-induced hippocampal neuronal death via regulation of lipocalin-2-associated neuroinflammation.

Statins mediate vascular protection and reduce the prevalence of cardiovascular diseases. Recent work indicates that statins have anticonvulsive effects in the brain; however, little is known about the precise mechanism for its protective effect in kainic acid (KA)-induced seizures. Here, we investigated the protective effects of atorvastatin pretreatment on KA-induced neuroinflammation and hippocampal cell death. Mice were treated via intragastric administration of atorvastatin for 7 days, injected with KA, and then sacrificed after 24 h. We observed that atorvastatin pretreatment reduced KA-induced seizure activity, hippocampal cell death, and neuroinflammation. Atorvastatin pretreatment also inhibited KA-induced lipocalin-2 expression in the hippocampus and attenuated KA-induced hippocampal cyclooxygenase-2 expression and glial activation. Moreover, AKT phosphorylation in KA-treated hippocampus was inhibited by atorvastatin pretreatment. These findings suggest that atorvastatin pretreatment may protect hippocampal neurons during seizures by controlling lipocalin-2-associated neuroinflammation.

Hemianopic line bisection error in a patient with Alzheimer's disease.

Visual symptoms are frequently observed in posterior cortical atrophy compared to typical amnestic Alzheimer's disease (AD). We report the case of a patient with amnestic AD with long-lasting homonymous hemianopia. A 62-year-old woman, who was diagnosed in amnestic AD, complained of visual disturbance. She had left homonymous hemianopia in the perimetry test and left tactile extinction. Regardless of posture, retinotopically leftward error was observed on 21 cm line bisection test. Brain single photon emission computerized tomography (SPECT) showed bilateral temporoparietal hypoperfusion, which was more severe to the right than left side. This case suggested that long-lasting hemianopia could occur in the patient with amnestic AD and that hemianopic line bisection error might be compensatory mechanism.

Simultaneous event of brachial artery occlusion and acute embolic stroke.

Although the rapid and accurate diagnosis of both acute ischemic stroke and extremity ischemia is essential to the timely and appropriate treatment, it is not always easy to differentiate between true stroke and stroke mimics. Although in general, limb ischemia due to extremity embolism is not included in stroke mimics or misdiagnosis, limb arterial embolism should be considered in thedifferential diagnosis of acute monoparesis because the diagnosis maybe missed if the other typical manifestations of this presentation(pain, pallor, pulselessness, sensory loss, and coolness of the arm) are overlooked. Therefore, it is important to ensure that important signsare not missed whether the evaluation of the patient is done at thebedside. We report a case of a male patient presented to an emergency department with acute right upper extremity pain with headache, gait disturbance, and confused mentality. He was diagnosed by simultaneou sbrachial artery occlusion and acute stroke, which resulted in emergency surgical embolectomy and anticoagulation therapy.

Establishment of government-initiated comprehensive stroke centers for acute ischemic stroke management in South Korea.

BACKGROUND AND PURPOSE: In 2008, the Ministry of Health and Welfare of South Korea initiated the Regional Comprehensive Stroke Center (CSC) program to decrease the incidence and mortality of stroke nationwide. We evaluated the performance of acute ischemic stroke management after the Regional CSC program was introduced. METHODS: The Ministry of Health and Welfare established 9 Regional CSCs in different provinces from 2008 to 2010. All Regional CSCs have been able to execute the critical processes independently for stroke management since 2011. The Ministry of Health and Welfare was responsible for program development and financial support, the Regional CSC for program execution, and the Korea Centers for Disease Control and Prevention for auditing the execution. We analyzed prospectively collected data on the required indices from 2011 and repeated the analysis the following year for comparison. RESULTS: After the Regional CSCs were established, the first brain image was taken within 1 hour from arrival at the emergency room for all patients with stroke; the length of hospital stay decreased from 14 to 12 days; for the rapid execution of thrombolysis, the first brain image was taken within 12 minutes; intravenous and intra-arterial thrombolysis were started within 40 and 110 minutes, respectively, after emergency room arrival; and the hospital stay of thrombolytic patients decreased from 19 to 15 days. CONCLUSIONS: The Regional CSC program has improved the performance of acute stroke management in South Korea and can be used as a model for rapidly improving stroke management.

Ipsilateral hemiparesis and spontaneous horizontal nystagmus caused by middle cerebral artery territory infarct in a patient with agenesis of the corpus callosum.

Ipsilateral hemiparesis and spontaneous nystagmus have rarely been reported after a cerebral lesion. A 35-year-old man with agenesis of the corpus callosum developed ipsilateral hemiparesis and spontaneous horizontal nystagmus after an infarct in the right middle cerebral artery territory. Magnetic resonance imaging revealed the presence of an acute infarct in the right middle and inferior frontal gyrus, supramarginal gyrus, insular gyrus, internal capsule, head of caudate nucleus, putamen, and globus pallidus. Transcranial stimulation of the hand area of the cerebral motor cortex produced motor-evoked potentials in the abductor pollicis brevis muscle exclusively on the ipsilateral side. No motor-evoked potentials were evoked in the abductor pollicis brevis muscle contralateral to the stimulation. The motor-evoked potentials and magnetic resonance imaging findings in our case suggest that anomalies of the decussation of the corticospinal tracts can be found in agenesis of the corpus callosum.

Comparisons of Prehospital Delay and Related Factors Between Acute Ischemic Stroke and Acute Myocardial Infarction.

Background Prehospital delay is an important contributor to poor outcomes in both acute ischemic stroke (AIS) and acute myocardial infarction (AMI). We aimed to compare the prehospital delay and related factors between AIS and AMI. Methods and Results We identified patients with AIS and AMI who were admitted to the 11 Korean Regional Cardiocerebrovascular Centers via the emergency room between July 2016 and December 2018. Delayed arrival was defined as a prehospital delay of >3 hours, and the generalized linear mixed-effects model was applied to explore the effects of potential predictors on delayed arrival. This study included 17 895 and 8322 patients with AIS and AMI, respectively. The median value of prehospital delay was 6.05 hours in AIS and 3.00 hours in AMI. The use of emergency medical services was the key determinant of delayed arrival in both groups. Previous history, 1-person household, weekday presentation, and interhospital transfer had higher odds of delayed arrival in both groups. Age and sex had no or minimal effects on delayed arrival in AIS; however, age and female sex were associated with higher odds of delayed arrival in AMI. More severe symptoms had lower odds of delayed arrival in AIS, whereas no significant effect was observed in AMI. Off-hour presentation had higher and prehospital awareness had lower odds of delayed arrival; however, the magnitude of their effects differed quantitatively between AIS and AMI. Conclusions The effects of some nonmodifiable and modifiable factors on prehospital delay differed between AIS and AMI. A differentiated strategy might be required to reduce prehospital delay.

Change in blood pressure variability in patients with acute ischemic stroke and its effect on early neurologic outcome.

BACKGROUND: How short-term blood pressure variability (BPV) is affected in the acute stage of ischemic stroke and whether BPV is associated with early neurologic outcomes remains unclear. METHODS: Patients who admitted for ischemic stroke within 24 h of symptom onset were consecutively identified between January 2010 and January 2015. BP profiles measured in real-time were summarized into short-term, 24-h time intervals, based on standard deviation (SD) and mean of systolic BP (SBPSD) during the first 3 days. The primary outcome was daily assessment of early neurological deterioration (END). The associations between short-term SBPSD values and the secular trend for primary outcome were examined. RESULTS: A total of 2,545 subjects (mean age, 67.1 ± 13.5 years old and median baseline National Institutes of Health Stroke Scale score, 3) arrived at the hospital an average of 6.1 ± 6.6 h after symptom onset. SBPSD values at day 1 (SD#D1), SD#D2, and SD#D3 were 14.4 ± 5.0, 12.5 ± 4.5, and 12.2 ± 4.6 mmHg, respectively. Multivariable analyses showed that SD#D2 was independently associated with onset of END at day 2 (adjusted odds ratio, 1.08; 95% confidence interval, 1.03-1.13), and SD#D3 was independently associated with END#D3 (1.07, 1.01-1.14), with adjustments for predetermined covariates, SBPmean, and interactions with daily SBPSD. CONCLUSION: Short-term BPV changed and stabilized from the first day of ischemic stroke. Daily high BPV may be associated with neurological deterioration independent of BPV on the previous day.

Toxocara canis-Associated Myelitis with Eosinophilic Pneumonia.

The existence of Toxocara canis-specific antibodies has recently been reported in patients with atopic myelitis. Here, we report the case of a 35-year-old male patient admitted with a chief complaint of right lower limb hypoesthesia lasting for a month. The patient was diagnosed with eosinophilic pneumonia 3 months ago, and a spine MRI revealed the presence of myelitis in the cervicothoracic cord. After confirming the presence of hyper-IgE-emia and Toxocara canis antibodies, the patient was treated with steroids and albendazole treatment, which improved his symptoms. To our knowledge, this is the first case of Toxocara canis-associated myelitis with eosinophilic pneumonia.

Comparison of Solitaire thrombectomy and Penumbra suction thrombectomy in patients with acute ischemic stroke caused by basilar artery occlusion.

BACKGROUND AND PURPOSE: Acute ischemic stroke (AIS) caused by basilar artery occlusion (BAO) is a very severe neurological disease with a high mortality rate and poor clinical outcomes. In this study, we compared our experience of mechanical thrombectomy using the Solitaire stent (Solitaire thrombectomy) and manual aspiration thrombectomy using the Penumbra reperfusion catheter (Penumbra suction thrombectomy) in patients with AIS caused by BAO. MATERIALS AND METHODS: Between March 2011 and December 2011, 13 patients received Solitaire thrombectomy. In January 2012, the Korean Food and Drug Administration banned the use of the Solitaire stent as a thrombectomy device, and a further 18 patients received Penumbra suction thrombectomy until December 2013. We compared parameters between patients treated with each device. RESULTS: Successful recanalization rates (Thrombolysis in Cerebral Infarction (TICI) score ≥2b: 84.6% vs 100%, p=0.168) and clinical outcomes (judged by the modified Rankin Scale scores recorded at 3 months: 3.6±2.6 vs 3.2±2.6, p=0.726) were not significantly different between the two groups. However, complete recanalization rates (TICI score of 3: 23.1% vs 72.2%, p=0.015) and total procedure times (101.9±41.4 vs 62.3±34.8 min, p=0.044) were significantly higher, and shorter, respectively, in patients treated by Penumbra suction thrombectomy. CONCLUSIONS: The two thrombectomy devices were associated with similar recanalization rates and clinical outcomes in patients with AIS caused by BAO. However, Penumbra suction thrombectomy seemed to allow more rapid and complete recanalization than Solitaire thrombectomy.

Location of Irritative Zone in Epileptic Brains of Schizencephalic Patients.

Although many schizencephaly patients suffer from epilepsy, the relationship between schizencephalic lesions and epileptic foci remains unclear. Previous studies have shown that schizencephalic lesions may be associated with, rather than contain, epileptogenic zones. Thus, the purpose of this study was to investigate the current source distribution (CSD) of epileptiform discharges in schizencephalic patients and to correlate this activity with existing structural lesions. A consecutive series of 30 schizencephalic patients who were diagnosed using brain magnetic resonance imaging (MRI) were selected retrospectively and prospectively. Of the original 30 subjects selected, 13 had epilepsy, and 6 of these patients exhibited schizencephaly, epilepsy, and interictal spikes on electroencephalograms (EEG) and were enrolled in the present study investigating the current source analysis of interictal spikes. The CSDs of the initial rising phases and the peak points of the interictal spikes were obtained using standardized low-resolution brain electromagnetic tomography (LORETA). Five patients exhibited a single focus of interictal spikes, while 1 patient showed 2 foci. Relative to the structural brain lesions, 5 patients displayed extrinsically localized CSDs, while 1 patient showed a partially intrinsically localized CSD. The present findings demonstrate that the CSDs of interictal spikes in schizencephalic patients are in general anatomically distinct from the cerebral schizencephalic lesions and that these lesions may display an extrinsic epileptogenicity.

Initial factors affecting the clinical outcome after successful recanalization via MR-based mechanical thrombectomy in patients with acute ischemic stroke due to basilar artery occlusion.

BACKGROUND AND PURPOSE: To determine the initial factors, including patient characteristics, stroke etiology and severity, time factors, and imaging findings, that could affect the clinical outcome of patients with acute ischemic stroke (AIS) caused by basilar artery occlusion (BAO) where successful recanalization was achieved via mechanical thrombectomy. METHODS: Between March 2011 and December 2014, 35 patients with AIS caused by BAO received MRI/MR angiography-based mechanical thrombectomies, and recanalization was achieved with a Thrombolysis In Cerebral Infarction score of >2b. The patients were divided into a good outcome group (n=19), defined as those with a modified Rankin Scale (mRS) score of 0-2 at 3 months after stroke onset, and a poor outcome group (n=16), defined as a mRS score of 3-6. The differences between the groups were analyzed. RESULTS: Initial National Institutes of Health Stroke Scale (NIHSS) score (good vs poor: 17.9±8.9 vs 27.6±8.5, p=0.003), posterior circulation Acute Stroke Prognosis Early CT Score (pc-ASPECTS) based on initial diffusion-weighted images (DWI) (good vs poor: 7.8±1.6 vs 5.4±1.8, p=0.001), pc-ASPECTS based on contrast staining on the post-thrombectomy control CT (good vs poor: 9.2±1.5 vs 6.3±2.2, p<0.001), and presence of contrast staining in the brainstem on that CT (good vs poor: 15.8% vs 81.6%, p<0.001) were significantly different between the groups. CONCLUSIONS: Patients with AIS caused by BAO with a lower initial NIHSS score, fewer lesions on initial DWI, and less contrast staining on the post-thrombectomy control CT have higher probabilities of a good clinical outcome after successful recanalization via a mechanical thrombectomy.

Carotid stent infection: a rare but potentially fatal complication of carotid artery stenting.

Infections involving endovascular devices are rare and, to our knowledge, only three cases of infection with an inserted carotid stent have ever been reported. A 68-year-old man underwent carotid artery stenting (CAS) of the left proximal internal carotid artery. Two days after CAS the patient developed a high fever and investigation showed that the inserted carotid stent was infected. The infection could not be controlled despite adequate antibiotic therapy. Eventually a rupture of the carotid artery occurred and the patient underwent emergency resection of the left carotid bifurcation in addition to stent removal and reconstruction with a saphenous vein interposition graft. The patient recovered fully without any neurological sequelae.

Emergency carotid artery stenting in patients with acute ischemic stroke due to occlusion or stenosis of the proximal internal carotid artery: a single-center experience.

BACKGROUND: The feasibility, safety and effectiveness of emergency carotid artery stenting (eCAS) in patients with acute ischemic stroke (AIS) due to proximal internal carotid artery (ICA) stenosis or occlusion are still controversial. In this study we analyzed our experience with eCAS in patients with AIS. METHODS: Twenty-two eCAS procedures for proximal ICA stenosis or occlusion were performed in 22 patients at our institution between January 2011 and November 2013. The mean time from stroke symptom onset to presentation was 204 min (range 50-630 min) and the mean initial score on the National Institutes of Health Stroke Scale (NIHSS) was 12.55 (range 5-23). Ten patients had total occlusion of the proximal ICA and the remaining 12 patients had near total occlusion or severe stenosis (mean degree 90.7%, range 80-100%). Eleven patients also had tandem occlusion on the more distal intracranial arteries. RESULTS: Successful stent insertion was achieved in all patients and additional thrombectomy using a Solitaire stent or Penumbra aspiration catheter achieved a Thrombolysis In Cerebral Infarction grade of more than 2a in all patients with distal tandem occlusion. Procedure-related complications occurred in one patient (cerebral hyperperfusion syndrome) who recovered successfully. The mean NIHSS score at discharge was 3.55 (range 0-18). The mean modified Rankin Scale score at 3 months was 1 ± 1.67 (range 0-6). CONCLUSIONS: eCAS in patients with AIS due to proximal ICA stenosis or occlusion appears to be a technically feasible and effective method for achieving good clinical outcomes.

Carotid stent infection: a rare but potentially fatal complication of carotid artery stenting.

Infections involving endovascular devices are rare and, to our knowledge, only three cases of infection with an inserted carotid stent have ever been reported. A 68-year-old man underwent carotid artery stenting (CAS) of the left proximal internal carotid artery. Two days after CAS the patient developed a high fever and investigation showed that the inserted carotid stent was infected. The infection could not be controlled despite adequate antibiotic therapy. Eventually a rupture of the carotid artery occurred and the patient underwent emergency resection of the left carotid bifurcation in addition to stent removal and reconstruction with a saphenous vein interposition graft. The patient recovered fully without any neurological sequelae.

Carotid artery stenting in patients with near occlusion: a single-center experience and comparison with recent studies.

OBJECTIVE: The optimal management strategy for carotid artery near occlusion is still controversial. Nevertheless, prior studies about carotid artery stenting in patients with near occlusion reported both technically and clinically inspiring results. To define the effectiveness, safety, and clinical outcomes of carotid artery stenting in patients with near occlusion, we analyzed our experiences and compared with recent studies. METHODS: We performed 24 carotid artery stenting procedures in 24 patients with near occlusion between January 2010 and July 2012. The patient group comprised 20 men (83.3%) and four women (16.7%) with a mean age of 69.5 years (range, 53-85 years). Eighteen patients had prior stroke or transient ischemic attack (75%), and six patients were asymptomatic (25%). RESULTS: Successful stent insertion was achieved in 23 of 24 patients (95.8%). Cerebral hyperperfusion syndrome and post-procedural vascular events occurred in four patients, and all of these developed within 24h after the procedure (17.4%; two: hyperperfusion syndrome, two: acute myocardial infarction). The mean follow-up period after carotid artery stenting was 16.7±9.2 months (range, 6-32 months). No stroke related to carotid artery stenting or significant restenosis of the inserted stent developed during the follow-up period. CONCLUSIONS: Carotid artery stenting in patients with near occlusion seems to be a technically feasible and effective method to prevent stroke recurrence. But hyperperfusion syndrome and post-procedural vascular event rates may be high, as shown in this study.