Chin Sang Chung

Ischemic Stroke and Cancer: Stroke Severely Impacts Cancer Patients, While Cancer Increases the Number of Strokes

Background Cancer and ischemic stroke are two of the most common causes of death among the elderly, and associations between them have been reported. However, the main pathomechanisms of stroke in cancer patients are not well known, and can only be established based on accurate knowledge of the characteristics of cancer-related strokes. We review herein recent studies concerning the clinical, laboratory, and radiological features of patients with cancer-related stroke. Main Contents This review covers the epidemiology, underlying mechanisms, and acute and preventive treatments for cancer-related stroke. First, the characteristics of stroke (clinical and radiological features) and systemic cancer (type and extent) in patients with cancer-specific stroke are discussed. Second, the role of laboratory tests in the early identification of patients with cancer-specific stroke is discussed. Specifically, serum D-dimer levels (as a marker of a hypercoagulable state) and embolic signals on transcranial Doppler (suggestive of embolic origin) may provide clues regarding changes in the levels of coagulopathy related to cancer and anticoagulation. Finally, strategies for stroke treatment in cancer patients are discussed, emphasizing the importance of preventive strategies (i.e., the use of anticoagulants) over acute revascularization therapy in cancer-related stroke. Conclusion Recent studies have revealed that the characteristics of cancer-related stroke are distinct from those of conventional stroke. Our understanding of the characteristics of cancer-related stroke is essential to the correct management of these patients. The studies presented in this review highlight the importance of a personalized approach in treating stroke patients with cancer.

Prevalence and Impact of Migraine and Tension-Type Headache in Korea

Background and Purpose The epidemiology and impact of headache disorders are only partially documented for Asian countries. We investigated the prevalence and impact of migraine and tension-type headache - which are the two most common primary headache disorders - in a Korean population. Methods A stratified random population sample of Koreans older than 19 years was selected and evaluated using a 29-item, semistructured interview. The questionnaire was designed to classify headache types according to the criteria of the International Classification of Headache Disorders, second edition, including migraine and tension-type headache. The questionnaire also included items on basic demographics such as age, gender, geographical region, education level, and income, and the impact of headache on the participant. Results Among the 1507 participants, the 1-year prevalence of all types of headaches was 61.4% (69.9% in women and 52.8% in men). The overall prevalence rates of migraine and tension-type headaches were 6.1% (9.2% in women and 2.9% in men) and 30.8% (29.3% in women and 32.2% in men), respectively. The prevalence of migraine peaked at the age of 40-49 years in women and 19-29 years in men. In contrast to migraine, the prevalence of tension-type headache was not influenced by either age or gender. Among individuals with migraine and tension-type headache, 31.5% and 7% reported being substantially or severely impacted by headache, respectively (Headache Impact Test score ≥56). Overall, 13.4% of all headache sufferers reported being either substantially or severely impacted by headache. Conclusions The 1-year prevalence rates of migraine and tension-type headache in the studied Korean population were 6.1% and 30.8%, respectively. One-third of migraineurs and some individuals with tension-type headache reported being either substantially or severely impacted by headache.

Elevated serum lipoprotein(a) as a potential predictor for combined intracranial and extracranial artery stenosis in patients with ischemic stroke

OBJECTIVES Despite compelling evidence of lipoprotein(a) [Lp(a)] as a risk factor for ischemic stroke, its underlying mechanism remains unclear. Our aim is to investigate whether serum Lp(a) level is associated with the extent and location of cerebral steno-occlusive lesions, and with large artery atherosclerotic (LAA) stroke in Korean patients. METHODS We analyzed data prospectively collected over a 3-year period on consecutive patients with stroke or TIA. Based on an angiographic study, a total of 1012 patients were classified into four subtypes: non-cerebral stenosis (n=654), intracranial stenosis (n=198), extracranial carotid stenosis (n=86), and combined intracranial and extracranial carotid stenosis (n=74). Independent associations of Lp(a) levels with the extent and location of cerebral stenosis were evaluated, and Lp(a) levels of subtypes by the TOAST criteria were compared. RESULTS Lp(a) levels of LAA stroke were significantly higher than those of the other four stroke mechanisms. Patients with more advanced intracranial (p=0.001) and extracranial carotid stenoses (p=0.001) tended to have higher Lp(a) levels. In multiple regression analysis, the third Lp(a) quartile was the strongest risk factor for isolated intracranial (OR 3.36, 95% CI 1.77-6.37) or extracranial stenosis (OR 4.82, 95% CI 1.96-11.88), whereas the fourth Lp(a) quartile was the most powerful predictor for combined intracranial and extracranial carotid stenosis (OR 4.98, 95% CI 1.92-12.91). CONCLUSIONS Our results indicate that greatly elevated Lp(a) levels are associated with LAA stroke and extensive burden of cervicocerebral steno-occlusive lesions, which might offer indirect evidence of proatherothrombogenic role of Lp(a) in ischemic stroke.

Update of the Korean Clinical Practice Guidelines for Endovascular Recanalization Therapy in Patients with Acute Ischemic Stroke

Patients with severe stroke due to acute large cerebral artery occlusion are likely to be severely disabled or dead without timely reperfusion. Previously, intravenous tissue plasminogen activator (IV-TPA) within 4.5 hours after stroke onset was the only proven therapy, but IV-TPA alone does not sufficiently improve the outcome of patients with acute large artery occlusion. With the introduction of the advanced endovascular therapy, which enables more fast and more successful recanalization, recent randomized trials consecutively and consistently demonstrated the benefit of endovascular recanalization therapy (ERT) when added to IV-TPA. Accordingly, to update the recommendations, we assembled members of the writing committee appointed by the Korean Stroke Society, the Korean Society of Interventional Neuroradiology, and the Society of Korean Endovascular Neurosurgeons. Reviewing the evidences that have been accumulated, the writing members revised recommendations, for which formal consensus was achieved by convening a panel composed of 34 experts from the participating academic societies. The current guideline provides the evidence-based recommendations for ERT in patients with acute large cerebral artery occlusion regarding patient selection, treatment modalities, neuroimaging evaluation, and system organization.

Large-Artery Stenosis Predicts Subsequent Vascular Events in Patients with Transient Ischemic Attack

Background and purpose We investigated subsequent vascular events in patients with transient ischemic attack (TIA) and determined the predictors of such events among vascular risk factors including large-artery disease, TIA-symptom duration, and acute ischemic lesions on diffusion-weighted imaging (DWI). Methods We identified 98 consecutive patients with TIA who visited a tertiary university hospital and underwent DWI and brain magnetic resonance angiography within 48 hours of symptom onset. We reviewed the medical records to assess the clinical characteristics of TIA, demographics, and the subsequent vascular events including acute ischemic stroke, TIA, and myocardial infarction. Results Large-artery disease was detected in 55 patients (56%). Ten patients (10%) experienced TIA symptoms for longer than 1 hour, and acute infarctions on DWI were identified in 30 patients (31%). During the mean follow-up period of 19 months, seven patients (7%) had an acute ischemic stroke and 20 patients (20%) had TIA. Retinal artery occlusion in two patients, spinal cord infarction in one patient, and peripheral vascular claudication in one patient were also recorded. Cox proportional-hazards multivariate analysis revealed that large-artery disease was an independent predictor of subsequent cerebral ischemia (hazard ratio [HR], 2.8; 95% confidence interval [CI], 1.1-7.1; p=0.02) and subsequent vascular events (HR, 2.9; 95% CI, 1.2-6.7; p=0.01). Conclusions In patients with TIA, large-artery disease is an independent predictor of subsequent vascular events. Acute infarction on DWI and a symptom duration of more than 1 hour are not significantly correlated with a higher risk of subsequent vascular events. These findings suggest that the underlying vascular status is more important than symptom duration or acute ischemic lesion on DWI.

Routine cardiac evaluation in patients with ischaemic stroke and absence of known atrial fibrillation or coronary heart disease: transthoracic echocardiography vs. multidetector cardiac computed tomography

Background and purpose:  Cardiac evaluation is routinely conducted in patients with ischaemic stroke because embolisms originating from the heart are an important cause of stroke. We compared the prevalence of cardioaortic sources of cerebral embolism (CSCE) in patients with ischaemic stroke detected by transthoracic echocardiography (TTE) and/or multidetector cardiac computed tomography (MDCT). Additionaly, we investigated the frequency and severity of asymptomatic coronary artery disease (CAD) in patients who underwent MDCT.

Clinical Performance Examination Utilizing Standardized Patients in Board Examination: Based on the Board Examination of Korean Neurological Association for Three Years

PURPOSE Evaluation of clinical skills and attitude including development of dynamic patient-doctor relationship is important in board examination (BE). Korean Neurological Association (KNA) has introduced clinical performance examination (CPX) utilizing standardized patients (SP) to BE in 2007. In this study, the authors describe the 3-year experience of CPX in BE through 2009. METHODS To implement CPX session in BE, KNA developed CPX workshop for BE attendees and members of grading committee. CPX sessions in BE consisted of two model scenarios mimicking neurological patients in clinical practice. The total score and itemized scores of CPX sessions were compared with other areas of BE, and scores from each year were also compared. RESULTS Scores from CPX sessions were significantly correlated with BE step II. Among the itemized scores of CPX sessions, clinical items including history taking and physical examination were significantly correlated with scores from other areas of BE. However, scores from global assessment from SP were strongly associated with patient-doctor relationship, history taking, and patient education. CONCLUSION Our experiences suggest that CPX utilizing SP is a useful tool to assess the clinical skills in BE. In order to produce clinically well qualified neurologists, more efforts should be made to develop cases and to improve assessment tools for CPX.

Repetitive leg movements mimicking periodic leg movement during sleep in a brain‐dead patient

Sir, Spontaneous movements are noted in up to 75% of brain-dead patients [1]. We present a brain-dead patient who showed periodic leg movement (PLM) mimicking periodic limb movement during sleep. Informed consent was obtained from the patient’s family. A 50-year-old untreated hypertensive man became abruptly comatose. He scored 3 on the Glasgow Coma Scale at initial examination in another hospital. Brain computed tomography showed a massive intracranial hemorrhage in the left hemisphere (Fig. 1). He was transferred to our hospital for verification of brain death and donation of organs for transplantation after 24 h in coma. Apart from hypertension, his medical history was unremarkable. His family denied any history of sleep disorders. The first examination to determine brain death was performed immediately according to the national guidelines and the American Academy of Neurology Practice Parameters [2] as follows: (i) thorough clinical neurological examination, including documentation of coma, the absence of brainstem reflexes, and apnea; (ii) these clinical features were verified to be present for at least 6 h for determination of irreversibility; (iii) hypothermia, drug intoxication, and other metabolic causes of coma were excluded; (iv) Electroencephalogram was recorded as a confirmatory test after the second examination and to demonstrate electrocerebral inactivity. The patient was in a state of coma, and strong painful stimulation did not evoke any motor response. His pupils were largely dilated and unresponsive to light. No oculocephalic movements were elicited by rapid turning of the head. The caloric test showed no reflex eyeball movement. Corneal and cough reflexes were absent. The apnea test revealed no spontaneous respiratory drive at a 60 mmHg partial pressure of arterial carbon dioxide (baseline arterial blood gas: pH 7.398, PaCO2 40.2 mmHg, PaO2 372.8 mmHg; 8 min after apnea: pH 7.226, PaCO2 71.6 mmHg, PaO2 533.3 mmHg). At this time, the patient did not show any spontaneous or reflex movement. After a 12-h observation period, the second evaluation for brain death revealed no change in his neurological status. EEG demonstrated electrocerebral inactivity, confirming brain death. Subsequently, his right leg moved periodically. The periodic movement occurred approximately 10 to 20 times per hour without apparent provocation. It consisted of dorsiflexion of the foot and slight flexion of the knee and hip lasting for 2–3 s and recurring at a frequency of approximately once every 20–30 s (Fig. 2). It was approximately 30 h before these periodic movements ceased. Spontaneous or reflex movements such as plantar responses, muscle stretch reflexes, abdominal reflexes, plantar withdrawal, and finger jerks have been reported in patients with brain death. They are considered spinal reflexes and therefore do not preclude the diagnosis of brain death [1]. PLM during sleep involves repetitive, stereotypic extension of the great toe and dorsiflexion of the ankle with occasional flexion of the knee and hip, each movement lasting approximately 0.5–5.0 s with

Neuropsychological Correlates of the Proportional Impact of White Matter Hyperintensities on Mild to Moderate Dementia: The MRI 300 Study

Background: White matter hyperintensities (WMH) increase cognitive impairment in patients with dementia. Objective: We investigated the impact of WMH on the neuropsychological profiles in patients with mild to moderate dementia. Methods: We consecutively recruited newly diagnosed patients with mild to moderate dementia across South Korea for 1 year. The participants completed neuropsychological tests, magnetic resonance imaging, and structured neurological evaluations. The patients were divided into 3 categories, i.e. minimal, moderate, and severe WMH groups, according to the proportional degree of WMH. Results: 289 patients were recruited; 140 (48.3%) for the minimal WMH group, 99 (34.2%) for the moderate group, and 50 (17.5%) for the severe group. Both advanced age and low general cognitive level were significant contributors to WMH in patients with dementia. After adjusting for age, the neuropsychological correlates of the proportional impact of WMH were frontal executive, language, and attention profiles. However, the only significant neuropsychological correlate was the recognition memory profile after adjusting for both age and general cognitive level simultaneously. Conclusion: The results suggest that the most significant neuropsychological profile impacting the burden of WMH in patients with mild to moderate dementia was the recognition memory profile, regardless of age and general cognitive function.

Transcortical sensory aphasia following a left frontal lobe infarction probably due to anomalously represented language areas

A 57-year-old right-handed man presented with speech disturbance 1 day prior to his admission. The standardized aphasia test batteries showed transcortical sensory aphasia. MRI revealed a left frontal and insular infarct. Positron emission tomography scans also revealed a glucose hypometabolism in the same region as the infarcted area on MRI. Repeated aphasia testing showed that his aphasia only partially improved.