Gim-Thean Khor

Eligibility and rate of treatment for recombinant tissue plasminogen activator in acute ischemic stroke using different criteria.

OBJECTIVES The rate of recombinant tissue plasminogen activator (rtPA) use for stroke is low among the Chinese-Taiwanese. The study objective was to determine if less restrictive exclusion criteria for rtPA would increase eligibility and the rate of treatment. METHODS This retrospective before-and-after study was conducted from 2006 to 2009. The authors compared stroke patients treated under the old rtPA exclusion criteria (January 2006 to December 2008) with those treated with less restrictive rtPA exclusion criteria (January to December 2009). Rates of eligibility and treatment and reasons for exclusion from rtPA between the two phases were assessed. RESULTS Of 461 eligible patients during the study period, 333 were evaluated by the old criteria and 128 were evaluated by the less restrictive criteria. Minor or improving stroke was the primary exclusion reason in both groups (194/333, 58% vs. 70/128, 55%). Eligibility for rtPA was increased in the less restrictive criteria (35/127, 27%, 95% confidence interval [CI] = 20% to 36%) compared to the old criteria (40/333, 12%, 95% CI = 8.7% to 16%; p = 0.0001). Fewer patients were excluded due to old age in the less restrictive criteria (0/128, 0%) compared to the old criteria (37/333, 11%; p = 0.0001). The rate of consent refusal increased in the less restrictive criteria (27/128, 21%, 95% CI = 14% to 29%) compared to the old criteria (23/333, 6.9%, 95% CI = 4.4% to 10%; p < 0.0001). Rate of rtPA treatment was unchanged between the less restrictive criteria (8/128, 6.3%, 95% CI = 2.7% to 12%) and the old criteria (17/333, 5.1%, 95% CI = 3% to 8%; p = 0.63). CONCLUSIONS Increasing eligibility for rtPA does not increase the rate of treatment, possibly due to the high symptomatic intracerebral hemorrhage rate among Chinese-Taiwanese, which is a major concern among emergency physicians (EPs), neurologists, and patients. Dealing with perceived safety issues of rtPA is crucial before the rate of treatment can be increased.

Sex Differential Genetic Effect of Chromosome 9p21 on Subclinical Atherosclerosis

Background Chromosome 9p21 has recently been shown to be a risk region for a broad range of vascular diseases. Since carotid intima-media thickness (IMT) and plaque are independent predictors for vascular diseases, the association between 9p21 and these two phenotypes was investigated. Methodology/Principal Findings Carotid segment-specific IMT and plaques were obtained in 1083 stroke- and myocardial infarction-free volunteers. We tested the genotypes and haplotypes of key single nucleotide polymorphisms (SNPs) on chromosome 9p21 for the associations with carotid IMT and plaque. Multivariate permutation analyses demonstrated that carriers of the T allele of SNP rs1333040 were significantly associated with thicker common carotid artery (CCA) IMT (p = 0.021) and internal carotid artery (ICA) IMT (p = 0.033). The risk G allele of SNP rs2383207 was associated with ICA IMT (p = 0.007). Carriers of the C allele of SNP rs1333049 were found to be significantly associated with thicker ICA IMT (p = 0.010) and the greater risk for the presence of carotid plaque (OR = 1.57 for heterozygous carriers; OR = 1.75 for homozygous carriers). Haplotype analysis showed a global p value of 0.031 for ICA IMT and 0.115 for the presence of carotid plaque. Comparing with the other haplotypes, the risk TGC haplotype yielded an adjusted p value of 0.011 and 0.017 for thicker ICA IMT and the presence of carotid plaque respectively. Further analyzing the data separated by sex, the results were significant only in men but not in women. Conclusions Chromosome 9p21 had a significant association with carotid atherosclerosis, especially ICA IMT. Furthermore, such genetic effect was in a gender-specific manner in the Han Chinese population.

Identification of subgroups of acquired idiopathic generalized anhidrosis.

Background:Acquired idiopathic generalized anhidrosis (AIGA) is a rarely encountered clinical syndrome. Sixty-five cases have been reported and 62 of them are Japanese. AIGA was further classified into 3 subgroups with idiopathic pure sudomotor failure being the most common. However, it is burdensome to diagnose AIGA and identify its subgroups. Some of the tools used to diagnose AIGA such as the quantitative sudomotor axon reflex test and microneurography are not generally available. Case Summary:We report the first Chinese patient with AIGA and review the literature to develop a flowchart for the diagnosis and identification of subgroups of AIGA. Conclusion:We conclude that skin biopsy is crucial for the identification of subgroups of AIGA.

Isolated ataxia after pure left insular cortex infarction.

Acute insular infarction, due to its anatomic and functional complexity and wide connections, may present with various clinical presentations, such as somatosensory deficits, gustatory disorder, vestibular-like syndrome, cardiovascular disturbances, neuropsychological disorders, movement disorders, autonomic dysfunction and empathy impairment. However, there was no mention of the symptoms involving the cerebellar system in the related literature. We present a case of pure left insular cortex infarction with isolated truncal ataxia and demonstrate a crucial relationship between the left insular cortex and the cerebellar system. The possible connections are through the spinocerebellar and dentatorubrothalamic pathway. In conclusions, left insular cortex lesions should be considered in the differential diagnosis of isolated truncal ataxia.

Giant cell arteritis with multiple cranial nerve palsy and reversible proptosis: a case report.

Giant cell arteritis (GCA) often presents with symptoms of headache, jaw claudication, polymyalgia rheumatica, and blurred vision. GCA is relatively rare and may have atypical manifestations in Asians, including multiple cranial nerve palsy and reversible proptosis. A high suspicion of GCA is suggested when any older Asian suffers from headache that is new‐onset or different from the previous pattern, even without other typical manifestations of GCA.

Susceptibility weighted imaging in a patient with paroxysmal sympathetic storms

JO N 2 95 7 from FES and lesion localization of PSS [6]. A 19-year-old male college student without significant medical history was injured in a car crash. He collided with a car while riding motorcycle and was thrown to the ground. He did not lose consciousness at the scene and was then sent to our emergency department. At the emergency department, the patient was alert and had a Glasgow Coma Scale (GCS) score of 15. His vital signs were stable and physical examination revealed facial contusion and a deformed left lower limb. Neurological examination revealed retrograde amnesia without other focal deficits. X-rays of the left lower limb showed left femur and tibia fractures. Due to retrograde amnesia and facial contusion which indicated possible brain injury, brain computed tomography (CT) was arranged and revealed normal findings. After complete survey, the patient was sent to the operating room for surgical repair and left with full consciousness. Ten hours after the car crash, the patient’s consciousness deteriorated rapidly from GCS score 15 to 6 (E1V1M4). Desaturation was then noted and the patient was intubated. Another brain CT was arranged and the result was still negative. Under the impression of FES, the patient was transferred to the neurological intensive care unit (NICU) for further management and survey. At the NICU, chest CT was arranged and showed no evidence of emboli. No petechial rash was noted and funduscopic examination revealed no fat globules. On day 7 of hospitalization, the patient began to suffer from episodes of high fever (up to 40 oC), tachycardia (up to 160 beats/min), elevated blood pressure (systolic, up to 180 mmHg), tachypnea (40/min), diaphoresis and decerebrate posturing. These episodes occurred 3 Poyin Huang Wei-Chen Lin Po-Kai Huang Gim-Thean Khor

Potential Risk and Protective Factors for In-Hospital Mortality in Hyperacute Ischemic Stroke Patients

In the era of thrombolytic therapy for hyperacute ischemic stroke, most investigators have focused their attention on the factors influencing mortality and functional outcomes in patients treated with thrombolysis, but very few have focused on these factors among patients not receiving thrombolysis. The aim of this study was to investigate the prognostic factors for mortality in all hyperacute stroke patients with or without thrombolysis. In 2005, we enrolled 101 ischemic stroke patients (43 females, 58 males; mean age, 68 years) who were transported to the emergency department (ED) within 4 hours of symptom onset. The overall in‐hospital mortality rate was 17.8% (18/101). According to t test analysis, age (p = 0.034), time interval from neurologist consultation (p < 0.0001) and ED to ward admission (p = 0.001), Glasgow coma scale (GCS) (p = 0.001), National Institutes of Health Stroke Scale (NIHSS) (p < 0.0001) and the sum of major risk factors of cerebrovascular disease (CVD) (p < 0.0001) were significantly different between mortality and survivor groups. Further χ2 test analysis revealed significant differences in the presenting consciousness disturbance (p = 0.001), place of attack (p = 0.04), and referral transportation (p = 0.008) between these groups. In conclusion, old age, delay between neurologist consultation and ward admission, severity of stroke, and multiple risk factors of CVD are significant risk factors for in‐hospital mortality. Conversely, being free of initial consciousness disturbance, living in an urban area, and having direct transportation to a stroke center are protective factors in survivors. The concept of “brain attack” should be re‐emphasized among ED physicians. The interconnection between stroke centers and emergency medical systems (EMS) should be more tightly built to promote timely management for hyperacute stroke care.

Wallenbergʼs Syndrome With Proximal Quadriparesis

BackgroundThere are several variants of Wallenbergs syndrome. Wallenbergs syndrome with proximal quadriparesis has not been reported before. Case SummaryWe report a 25-year-old woman presenting with sudden onset of vertigo, hoarseness, dysphagia, right facial numbness, and proximal quadriparesis. Brain magnetic resonance imaging revealed right posterolateral medullary infarction with medial extension and sparing of the pyramidal tracts. The proximal quadriparesis improved substantially 2 weeks after stroke onset. ConclusionThe proximal quadriparesis can be explained by involvement of the right medial medullary reticular formation. Our observation supports the hypothesis that the proximal part of the limb is bilaterally innervated by axons of the corticoreticulospinal tracts in human beings. The rapid recovery of proximal quadriparesis also supports the concept that a functional pyramidal tract seems crucial for recovery after stroke.

Simultaneous Thrombosis of Cerebral Artery and Venous Sinus

Cerebral venous thrombosis (CVT) is infrequent among cerebrovascular diseases. The simultaneous thrombosis involving both cerebral artery and venous sinus is even extremely rare. We reported a 41-year-old woman who presented with acute headache and left hemiparesis due to concomitant arterial ischemic stroke and recurrent CVT. Extensive investigation disclosed acquired protein C and protein S deficiency, iron deficiency anemia (IDA) and cryoglobulinemia. She was treated with intravenous injection of heparin followed by oral anticoagulant therapy. The headache rapidly subsided; however, left hemiparesis persisted over five months. The rare condition of simultaneous thrombosis of cerebral artery and venous sinus may be caused by the synergistic effect of coagulation disorders, IDA and cryoglobulinemia.

COGNITIVE DYSFUNCTION AFTER ACUTE LACUNAR INFARCT

Vascular dementia and vascular cognitive impairment have attracted more attention recently due to their association with increased risk of death and institutionalization. The purpose of the present study was to detect and identify the characteristics of cognitive impairments during the early stage of lacunar stroke. The subjects consisted of 23 consecutive first‐ever acute lacunar infarction patients who were admitted to the Department of Neurology, Kaohsiung Municipal Hsiao‐Kang Hospital, Taiwan, from November 2001 to October 2002. The National Institutes of Health Stroke Scale and Cognitive Abilities Screening Instrument (CASI) were used to evaluate stroke severity and cognitive function, and assessments were performed by a neurologist and psychologist, within 10 days of stroke onset. Of the 23 patients, 21 (91.3%) had CASI scores below their respective cutoff values and all patients had cognitive impairment in at least one cognitive domain in CASI. There were no significant correlations between CASI abnormality (below the cutoff value) and patient age, education, or the interval from stroke onset. Recent memory impairment was the most often impaired cognitive domain on CASI (19 patients, 82.6%). There were significant correlations between recent memory and “attention or concentration” (correlation coefficient, 0.52; p < 0.05), and “abstraction and judgment” (correlation coefficient, 0.44; p < 0.05). The correlations between recent memory and other domains were not significant. It was concluded that cognitive impairment after acute lacunar infarct is quite common and recent memory is the most often impaired cognitive domain. This may have been caused by the location of the specific lesion as well as by the impairment in “attention or concentration” or “abstraction and judgment”.