Hyuk Sung Kwon

Association of Ambulatory Blood Pressure and Heart Rate With Advanced White Matter Lesions in Ischemic Stroke Patients

BACKGROUND White matter lesions (WMLs) are a common finding in stroke patients, and the most important risk factors are old age and hypertension. Although many studies have described the association between WMLs and ambulatory blood pressure monitoring (ABPM) parameters in healthy subjects and hypertensive patients, little is known about the association in hypertensive ischemic stroke patients. METHODS From July 2009 to June 2012, 169 consecutive hypertensive noncardioembolic ischemic stroke patients were recruited within 1 week of suffering a stroke, and ABPM was applied 1 or 2 weeks after stroke onset. The subjects were classified into 2 groups according to the presence of advanced WMLs, and their ABPM parameters were compared. Finally, multivariable logistic regression analyses were performed to investigate the independent relationships between WMLs and ABPM parameters. RESULTS Seventy (41%) patients had advanced WMLs. In univariable analysis, higher 24-hour, awake, and asleep systolic blood pressure (SBP)/diastolic blood pressure levels and 24-hour pulse pressure were associated with advanced WMLs. However, circadian blood pressure parameters such as 24-hour BP variability, morning surge, and nocturnal dipping pattern were not associated with advanced WMLs. After adjustments, old age (odds ratio (OR) = 1.063; 95% confidence interval (CI) = 1.024-1.104; P = 0.002), high 24-hour SBP levels (OR = 1.055; 95% CI = 1.028-1.082; P < 0.001), and high 24-hour heart rate (OR = 1.041; 95% CI = 1.006-1.078; P = 0.023) were independently associated with advanced WMLs. CONCLUSIONS In addition to old age and elevated 24-hour SBP, increased heart rate is associated with advanced WMLs in ischemic stroke patients. Heart rate deserves more attention in predicting advanced WMLs in those patients.

Increased VEGF and Decreased SDF-1α in Patients with Silent Brain Infarction Are Associated with Better Prognosis after First-Ever Acute Lacunar Stroke

BACKGROUND Pre-existing silent brain infarctions (SBIs) have been reported to be associated with better outcomes after first-ever symptomatic ischemic stroke, although the mechanism of this remains unclear. We investigated the association between SBIs, outcomes of acute lacunar infarction, and biomarkers including vascular endothelial growth factor (VEGF), stromal cell-derived factor-1α (SDF-1α), macrophage migration inhibitory factor (MIF), and high-mobility group box-1 (HMGB1). METHODS A total of 68 consecutive patients diagnosed with first-ever lacunar infarction (<20 mm) within 24 hours of symptom onset were included in this study. Clinical, laboratory, and imaging data were obtained. Plasma levels of VEGF, SDF-1α, MIF, and HMGB1 were assessed using Enzyme-Linked Immunosorbent Assay kits. RESULTS SBIs were noted in 31 of the 68 patients. Although the initial National Institutes of Health Stroke Scale scores were not related with the presence of SBIs (P = .313), patients with SBIs had better outcomes at 3 months (P = .029). Additionally, plasma VEGF levels were higher (P = .035) and SDF-1α levels were lower (P < .001) in patients with SBIs. Logistic regression analysis indicated that VEGF and SDF-1α were independently associated with the presence of SBIs. CONCLUSIONS SBIs are associated with favorable outcomes in patients with first-ever acute lacunar infarction and higher levels of VEGF, and lower levels of SDF-1α in these patients may contribute to their more favorable prognosis.

Protocol of the Stroke in Korean Young Adults Study: A Multicenter Case-Control Study and Prospective Cohort Study

BACKGROUND The incidence of ischemic stroke in young adults has been rising over recent decades, but there is still limited information on its risk factors, etiologies, and outcomes. Because these patients generally participate in social life, risk factors associated with lifestyle may have a great impact and need to be identified. METHODS The SKY (Stroke in Korean Young Adults) study is a multicenter case-control study and a prospective cohort study in 8 tertiary medical centers in the Republic of Korea. The case subjects are patients aged 18-44 years with first-ever ischemic stroke occurring within 1 month of stroke onset, and the control subjects are age- and gender-matched community controls. Our aim is to include 470 cases and 470 controls. The main objective of our study is to determine the risk factors and the causes of ischemic stroke in Korean young adults. Both well-documented risk factors and little-known lifestyle-related risk factors such as lifestyle habits and psychological distress including job strain will be evaluated by comparing cases and controls using a structured questionnaire. Secondary objectives are to determine the risks of mortality, recurrent vascular events, and poststroke epilepsy in these patients. Conditional logistic regression analysis will be used to estimate odds ratios and 95% confidence intervals. CONCLUSIONS The SKY study is designed to obtain more insights into relatively little-known risk factors in young Korean adults with ischemic stroke. The results may also help identify the frequencies of uncommon etiologies and outcomes in these patients.

Preparation and characterization of a new cement-based composite with sulfur polymer

The addition of sulfur polymer (SP) and the resulting effects on the hydration and physical properties of polymer-cement mortars were investigated. Sulfur polymer-cement mortars (SPMs) with 5 wt%, 10 wt%, and 20 wt% of SPs were prepared to evaluate the compressive strength and impermeability in comparison to ordinary Portland cement mortars (PCMs). After curing for 28 days, the compressive strength of SPM with 5 wt% of SP increased by approximately 8.0% compared to PCM by hardened SP binder as well as proper hydration of hydrates. The impermeability of SPMs cured for 28 days was two times higher than that of PCM cured for the same period. The outstanding enhancement of the compressive strength and impermeability are attributed to SP additive formed inside the hydrated cement.

Association between nocturnal blood pressure variation and wake-up ischemic stroke

Ischemic stroke during nocturnal sleep, known as wake-up stroke (WUS), has been reported to have more severe symptoms and worse outcomes than non-WUS. However, studies on risk factors for WUS are scarce and the association between nocturnal blood pressure (BP) and WUS is unclear. In this study, we used ambulatory blood pressure monitoring (ABPM) to examine the association between WUS and variation in nocturnal BP. A total of 369 patients with ischemic stroke within one week were consecutively enrolled. ABPM was applied 1-2weeks after the ictus because of possible reactive increments of BP; antihypertensive medications were delayed until ABPM. Patients were classified into two groups: WUS and non-WUS. Clinical characteristics, including ABPM parameters, were compared. Sixty-seven (18%) patients had WUS. In univariate analysis, patients with WUS had more severe stroke symptoms than patients with non-WUS. There were no differences in clinical characteristics. In addition, ABPM parameters, including nocturnal BP dipping and morning BP surge, were not associated with occurrence of WUS. Patients with WUS had more severe stroke symptoms and worse outcomes than those with non-WUS. Variation in nocturnal BP may not associated with the occurrence of WUS.

A Parkinson's disease patient with camptocormia caused by an esophageal hiatal hernia

A 78-year-old woman diagnosed with Parkinson’s disease (PD) 8 years previously visited our hospital for progressive gait deterioration and abnormal posture. She had been treated with levodopa with good response. She had suffered from forward trunk flexion for more than 3 years and also complained of nausea, gastric discomfort, and mild back pain. Her gastrointestinal symptoms were not evaluated. There was no medical history that indicated the induction of antidopaminergic activity. No motor weakness of the spinal erector muscle was detected. The forward flexion was nearly resolved in the supine position but was immediately evident on positional changes, such as walking or standing, increasing to approximately 65 degrees (Fig. 1 and Video Segment 1). Dopamine transporter imaging showed marked bilateral reduced uptake in the putamen and caudate nucleus, and brain magnetic resonance imaging (MRI) did not reveal any significant findings that could cause truncal dystonia. Wholespine MRI also showed no significant cord or paraspinal muscle abnormalities. The patient had normal laboratory findings. Surface and needle electromyography of the upper, lower, and paraspinal muscles was normal. Examination of nerve conduction and evoked potentials also failed to reveal abnormalities. As a result, the patient’s camptocormia was considered a sign of PD. The levodopa dose was increased (from 600 to 1500 mg per day), and the patient received physiotherapy. However, the symptoms did not improve. A routine simple radiography revealed kyphoscoliosis of approximately 20 degrees of the Cobb angle in the standing position, and a type I hiatal hernia was discovered inciden-

A Sudden Deterioration in Cognitive Functions as the Result of a Central Nervous System Lymphoma

Brain imaging is an essential tool utilized in the diagnostic process of patients with dementia symptoms.1,2 Although the brain magnetic resonance imaging (MRI) is a principal test to determine dementia in a patient, in some circumstances, it has been replaced with the use of computed tomography (CT) scans, for limiting the financial difficulties of patients and caregivers or for large-scale community dementia examinations.3 Most cases of Alzheimers disease or vascular dementia, which is a major part of the disease caused by dementia, can be diagnosed with the use of a CT scan alone, but some dementia patients are not sufficiently reviewed for diagnosis based on the results of only a CT examination alone.

Association Between Wake-up Stroke and Ambulatory Blood Pressure Monitoring Parameters

Background: Approximately 25% of ischemic strokes occur during nocturnal sleep. It has been known as wake-up stroke (WUS) and has been reported to have more severe symptoms and worse clinical outcomes. However, the association between nocturnal blood pressure change and WUS has not been evaluated. Objective: The objective of our study is to investigate association between WUS and nocturnal blood pressure change by ambulatory blood pressure monitoring (ABPM). Method: From March 2011 to February 2014, a total 369ischemic stroke within one week were consecutively included. Patients with following characteristics were excluded: severe hypertension (systolic > 220 mmHg or diastolic >120 mmHg), secondary hypertension, life-threatening medical condition, night-shift working, bed-ridden status and inadequate ABPM data. ABPM was applied 1∼2 weeks after the ictus and antihypertensive medications were suspended until ABPM monitoring. WUS was defined as stroke onset during nocturnal sleep. The subjects were classified into two groups by the presence of WUS and compared clinical characteristics including ABPM parameters. Results and conclusion: Sixty-seven(18%) subjects had WUS. In univariate analysis, patients with WUS had higher initial NIHSS score, discharge NIHSS score and discharge mRS score. There were no differences in age, gender, stroke subtype, risk factors and previous medications between two groups. In addition, ABPM parameters including nocturnal dipping pattern did not showed any association with the occurrence of WUS. In conclusion,patients with WUS had more severe clinical stroke symptoms and worse clinical outcomes. Nocturnal dipping pattern of blood pressure may not affect the occurrence of WUS.