Jin Man Jung

Mini-Mental Status Examination as predictors of mortality in the elderly

Objective:  Because the number of elderly is increasing worldwide, cognitive dysfunction becomes important health care issue. This study investigated the association between cognitive dysfunction and mortality in the elderly.

Takotsubo-Like Myocardial Dysfunction in Ischemic Stroke: A Hospital-Based Registry and Systematic Literature Review.

Background and Purpose— We investigated clinical and radiological characteristics of ischemic stroke patients with Takotsubo-like myocardial dysfunction. Methods— From multicenter stroke registry database, ischemic stroke patients who underwent transthoracic echocardiography were found. Among these, patients were classified if they had specific ventricular regional wall motion abnormalities discording with coronary artery distribution, such as apical (typical pattern) or nonapical ballooning (atypical pattern), considered as echocardiographic findings of Takotsubo cardiomyopathy. Patients with ischemic heart disease history, myocarditis, or pheochromocytoma were excluded. We compared patients with Takotsubo-like myocardial dysfunction with those without and further performed systematic literature review on those with Takotsubo cardiomyopathy. Results— This study included 23 patients (0.42%). The mean age was 70.7±13.9 years, with predominance of women (73.9%) and typical pattern of Takotsubo-like myocardial dysfunction (91.3%). They were associated with short-term poor functional outcomes, including high mortality, neurological deterioration, and functional status at discharge, compared with those without (39.1% versus 2.4%, 47.8% versus 7.4%; and median [interquartile range], 5 [5–6] versus 3 [2–4]; all P<0.001). They had a higher inflammatory marker level and lower triglyceride level. Ischemic lesions were more commonly found in the right anterior circulation with specific dominant regions being the insula and peri-insular areas. In addition, a trend toward a remarkable mortality rate and higher prevalence of insular involvement was observed in the propensity-score matching, subgroup fulfilling the strict Takotsubo cardiomyopath criteria, and was as reported in literature review. Conclusion— Stroke patients with Takotsubo-like myocardial dysfunction may differ from those without in clinical outcomes, laboratory findings, and radiological features.

Statins Improve Survival in Patients With Cardioembolic Stroke

Background and Purpose— The objective of this study was to investigate the potential benefits of statin therapy on mortality and stroke recurrence after cardioembolic stroke. Methods— In this retrospective observational study, we analyzed data from 535 patients with first-ever cardioembolic stroke. Patients were classified into nonstatin, low-potency statin, and high-potency statin groups. The primary outcomes were time to mortality and time to recurrent stroke. Results— The mean duration of follow-up was 22.2 months. The cumulative mortality rate was 7% at the end of the first year and 10% at the end of the third year. Statin therapy was independently associated with reduced mortality (hazard ratio, 0.237; 95% confidence interval, 0.080–0.703 for nonstatin versus low-potency statin; hazard ratio, 0.158; 95% confidence interval, 0.037–0.686 for nonstatin versus high-potency statin). Statin treatment did not affect the incidence of recurrent stroke in patients with cardioembolic stroke. Conclusions— Statin therapy could be associated with reduced mortality in patients with cardioembolic stroke.

Chronic kidney disease and intravenous thrombolysis in acute stroke: A systematic review and meta-analysis.

BACKGROUND The association between chronic kidney disease (CKD) and hemorrhagic complications or clinical outcomes in patients treated with intravenous (IV) thrombolytic agents is controversial. METHODS We searched multiple databases for studies on the association between CKD and symptomatic intracerebral hemorrhage (ICH) and/or clinical outcomes in acute stroke patients treated with IV tissue plasminogen activator (tPA). Observational studies that evaluated the association between CKD and outcomes after adjusting for other confounding factors were eligible. We assessed study quality and performed a meta-analysis. The main outcome was symptomatic ICH. The secondary outcomes were poor functional status at 3 months using the modified Rankin Scale, mortality at 3 months, and any ICH. RESULTS Seven studies were selected based on our eligibility criteria. Of 7168 patients treated with IV tPA, 2001 (27.9%) had CKD. Patients with CKD had a higher risk of symptomatic ICH and mortality [pooled odds ratio (OR) 1.56, 95% confidence interval (CI) 1.05-2.33 and pooled OR 1.70, 95% CI 1.03-2.81, respectively]. Patients with CKD were likely to have an increased risk of poor outcome at 3 months. There was no significant association between CKD and any ICH. CONCLUSIONS Chronic kidney disease may significantly affect symptomatic hemorrhagic complications and poor clinical outcomes following administration of IV tPA.

Abnormal Head Impulse Test in a Unilateral Cerebellar Lesion

Background The findings of head impulse tests (HIT) are usually normal in cerebellar lesions. Case Report A 46-year-old male presented with progressive dizziness and imbalance of 3 weeks duration. The patient exhibited catch-up saccades during bedside horizontal HIT to either side, which was more evident during the rightward HIT. However, results of bithermal caloric tests and rotatory chair test were normal. MRI revealed a lesion in the inferior cerebellum near the flocculus. Conclusions This case provides additional evidence that damage to the flocculus or its connections may impair the vestibulo-ocular reflex only during high-speed stimuli, especially when the stimuli are applied to the contralesional side. By observing accompanying cerebellar signs, the abnormal HIT findings caused by a cerebellar disorder can be distinguished from those produced by peripheral vestibular disorders.

Characteristics and mechanism of perverted head-shaking nystagmus in central lesions: Video-oculography analysis

OBJECTIVE Perverted downbeat head-shaking nystagmus (pdHSN) has been considered a sign of central pathology. Two hypotheses have been advanced as the mechanisms of pdHSN without proper validation. This study aimed to elucidate the mechanism of pdHSN. METHODS Eighteen patients with pdHSN due to central lesions were subjected to analyses of their oculographic characteristics. The peak velocity, temporal features including the duration and time constant (TC), rotational axis of pdHSN were analyzed. To determine the most relevant mechanism of pdHSN, we compared the TCs of pdHSN with those of downbeat nystagmus after vertical head-shaking in four subjects, and with the TCs of horizontal head-shaking nystagmus (HSN) in three subjects who had both horizontal and downbeat nystagmus after head-shaking. RESULTS The duration of pdHSN ranged from 14 to 25s and the estimated TC was from 3.9 to 7.8s. When the data were pooled after the intensities of the nystagmus in each patient were normalized, the TC was 5.2 (95% CI=5.0-5.4) seconds from nonlinear regression test. The rotational vectors of pdHSN (n=8) were mostly aligned between the anterior semicircular canals. The estimated TC of downbeat nystagmus after vertical head-shaking (5.8s) was similar to that of pdHSN (6.0s) in four subjects tested. In contrast, the TC of horizontal HSN (10.9s) was significantly larger than that of pdHSN (4.9s) in three subjects. CONCLUSIONS The characteristics of TCs of HSN in our patients with central lesions suggest that pdHSN is due to enhanced activities of the central anterior canal pathway. SIGNIFICANCE pdHSN is a sign indicative of central pathology causing cerebellar dysfunction, especially when it associated with other neuro-otological signs.

Reversed Corrective Saccades during Head Impulse Test in Acute Cerebellar Dysfunction

Patients with cerebellar lesions may show horizontal (positive)- or downward (perverted)-corrective saccades during horizontal head impulse test (HIT). However, corrective saccades in the direction of head rotation (reversed corrective saccades) have not been reported during HIT. We present two patients who showed reversed corrective saccades during horizontal HIT as an initial sign of acute cerebellitis. In contrast to the corrective saccades mostly observed in peripheral vestibular paresis, this paradoxical response indicates abnormally increased vestibulo-ocular responses due to cerebellar disinhibition over the vestibulo-ocular reflex. This paradoxical response should be considered an additional bedside cerebellar sign.

Perverted head-shaking and positional downbeat nystagmus in pregabalin intoxication

Dizziness and ataxia are known adverse effects of pregabalin, but characteristic oculomotor signs in pregabalin intoxication have not been reported. Here we describe a patient who displayed perverted head-shaking and positional downbeat nystagmus after prescription of a high dosage of pregabalin. Since pregabalin reduces excitatory neurotransmitter secretion in the central nervous system, decreased excitatory inputs from the brainstem may lead to cerebellar dysfunction, causing perverted head-shaking and positional downbeat nystagmus.

Free fatty acid as an outcome predictor of atrial fibrillation‐associated stroke

We investigated whether baseline plasma free fatty acid (FFA) concentration is associated with any (ischemic/hemorrhagic) stroke, ischemic stroke/systemic embolism (ISSE), or ischemic stroke among stroke survivors with atrial fibrillation (A‐fib). Moreover, we compared the outcome predictability of FFA with previously adopted models, including the CHADS2 and CHA2DS2‐VASc scoring systems.

Novel composite score to predict atrial Fibrillation in acute stroke patients: AF predicting score in acute stroke

BACKGROUND AND PURPOSE Identification of high risk population for atrial fibrillation among acute stroke patients is a center of attention. The objective of the present study was to construct a model that can predict the presence of atrial fibrillation in ischemic stroke patients and to validate the model. METHODS From a prospectively collected hospital-based stroke registry participated by two hospital, we selected data of patients who were admitted within 24 h after the onset of symptoms. Using a dataset of 1355 acute ischemic stroke patients, a model to predict the presence of atrial fibrillation was constructed and the probability of the presence of atrial fibrillation (AF-probability) was calculated. The patients were classified into low-risk, moderate-risk, and high-risk groups according to AF-probability. The performance of the model to predict atrial fibrillation among acute stroke patients was investigated and validated. RESULTS Seven factors were selected as constituents of the model including age, left atrial size, free fatty acid level, triglyceride level, susceptibility vessel sign, hemorrhagic transformation, and cortical involvement. The performance of the model was excellent, with a C-statistic of 0.908 (95% confidence interval 0.887-0.930). According to risk group, true positivity for atrial fibrillation was 4.3%, 36.5%, 91.2% in the low-risk, moderate-risk, and high-risk groups, respectively. The internal and external validation test showed stable consistency of the model. CONCLUSION The model constructed in this study could stratify stroke patients according to their risk of AF and may be helpful for selecting candidates who need extensive cardiac monitoring.