Minju Yeo

Predictive Value of Pulse Pressure in Acute Ischemic Stroke for Future Major Vascular Events

Background and Purpose— This study aimed to investigate whether pulse pressure (PP) obtained during the acute stage of ischemic stroke can be used as a predictor for future major vascular events. Methods— Using a multicenter prospective stroke registry database, patients who were hospitalized for ischemic stroke within 48 hours of onset were enrolled in this study. We analyzed blood pressure (BP) data measured during the first 3 days from onset. Primary and secondary outcomes were time to a composite of stroke recurrence, myocardial infarction, all-cause death, and time to stroke recurrence, respectively. Results— Of 9840 patients, 4.3% experienced stroke recurrence, 0.2% myocardial infarction, and 7.3% death during a 1-year follow-up period. In Cox proportional hazards models including both linear and quadratic terms of PP, PP had a nonlinear J-shaped relationship with primary (for a quadratic term of PP, P=0.004) and secondary (P<0.001) outcomes. The overall effects of PP and other BP parameters on primary and secondary outcomes were also significant (P<0.05). When predictive power of BP parameters was compared using a statistic of −2 log-likelihood differences, PP was a stronger predictor than systolic BP (8.49 versus 5.91; 6.32 versus 4.56), diastolic BP (11.42 versus 11.05; 10.07 versus 4.56), and mean atrial pressure (8.75 versus 5.91; 7.03 versus 4.56) for the primary and secondary outcomes, respectively. Conclusions— Our study shows that PP when measured in the acute period of ischemic stroke has nonlinear J-shaped relationships with major vascular events and stroke recurrence, and may have a stronger predictive power than other commonly used BP parameters.

Recurrent optic neuritis and neuromyelitis optica-IgG following first and second human papillomavirus vaccinations

Human papillomavirus (HPV) vaccine is widely used to prevent cervical cancer caused by certain types of HPV in girls and young women. Demyelinating disorders within months following HPV innoculation have been reported, but the causal link between HPV vaccination and the onset of demyelinating disorders have not been certain. We report a case of neuromyelitis optica spectrum disorder (NMOSD) that was noteworthy because optic neuritis (ON) occurred in a very close temporal association with both the first and second HPV vaccinations, which might suggest an association between HPV vaccination and the development of NMO-IgG and recurrent ON. This emphasizes the necessity for continuing surveillance for adverse events after HPV vaccination.

Unusual Case of Cerebral Venous Thrombosis in Patient with Crohn's Disease

The development of cerebral venous thrombosis (CVT) as a secondary complication of Crohns disease (CD) seems to be rare, but it is generally accepted that the disease activity of CD contributes to the establishment of a hypercoagulable state. Here, we describe a case of CVT that developed outside the active phase of CD. A 17-year-old male visited the emergency room because of a sudden onset of right-sided weakness and right-sided hypesthesia. He had been diagnosed with CD 1 year before and was on a maintenance regimen of mesalazine and azathioprine. He did not exhibit any symptoms indicating a CD flare-up (bloody stools, abdominal pain, complications, or weight loss). A brain MRI scan revealed an acute infarction of the left frontal cortex and a cortical subarachnoid hemorrhage. Additionally, a magnetic resonance venography revealed a segmental filling defect in the superior sagittal sinus and also the non-visualizability of some bilateral cortical veins. The characteristics of the present case suggest that the risk of CVT is most likely related to CD per se rather than disease activity associated with CD.

Clinical characteristics of headache or facial pain prior to the development of acute herpes zoster of the head

OBJECTIVES When physicians encounter patients with headache or facial pain (preeruptive pain) associated with acute herpes zoster of the head, especially before the appearance of characteristic skin eruptions (preeruptive phase), they typically find it difficult to make clinical impressions and apply appropriate diagnostic or therapeutic procedures. The objectives of this study were to describe the clinical characteristics of headache or facial pain associated with acute herpes zoster of the head and to elucidate the association between the manifestation of these symptoms in the preeruptive phase and incoming herpes zoster. METHODS We retrospectively analyzed the clinical features of 152 patients with acute herpes zoster involving only the head who presented within 10days of rash onset at Chungbuk National University Hospital, a tertiary hospital in Chungcheongbuk-do in South Korea, between January 2011 and December 2015. RESULTS The mean age of the patients was 54.3±19.8years. One hundred patients had herpes zoster in the trigeminal nerve, 34 in the nervus intermedius, and 18 in the upper cervical nerves. Preeruptive pain was present in 112 (73.7%) patients and had a mean duration of 3.0±1.3days (range, 1-6days). Severity of pain was associated with the presence of preeruptive pain (p=0.040). Headache or facial pain was limited to the ipsilateral side of the face and head in all patients, except for two who had with severe symptoms of meningitis, and was of moderate to severe intensity (90.1%). Pain of a stabbing nature was observed in 128 (84.2%) patients, and 146 (96.1%) reported experiencing this type of pain for the first time. Pain awakened 94 (61.8%) patients from sleep. Sixty-one (54.5%) of the 112 patients with preeruptive pain visited a hospital during the preeruptive phase; their preeruptive phase was significantly longer (p<0.001) and more frequently awakened them from sleep (p=0.008). Their presumptive diagnoses were as follows: tension-type headache (n=20, 32.8%); no decision (n=18, 29.5%); herpes zoster (n=5, 8.2%); migraine (n=3, 4.9%); pain associated with upper respiratory tract infection (n=3, 4.9%); parotitis (n=2, 3.3%); dry eye (n=2, 3.3%); and other (n=1 each: trigeminal neuralgia, glaucoma, pharyngitis, vestibular neuronitis, tonsillitis, teeth problems, otitis media, and occipital neuralgia). CONCLUSION These results suggest that the typical pain of acute herpes zoster of the head has a stabbing quality, is felt unilaterally, is moderate to severe, often awakens patients from sleep, and has not been previously experienced by most patients. When encountering patients with these features accompanied by pain onset of less than one week, acute herpes zoster of the head should be considered, even without characteristic vesicles, after excluding other secondary causes by appropriate diagnostic workup.

Clinical usefulness of ankle brachial index and brachial-ankle pulse wave velocity in patients with ischemic stroke

Abstract Ankle brachial index (ABI) and brachial-ankle pulse wave velocity (baPWV) are widely used noninvasive modalities to evaluate atherosclerosis. Recently, evidence has increased supporting the use of ABI and baPWV as markers of cerebrovascular disease. This study sought to examine the relationship between ABI and baPWV with ischemic stroke. This study also aimed to determine which pathogenic mechanism, large artery disease (LAD) or small vessel disease (SVD), is related to ABI or baPWV. Retrospectively, 121 patients with ischemic stroke and 38 subjects with no obvious ischemic stroke history were recruited. First, ABI and baPWV were compared between the groups. Then, within the stroke group, the relevance of ABI and baPWV with regard to SVD and LAD, which were classified by brain magnetic resonance image (MRI) and magnetic resonance angiography (MRA) or computed tomography angiography (CTA) findings, was assessed. The baPWV was higher in the stroke group than non-stroke group (1,944.18±416.6 cm/s vs. 1,749.76±669.6 cm/s, P<0.01). Regarding LAD, we found that mean ABI value was lower in the group with extracranial large artery stenosis (P<0.01), and there was an inverse linear correlation between ABI and the grade of extracranial large artery stenosis (P<0.01). For SVD, there was a significant correlation between SVD and baPWV (2,057.6±456.57 cm/s in the SVD (+) group vs. 1,491±271.62 cm/s in the SVD (-) group; P<0.01). However, the grade of abnormalities detected in SVD did not correlate linearly with baPWV. These findings show that baPWV is a reliable surrogate marker of ischemic stroke. Furthermore, baPWV and ABI can be used to indicate the presence of small vessel disease and large arterial disease, respectively.

Effect of statin on progression of symptomatic basilar artery stenosis and subsequent ischemic stroke.

Background and objective Symptomatic basilar artery stenosis (BAS) is associated with high risk of ischemic stroke recurrence. We aimed to investigate whether statin therapy might prevent the progression of symptomatic BAS and stroke recurrence. Methods We retrospectively analyzed the data of patients with acute ischemia with symptomatic BAS, which was assessed using magnetic resonance angiogram (MRA) imaging on admission day, and 1 year later (or the day of the clinical event). The clinical endpoints were recurrent ischemic stroke and its composites, transient ischemic attack, coronary disease, and vascular death. Results Of the 153 patients with symptomatic BAS, 114 (74.5%) were treated with a statin after experiencing a stroke. Statin therapy significantly prevented the progression of symptomatic BAS (7.0% vs 28.2%) and induced regression (22.8% vs 15.4%) compared to non-statin users (p = 0.002). There were 31 ischemic stroke incidences and 38 composite vascular events. Statin users showed significantly lower stroke recurrence (14.9% vs 35.9%, p = 0.05) and composite vascular events (17.5% vs 46.2%; odds ratio [OR], 0.29; 95% confidence interval [CI], 0.13–0.64) than those not using statins did. Recurrent stroke in the basilar territory and composite vascular events were more common in patients with progression of BAS than they were in other patients (OR, 5.16; 95% CI, 1.63–16.25 vs OR, 4.2; 95% CI, 1.56–11.34). Conclusion Our study suggests that statin therapy may prevent the progression of symptomatic BAS and decrease the risk of subsequent ischemic stroke. Large randomized trials are needed to confirm this result.

Simple Estimates of Symptomatic Intracranial Hemorrhage Risk and Outcome after Intravenous Thrombolysis Using Age and Stroke Severity

Hye Jung Lee, Ji Sung Lee, Jay Chol Choi, Yong-Jin Cho, Beom Joon Kim, Hee-Joon Bae, Dong-Eog Kim, Wi-Sun Ryu, Jae-Kwan Cha, Dae Hyun Kim, Hyun-Wook Nah, Kang-Ho Choi, Joon-Tae Kim, Man-Seok Park, Jeong-Ho Hong, Sung Il Sohn, Kyusik Kang, Jong-Moo Park, Wook-Joo Kim, Jun Lee, Dong-Ick Shin, Min-Ju Yeo, Kyung Bok Lee, Jae Guk Kim, Soo Joo Lee, Byung-Chul Lee, Mi Sun Oh, Kyung-Ho Yu, Tai Hwan Park, Juneyoung Lee, Keun-Sik Hong Department of Neurology, Ilsan Paik Hospital, Inje University, Goyang, Korea Clinical Research Center, Asan Medical Center, Seoul, Korea Department of Neurology, Jeju National University, Jeju, Korea Department of Neurology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea Department of Neurology, Dongguk University Ilsan Hospital, Goyang, Korea Department of Neurology, Dong-A University College of Medicine, Busan, Korea Department of Neurology, Chonnam National University Medical School and Hospital, Gwangju, Korea Department of Neurology, Keimyung University Dongsan Medical Center, Daegu, Korea Department of Neurology, Eulji General Hospital, Eulji University, Seoul, Korea Department of Neurology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea Department of Neurology, Yeungnam University Hospital, Daegu, Korea Department of Neurology, Chungbuk National University Hospital, Cheongju, Korea Department of Neurology, Soonchunhyang University College of Medicine, Seoul, Korea Department of Neurology, Eulji University Hospital, Daejeon, Korea Department of Neurology, Hallym University Sacred Heart Hospital, Anyang, Korea Department of Neurology, Seoul Medical Center, Seoul, Korea Department of Biostatistics, Korea University College of Medicine, Seoul, Korea

Neuro-Behcet disease presenting as a solitary cerebellar hemorrhagic lesion: a case report and review of the literature

BackgroundBehcet’s disease is a heterogeneous, multisystem, inflammatory disorder of unknown etiology. The classic triad of oral and genital ulcerations in conjunction with uveitis was originally described by the Turkish dermatologist Hulusi Behcet in 1937, but associated symptoms of the cardiovascular, central nervous, pulmonary, and gastrointestinal systems were later identified. In fact, Behcet’s disease with neurological involvement (neuro-Behcet’s disease) is not uncommon. Patients with neuro-Behcet’s disease typically exhibit a diverse array of symptoms, most commonly in the brainstem and diencephalic regions. Herein, we report an unusual case of neuro-Behcet’s disease in a patient who presented with a solitary cerebellar hemorrhage.Case presentationA 39-year-old Asian woman was admitted to our hospital with complaints of a sudden speech difficulty that had manifested the same morning, and dizziness and mild vomiting experienced over the previous 3 days. Magnetic resonance images revealed target-like hemorrhagic lesions in the right hemisphere of the cerebellum. Risk factors that may result in cerebellar hemorrhage, such as high blood pressure or bleeding diathesis, were ruled out, and subsequent brain angiograms were normal.ConclusionsThese findings suggest that the patient’s cerebellar hemorrhage could have been due to intracranial vasculitis in a rare, if not unique, complication of neuro-Behcet’s disease.

Trajectory Groups of 24-Hour Systolic Blood Pressure After Acute Ischemic Stroke and Recurrent Vascular Events

Background and Purpose— Blood pressure dynamics in patients with acute ischemic stroke may serve as an important modifiable and prognostic factor. Methods— A total of 8376 patients with acute ischemic stroke were studied from a prospective multicenter registry. Patients were eligible if they had been admitted within 24 hours of symptom onset and had ≥5 systolic blood pressure (SBP) measurements during the first 24 hours of hospitalization. SBP trajectory groups in the first 24 hours were identified using the TRAJ procedure in SAS software with delta-Bayesian Information Criterion and prespecified modeling parameters. Vascular events, including recurrent stroke, myocardial infarction, and death, were prospectively collected. The risk of having vascular events was calculated using the frailty model to adjust for clustering by hospital. Results— The group-based trajectory model classified patients with acute ischemic stroke into 5 SBP trajectory groups: low (22.3%), moderate (40.8%), rapidly stabilized (11.9%), acutely elevated (18.5%), and persistently high (6.4%) SBP. The risk of having vascular events was increased in the acutely elevated (hazard ratio, 1.28 [95% confidence interval, 1.12–1.47]) and the persistently high SBP groups (hazard ratio, 1.67 [95% confidence interval, 1.37–2.04]) but not in the rapidly stabilized group (hazard ratio, 1.13 [95% confidence interval, 0.95–1.34]), when compared with the moderate SBP group. Conclusions— SBP during the first 24 hours after acute ischemic stroke may be categorized into distinct trajectory groups, which differ in relation to stroke characteristics and frequency of subsequent recurrent vascular event risks. The findings may help to recognize potential candidates for future blood pressure control trials.

Should we exclude acute stroke patients with previous intracerebral hemorrhage from receiving intravenous thrombolysis

Background Current guidelines have contraindicated history of intracerebral hemorrhage for intravenous recombinant tissue plasminogen activator. Aim This study aimed to investigate the safety and effectiveness of intravenous recombinant tissue plasminogen activator for patients who had previous intracerebral hemorrhage on history or initial brain magnetic resonance imaging. Methods Using a prospective multicenter stroke registry database, we identified acute ischemic stroke patients treated with intravenous recombinant tissue plasminogen activator within 4.5 h of onset. Previous intracerebral hemorrhage was defined as having a clinical history or evidence of old intracerebral hemorrhage on initial brain magnetic resonance imaging. Associations of previous intracerebral hemorrhage with symptomatic hemorrhagic transformation during hospitalization and functional outcome and mortality at discharge and three months were analyzed. Results Among 1495 patients who were treated with intravenous recombinant tissue plasminogen activator, 73 (4.9%) had previous intracerebral hemorrhage; 9 on history only, 61 on magnetic resonance imaging only and 3 on both. Of those 1495 patients, 71 (4.7%) experienced symptomatic hemorrhagic transformation; 6.8% in patients with previous intracerebral hemorrhage and 4.6% in those without previous intracerebral hemorrhage. Multivariable logistic regression analysis showed that previous intracerebral hemorrhage did not significantly increase the risk of symptomatic hemorrhagic transformation (odds ratio 1.08, 95% confidence interval 0.39–2.96) mortality, and most of functional outcome measures Conclusions Previous intracerebral hemorrhage may neither increase the risk of symptomatic hemorrhagic transformation nor alter major clinical outcomes in acute ischemic stroke patients receiving intravenous recombinant tissue plasminogen activator. This study suggests reconsideration of prior history of intracerebral hemorrhage as an exclusion criterion for intravenous recombinant tissue plasminogen activator administration in acute ischemic stroke.