Poyin Huang

Eligibility for Recombinant Tissue Plasminogen Activator in Acute Ischemic Stroke

Background: The eligibility for recombinant tissue plasminogen activator (rtPA) is rare. We analyze the reasons for exclusion from rtPA among patients who were admitted to our hospital within 3 h. Methods: A strict protocol for hyperacute stroke was set in a university teaching hospital. Consecutive patients activating the protocol from June 2004 to October 2005 were prospectively registered and entered into a computerized database. The patients were excluded from rtPA according to the modified exclusion criteria from the National Institute of Neurological Disorders and Stroke rtPA trial. Results: Of the 182 patients activating the protocol, only 11 (6.04%) received intravenous rtPA and 4 (2.2%) IA thrombolysis. Patients were excluded for multiple reasons, and the main reasons for exclusion were minor or improving stroke (46.15%), hypertension (35.16%), insufficient time to complete studies or onset beyond 3 h after reconfirmation (24.17%) and intracranial hemorrhage (15.93%). Of 167 excluded patients, 72 (43.11%) were excluded by a single criterion, 53 (31.73%) by 2 criteria and 29 (17.36%) by 3 criteria. The mean time from hospital arrival to presentation to a neurologist was 9.24 ± 15.11 min (n = 164, median = 8.00, mode = 10, range = 0–65). The mean time from hospital arrival to computed tomography (CT) was 21.67 ± 23.95 min (n = 167, median = 20.00, mode = 10, range = 4–68). Conclusion: An intrahospital stroke code was implemented to minimize intrahospital delay. However, only 11 patients received intravenous rtPA and 4 IA thrombolysis at our hospital from June 2004 to October 2005. The result brings into question the neurologist’s conservative interpretation of the criteria and the necessity to clearly define some criteria. Furthermore an intrahospital stroke code should also be implemented for inpatients to maximize the eligibility for rtPA.

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.

The rapid-eye-movement sleep behavior disorder in Chinese-Taiwanese patients

Aims:  While the features of rapid‐eye‐movement sleep behavior disorder (RBD) have been reported in Caucasian patients, the characteristics of Chinese‐Taiwanese patients with RBD have never been examined.

Serum free hemoglobin as a novel potential biomarker for acute ischemic stroke

ObjectiveCurrently, no practical biomarker is available for the diagnosis of acute ischemic stroke. Matrix-assisted laser desorption/ionization time-of-flight mass spectrometry (MALDI-TOF MS) has being applied extensively to analyze large biomolecules such as proteins. The technique is likely to be of remarkable value as indicators of systemic processes such as atherosclerosis and stroke. The aim of this study is to identify potential protein biomarkers for ischemic stroke diagnosis utilizing MALDITOF MS.MethodsSerum samples obtained from acute ischemic stroke patients (n = 47) and controls (n = 34) were analyzed by MALDI-TOF MS. Stroke severity was assessed by the National Institutes of Health Stroke Scale (NIHSS), subtype by the Trial of Org 10172 in Acute Stroke Treatment (TOAST), functional outcome by the modified Rankin Scale (mRS) and infarct volume by the diffusion-weighted images. Risk factors and routine laboratory data of the stroke patients were registered prospectively.ResultsThe peaks of hemoglobin (Hb) α-chain and β-chain were differentially expressed between stroke patients and controls (p < 0.0001). Hb ions were detected in the samples collected from 33 (70.2 %) stroke patients and 5 (14.7 %) controls. The sensitivity is 70.2 % and the specificity is 85.3 %. Among stroke patients, there is no significant correlation (p > 0.05) between Hb peaks and the NIHSS, TOAST, mRS, stroke risk factors, infarct volume, infarct location and laboratory data.ConclusionsSerum free Hb may serve as a novel potential biomarker for the diagnosis of acute ischemic stroke. The clinical value of this potential biomarker may be clarified by further studies quantifying serum free Hb levels.

Pre-hospital and In-hospital Delays After Onset of Acute Ischemic Stroke—A Hospital-based Study in Southern Taiwan

The biggest hurdle for early hospital presentation is the narrow therapeutic window after stroke. The aims of our study were to investigate the time lags and the factors causing pre‐hospital and emergency department (ED) delay during acute ischemic stroke attack. Between June 2004 and October 2005, we prospectively studied 129 acute ischemic stroke patients who presented to the ED of the study hospital within 4 hours after symptom onset. Chi‐square testing for trend, uni‐variate and multiple logistic regression analyses was performed to evaluate the factors influencing delays in the ED presentation of acute ischemic stroke patients. The median time from symptom onset to ED arrival was 71 (mean ± SD, 82.7 ± 57.7) minutes. The median times from ED arrival to neurologic consultation, computed tomography scan, electrocardiogram, and laboratory data completion were 10 (11.3±9.9) minutes, 17 (9.6±11.3) minutes, 14 (23.3±55) minutes, and 39 (44.4±24.5) minutes, respectively. Univariate and multiple logistic regression models revealed that age < 65 years, illiteracy and awakening with symptoms were the most significant factors related to a delay in ED presentation. This study indicates that 2 hours of pre‐hospital delay is the cutoff point for thrombolytic therapy. Organization of a stroke team and standardized stroke pathways may help to shorten in‐hospital time consumption. Educational efforts should not only focus on the public, but also on the training of ED physicians and other medical personnel.

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.

Slow orthostatic tremor as the first manifestation of Grave's disease.

Orthostatic tremor (OT) is generally idiopathic or secondary to brain stem lesion. We report a case of slow OT as the first manifestation of Grave’s disease. A 26-year-old man presented with a 4-month history of bilateral leg tremor and unsteadiness while standing. The tremor totally subsided while he sat or walked, but not when he talked, read, or thought while standing. He did not complain of tremor elsewhere, including the jaw, hands, and head. There were no systemic symptoms such as goiter, nervousness, excessive sweating, or palpitations. Neurological findings were unremarkable, except for a relatively highfrequency tremor in both legs while standing (see Video). While he was standing, tremography of the legs and a tremor-power spectrum had a dominant peak at 8–9 Hz (Fig. 1). Magnetic resonance imaging findings in the brain and thoracic and lumbosacral spine were unremarkable. Biochemical test results were normal except for hyperthyroidism (T3 thyroid hormone, 273.04 ng/dL; T4 thyroid hormone, 11.17 fg/dL; thyroid-stimulating hormone [TSH], 0.04 FIU/mL). Further results were compatible with Grave’s disease (TSH receptor antibody > 40 IU/L; microsomal antibody, 4101 IU/mL). There was no improvement following initial treatment with clonazepam. Slow OT caused by Grave’s disease was suspected; thus, we administered methimazole. The symptoms of OT improved with normalization of his thyroid profile. OT is a rare tremor of the lower extremities that is evident while standing and improves on walking. OT may be generated by spontaneous oscillation in the central nervous system and can be secondary to other diseases. Symptomatic slow OT has been reported in patients with demyelinating lesions of the brachium pontis and cerebellar disorders. We initially suspected psychogenic tremor, but we did not observe the characteristic features of abrupt onset, distractibility, variable amplitude, and location (predominantly) in the upper extremities. To our knowledge, this is the first report of slow OT caused by Grave’s disease. Furthermore, slow OT was the first manifestation of Grave’s disease in our case. The circuitry of OT pathogenesis may be complex and involve more than 1 brain region. Positron emission tomography demonstrated activation in both cerebellar TABLE 1. Descriptive statistics

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.