Tai-Seung Nam

Early Outcome of Combined Thrombolysis Based on the Mismatch on Perfusion CT

Background: Possible factors associated with early outcome after thrombolysis are the recanalization time and the status of tissue. We assessed whether combined intravenous (IV) and intra-arterial (IA) thrombolysis performed according to the status of tissue based on perfusion computed tomography (PCT) is beneficial for the early outcome in patients with acute ischemic stroke. Methods: To improve the recanalization time, we assumed that combined IA thrombolysis after IV thrombolysis would be beneficial. Eligible patients for combined thrombolysis were selected according to the status of tissue based on PCT. Recanalization was defined as Thrombolysis in Myocardial Infarction (TIMI) grade 2 or 3. ‘Good functional outcome’ was defined as a Modified Rankin Scale (mRS) score of 2 or less at discharge. Results: Eighteen patients (11 men) underwent combined IV/IA thrombolysis. The recanalization rate after combined IV/IA thrombolysis was 88.9% (TIMI 2, 4; TIMI 3, 12). A good functional outcome at discharge was noted in 12 patients (66.7%). The incidence of symptomatic intracranial hemorrhage was 5.6% (1/18). Conclusions: The results of this study suggest that combined IV/IA thrombolysis based on the presence of mismatches on PCT might have a relatively high rate of recanalization and a favorable early outcome. In addition, the incidence of symptomatic intracranial hemorrhage was acceptable.

Meningitis Caused by Streptococcus suis: Case Report and Review of the Literature

Background Human infection with Streptococcus suis (S. suis), a zoonotic pathogen, has been reported mainly in pig-rearing and pork-consuming countries. Meningitis is the most-common clinical manifestation and is often associated with deafness and vestibular dysfunction. Case Report A 57-year-old man was referred to the hospital with headaches, fevers, chills, and hearing impairment. Meningitis was confirmed and S. suis was isolated from the cerebrospinal fluid. Spondylodiscitis occurred after 2 weeks of antibiotic treatment, and was successfully treated with a prolonged course of antibiotics for another 4 weeks. His hearing loss was irreversible despite the improvement of other symptoms. Conclusions We report the first human case of S. suis infection in Korea. In patients presenting with meningitis, S. suis should be considered if the characteristic features of prominent and early hearing loss are present.

The serum ferritin level is an important predictor of hemorrhagic transformation in acute ischaemic stroke.

Background and purpose:  Because hemorrhagic transformation (HT) is associated with morbidity and mortality, we need a better understanding of the factors that predict HT after ischaemic stroke. HT is a well‐known factor that limits the use of thrombolytics and it negates the effect of treatment. This study investigated whether a high serum ferritin level is associated with HT in acute ischaemic stroke.

Thrombolysis as a factor associated with favorable outcomes in patients with unclear-onset stroke.

Background and purpose:  Clinical and radiological features of patients with unclear‐onset stroke do not differ significantly from those with known‐onset stroke. There is a lack of evidence for the safety and efficacy of thrombolysis in patients with unclear‐onset stroke. We sought to provide supportive data on the safety and efficiency of thrombolysis in patients with unclear‐onset stroke.

The CBV-ASPECT Score as a Predictor of Fatal Stroke in a Hyperacute State

Background: Many parameters of multimodal computed tomography (CT) have been assessed to predict clinical outcome and recanalization after thrombolysis. However, an early predictor of fatal stroke has not been clearly identified. Therefore, this study was conducted to identify early predictors related to fatal stroke. Methods: We retrospectively analyzed subjects with acute ischemic stroke within 6 h of onset between March 2007 and January 2009. Early fatal stroke was defined as death or coma within 1 week of the initial ischemic stroke. Multimodal CT images were scored according to previous studies, such as the Alberta Stroke Program Early CT Score (ASPECTS), collateral score (CS) and clot burden score (CBS). Results: A total of 68 patients were analyzed in this study. Twenty-two patients (32.4%) fell into a coma or died within 1 week of the initial stroke. Patients with fatal stroke had a lower CS, CBS and ASPECTS in the cerebral blood volume (CBV) and time-to-peak maps than those with nonfatal stroke. The initial NIHSS score, CBV-ASPECTS, age and diabetes mellitus were associated with fatal infarct in multivariate logistic regression analysis. Conclusions: Our study demonstrated that initially low CBV-ASPECTS on perfusion CT could predict early fatal stroke and that a CBV-ASPECTS threshold of <4 with a modest sensitivity and specificity could be considered as an early predictor of fatal stroke.

White Matter Hyperintensity as a Factor Associated with Delayed Mood Disorders in Patients with Acute Ischemic Stroke

Background: Mood disorder is a frequent complication of stroke. Comorbid depressive and anxiety disorders are very common, indicating that it is advisable to assess both disorders at the same time. The aim of the present study was to examine the prevalence of post-stroke depression (PSD) and poststroke anxiety (PSA) at baseline and to evaluate factors related to delayed PSD and PSA at 3 months after stroke onset. Methods: This was a prospectively registered and retrospectively analyzed study of patients with acute ischemic stroke between January 2009 and March 2010. Patients included in this study were interviewed in order to evaluate their Hospital Anxiety and Depression Scale (HADS) scores. In this study, each depression and anxiety score was dichotomized into ‘nondepressive and nonanxious’ (HADS-D and HADS-A ≤7) and ‘depressive and anxious’ (HADS-D and HADS-A >7). Multiple logistic regression analysis was used to evaluate the independent factors of depressive and anxious symptoms 3 months after stroke onset. Results: Of the 133 patients, 47.4% were ‘depressive’ and 56.4% were ‘anxious’ at baseline. The depressive and anxious groups had a significantly higher frequency of severe white matter hyperintensity (WMH) than the nondepressive and nonanxious groups (p < 0.05). The independent factors of PSD and PSA at 3 months were deep white matter hyperintensities (DWMH) and modified Rankin scale 0 to 1 at 3 months. Conclusion: In conclusions, the results of our study demonstrated that delayed depression and anxiety after ischemic stroke were related to the severity of DWMH and unfavorable outcomes at 3 months, regardless of anti-anxiety treatment. Our results suggested that WMH might be associated with pathomechanism of delayed depression and anxiety.

Midbrain atrophy in vascular Parkinsonism.

Background: Midbrain atrophy is a well-known feature of progressive supranuclear palsy (PSP). Some clinical features of vascular parkinsonism (VP) such as pseudobulbar phenomena, lower body predominance and early postural instability suggest that the brainstem could be associated with VP. The aim of this study was to determine whether midbrain atrophy was present in patients with VP. Methods: We measured the midbrain (Amd) and pons area (Apn) of 20 patients with VP, 15 patients with probable PSP and 30 patients with idiopathic Parkinson’s disease (IPD). The Amd and Apn were measured on mid-sagittal T1-weighted MRI scans using a computerized image analysis system. Results: For the Amd, the patients with VP (99.86 mm2) and PSP (87.30 mm2) had significantly smaller areas than the patients with IPD (130.52 mm2). For the Apn, there was a significant difference only between the VP (407.23 mm2) and the IPD (445.05 mm2) patients. The Amd/Apn ratios of the patients with VP (0.245) and PSP (0.208) were significantly smaller than in the patients with IPD (0.292). Conclusions: Our study shows that brainstem atrophy often occurs in patients with VP and the midbrain is more vulnerable than the pons to atrophic changes.

Clinical implications of collateral middle cerebral artery flow in acute ischaemic stroke with internal carotid artery occlusion

Background and purpose:  The presence of collateral middle cerebral artery (MCA) flow via the primary collateral pathway is thought to protect against the progression of cerebral ischaemia. However, there have been few reports on early clinical outcomes according to the presence of collateral MCA flow in acute ischaemic stroke (AIS) with internal carotid artery (ICA) occlusion. Therefore, we sought to investigate the early clinical outcomes and lesion patterns according to the presence of collateral MCA flows in AIS with ICA occlusion.

Two common mutations (p.Gln832X and c.663+1G>C) account for about a third of the DYSF mutations in Korean patients with dysferlinopathy.

Dysferlinopathy refers to autosomal recessive muscular dystrophies caused by mutations in dysferlin gene (DYSF). It includes two major distinct disorders, Miyoshi myopathy and limb-girdle muscular dystrophy type 2B. Twenty-three Korean patients were recruited. Full sequence analysis of DYSF detected 10 novel and 9 known mutations. The p.Gln832X showed the highest allele frequency (10/46) as a unique recurrent mutation among Korean population, and two common mutations (p.Gln832X and c.663+1G>C) accounted for 34.8% of the identified mutations. Korean DYSF mutations appeared to cluster in the N-terminal region. Notably, none of homozygous mutations was found in this study. Clinical features were similar to previous reports showing onset in early adulthood, high serum CK and inflammatory reactions on muscle pathology. In Miyoshi myopathy, gastrocnemius muscle was first affected on muscle CT scans, and anterior lower legs and thigh muscles were then affected with disease progression. Despite the genetic variety of DYSF mutations, clinical features were rather invariable among the patients.

Serum triglyceride level is an important predictor of early prognosis in patients with acute ischemic stroke

BACKGROUND Some recent studies have shown that poor outcomes after acute ischemic stroke (AIS) were closely related to lower serum triglyceride (TG) levels, not hypertriglyceridemia. However, hypertriglyceridemia has been shown to be an independent predictor for poor outcome in patients with coronary artery disease. This study attempted to evaluate the association between serum TG levels and early prognosis of AIS. METHODS We enrolled 736 consecutive patients with AIS. Based on the TG level, patients were divided into 5 groups based on the guidelines of the National Cholesterol Education Program (NCEP). We defined early neurological deterioration (END) as a 4-point or greater deterioration of the NIH stroke scale (NIHSS) score and early clinical improvement (ECI) as a 4-point reduction of NIHSS within a week after symptom onset. We compared patients with END, ECI, and neither END nor ECI. RESULTS The risk of END was significantly higher in the hyperTG and hypoTG groups compared with the normal group. The percentages of ECI were significantly lower in the hypoTG, borderline, and hyperTG groups compared with the normal group. For END, the multivariable adjusted odds ratios were significantly higher in the hypoTG, borderline, and hyperTG groups compared with the low normal group (50 to 100mg/dl). CONCLUSIONS TG had a nonlinear, J-shaped association with poor outcome and a reverse J-shaped association with good outcome in AIS. This study suggests that both hyperTG and hypoTG can be risk factors for poor early outcome in AIS.