Yong-Seok Lee

Leukoaraiosis is associated with pneumonia after acute ischemic stroke

BackgroundStroke-associated pneumonia (SAP) is common in patients with acute ischemic stroke, and several risk factors have been reported. However, the relationship between underlying leukoaraiosis (LA) and SAP has not been addressed.MethodsWe collected consecutive patients with acute ischemic stroke within 24xa0h of symptom onset. SAP was defined as the lower respiratory tract infection within the first 7xa0days after stroke onset, according to the modified Centers for Disease Control and Prevention criteria. LA was graded using the Fazekas scale in both the periventricular and subcortical areas. We evaluated LA burden by summing the grade and dichotomized into mild LA (0–2) or severe LA (3–6). Relationship between LA and SAP was analyzed by binary logistic regression analysis with variables of Pu2009<u20090.05 in univariate analysis.ResultsThree hundred eight consecutive patients were enrolled, and SAP developed in 44 patients (14%). Univariate analysis revealed that SAP correlated with age, initial NIHSS score, atrial fibrillation, impaired consciousness, dysphagia, severe LA and hyperlipidemia. On multivariate analysis, severe LA [adjusted OR (aOR)u2009=u20094.41, 95% CIu2009=u20092.04–9.55, Pu2009<u20090.001 remained independent predictors of SAP after adjusted confounders.ConclusionsIn this study, LA was an independent predictor of SAP. This observation needs to be confirmed in suitably-designed, prospective studies.

The correlation between cerebral arterial pulsatility and cognitive dysfunction in Alzheimer's disease patients

BACKGROUNDnPotential role of vascular dysfunction has been suggested in the pathogenesis of Alzheimers disease (AD). Previous cross-sectional studies have demonstrated relations between abnormal transcranial Doppler (TCD) parameters and cognitive impairment. We aimed to investigate the associations between longitudinal changes of TCD parameters and cognitive decline in patients with AD.nnnMETHODSnWe have enrolled patients with mild to moderate AD who aged 60 to 79years. Mean flow velocity and pulsatility index (PI) of anterior (ACA), middle (MCA), and posterior (PCA) cerebral arteries were evaluated. Cognitive functions were assessed using mini-mental state examination (MMSE), clinical dementia rating sum of boxes (SOB), and Alzheimers Disease Assessment Scale (ADAS-cog), which was further categorized as praxis, language, and memory subscores. TCD and cognitive assessments were followed up 1year later, and the longitudinal changes (Δ) between the baseline and follow-up measurements were evaluated.nnnRESULTSnA total of 51 patients completed the follow-up evaluations (baseline age 71.5years, MMSE 21.2). In the baseline evaluations, high PI values of ACA and MCA were associated with poor MMSE score, ADAS-cog total, memory, and praxis subscores. After 1year, the increases of ACA and MCA PI were correlated with the aggravation of ADAS language subscore, and ΔACA PI was also correlated with ΔSOB. The decrease in mean flow velocity of ACA was associated with aggravation of ADAS-cog praxis score.nnnCONCLUSIONSnThere was significant correlation between longitudinal changes of TCD parameters and cognitive dysfunction in patients with mild to moderate AD. Serial assessment of TCD may provide useful information regarding to the disease progression.

Clinical relevance of abnormal neuroimaging findings and long‐term risk of stroke recurrence

Previous studies have revealed that the predictors of short‐ and long‐term stroke recurrence are different. We designed a comprehensive stroke recurrence (CSR) model, composed of demographic, clinical and radiological findings, to predict long‐term ischaemic stroke recurrences.

Association between eprosartan-based hypertension therapy and improvement in cognitive function score: long-term follow-up from the OSCAR observational study

Objective: The Observational Study on Cognitive function And systolic blood pressure Reduction (OSCAR) was designed to evaluate the impact of eprosartan-based therapy on cognitive function in a cohort of 25,745 hypertensive subjects followed for six months. Methods: In this supplementary analysis, we studied the relationship between eprosartan-based therapy and cognitive function (assessed using the Mini-Mental State Examination (MMSE)) after 12-month follow-up of 3600 patients (the long-term follow-up on-treatment population). Results: Reduction in blood pressure was sustained over 12 months, with mean systolic blood pressure/diastolic blood pressure 130.9/79 mmHg at one year, compared with 164.3/92.8 mmHg at baseline (p<0.001). The overall mean MMSE score at completion of 12-month follow-up was significantly increased from baseline (27.8±2.7 vs. 26.3±3.5; p<0.001). The increase in MMSE score was observed when the population was stratified by age (p<0.001) and in a subgroup of patients with cerebrovascular disease at baseline (n=290) (p<0.001, 12 months vs. baseline). Conclusions: In this cohort of patients, use of eprosartan-based treatment for one year was associated with sustained reduction in blood pressure and stabilization or improvement of MMSE scores. These data are supportive of a role for blood pressure control in the prevention or delay of cognitive decline.

Transient isolated ocular motor abnormality related to perilesional edema of an acute medullary microbleed: A case report and review of the literatures

We report a case of transient isolated gaze-evoked nystagmus with ocular lateropulsion in a patient with an acute medullary microbleed which was detected by brain magnetic resonance imaging. Considering the correlation between the neural structures involved by the lesion and the ocular motor symptoms of this patient, we suggest that the perilesional edema of the acute medullary microbleed is responsible for this transient ocular motor abnormality.

Multiple cerebral hemorrhages associated with Friend leukemia integration 1 (FLI1) positive cardiac angiosarcoma and left atrial thrombi

Multiple simultaneous cerebral hemorrhages can be rare manifestations of the thrombogenic conditions in the heart. Here we report a case of cardiac angiosarcoma that coexisted with a large thrombus in the left atrium presented as multiple hemorrhages in the cerebrum. A 65-year-old, previously healthy woman complained of headache developed a month ago. Neurologic examination revealed right hemianopia. In brain magnetic resonance imaging (MRI), multiple scattered hemorrhages were found in both cerebral hemispheres (Fig. 1a,b). Most of them contained cerebromalatic change without enhancement, suggesting simultaneous hemorrhagic embolisms. On the chest computed tomography, two discrete large masses in the dilated left atrium were found; a large hypoattenuated, nonenhancing mass along the right wall, and another hypo-attenuated, heterogeneously enhancing mass in the appendage (Fig. 1c). Transthoracic echocardiograph revealed left atrial wall mass as a thrombi, and the distinct mass with spontaneous echo-contrast in the appendage. On whole-body positron emission tomography (PET), the mass in the appendage was hypermetabolic with maximal standardized uptake value (SUV) 7·5, suggesting a malignant tumor. The left atrial thrombus and multiple cerebral lesions homogeneously appeared as metabolic defects. Additionally, there were multiple hyper-uptakes in bilateral adrenal glands, vertebras, left femur, scapula, and ninth-rib with maximum SUV 10·6, suggesting metastasis (Fig. 1d– e). Biopsy performed at the rib was confirmed as a high-grade angiosarcoma with positive Friend leukemia integration 1 (FLI1) (Fig. 2). Although rare, cardiac angiosarcoma is mostly located in the right atrium presenting as multiple pulmonary hemorrhages (1). However, in this case, angiosarcoma situated in the left atrium might have provoked multiple cerebral hemorrhagic embolisms. Furthermore,

Acute hyperammonemic encephalopathy presenting as a stroke-like episode: clinical and radiological findings.

Acute hyperammonemic encephalopathy (AHE) generally presents as non-focal manifestations such as drowsiness, seizure, coma with diffuse brain swelling, and symmetric lesions (1). However, AHE might present as a stroke-like episode in rare instances, as the case we report. A 62-year-old man with mild alcoholic liver cirrhosis and had abstained from alcohol for two-years developed massive hemoptysis with rapid haemoglobin concentration decrement of 2·9g/dl. Emergent esophago-gastroscopy revealed an esophageal varix bleeding and immediate hemostasis with variceal ligation was successfully performed. After 24 h from the bleeding event, left arm complete monoplegia and hemi-neglect of left visual/tactile stimulus suddenly developed. He was alert, oriented, and denied nausea or headache. Brain magnetic resonance imaging (MRI) showed high signal intensities (HSIs) in the diffusionweighted image (DWI) and fluidattenuated inversion recovery (FLAIR) in the right-side dominant bilateral medial occipito-parietal area, with decreased apparent diffusion coefficient (ADC) value. (Fig. 1) Magnetic resonance angiography showed no stenotic lesion. Laboratory workup detected moderate hyperammonemia (124 μg/dl), but was otherwise normal. Blood pressure was ≤140 mmHg during the whole hospital course. The left arm monoplegia and the left hemi-neglect completely disappeared after three-days. After six-days from the onset, follow-up MRI revealed increased extent of DWI, FLAIR, and HSI to the bilateral temporal and frontal area, and conversion of ADC from low to high values (Fig. 1). This patient presented a sudden focal neurologic deficit mimicking a stroke. Although the MRI pattern was somewhat similar to a posterior reversible encephalopathy syndrome (PRES), initially decreased ADC with following incremental transition suggests a cytotoxic damage and subsequent swelling (2). This mechanism is not compatible with PRES but AHE, the presumptive consequence of massive esophageal bleeding (3). Hyperammonemia provokes mitochondrial energy dysfunction by inhibiting tricarboxylic-acid cycle enzyme gammaketoglutarate-dehydrogenase and by activating N-methyl-D-aspartate (NMDA) receptor, resulting in cytotoxic neuronal damage (4). Accordingly, hyperammonemic mitochondrial metabolism disorders such as HHH (hyperornithinemia– hyperammonemia–homocitrullinuria) are reported to incur stroke-like episodes, like the presenting case (5). Therefore, AHE can induce stroke-like clinical/ radiological presentation through mitochondrial dysfunction, warranting meticulous clinical consideration. Correspondence: Yong-Seok Lee*, Department of Neurology, College of Medicine Seoul National University, Seoul National University-Seoul Metropolitan Government Boramae Medical Center, Dongjak-gu, Shindaebang-dong, Boramae 5 Road 20, 156-707, Seoul, Republic of Korea. E-mail: mercades@snu.ac.kr