1,721,148 research outputs found
David G. Sherman Lecture Award: 15-Year Experience of the Nationwide Multicenter Stroke Registry in Korea
No full textThe expected growth of stroke burden in Korea in early 2000s led to the initiation of a government-funded clinical research project with the goal of development and implementation of national stroke guidelines. The CRCS-K (Clinical Research Collaboration for Stroke in Korea) began as a part of this project. For stroke epidemiology and quality of care research, the CRCS-K developed a multicenter, prospective, stroke registry and began collection of data in 2008. Now, about 100 000 cases have been registered at 17 university hospitals or regional stroke centers and about 200 articles have been published based on the registry experience. The analysis of the 10-year secular trends showed overall improvement of stroke care and outcomes and areas for improvement. This large-scale, high-quality dataset provides opportunities to explore and compare treatment disparities using the comparative effectiveness research methods, design and conduct a registry-based randomized clinical trial, connect the registry data with other data sources including the national claims data and neuroimaging or genetic data, and collaborate with other international researchers. An international stroke registry consortium may be a viable future direction.N
The Changing Effect of Blood Pressure on Stroke Outcomes Through Acute to Subacute Stage of Ischemic Stroke
No full textBackground: This study explored the associations of blood pressure (BP) with various stroke outcomes and investigated their changes by the elapsed time after stroke onset. Methods: Patients who arrived within 48 hours of stroke onset between April 2008 and September 2014 were consecutively enrolled. For 10 days of hospitalization, all measured systolic BP (SBP) was summarized into mean at acute (first 3 days) and subacute stage (afterward to 7 days) for each patient. Coprimary outcomes were unfavorable outcome (modified Rankin Scale > 2) at discharge and time to composite cardiovascular event of stroke, myocardial infarction, and vascular death for 1-year follow-up. Adjusted odds ratios (AOR) through SBPmean in both acute and subacute stages were interpolated using restricted cubic spline technique and adopted logistic regression models with predetermined covariates. The adjusted hazard ratios for cardiovascular event by SBPmean in both stages were interpolated. Results: The study enrolled 3723 subjects (mean age, 66.7 +/- 13.2 years old and median baseline National Institute of Health Stroke Scale score, 3). SBPmean in both stages showed linear trends for risks of unfavorable outcome, while the increase of AOR was observed explicitly in acute stage rather than subacute stage, especially in higher values. In contrast, SBPmean demonstrated the U-shaped associations with cardiovascular event in subacute stage rather than acute stage. Conclusions: In ischemic stroke, association patterns of BP would be different depending on stroke outcomes. The risky interval of BP would be changed by the elapsed time after stroke onset.N
Neuroimaging markers for early neurologic deterioration in single small subcortical infarction
No full textBackground and Purpose-Early neurological deterioration (END) occurs in >= 20% of single small subcortical infarctions (SSSIs; axial diameter <= 20 mm in the perforator territories) and deters functional recovery. Both microvasculopathies and atherosclerosis have been proposed to independently contribute to the occurrence of END in SSSI cases. We hypothesized that the occurrence of END in SSSIs differs according to the pathological process. Methods-We collected data from 587 patients with SSSI within 48 hours of onset from a prospective stroke registry containing 4961 case records. Independent reviewers, blinded to END information, rated neuroimaging characteristics, including relevant artery stenosis (0% to 50% stenosis of the adjacent arteries on magnetic resonance angiography), branch atheromatous lesions (>= 4 consecutive axial cuts or extensions from the basal surface of the pons), white matter hyperintensities, old lacunar infarctions, and cerebral microbleeds. Results-END occurred in 79 (13.5%) cases, including 6 recurrences, 68 progressions, 1 symptomatic hemorrhagic transformation, 1 others, and 3 unknowns. END increased the National Institutes of Health Stroke Scale score by 2.3 +/- 1.4 points. Patients with END showed higher frequencies of modified Rankin Scale scores of 3 to 6 after 3 months compared with patients without END (49% versus 23%). Patients with relevant artery stenosis (adjusted odds ratio, 1.91; 95% confidence interval, 1.13-3.21) and branch atheromatous lesions (adjusted odds ratio, 2.98; 95% confidence interval, 1.80-4.93) had significantly higher odds of exhibiting END. However, such an association was not detected with small vessel disease markers. Conclusions-Our analysis indicated a potential contribution of the localized atherosclerotic process to END in SSSIs. Precautionary measures might be used for SSSIs suggestive of atherosclerotic pathologies.Y
Hematoma Hounsfield units and expansion of intracerebral hemorrhage: A potential marker of hemostatic clot contraction
No full textBackground Clot contraction reinforces hemostasis by providing an impermeable barrier and contractile force. Since computed tomography attenuation of intracerebral hemorrhage is largely determined by the density of red blood cells, clot contraction can be reflected in an increase of Hounsfield unit (HU) of hematoma. Aims We hypothesized that hematoma expansion is inversely associated with mean HU of intracerebral hemorrhage at presentation. Methods Eighty-nine consecutive spontaneous intracerebral hemorrhage patients with onset to first computed tomography within 24 h were included. Hematomas were segmented using semiautomated planimetry to measure the volume and mean HU. Hematoma expansion was defined as an increase in hematoma volume by over 33% or 6 mL. Multivariable logistic regression was performed for hematoma expansion. The discrimination power of mean HU for hematoma expansion was assessed using C-statistic. Results The computed tomography attenuation of hematoma at presentation was 57.5 +/- 3.3 HU and the volume was 16.9 +/- 23.2 mL. Hematoma expansion occurred in 37.1% of patients. The computed tomography attenuation of hematoma was lower in patients with hematoma expansion than with no expansion (55.7 +/- 2.9 HU vs. 58.6 +/- 3.1 HU, p-value < 0.01). Multivariable logistic regression revealed that the mean HU of hematoma was inversely associated with hematoma expansion (adjusted odds ratio, 0.64; 95% confidence interval, 0.51-0.80). The C-statistic of the model with four known predictors increased from 0.66 to 0.84 after incorporating mean HU (p-value < 0.01). Conclusions Intracerebral hemorrhage with lower mean HU of hematoma at presentation is more likely to undergo hematoma expansion. This finding suggests the potential presence of clot contraction process that reinforces hemostasis in intracerebral hemorrhage.N
Blood Pressure Drop and Penumbral Tissue Loss in Nonrecanalized Emergent Large Vessel Occlusion
No full textBackground and Purpose-For patients with emergent large vessel occlusion who may not benefit from timely recanalization treatment, maintaining adequate cerebral perfusion to prevent penumbral tissue loss is a key therapeutic strategy. Cerebral perfusion should be proportional to systemic blood pressure (BP) due to the loss of autoregulation properties in ischemic brain tissue. We hypothesized that acute fluctuations in BP would lead to aggravated penumbral tissue loss in persistent large vessel occlusion. Methods-A total of 80 patients with persistent large vessel occlusion of internal carotid artery or middle cerebral artery admitted within 24 hours after onset, and with a baseline, National Institutes of Health Stroke Scale score >= 4-point were included. Baseline and follow-up (median 88 hours) magnetic resonance images were analyzed, and penumbra was defined as the T-max>6 s region excluding baseline infarction. The hypoperfusion intensity ratio (T-max>10 s/T-max>6 s) was calculated within the penumbra. Penumbral tissue loss (%) was defined as the proportion of follow-up infarct in the penumbra. With serial BP measurements in the first 24 hours (median 29, interquartile range 26-35), BP and BP variability parameters, including BPdropmax (change from local maxima to minima), were calculated and compared. Generalized linear models were applied to examine the association between BP parameters and the penumbral tissue loss. Results-The median penumbral volume was 79.3 mL (interquartile range, 38.2-129.6) and median penumbral tissue loss was 36.7% (interquartile range, 12.0-56.1). In a multivariable analysis, systolic BP (SBP) SBPdropmax (beta +/- SE of fourth quartile, 17.82 +/- 6.58; P value, 0.01) and diastolic BP (DBP) DBPdropmax (beta +/- SE of fourth quartile, 14.04 +/- 6.38; P value, 0.01) were associated with increasing penumbral tissue loss, independently of age, baseline infarction and hypoperfusion intensity ratio. DBPincmax, SBPmax, DBPmax, SBPmax-min, DBPmax-min, and most of the DBP variability indices were associated with penumbral tissue loss. Conclusions-BP fluctuations, even a brief and drastic BP drop in the first 24 hours, significantly contributed to penumbral tissue loss irrespective of baseline hypoperfusion.N
Left ventricular diastolic dysfunction in ischemic Stroke: Functional and vascular outcomes
No full textBackground and Purpose Left ventricular (LV) diastolic dysfunction, developed in relation to myocardial dysfunction and remodeling, is documented in 15%-25% of the population. However, its role in functional recovery and recurrent vascular events after acute ischemic stroke has not been thoroughly investigated. Methods In this retrospective observational study, we identified 2,827 ischemic stroke cases with adequate echocardiographic evaluations to assess LV diastolic dysfunction within 1 month after the index stroke. The peak transmitral filling velocity/mean mitral annular velocity during early diastole (E/e') was used to estimate LV diastolic dysfunction. We divided patients into 3 groups according to E/e' as follows: <8, 8-15, and >= 15. Recurrent vascular events and functional recovery were prospectively collected at 3 months and 1 year. Results Among included patients, E/e' was 10.6 +/- 6.4: E/e' <8 in 993 (35%), 8-15 in 1,444 (51%), and >= 15 in 378 (13%) cases. Functional dependency or death (modified Rankin Scale score >= 2) and composite vascular events were documented in 1,298 (46%) and 187 (7%) patients, respectively, at 3 months. In multivariable analyses, ischemic stroke cases with E/e' 15 had increased odds of functional dependence or death at 3 months (adjusted OR [95% CI]: 1.73 [1.27-2.35]) or 1 year (1.47 [1.06-2.06]) and vascular events within 1 year (1.65 [1.08-2.51]). Subgroups with normal ejection fraction or sinus rhythm exhibited a similar overall pattern and direction. Conclusions LV diastolic dysfunction was associated with poor functional outcomes and composite vascular events up to 1 year.Y
Stroke outcomes with use of antithrombotics within 24 hours after recanalization treatment
No full textObjective:To compare clinical outcomes of patients who received early initiation (<24 hours) of antithrombotics with those who received standard management (antithrombotics administered 24 hours).Methods:A total of 712 patients who had an acute ischemic stroke and underwent IV or endovascular (intra-arterial [IA]) recanalization between July 2007 and March 2015 were selected from a prospective clinical registry. Antithrombotics were initiated by an individual clinical decision. We systemically gathered information regarding the exact timing of antithrombotic initiation from a database of the electronic barcode medication administration system.Results:The recanalization treatment cases included in this study comprised 34% (n = 243) IV only, 32% (n = 229) IA only, and 34% (n = 240) combined IV-IA strategies. Antithrombotics were administered within 24 hours in 64% (n = 456) of the patients. Earlier initiation of antithrombotics was associated with decreased odds of having any hemorrhages (adjusted odds ratio 0.56; 95% confidence interval 0.35-0.89), but was not associated with symptomatic hemorrhages (0.85; 0.35-2.10) or modified Rankin Scale scores of 0-1 at 3 months after stroke (1.09; 0.75-1.59). Ultra-early initiation (<12 hours) did not increase the odds of hemorrhagic transformation (0.26; 0.12-0.52). The effects of earlier antithrombotics on the clinical outcomes were not significantly modified by the modality of recanalization treatment.Conclusions:In our retrospective analysis of a prospective registry, early antithrombotic (within 24 hours after initiation) administration did not increase hemorrhages after recanalization treatment. Early antithrombotic therapy may be advantageous for a subset of stroke patients despite the current guidelines.N
Dominant vertebral artery status and functional outcome after endovascular therapy of symptomatic basilar artery occlusion
No full textBackground and purpose. - To determine whether status of dominant vertebral artery could affect clinical outcome in patients with symptomatic basilar artery occlusion (BAD). Methods. - We reviewed patients with symptomatic BAO who underwent endovascular treatment at the institute between January 2007 and July 2014. Patients were categorized into 2 groups according to functional outcome and baseline characteristics, treatment related factors were compared. Variables including clinical and imaging parameters were also compared according to the dominant V1 lesion. Results. - Fifty-nine of 101 patients underwent endovascular treatment and 23 patients (39.0%) showed favorable outcome (modified Rankin score <= 3 at 3 month). Younger age, male sex, lower baseline NIHSS score, higher PC-ASPECTS, absence of hemorrhagic transformation, shorter procedure time, and complete recanalization were associated with favorable outcome. Procedure time tended to be longer in patients with dominant V1 lesion (130.0; range, 105.0-179.0 vs. 101.5; range, 48.0-138.0, P=0.05). Among patients with large artery disease (LAD), higher initial NIHSS, and clinical manifestation of decreased mental status were significantly associated with dominant V1 lesion. Endovascular procedure time tended to be longer, distal basilar occlusion tended to be more frequent, and proportion of the patients with complete recanalization tended to be less in patient with dominant V1 lesion. Poor outcome tended to be more frequent in dominant V1 lesion with LAD (88.9% vs. 42.9%, P=0.05). These findings were comparable in patients who underwent mechanical thrombectomy. Conclusion. - Dominant V1 steno-occlusion may be associated with poor functional outcome in patients with the symptomatic BAO. Status of dominant VA and various treatment strategy should be considered when performing endovascular treatment for recanalization in patients with symptomatic BAO. (C) 2017 Elsevier Masson SAS. All rights reserved.N
Recurrent ischemic stroke in atrial fibrillation with non-vitamin K antagonist oral anticoagulation
No full textThe etiology or rate of recurrent ischemic stroke according to dosing methods including drug adherence in patients taking non-vitamin K antagonist oral anticoagulants (NOACs) remain uncertain. We investigated the association between dosing methods including drug adherence achieved with NOACs and the presence of major vessel occlusion (MVO) in patients with ischemic stroke with non-valvular atrial fibrillation (NVAF). From July 2013 through December 2016, 120 patients with recurrent ischemic stroke with NVAF on NOACs were retrospectively analyzed. Patients taking non-standard doses of NOACs were divided into the missed dose group that discontinued NOACs for >= 48 h prior to arrival, and the under-dose group that used lower doses of NOACs. A logistic regression analysis was performed to determine the association between MVO and dosing methods including drug adherence. There were 60 (50.0%), 39 (32.5%), and 21 (17.5%) patients, respectively, in the standard dose, under-dose, and missed dose groups. Twelve patients (20.0%) in the standard dose group, 15 (38.5%) in the under-dose group, and 13 (61.9%) in the missed dose group had MVO. MVO was significantly higher in the missed dose group than in the standard dose and under-dose groups (P = 0.002). In patients with ischemic stroke with NVAF, who are on NOACs, anticoagulation caused by missed or lowered doses of NOACs was significantly associated with MVO in patients with recurrent cardioembolic stroke. (C) 2019 Elsevier Ltd. All rights reserved.N
Time-dependent shift of the relationship between systolic blood pressure and clinical outcome in acute lacunar stroke
No full textBackground and aims This study explores the relationship between systolic blood pressure during the acute period of stroke and poor functional outcome in patients with lacunar stroke, emphasizing a possible time-dependent nature of the relationship. Methods Based on multicenter stroke registry data, patients with acute lacunar stroke were identified, and systolic blood pressure levels at eight time points (1, 2, 4, 8, 16, 24, 48, and 72 h) after stroke onset were extracted at the 15 participating centers in South Korea. Poor functional outcome was defined as a three-month modified Rankin Scale score of 2-6. Non-linear restricted cubic spline and linear models were used for assessing the relationship at each time point. Results A total of 97,349 systolic blood pressure measurements of 3,042 patients were analyzed. At 1 h and 4 h after stroke onset, the relationship between systolic blood pressure and poor outcome showed a non-linear association. The nadir was 155 mmHg at 1 h and 124 mmHg at 4 h. After this time period, a higher systolic blood pressure was associated with a poorer outcome. This linear relationship weakened over time after 12 h (coefficient values of the adjusted linear models: 0.0081 at 8 h, 0.0105 at 12 h, 0.0102 at 24 h, 0.0082 at 48 h, 0.0054 at 72 h). Conclusions Based on our cohort of large number of lacunar stroke patients, our findings suggest that systolic blood pressure levels may follow a time-dependent course in relation to prediction of outcome at three months. The findings may be valuable for hypothesis generation in association with clinical trial development for blood pressure control in acute stroke patients.N
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