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ABSTRACT: Purpose: Cerebral ischemic lesions are frequently observed after carotid artery stenting (CAS), and anti-platelet agents are used to prevent stent thrombosis and peri-procedural complications. However, despite the premedication, cerebral ischemic lesions are observed, suggesting that they may rather be related to anti-platelet resistance. We, therefore, investigated the effects of anti-platelet resistance on the development of cerebral ischemic lesions after CAS. Materials and Methods: We retrospectively reviewed patients who received CAS and selected patients for whom brain MRI was performed within 24 hours after CAS and for whom anti-platelet resistance was checked. Anti-platelet resistance was examined by the VerifyNow system. We analyzed the correlation between anti-platelet resistance and cerebral ischemic lesions detected on follow-up MRI. Results: Among 76 patients, 45 (59.2%) developed new ischemic lesions after CAS. Twelve (15.8%) patients showed aspirin resistance and 50 (65.8%) patients showed clopidogrel resistance. Patients with a new ischemic lesion demonstrated a significantly greater frequency of clopidogrel resistance than those who had no new ischemic lesion (82.2% versus 41.9%, p=0.001). The frequency of aspirin resistance was not significantly different between the groups of patients with and without new ischemic lesions (20.0% versus 9.7%, p=0.340). In multivariate analysis, clopidogrel resistance was a significant risk factor for post-procedural cerebral ischemia. Conclusion: Anti-platelet resistance can be used to predict new ischemic lesions after CAS. Anti-platelet resistance should be evaluated in all patients prior to CAS to prevent ischemic complications related to CAS.
Yonsei medical journal 03/2013; 54(2):288-94. · 0.77 Impact Factor
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ABSTRACT: A healthy, 66-year-old, right-handed man was admitted to our university hospital and diagnosed with herpes zoster ophthalmicus (HZO). After 4weeks, he complained of hemichorea on his left side. Brain MRI showed a focal hemorrhage in the right subthalamic area. No evidence of aneurysmal lesion or cerebral angiitis was observed on cerebral angiography.
Journal of Clinical Neuroscience 02/2013; · 1.25 Impact Factor
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Sang Won Han,
Sung-Soo Lee,
Seo Hyun Kim,
Jun Hong Lee,
Gyu Sik Kim,
Ok-Joon Kim,
Im-Seok Koh,
Jong Yun Lee,
Seung-Han Suk,
Sung Ik Lee,
Hyo Suk Nam,
Won-Joo Kim,
Seok Woo Yong, Kyung-Yul Lee,
Jae Hyeon Park
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ABSTRACT: Background: This study is intended to evaluate the propensities of cilostazol to reduce the pulsatility index (PI) in patients with acute lacunar infarction using the serial transcranial Doppler (TCD) examinations. Methods: In a multicenter, randomized, double-blind, placebo-controlled trial, patients were randomly assigned to receive either placebo or 100 mg cilostazol twice a day as well as aspirin 100 mg a day. The primary outcomes were the changes of middle cerebral artery (MCA) and basilar artery (BA) PIs at 14 and 90 days from the baseline TCD study. This study is registered with ClinicalTrials.gov (NCT00741286). Results: Trial medication was given to 203 patients, with 100 receiving cilostazol and 103 receiving placebo, and 164 were included in the per-protocol analysis of the primary outcome. Results from the linear mixed model showed that significant effects were obtained for time-by-group interactions (p = 0.008 in right MCA, p = 0.015 in left MCA, p = 0.002 in BA), suggesting that changes of PIs from the baseline to the 90-day study were different across the groups. Conclusions: Cilostazol further decreased TCD PIs at 90 days from baseline compared to placebo in acute lacunar infarction. This result may be related to pleiotropic effects, such as vasodilation, beyond its antiplatelet activity.
European Neurology 11/2012; 69(1):33-40. · 1.81 Impact Factor
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ABSTRACT: Purpose: Late diagnosis and treatment lead to high mortality and poor prognosis in tuberculous meningitis (TbM). A rapid and accurate diagnosis is necessary for a good prognosis. Neuron-specific enolase (NSE) has been investigated as a biochemical marker of nervous tissue damage. In the present study, the usefulness of NSE was evaluated, and a cut-off value for the differential diagnosis of TbM was proposed. Materials and Methods: Patient charts were reviewed for levels of serum and cerebrospinal fluid (CSF) NSE, obtained from a diagnostic CSF study of samples in age- and gender-matched TbM (n=15), aseptic meningitis (n=28) and control (n=37) patients. Results: CSF/serum NSE ratio was higher in the TbM group than those of the control and aseptic groups (p=0.001). In binary logistic regression, CSF white blood cell count and CSF/serum NSE ratio were significant factors for diagnosis of TbM. When the cut-off value of the CSF/serum NSE ratio was 1.21, the sensitivity was 86.7% and the specificity was 75.4%. Conclusion: The CSF/serum NSE ratio could be a useful parameter for the early diagnosis of TbM. In addition, the authors of the present study suggest a cut-off value of 1.21 for CSF/serum NSE ratio.
Yonsei medical journal 11/2012; 53(6):1068-72. · 0.77 Impact Factor
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ABSTRACT: Acute disseminated encephalomyelitis (ADEM) is a monophasic autoimmune demyelinating disease of the central nervous system, which typically follows acute viral or bacterial infection or vaccination. We report a case of ADEM associated with hepatitis C virus (HCV) infection with positive serum and cerebrospinal fluid (CSF) anti-HCV antibody. After steroid treatment, neurologic symptoms were improved. Virus triggers autoimmunity or direct viral invasion plays a part in the genesis of ADEM. This is the first reported case of ADEM with anti-HCV antibody in the CSF.
Yonsei medical journal 07/2012; 53(4):856-8. · 0.77 Impact Factor
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ABSTRACT: We describe our experience in which a retrievable Enterprise stent was used as a temporary recanalization and embolectomy
device in an acute middle cerebral artery (MCA) occlusion after urgent stenting for ipsilateral carotid artery stenosis.
Neuroradiology 04/2012; 51(8):541-544. · 2.82 Impact Factor
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ABSTRACT: Clopidogrel is a prodrug that requires transformation into an active metabolite by cytochrome P450 (CYP) in the liver in order to irreversibly inhibit the P2Y12 adenosine diphosphate platelet receptor. CYP2C19 polymorphism has been reported to correlate with reduced antiplatelet activity of clopidogrel in coronary artery disease. We assessed the association between CYP2C19 polymorphism and clopidogrel resistance in patients with cerebrovascular disease.
We retrospectively gathered data from patients who experienced cerebrovascular disease, received clopidogrel, and were tested for clopidogrel resistance and CYP2C19 polymorphism. Clopidogrel resistance was tested by the VerifyNow P2Y12 system, and the CYP2C19 polymorphism was tested by the Seeplex CYP2C19 ACE Genotyping system. Clopidogrel resistance was expressed in P2Y12 reaction units (PRU) and percent inhibition. High PRU and low percent inhibition suggests clopidogrel resistance. CYP2C19 polymorphisms were expressed as extensive, intermediate, and poor metabolizers. Clopidogrel resistance was assessed according to the subgroup of CYP2C19 polymorphism.
A total of 166 patients were evaluated. The PRU values of extensive CYP2C19 metabolizers (195.0±84.9) were significantly lower than those of intermediate and poor metabolizers (237.9±88.0, 302.2±58.9). The percent inhibition of extensive metabolizers (44.6±21.8) was significantly higher than that of intermediate and poor metabolizers (30.5±21.5, 14.0±13.4).
Intermediate and poor metabolizing CYP2C19 polymorphism is associated with reduced clopidogrel antiplatelet activity in patients with cerebrovascular disease. The clinical implications of this finding require further investigation.
Yonsei medical journal 09/2011; 52(5):734-8. · 0.77 Impact Factor
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ABSTRACT: We report herein a case of hyperacute onset of spontaneous cervical spinal subdural hematoma treated with methylprednisolone pulse therapy that showed good results. A 57-year-old man was admitted for posterior neck pain and paraparesis which occurred an hour ago. MRI revealed a ventral subdural hematoma distributed from the level of C1 down to T3, compressing the spinal cord. Conservative management with methylprednisolone pulse therapy was administered considering the patient's poor general condition. Although emergent surgical decompression is necessary in most cases of spinal subdural hematoma, conservative management with steroid therapy could be effective.
Yonsei medical journal 07/2011; 52(4):692-4. · 0.77 Impact Factor
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ABSTRACT: Intracranial pseudoaneurysm (IPA) is a rare disease entity associated with blunt trauma or penetration injury and less likely surgical or endovascular procedure. Decision of the therapeutic option is difficult and challenging in the treatment of iatrogenic pseudoaneurysm from the middle cerebral artery (MCA) that is necessary to maintain. We report our experience of reconstructive treatment of iatrogenic IPA, which was developed after stenting and balloon angioplasty, in the left MCA with overlapping Enterprise stents.
Journal of neuroimaging: official journal of the American Society of Neuroimaging 03/2011; 22(2):194-6. · 1.72 Impact Factor
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ABSTRACT: Antiphospholipid antibodies (aPLs) are associated with vascular occlusive events. Lupus anticoagulant (LA) and anticardiolipin antibody (aCL) are two aPLs commonly used for screening test. However, other aPLs are reported to play a role in the thrombotic events in other disorders, especially autoimmune disease. We investigated the clinical significance of the anti-annexin V antibody (aAV) in patients with acute cerebral ischemia; annexin V promotes anticoagulant activity via inhibition of prothrombin activation.
A total of 187 patients with acute cerebral infarction or transient ischemic attack, and 66 control subjects were included in this prospective study. IgG type aAV was determined by enzyme-linked immunosorbent sandwich assay in the patient and control groups. The presence of LA and aCL were determined in the patient group using the usual screening method.
IgG aAV was detected in 26 of the 187 patients (13.9%), but only in three of the 66 control subjects (4.5%; P=0.043). Among the 26 aAV positive patients, only five patients were positive for LA or aCL. The presence of IgG aAV was significantly associated with acute cerebral ischemia: one stroke event (OR, 4.39; 95% CI, 1.21-16.01), and two or more stroke events (OR, 3.91; 95% CI, 1.09-14.07).
IgG aAV was detected in a significant percentage of the patients with acute cerebral ischemia compared with the control group. The presence of IgG aAV did not usually coincide with LA or aCL. Thus aAV should be considered as a possible associated factor for acute cerebral ischemia.
Journal of the neurological sciences 03/2011; 305(1-2):53-6. · 2.32 Impact Factor
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Neurological Sciences 02/2011; 32(4):743-6. · 1.32 Impact Factor
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ABSTRACT: Hemorrhage is a major complication of thrombolytic treatment. Concerns have been raised about the risk of hemorrhage in patients having received warfarin. Therefore, different indications for thrombolytic treatment are in use for stroke patients on warfarin. However, it remains uncertain whether the prior warfarin use actually increases their risk of bleeding in patients treated with thrombolysis.
This study included 179 consecutive patients who had high-risk cardioembolic sources and received thrombolytic treatment. Patients were treated with intravenous thrombolytic agents, or underwent intraarterial thrombolysis if their international normalized ratio (INR) was ≤1.7. We compared the frequency of bleeding complications between patients with prior warfarin use and those without. We also investigated whether there were differences in functional outcome and recanalization rates between them.
A prior warfarin use was present in 28 patients (15.6%). Although INR levels were higher in the prior warfarin group, the frequency of bleeding complications was not different between patients who received prior warfarin and those who did not. No differences were observed in patients with or without prior warfarin use, for successful recanalization rate (Thrombolysis in Myocardial Infarction grade 2 or 3), mortality, or modified Rankin score (≤2) at 3months.
Thrombolytic therapy for patients who previously received warfarin and had an INR≤1.7 did not affect bleeding risk, clinical outcome, or recanalization rate. Our data suggest that patients with a history of prior warfarin use may be safely treated with thrombolytic agents when their INR levels are low.
Journal of the neurological sciences 11/2010; 298(1-2):101-5. · 2.32 Impact Factor
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ABSTRACT: Claude's syndrome is a distinctive brainstem syndrome characterized by ipsilateral third cranial nerve palsy with contralateral hemiataxia and is due to an intrinsic or extrinsic lesion in the midbrain. We report a case of Claude's syndrome caused by neurocysticercosis infection. A 68 year-old Asian man was admitted to our hospital because of ataxia, left ptosis, and diplopia. Brain magnetic resonance imaging (MRI) showed a cystic lesion in the midbrain, which was surrounded by ring enhancement and peripheral edema. Neurocysticercosis infection was diagnosed by the cerebral spinal fluid study. The patient was treated with albendazole and steroids. A follow-up brain MRI three months later demonstrated the disappearance of a surrounding brain edema and rim enhancement. The most common cause of Claude's syndrome is cerebrovascular disease and malignancy. However, there is no report caused by neurocysticercosis infection. Therefore, if we encounter Claude's syndrome, we should consider neurocysticercosis infection as one of the etiologic factors.
Yonsei medical journal 11/2010; 51(6):978-9. · 0.77 Impact Factor
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Neurology 08/2010; 75(7):668. · 8.31 Impact Factor
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ABSTRACT: Transient global amnesia (TGA) patients were retrospectively reviewed to determine the usefulness of high-field strength MRI in detecting probable ischemic lesions in TGA.
We investigated the lesion detection rate in patients with TGA using 1.5T and 3.0T MRI. Acute probable ischemic lesions were defined as regions of high-signal intensity in diffusion weighted image with corresponding low-signal intensity in apparent diffusion coefficient map.
3.0T MRI showed 11 out of 32 patients with probable ischemic lesions in the hippocampus with mean lesion size of 2.8 +/- 0.6 mm, whereas 1.5T MRI detected no lesion in any of 11 patients. There were no significant differences in clinical characteristics between the groups of 1.5 and 3.0T MRI.
High-field strength MRI has a higher detection rate of probable ischemic lesions than low-field strength MRI in patients with TGA.
Yonsei medical journal 05/2009; 50(2):211-4. · 0.77 Impact Factor
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ABSTRACT: We investigated a method for assessing early improvement and predictive factors of early and late outcomes in patients receiving thrombolytic therapy.
A total of 160 consecutive patients who received thrombolytic therapy were included in the study. Using National Institutes of Health Stroke Scale (NIHSS) scores, percent improvement [(baseline NIHSS score-24-hour NIHSS score)/baseline NIHSS score x 100] was calculated and compared with delta (baseline NIHSS score-24-hour NIHSS score) and with major neurological improvement (MNI, NIHSS score of 0-1 or >or=8 point improvement at 24 h) by receiver operating characteristic (ROC) curve analysis. Finally, we investigated the independent predictors of improvement at 24 h after the thrombolytic therapy and of favorable 3-month outcome (modified Rankin scale score 0-2).
By pairwise comparison of ROC curves, percent improvement was stronger than delta (p=0.004) and MNI (p<0.001) in predicting long-term outcome. First day improvement (FDI), defined as greater than 20% improvement, was a strong predictor of favorable 3-month outcome (OR 12.55, 95% CI 5.41-29.10). Recanalization (OR 3.30, 95% CI 1.28-8.45), absence of carotid T occlusion (OR 0.09, 95% CI 0.02-0.42) and hemorrhagic transformation (OR 0.25, 95% CI 0.09-0.73) were independent predictors of FDI. Independent predictors of favorable 3-month outcome were FDI, current smoking, absence of carotid T occlusion and hemorrhagic transformation.
Percent improvement at 24 h after thrombolytic therapy is a useful surrogate marker for predicting the long-term outcome. Our findings highlight the importance of early stroke management.
Journal of the neurological sciences 04/2009; 281(1-2):69-73. · 2.32 Impact Factor
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ABSTRACT: The prevalence of extracranial (EC) and intracranial (IC) atherosclerosis varies among races. Although several studies have sought to identify specific vascular risk factors that are associated with EC or IC atherosclerosis, the exact relationships are uncertain. This study aimed to determine if there are any specific risk factors for EC or IC atherosclerosis.
For this study, we considered 3,349 consecutive patients who had been entered into a stroke registry between January 1999 and June 2007. After the exclusion of patients who had not undergone angiography, patients with cardiac sources of embolism or other causes of stroke, and non-Koreans, we had a total of 2,169 patients of single ethnicity with an angiographic analysis. Patients with atherosclerosis in both the IC and EC arteries (856 patients) were excluded. Finally, we identified 1,313 patients who had EC atherosclerosis (EC group, n = 256), IC atherosclerosis (IC group, n = 566) or normal angiographic findings (no-lesion group, n = 488). The frequency of risk factors and the demographic parameters were compared among these groups.
When compared to the normal group, the IC group was associated with older age and hypertension, and the EC group was associated with older age, higher initial blood sugar and low-density lipoprotein cholesterol levels. However, in a direct comparison between the IC and EC groups, we did not observe any significant risk factors or variables except for a higher frequency of males and higher total cholesterol levels in the EC group.
Vascular risk factors may not be major determinants of location for atherosclerosis in the EC or IC arteries.
Neuroepidemiology 02/2009; 32(3):201-7. · 2.31 Impact Factor
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In Koo Hwang,
Ki-Yeon Yoo,
Sun Shin Yi,
Il Yong Kim,
Hye Sook Hwang, Kyung-Yul Lee,
Sun Mi Choi,
In Se Lee,
Yeo Sung Yoon,
Soo Youl Kim,
Moo Ho Won,
Je Kyung Seong
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ABSTRACT: Chronological changes of tissue-type transglutaminase (tTG) were observed in the hippocampal CA1 region after transient forebrain ischemia in gerbils. In the sham-operated group, tTG immunoreactivity was weakly detected in blood vessels which were immunostained with platelet endothelial cell adhesion molecule-1 (PECAM-1), and tTG immunoreactivity in blood vessels was highest 5 days after ischemia/reperfusion. In addition, tTG immunoreaction was expressed in microglia which were immunostained with Iba-1 at 4 days post-ischemia, and tTG immunoreactivity in the microglia was also highest at 5 days post-ischemia. In Western blot analysis, tTG protein levels in the CA1 region after ischemia/reperfusion began to increase 3 days after ischemia/reperfusion and peaked 5 days after ischemia/reperfusion. The expression of tTG in PECAM-1-immunoreactive blood vessels may be associated with integrin regulation or transendothelial migration of leukocytes in the ischemic CA1 region. In this study, we also observed the effect of cystamine, a tTG inhibitor, against ischemic damage. Administration of cystamine protected in certain degree neuronal damage from ischemic damage in the CA1 region. These results suggest that tTG may be associated with neuronal death in the hippocampal CA1 region induced by ischemia/reperfusion.
Brain research 02/2009; 1263:134-42. · 2.46 Impact Factor
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ABSTRACT: Rapid arterial rethrombosis is associated with high-grade residual stenosis and usually occurs at the site of the initial occlusion, resulting in reocclusion of the recanalized artery. Platelets may play an active role in such rethrombosis after thrombolytic-induced clot lysis. Given that glycoprotein IIb/IIIa receptor blockers, like tirofiban, prevent thrombus formation by inhibiting the final common pathway of platelet aggregation, they may be helpful for treating rethrombosis after thrombolysis. A 64-year-old man presented with an acute ischemic stroke due to internal carotid artery (ICA) occlusion. The ICA was recanalized by intravenous thrombolysis but reoccluded shortly after recanalization. The reoccluded ICA was successfully recanalized using intra-arterial tirofiban. A carotid stent was subsequently inserted to relieve severe stenosis and to prevent recurrent stroke. Here, we report a case of rescue treatment of a successfully recanalized ICA by intra- arterial tirofiban. We suggest that rescue use of intra-arterial tirofiban may be effective and safe, especially in hemorrhage prone situations, due to the relatively lower dose of tirofiban compared with intravenous doses.
Yonsei Medical Journal 11/2008; 49(5):857-9. · 1.14 Impact Factor
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ABSTRACT: Mechanical thrombolysis may effectively enhance the efficacy of thrombolysis for hyperacute ischemic stroke patients.
To assess the feasibility and results of simple mechanical-based thrombolysis using microwire and microcatheter with adjuvant low-dose intraarterial (i.a.) urokinase (UK) for the treatment of hyperacute ischemic stroke.
Nineteen consecutive patients with hyperacute proximal middle cerebral artery (MCA) occlusions treated by a standardized protocol using microwire and microcatheter for mechanical thrombus disruption with adjuvant i.a. UK were reviewed. Simple to-and-fro passages through the clot with the microwire and microcatheter followed by disruptions by a J- or pigtail-shaped wire tip with alternating small-dose injections of UK distal, within, and proximal to the clot were performed. The recanalization rates, post-thrombolysis hemorrhage, and clinical outcome (baseline and discharge National Institute of Health Stroke Scale [NIHSS], mortality, 3-month modified Rankin scale [mRS]) were evaluated.
Recanalization was achieved in 18 of 19 patients (94.7%). The mean UK dose was 375,789 IU (range 130,000-580,000 IU). Two patients (10.5%) developed symptomatic hemorrhage. One of the hemorrhages included a patient who developed subarachnoid hemorrhage. Mortality rate was 15.8% (n = 3). The median baseline NIHSS scores showed improvement from 17 to 10 at presentation and discharge, respectively. At three months, good outcome was noted in 11 of 19 patients (57.9%, mRS 0-2).
Simple mechanical-based thrombolysis using microwire and microcatheter with adjuvant low-dose i.a. UK is safe and effective in achieving recanalization with good long-term outcome.
Acta Radiologica 05/2008; 49(3):351-7. · 1.37 Impact Factor
