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ABSTRACT: Background: Studies investigating the clinical features and stroke mechanisms of anterior choroidal artery (AchA) infarction have reported inconsistent results. This may be partly due to different degrees of inclusion of patients with isolated posterior limb of the internal capsule (PLIC) lesions, which may be supplied by lenticulostriate arteries rather than AchA. The purpose of this study was to investigate clinical features and stroke mechanisms of AchA infarction, with particular attention to the above problem. Methods: We evaluated patients with AchA infarction assessed with diffusion-weighted imaging and magnetic resonance angiography, who were admitted to the Asan Medical Center from July 2001 to April 2011. Probable AchA (pAchA) infarction was diagnosed when the lesions were confined to the lower part of the PLIC, while definite AchA (dAchA) infarction was diagnosed when the lateral geniculate body, the uncus, or the cerebral peduncle were concomitantly involved. We assessed imaging findings, stroke mechanisms, and clinical features, and investigated the differences between patients with dAchA infarction and those with pAchA infarction. Results: We identified 127 patients with AchA infarction: 34 with dAchA infarctions, 90 with pAchA infarctions, and 3 without PLIC lesions. The most important stroke mechanism was small artery disease (SAD), followed by large artery disease (LAD). In patients with LAD, distal internal carotid artery (ICA) disease was a relatively important cause of stroke. The dAchA group, as compared with the pAchA group, was more frequently related to cardioembolism (12 vs. 2%, p = 0.03), distal ICA steno-occlusion (35 vs. 2%, p = 0.001), severe neurologic deficits (higher National Institute of Health Stroke Scale scores and more severe limb weakness), and less often associated with SAD (56 vs. 78%, p = 0.02). Conclusion: In general, SAD was the most important stroke mechanism for AchA infarction followed by LAD. However, dAchA infarction and pAchA infarction differ in that the former was more often associated with cardioembolism, distal ICA steno-occlusion, a worse clinical status and less often associated with SAD than the latter. The different proportion of patients with pure PLIC lesions included in previous studies may have led to inconsistent and confusing results, which should be considered to gain a proper understanding of AchA infarction.
Cerebrovascular Diseases 03/2013; 35(3):228-234. · 2.72 Impact Factor
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ABSTRACT: BACKGROUND: To investigate whether ischemic lesion burden including lesion pattern, number, and volume would vary depending on risk stratification of aortic atheroma (AA). METHODS: Acute stroke patients were enrolled if they had (1) acute ischemic lesions on diffusion-weighted imaging within 5 days of symptom onset, (2) cardioembolic stroke established through extensive workup, and (3) only ascending or arch AA detected by transesophageal echocardiography as an embolic source. AA was classified as complex (protruding ≥4 mm into the aortic lumen or any mobile or ulcerative component) or simple (<4 mm). RESULTS: Eighty-one patients (male: 65.4% and age: 66.7 ± 11.0 years) were included in the study. Thirty-four patients (41.9%) had complex atheroma. These patients had a greater number of ischemic lesions (median: 2 lesions [range: 1-42] versus one lesion [range: 1-27], P = .017) and a larger infarct size (9.01 cc [range: 3.58-49.14] versus 4.6 cc [range: 2.3-13.28), P = .056) than the simple atheroma group. Multivariable logistic regression analysis showed that ischemic lesion volume was independently associated with complex atheroma (odds ratio: 1.03, 95% confidence interval: 1.002-2.148, P = .035), while multiple lesions were related (odds ratio: 3.03, 95% confidence interval: .88-10.42, P = .079). CONCLUSIONS: Ischemic lesion burden in patients with AA differed according to AA characteristics, suggesting that the morphological features of AA could reflect an embolic potential of AA.
Journal of stroke and cerebrovascular diseases: the official journal of National Stroke Association 03/2013;
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Jong S Kim,
Hyun-Wook Nah,
Sea Mi Park,
Su-Kyung Kim,
Ki Hyun Cho,
Jun Lee,
Yong-Seok Lee,
Jei Kim,
Sang-Won Ha,
Eung-Gyu Kim,
Dong-Eog Kim,
Dong-Wha Kang, Sun U Kwon,
Kyung-Ho Yu,
Byung-Chul Lee
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ABSTRACT: BACKGROUND AND PURPOSE: The aim of this study was to investigate differences in risk factors and stroke mechanisms between intracranial atherosclerosis (ICAS) and extracranial atherosclerosis (ECAS) and between anterior and posterior circulation atherosclerosis METHODS: A multicenter, prospective, Web-based registry was performed on atherosclerotic strokes using diffusion-weighted magnetic resonance imaging and magnetic resonance angiography. Stroke mechanisms were categorized as artery-to-artery embolism, in situ thrombo-occlusion, local branch occlusion, or hemodynamic impairment RESULTS: One-thousand patients were enrolled from 9 university hospitals. Age (odds ratio [OR], 1.033; 95% confidence interval [CI], 1.018-1.049), male gender (OR, 3.399; 95% CI, 2.335-4.949), and hyperlipidemia (OR, 1.502; 95% CI, 1.117-2.018) were factors favoring ECAS (vs ICAS), whereas hypertension (OR, 1.826; 95% CI, 1.274-2.618; P=0.001) and diabetes mellitus (OR, 1.490; 95% CI, 1.105-2.010; P=0.009) were related to posterior (vs anterior) circulation diseases. Metabolic syndrome was a factor related to ICAS (vs ECAS) only in posterior circulation strokes (OR, 2.433; 95% CI, 1.005-5.890; P=0.007). Stroke mechanisms included artery-to-artery embolism (59.7%), local branch occlusion (14.9%), in situ thrombo-occlusion (13.7%), hemodynamic impairment (0.9%), and mixed (10.8%). Anterior ICAS was more often associated with artery-to-artery embolism (51.8% vs 34.0%) and less often associated with local branch occlusion (12.3% vs 40.4%) than posterior ICAS (P<0.001). CONCLUSIONS: The prevalence of risk factors and stroke mechanisms differ between ICAS and ECAS, and between anterior and posterior circulation atherosclerosis. Posterior ICAS seems to be closely associated with metabolic derangement and local branch occlusion. Prevention and management strategies may have to consider these differences.
Stroke 11/2012; · 5.73 Impact Factor
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ABSTRACT: Background: Symptomatic intracranial atherosclerosis (ICAS) is a dynamic disease that frequently progresses. Statins have been shown to have anti-atherosclerotic activity. We therefore investigated whether statins could prevent progression of ICAS. Methods: This retrospective cohort study assessed 55 patients with acute ischemic stroke and symptomatic ICAS in the middle cerebral or basilar arteries as shown on magnetic resonance angiography (MRA), with follow-up MRA performed more than 1 year after the index stroke. Change in ICAS was classified as progressive, regressive, or stable. Baseline clinical characteristics and risk factor control during follow-up were assessed, and laboratory tests were performed at the time of follow-up MRA. The statin group was defined as patients regularly treated with statins for more than 75% of the follow-up period; the remaining patients were defined as the non-statin group. Results: At a median follow-up time of 21.8 months (range, 11.8-66.1 months), the statin group consisted of 26 (47.3%) patients and the non-statin group of 29 (52.7%). During follow-up, 6 (10.9%) patients progressed, 14 (25.5%) regressed, and 35 (63.6%) remained stable. Statin treatment was significantly associated with non-progression of ICAS (p=0.024). Two patients in the non-statin group had recurrent strokes. Border-zone infarcts were associated with progression of ICAS (3/6, 50%; p=0.007), whereas risk factors and inflammatory biomarkers were not related to progression. Conclusions: Treatment with statins may prevent progression of symptomatic ICAS. Prospective randomized controlled trials are required to confirm that statins protect against such progression.
The Canadian journal of neurological sciences. Le journal canadien des sciences neurologiques 11/2012; 39(6):801-6. · 0.97 Impact Factor
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Dong-Wha Kang,
Sung-Il Sohn,
Keun-Sik Hong,
Kyung-Ho Yu,
Yang-Ha Hwang,
Moon-Ku Han,
Jun Lee,
Jong-Moo Park,
A-Hyun Cho,
Hye-Jin Kim,
Dong-Eog Kim,
Yong-Jin Cho,
Jaseong Koo,
Sung-Cheol Yun, Sun U Kwon,
Hee-Joon Bae,
Jong S Kim
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ABSTRACT: BACKGROUND AND PURPOSE: Unclear-onset strokes are generally excluded from time-based thrombolytic therapy. We examined the safety and feasibility of magnetic resonance imaging-based reperfusion therapy in unclear-onset stroke. METHODS: This prospective, multicenter, single-arm study screened consecutive unclear-onset stroke patients within 6 hours of symptom detection. Patients with perfusion-diffusion mismatch >20% and negative or subtle fluid-attenuated inversion recovery changes were treated with intravenous tissue plasminogen activator, intra-arterial therapy, or a combination. The safety outcome was symptomatic intracranial hemorrhage within 48 hours after treatment. The primary efficacy outcome was a 3-month modified Rankin Scale score of 0 to 2. Controls were untreated unclear-onset stroke patients prospectively captured in stroke registries. RESULTS: Of 430 unclear-onset stroke patients, 83 (19.3%) received reperfusion therapy (mean age, 67.5 ± 10.4 years; males, 66.3%; median baseline National Institutes of Health Stroke Scale, 14). Symptomatic intracranial hemorrhage with any neurological decline developed in 5 patients (6.0%). Symptomatic intracranial hemorrhage with National Institutes of Health Stroke Scale worsening ≥4 developed in 3 patients (3.6%). Thirty-seven patients (44.6%) achieved modified Rankin Scale score of 0 to 2, and 24 (28.9%) had modified Rankin Scale score of 0 to 1. Female, baseline National Institutes of Health Stroke Scale score, no immediate or early recanalization, and more white blood cells were independent predictors of poor outcome. Compared with untreated controls, the treated group was significantly associated with good outcomes of modified Rankin Scale score of 0 to 2 after adjusting for age, sex, and baseline National Institutes of Health Stroke Scale in logistic regression analysis (odds ratio, 2.25; 95% CI, 1.14-4.49). CONCLUSIONS: In unclear-onset stroke patients, magnetic resonance imaging-based reperfusion therapy was feasible and safe. Randomized controlled trials are warranted to confirm the benefit of reperfusion therapy for unclear-onset stroke.
Stroke 10/2012; · 5.73 Impact Factor
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ABSTRACT: BACKGROUND AND PURPOSE: Our goal was to investigate whether initial ischemic lesion pattern can predict stroke recurrence in patients with symptomatic intracranial arterial stenosis. METHODS: Of the Trial of Cilostazol in Symptomatic Intracranial Arterial Stenosis (TOSS)-2 trial participants, we included patients who underwent diffusion-weighted imaging and fluid attenuation inversion recovery imaging at baseline with a follow-up fluid attenuation inversion recovery imaging at 7 months. Based on the diffusion-weighted imaging findings, we classified the initial ischemic lesion patterns according to location (subcortical versus cortical versus subcorticocortical) and multiplicity (single versus multiple). We also evaluated the occurrence of new ischemic lesions on follow-up fluid attenuation inversion recovery as well as clinical stroke in the symptomatic intracranial arterial stenosis territory. RESULTS: Of 353 patients included in this study, 44 (12.5%) and 13 (3.7%) patients had new ischemic lesions and clinical recurrent stroke in the initial symptomatic intracranial arterial stenosis territory, respectively. On multivariable analysis, the initial lesion patterns of subcorticocortical and multiple lesions were independent predictors of new ischemic lesions in the symptomatic intracranial arterial stenosis territory (OR, 3.01; 95% CI, 1.33-7.01; P=0.03; OR, 2.81; 95% CI, 1.34-5.9; P=0.006). These patterns also predicted clinical recurrent stroke. CONCLUSIONS: Subcorticocortical lesions and multiple lesions are radiological predictors of recurrent ischemic stroke in symptomatic patients with intracranial arterial stenosis. Clinical Trial Registration- URL: www.clinicaltrials.gov. Unique identifier: NCT00130039.
Stroke 08/2012; 43(10):2785-2787. · 5.73 Impact Factor
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ABSTRACT: Acute cerebral infarction may coexist with hypertensive intracerebral hemorrhage (ICH) because lacunae and hypertensive ICH share common risk factors and small-vessel pathology. We sought to determine the frequency and predictors of new ischemic lesions (NIL) on diffusion-weighted imaging (DWI), in patients with acute hypertensive ICH, and to investigate whether NIL predicts subsequent clinical cerebrovascular events.
This prospective study enrolled 97 patients with acute hypertensive ICH diagnosed within 3 days after onset. DWI and gradient echo T2*-weighted imaging were performed 5 days after onset. NIL was defined as hyperintense DWI lesions accompanying low intensity on apparent diffusion coefficient maps. Patients were regularly followed up for subsequent clinical cerebrovascular events or vascular deaths.
Forty-nine asymptomatic NILs were observed in 26 (26.8%) patients, with 37 of the 49 NILs (75.5%) located in subcortical white matter or brainstem. Multiple logistic regression analysis showed that baseline microbleeds >2 and moderate to severe white matter leukoaraiosis were independently associated with NIL. During a median follow-up of 42 months (interquartile range, 38-47 months), 9 patients experienced clinical cerebrovascular events or vascular deaths. Cox proportional hazards models showed that NILs were independently associated with the composite of clinical cerebrovascular events or vascular death and marginally associated with clinical ischemic stroke.
NILs frequently occur during the acute phase of ICH and are mainly associated with small-vessel pathogenesis. NILs occurring together with ICH may be a useful marker to identify patients at high risk of future clinical cerebrovascular events or vascular death.
Neurology 07/2012; 79(9):848-55. · 8.31 Impact Factor
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ABSTRACT: The purpose of our study was to compare lesion location between moyamoya disease-related intracerebral hemorrhage (MMD-ICH) and primary intracerebral hemorrhage (P-ICH).
Ninety-three patients each with MMD-ICH and P-ICH were compared. In patients with MMD-ICH, angiographic findings were assessed with special attention to the prominent anterior choroidal artery. Follow-up data were obtained through clinical visit and telephone interview.
The location of hemorrhage was different between MMD-ICH and P-ICH, the most frequent one being intraventricular region (37.6%) in the former and putaminal region (46.2%) in the latter (P<0.001). Intraventricular hemorrhage was more frequent in MMD-ICH than P-ICH (80.6% versus 20.4%, P<0.001). In MMD-ICH, primary intraventricular hemorrhage was more closely associated with prominent ipsilateral anterior choroidal artery than ICHs without intraventricular hemorrhage (75.0% versus 16.7%, P<0.001). Higher rates of rebleeding and infarction were observed in MMD-ICH than in age- and sex-matched patients with P-ICH.
MMD-ICH may differ from P-ICH in hemorrhage location, generally presenting with intraventricular hemorrhage with or without ICH, which may be due to a prominent anterior choroidal artery. Patients with MMD may be more likely to experience recurrent bleeding and infarction.
Stroke 06/2012; 43(7):1947-50. · 5.73 Impact Factor
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ABSTRACT: Various biomarkers are linked with the pathophysiology of atherosclerosis. We hypothesized that these factors may be associated with the location and burden of cerebral atherosclerosis.
We evaluated 177 consecutive patients with chronic (>6 months) ischemic stroke: 68 with small vessel occlusion (SVO) and 109 with large-artery atherosclerosis (LAA), with the latter further sub-classified into 80 patients with intracranial atherosclerosis (ICAS) and 29 with extracranial atherosclerosis (ECAS). The number of ≥50% steno-occlusions on magnetic resonance angiography was used to assess the burden of atherosclerosis. Serum concentrations of the biomarkers (matrix metalloproteinases (MMP)-2 and -9, homocysteine, interleukin (IL)-6, tumor necrosis factor-α, C-reactive protein, adiponectin, leptin, resistin, free fatty acid, and lipoprotein(a)) and the metabolic syndrome were measured in each study subject.
Decreased plasma concentrations of MMP-2 (p = 0.020) and homocysteine (p = 0.038) were more closely associated with ICAS than with ECAS, whereas increased IL-6 concentrations were related to severe (≥4 steno-occlusions) atherosclerosis (p = 0.031). Multiple logistic regression analysis showed that the lowest tertile of MMP-2 was independently associated with ICAS (OR 4.84, 95% CI 1.29-18.19, p = 0.022).
Low MMP-2 plasma levels are associated with intracranial location of cerebral atherosclerosis, suggesting that MMP-2 may play a role in the development of ICAS.
Atherosclerosis 06/2012; 223(2):442-7. · 3.79 Impact Factor
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Dong-Eog Kim,
Jeong-Yeon Kim,
Sang-Wuk Jeong,
Yong-Jin Cho,
Jong-Moo Park,
Ju-Hun Lee,
Dong-Wha Kang,
Kyung-Ho Yu,
Hee-Joon Bae,
Keun-Sik Hong,
Ja-Seong Koo,
Seung-Hoon Lee,
Byung-Chul Lee,
Moon-Ku Han,
Joung-Ho Rha,
Yong-Seok Lee,
Gyeong-Moon Kim,
Seok-Lae Chae,
Jong S Kim, Sun U Kwon
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ABSTRACT: Predictors of progression of intracranial atherosclerotic stenosis have not been clearly identified. We investigated whether poststroke changes in lipid profiles would affect the prognosis of symptomatic intracranial atherosclerotic stenosis.
This is a substudy of Trial of cilOstazol in Symptomatic intracranial Stenosis 2 (TOSS-2). From 10 centers we enrolled 230 subjects with acute symptomatic stenosis in the M1 segment of the middle cerebral artery or basilar artery. At baseline and 7 months after stroke, subjects underwent MR angiogram and assessment of cardiovascular risk factors including lipoprotein levels. Progression of intracranial atherosclerotic stenosis was determined by comparing stenosis on the baseline and follow-up MR angiograms.
Cilostazol treatment was more frequently seen in the nonprogression group (109 of 198 [55.1%]) than in the progression group (11 of 32 [34.4%]). At 7 months after stroke when compared with baseline, low-density lipoprotein cholesterol and total cholesterol levels decreased in both groups. However, only nonprogressors showed increase in high-density lipoprotein cholesterol levels between baseline and follow-up. Changes in apolipoprotein B/apolipoprotein A-I levels were not different between the groups, although apolipoprotein B/A-I at 7 months was higher in progressors than in nonprogressors. Remnant lipoprotein cholesterol levels decreased in nonprogressors, whereas they did not change in progressors. In multivariable analyses, after adjusting for cilostazol treatment and remnant lipoprotein cholesterol reduction or apolipoprotein B/A-I at 7 months, high-density lipoprotein cholesterol elevation remained as a significant predictor for the nonprogression.
This is the first prospective multicenter study to demonstrate that high-density lipoprotein cholesterol elevation, along with remnant lipoprotein cholesterol reduction and low apolipoprotein B/A-I, is associated with prevention of angiographic progression of symptomatic intracranial atherosclerotic stenosis.
URL: http://www.clinicaltrials.gov. Unique identifier: NCT00130039.
Stroke 04/2012; 43(7):1824-30. · 5.73 Impact Factor
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ABSTRACT: Wake-up or unclear-onset strokes occur in up to one-fourth of patients with ischemic stroke. Although stroke severity and clinical outcomes appear to be poorer in wake-up strokes than nonwake-up strokes, many patients with wake-up strokes do not receive thrombolytic therapy because stroke onset time cannot be determined. Recent studies have suggested, however, that the actual onset time of wake-up stroke is close to the wake-up time. Furthermore, advanced imaging technologies may enable us to identify patients with favorable risk-benefit profiles for thrombolysis. Indeed, empirical thrombolytic treatments have suggested safety and feasibility of such therapy in these patients. Based on these promising results and the development of multimodal imaging methods, prospective thrombolysis trials using predefined imaging criteria are currently under way to test the safety and efficacy of thrombolysis in patients with wake-up or unclear-onset strokes. The establishment of optimal acute treatment strategies in this important yet so far neglected group of patients is eagerly awaited.
International Journal of Stroke 04/2012; 7(4):311-20. · 2.38 Impact Factor
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ABSTRACT: Ischemic lesion growth may be a surrogate marker of clinical outcome, but no such interrelationship after thrombolysis has yet been determined. We evaluated the association between early infarct growth on diffusion-weighted imaging (DWI) and long-term clinical outcome after thrombolysis.
We retrospectively reviewed outcomes in patients with acute middle cerebral artery territory stroke who had been treated with intravenous tissue plasminogen activator or intra-arterial urokinase. DWI lesion volumes were measured at baseline and within 7 days, and the difference was calculated. Clinical outcome was evaluated using the modified Rankin Scale (mRS) at 3 months. Good and poor clinical outcomes were defined as: a) mRS 0-1 vs. mRS 2-6, b) mRS 0-2 vs. mRS 3-6, and c) responder analysis which was influenced by the baseline National Institutes of Health Stroke Scale (NIHSS) scores: good and poor outcomes were defined as mRS 0 vs. mRS 1-6 if the baseline NIHSS score was <8, mRS 0-1 vs. mRS 2-6 if the NIHSS score was 8-14, and mRS 0-2 vs. mRS 3-6 if the NIHSS score was >14. The relationship between the ischemic lesion volume change and clinical outcome was explored. The cut-off value of infarct growth predicting long-term outcome was estimated using receiver operating characteristic analysis.
Of the 81 patients included, 67 (82.7%) showed lesion growth, and absolute growth was significantly related to poor outcomes (P<0.001 all for mRS 2-6, mRS 3-6, and responder analysis). Multivariate analysis showed that absolute lesion growth was an independent predictor of poor outcome, defined as mRS 2-6 (P=0.002; odds ratio [OR], 1.06; 95% confidence interval [CI], 1.02-1.10), mRS 3-6 (P=0.001; OR, 1.06; 95% CI, 1.02-1.10), and poor outcome by responder analysis (P=0.001; OR, 1.06; 95% CI, 1.03-1.10). The cut-off values of lesion growth that discriminated between good and poor outcomes were 14.11 cm(3) for mRS 2-6; 15.87 cm(3) for mRS 3-6; and 14.11 cm(3) in responder analysis.
Early DWI lesion growth is an independent predictor of poor outcome after thrombolysis and may serve a potential surrogate marker of clinical outcome in acute stroke trials.
Journal of the neurological sciences 02/2012; 316(1-2):99-103. · 2.32 Impact Factor
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ABSTRACT: A substantial number of acute stroke patients do not respond immediately to aggressive intra-arterial (IA) recanalization therapy. The factors and outcomes associated with timing of recanalization after IA thrombolysis, however, have not yet been determined.
Factors and outcomes in 75 acute ischemic stroke patients treated with IA urokinase (± intravenous tissue plasminogen activator) within 6 h of onset were retrospectively assessed. Immediate recanalization (IR) was assessed by the angiogram at the end of the IA procedure, and delayed (DR) and no (NR) recanalization were assessed by 5-day MR angiography. Modified Rankin Scale (mRS) scores were determined at 7 days and 3 months.
Of the 75 patients, 32 (42.7%) achieved IR, 21 (28%) achieved DR, and 22 (29.3%) showed NR. Good functional outcomes (mRS score ≤2) at 7 days and 3 months were observed in 59.4 and 62.5%, respectively, of the IR group, 14.3 and 38.1% of the DR group, and 22.7 and 27.3% of the NR group (p = 0.001 for 7 days, p = 0.028 for 3 months). Multivariate analysis showed that cardioembolism [odds ratio (OR), 3.74; 95% confidence interval (CI), 1.15-12.19] and middle cerebral artery occlusion (OR, 3.23; 95% CI, 1.04-10.04) were independent predictors of IR or DR compared with NR. Age (OR, 0.86; 95% CI, 0.77-0.95) and initial NIHSS score (OR, 1.20; 95% CI, 1.04-1.37) were independent predictors of DR compared with IR.
Patients receiving IA thrombolysis show different clinical and radiological characteristics according to the timing of recanalization. Earlier identification of DR patients and their more efficient recanalization may improve overall clinical outcomes after IA thrombolysis.
Cerebrovascular Diseases 01/2012; 33(3):255-61. · 2.72 Impact Factor
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ABSTRACT: Considering that insufficient platelet inhibition is related to thrombotic complications after coronary angiography, we hypothesized that the extent of platelet inhibition by antiplatelet agents is related to the occurrence of silent embolic cerebral infarction (SECI) after coronary angiography.
Among the patients scheduled for coronary artery bypass surgery, we retrospectively analyzed the location of SECI on diffusion-weighted imaging of 272 patients, which was performed after coronary angiography, as a presurgical evaluation in Phase 1 study. In Phase 2 study, we have prospectively recruited 102 patients to compare the extent of platelet inhibition measured by the VerifyNow system among patients with and without SECI.
SECI is observed in 45 patients (16.5%) in Phase 1 and 17 (16.7%) in Phase 2. The lesions were slightly more frequent in the right hemisphere. In the Phase 2 study, aspirin reaction units and P(2)Y(12) reaction units were higher in the patients with SECI than those without (aspirin reaction units: 490±72 versus 446±53, P=0.03; P(2)Y(12) reaction units: 352±65 versus 300±77, P=0.009). The incidence of SECI increased with the number of resistant antiplatelets; resistance to both antiplatelet agent (50%), resistance to 1 antiplatelet agent (22%), and no resistance (4%; P=0.023). From the result of logistic regression, higher aspirin reaction units, white blood cell count, low hemoglobin, and nonresponsiveness to antiplatelet agents were independent risk factors.
Insufficient platelet inhibition after administration of antiplatelet agents is related with SECI appearing after coronary angiography.
Stroke 12/2011; 43(3):727-32. · 5.73 Impact Factor
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ABSTRACT: To date, no large study has been conducted to investigate baseline stroke awareness within a nationally representative sample of the Korean population.
A total of 1000 residents were randomly sampled according to regional demographic characteristics and were interviewed in person by trained interviewers. Structured, open-ended and close-ended questions were asked to assess stroke awareness.
Among the respondents, 62% reported at least 1 stroke symptom and 56% reported at least 1 risk factor for stroke in open-ended questioning. Multivariate analysis revealed that completion of ≥12 years of education was independently associated with knowledge of symptoms (OR, 1.527; 95% CI, 1.146-2.034) and risk factors (OR, 1.577; 95% CI, 1.175-2.115). Approximately 31% and 33% of respondents, respectively, had some knowledge of thrombolysis and the proper action (call emergency medical services). Compared with subjects aged 20 to 39 years, those aged 40 to 59 years were more knowledgeable about thrombolysis (OR, 1.433; 95% CI, 1.045-1.964) and proper action (OR, 2.291; 95% CI, 1.646-3.188). The major source of information about stroke was television (59%), and the most reliable source was the respondents' physicians (55%). Among respondents 20 to 39 years of age, the Internet (37%) was the second greatest source of information.
Stroke awareness was suboptimal in Korea, especially among younger citizens and those with less education. To improve their knowledge, physicians should exert greater efforts to educate the public about stroke using mass media and the Internet.
Stroke 12/2011; 43(4):1146-9. · 5.73 Impact Factor
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Journal of the American College of Cardiology 12/2011; 58(24):2546. · 14.16 Impact Factor
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ABSTRACT: Ibudilast, a non-selective phosphodiesterase inhibitor, is clinically used in patients with stroke or dizziness. However, whether the compound exerts a beneficial effect on acute ischemic stroke remains to be established. We used a rat model of transient focal cerebral ischemia using middle cerebral artery occlusion (MCAO) and reperfusion, and explored the effects of ibudilast on infarction size, brain edema, atrophy, and nerve cell death. Neurological outcomes (behavior and mortality) of rats were also assessed. An intravenous administration of ibudilast attenuated the size of cerebral infarction in a dose-dependent manner, with the most significant reduction achieved at the dose of 10mg/kg. Ibudilast induced a significant reduction in infarct size when administered 30min before MCAO or 0-2h after reperfusion, with the largest reduction observed at 30min before MCAO and 1h after reperfusion. Ibudilast significantly attenuated brain edema formation, cerebral atrophy and apoptosis of nerve cells preferentially in the cortical penumbra area, and also significantly reduced mortality and improved neurological outcomes. Expression of various inflammatory mediator molecules in both hemispheres was markedly suppressed by ibudilast. We conclude that ibudilast exerts beneficial effects against acute brain ischemia in an animal model.
Brain research 11/2011; 1431:97-106. · 2.46 Impact Factor
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ABSTRACT: The etiologic diagnosis of intracranial arterial occlusion is sometimes challenging because of the dynamic nature of acute stroke. We investigated whether short-term follow-up vascular imaging adds additional information to the differential diagnosis between intracranial atherosclerotic and embolic occlusion.
Acute ischemic stroke patients with symptomatic middle cerebral artery (MCA) occlusion on MR angiography (MRA) within 24h of symptom onset were included. Follow-up MRA was performed 5-7days after stroke onset. Stroke subtypes were independently determined at baseline and follow-up MRAs based on clinical, laboratory and imaging findings.
In the 108 included patients, the most common etiologic subtype of initial stroke was intracranial large artery atherosclerosis (ICLAA) in 70 patients, followed by cardioembolism in 29 and other causes in 9. On follow-up MRA, 32 (29.6%) patients showed either significant or complete recanalization. Of these, 10 had been originally diagnosed with ICLAA, but were reclassified as a cryptogenic mechanism after follow-up MRA. Multiple logistic regression analysis showed that the presence of coexisting arterial atherosclerosis (odds ratio [OR], 6.91; 95% confidence interval [CI], 2.67-17.91; p<0.001); the absence of large territorial infarction (OR, 4.06; 95% CI, 1.39-11.85; p=0.010); and smoking (OR, 2.54; 95% CI, 1.028-6.29; p=0.043) were significantly associated with a final diagnosis of ICLAA.
In the absence of follow-up vascular imaging, a substantial proportion of patients with intracranial middle cerebral arterial occlusion may be misdiagnosed as ICLAA. Evaluation of early dynamic changes in intracranial middle cerebral arterial occlusion may provide useful information for the differential diagnosis of intrinsic atherosclerosis and embolic occlusion.
Journal of the neurological sciences 08/2011; 312(1-2):127-30. · 2.32 Impact Factor
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ABSTRACT: We described 9 consecutive patients who underwent operative carotid artery exploration with attempted carotid endarterectomy (CEA) for symptomatic internal carotid artery (ICA) occlusion. Indications for this surgery based on vascular imaging included segmental occlusion of the proximal ICA and also extensive occlusion of the distal ICA in selected patients in whom color-flow duplex ultrasound showed a poorly echogenic or anechoic thrombus with a flow void, suggestive of an acute thrombus. CEA was performed successfully to restore blood flow in all 9 patients:CEA in 5 and CEA with Fogarty thrombectomy in 4. Postoperative magnetic resonance (MR) angiography confirmed that revascularization had been successful in all 9 patients, and MR imaging displayed improved perfusion in 4 patients. Despite the lack of a generalized efficacy of surgical revascularization for symptomatic ICA occlusion, our study demonstrated that preoperative vascular imaging allows the selection of patients who may benefit from CEA.
Acta medica Okayama 08/2011; 65(4):239-45. · 0.84 Impact Factor
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Sun U Kwon,
Keun-Sik Hong,
Dong-Wha Kang,
Jong-Moo Park,
Ju-Hun Lee,
Yong-Jin Cho,
Kyung-Ho Yu,
Ja-Seong Koo,
K S Lawrence Wong,
Seung-Hoon Lee, [......],
Moon-Ku Han,
Joung-Ho Rha,
Hahn Young Kim,
Vincent C Mok,
Yong-Seok Lee,
Gyeong-Moon Kim,
Nijasri Charnnarong Suwanwela,
Sung-Cheol Yun,
Hyun-Wook Nah,
Jong S Kim
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ABSTRACT: An optimal strategy for management of symptomatic intracranial atherosclerotic stenosis (ICAS) has not yet been established. We compared the efficacy of 2 combinations of antiplatelets, aspirin plus cilostazol (cilostazol group) verus aspirin plus clopidogrel (clopidogrel group), on the progression of ICAS, which is known to be associated with clinical stroke recurrence.
In this investigator-initiated double-blind trial, 457 patients with acute symptomatic stenosis in the M1 segment of the middle cerebral artery or the basilar artery were randomly allocated into either a cilostazol group or a clopidogrel group. After 7 months of treatment, follow-up MR angiogram and MRI were performed. The primary end point was the progression of ICAS in comparison with stenosis on the baseline MR angiogram. Secondary end points included the occurrence of new ischemic lesions on MRI, composite of cardiovascular events, and major bleeding complications.
Cardiovascular events occurred in 15 of 232 patients (6.4%) in the cilostazol group and 10 of 225 (4.4%) in the clopidogrel group (P=0.312). Cilostazol did not reduce the progression of symptomatic ICAS (20 of 202) compared to clopidogrel (32 of 207) (odds ratio, 0.61; P=0.092), although favorable changes in serum lipoproteins were observed in the cilostazol group. There were no significant differences between the 2 groups with respect to new ischemic lesions (18.7% versus 12.0%; P=0.078) and major hemorrhagic complications (0.9% versus 2.6%; P=0.163).
This trial failed to show significant difference in preventing progression of ICAS and new ischemic lesions between the 2 combination antiplatelet therapies in the patients with symptomatic ICAS.
URL: http://www.clinicaltrials.gov. Unique identifier: NCT00130039.
Stroke 07/2011; 42(10):2883-90. · 5.73 Impact Factor
