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Prescriptions*

Lateral medullary syndrome is famous for its unique symptom complex such as crossed sensory change or Homer syndrome, and thus hardly can be misdiagnosed. Though this syndrome has been reported to be able to accompany ipsilateral motor weakness, the sensory change of extremities is known to be almost always contralateral to the lesion. We recently experienced one case presented with weakness and dysmetria on the right associated with ipsilateral sensory change. But few days later, he showed additional neurologic signs compatible with right lateral medullary syndrome. Brain MRI showed rostro-caudally elongated lesion extending from right lateral medulla to the upper cervical cord. Here we suggest the probable neuroanatomical substrate for this symptom and clinico-radiologic relationship with previous literature.
Brain ; Cerebellar Ataxia ; Extremities ; Lateral Medullary Syndrome* ; Magnetic Resonance Imaging ; Neurologic Manifestations ; Stroke*

Background & Objective: Sex differences in cerebral atherosclerosis and subsequent stroke have not been thoroughly investigated and conflicting data exist. The aim of this study was to investigate sex differences in the risk factors and distribution of large artery atherosclerotic stroke in a Korean population. Methods: We included consecutive acute ischemic stroke patients with symptomatic extracranial atherosclerosis (ECAS) or intracranial atherosclerosis (ICAS) based on brain and vascular imaging who presented at our hospital between January 2011 and December 2015. We then compared risk factor profiles and the proportion of symptomatic ECAS and ICAS between men and women. Results: Eight hundred and forty four patients were enrolled during the study period. The proportion of ECAS in men was notably higher than in women (19.4% in men vs. 9.3% in women; p < 0.001). A multiple regression analysis showed that male gender was a factor favoring ECAS (vs. ICAS, odds ratio [OR], 3.554; 95% confidence interval [CI], 2.175-5.808; p < 0.001). Age (OR, 1.051; 95% CI, 1.031-1.072; p = 0.001) and hyperlipidemia (OR, 2.330; 95% CI, 1.538-3.529; p < 0.001) were also factors favoring ECAS. However, after stratification by sex, the association was only significant in men. Conclusions: There is a sex difference in the distribution of atherosclerotic stroke. Sex may be an effect modifier of the association between atherosclerotic risk factors and atherosclerotic distribution.
Stroke

BACKGROUND: The intravenous thrombolysis is a well established treatment of acute ischemic stroke. However, baseline prognostic factors were poorly identified by previous studies. METHODS: From January 2001 to May 2006, prospective data of 121 patients treated with intravenous tissue plasminogen activator (tPA) were collected. The clinical, radiologic, transcranial Dopper (TCD) and laboratory finding were evaluated. Clinical assessment was done by National Institutes of Health Stroke Scale (NIHSS) for one week, and by modified Rankin Scale (mRS) at baseline for three months. Early improvement was defined as the complete resolution of the neurological deficit or an improvement of > or =4 points by NIHSS within 24 hours, and good outcome as mRS score of < or =2 at three months. We assessed the possible relationship of the factors with early improvement and good outcome, and also analyzed the correlation of TCD grade with NIHSS score. RESULTS: On univariate analysis, younger age, absence of abnormal CT findings (hyperdense middle cerebral artery sign [HMCAS], focal hypodensity >33% of total MCA territory) were significantly associated with early improvement. Good outcome was associated with younger age, lower levels of baseline NIHSS score, mean blood pressure, fasting glucose, lipoprotein (a), and normal CT finding. Multivariate analysis revealed age <66 years and no HMCAS as independent predictors of early improvement. Thrombolysis in brain ischemia grade by TCD monitoring significantly correlated with NIHSS score for 24 hours. CONCLUSIONS: These results suggest that younger age and normal CT findings are important prognostic factors of acute thrombolytic therapy.
Blood Pressure ; Brain Ischemia ; Fasting ; Glucose ; Humans ; Lipoprotein(a) ; Middle Cerebral Artery ; Multivariate Analysis ; National Institutes of Health (U.S.) ; Prognosis ; Prospective Studies ; Stroke* ; Thrombolytic Therapy* ; Tissue Plasminogen Activator

It has been known that the hypothermia have protective effect on neuronal survival after ischemic damage. We performed this study to evaluate the effect of the small changes in postischemic body temperature on the histopathological change of hippocampus in the transient global cerebral ischemia model. Mongolian gerbils were subjected to this study. Nine animal subgroups were investigated, including naive gerbils who underwent sham operation or carotid artery occlusion with postischemic rectal temperature maintained at 32.5, 34.5, 36.5 and 38.5C respectively. Carotid occlusion was maintained for 10 minutes and then reperfusion started. During ischemia, body temperature was maintained 36.5degrees C in all animals. For one hour after ischemia, body temperature was maintained constant at 36.5degrees C in the normothermia group, 38.5 degrees C in the hyperthemia group, 34.5 degrees C in mild hypothermia group, and 32.5 degrees C in moderate hypothermia group respectively. Seven days after the operation, the surviving animals were decapitated and perfusion fixated. After preparing coronal brain slices, viable neurons in hippocampal region were counted using cresyl violet staining. There were significant differences in the hippocampal neuronal survival in normothermia and hyperthermia groups compared with shamoperated group(P<0,01), and neuronal damages in mild and moderate hyperthemia groups were not significantly different from sham operated. Survival rate at postischemic 7th day was also significantly lower in hyperthermia group. We could confirm the protective effect of hypothermia on ischemic neuronal damage by histopathological study. Also hyperthemia was observed to aggravate neuronal death, Careful control of body temperature might have clinical effect in ischemic stroke.
Animals* ; Body Temperature ; Brain ; Brain Ischemia ; Carotid Arteries ; Fever ; Gerbillinae ; Hippocampus ; Hypothermia ; Ischemia* ; Models, Animal* ; Neurons* ; Perfusion ; Reperfusion ; Stroke ; Survival Rate ; Viola

There have been recent advances in the hyperacute treatment and secondary prevention of ischemic stroke. Thrombolysis with intravenous tissue plasminogen activator has been approved for a 3 to 4.5 hour time window, but the recent controversy over the optimal dose has not been resolved. Five endovascular trials published in 2015 have shown dramatically positive results. Regarding secondary prevention of ischemic stroke, a study suggesting the beneficial effect of a short course of dual antiplatelet therapy has been published. Non-vitamin K antagonist oral anticoagulation agents have been approved for stroke prevention in non-valvular atrial fibrillation. Here, we review these recent advances in ischemic stroke management.
Anticoagulants ; Atrial Fibrillation ; Endovascular Procedures ; Platelet Aggregation Inhibitors ; Secondary Prevention ; Stroke* ; Tissue Plasminogen Activator

BACKGROUND: Atrial fibrillation (AF), commonly considered as a cardiac embolic source, can itself be induced by stroke. We therefore tried to find and analyze this 'stroke-induced' AF. METHODS: From the Inha University Stroke Registry of the past 2 years, 143 middle cerebral artery (MCA) territorial infarct patients who had been admitted within 48 hours after stroke onset were recruited to participate in the study. Electrocardiograms (EKG) on admission and follow-up during hospitalization were analyzed. Also, MCA infarct was subdivided according to insular involvement by brain imaging. RESULTS: Among 143 MCA territorial infarcts, 38 patients had AF on admission (Rt:21; Lt:17). Of those, insular involvements of the MCA infarct was noted in 32 patients. All the patients had a follow-up EKG and AF disappeared in 3 patients (Rt:2; Lt:1). In the remaining 105 patients, 10 patients subsequently developed new AF within 1 week after hospitalization. All those 10 patients had right-sided MCA infarcts and insular involvements were present in 9 patients. In summary, among the 48 MCA infarct associated with AF, 13 AF (Rt:12; Lt:1) were presumed to be the consequence and not the cause of stroke. CONCLUSIONS: Though human insular stimulation and inactivation studies have suggested that AF would be more common in left insular destructive lesions, it was not always supported in clinical series. From our study, presumed 'stroke-induced' AF was highly associated with right insular lesions. The mechanism of arrhythmogenesis by ischemic stroke might be more complicated than previously expected and, not merely the simple inactivation of an anatomical substrate, the insular cortex.
Atrial Fibrillation* ; Electrocardiography ; Follow-Up Studies ; Hospitalization ; Humans ; Middle Cerebral Artery* ; Neuroimaging ; Stroke

The acute management of ischemic stroke consists of several components: general supportive care, thrombolysis, antithrombotics, prevention of medical and neurologic complications, rehabilitation, and if necessary, surgical intervention. However, for the adequate stroke care, not only the medical treatment but also the proper organization of each stroke care component is essential. This includes public education, well organized emergency medical referral system, pre-hospital identification tool of stroke, operation of stroke unit with quality improvement activity, and establishment of stroke center. The efficacy of stroke unit for the acute management of stroke was found to exceed those of conventional medical treatment such as antiplatelet therapy, and now stroke unit is considered to be the key element of acute stroke care. For the harmonious orchestration of these stroke care elements, there is growing need for the establishment of stroke center too. In this review, each component of stroke care is discussed.
Emergencies ; Quality Improvement ; Referral and Consultation ; Stroke

Carotid bruit is a physical sign derived from the turbulence of carotid blood flow and has been rgarded as one of the imponant risk factor of ischemic stroke. To estimate a crude prevalence of carotid bruit in ischemic stroke in Korea at present time, and evaluate the correlation of carotid bruit with carotid stenosis and site of ischemic lesion, we investigated the brain imaging studies (computed tomography and / or magnetic resonance imaging)and cerebral angiographict finding of fifty patiens with caoti bruit.Thirty-nine (3.9 %) ot of nine hundred and ninety-six ischemic stroke patients had bruit around the carotid bifurcation. And the other eleven cases who did not have ischemic stroke were detected to have carotid bruit during the routine neurological examination at the bedside.Th presence of infarction in one side of carotid territory was not significantly differentwhether the bruit was heard or not in that side, but the presece of carotid stenosis in angiographY had a tendency to be significantly different by the audible bruit on that side. Carotid bruit does not necessarily reflect the infarction of that side, but can only be used as a predictor of ipsilateral extracranial carotid occlusive disease in this preliminary study. Further extensive prospective study is needed for the exact prevalence of rate and the clinical usefulss of the carotid bruit in Korea.
Angiography ; Carotid Stenosis ; Humans ; Infarction ; Korea ; Neuroimaging ; Neurologic Examination ; Prevalence ; Risk Factors ; Stroke

BACKGROUND: Tissue plasminogen activator (tPA) is known to be effective if given within 3 hours after the onset of ischemic stroke. However, no study has been performed regarding what proportion of patients with acute ischemic stroke are actually given tPA within this time window. We therefore tried to figure out the performance rate of thrombolytic therapy and acute prognosis in hyperacute ischemic stroke patients. METHODS: We prospectively registered all the acute ischemic stroke patients. Thrombolyic therapy was decided strictly according to the NINDS tPA protocol and clinical monitoring was done by the NIH Stroke Scale (NIHSS). If tPA was not given, the reason was recorded. RESULTS: Among 613 acute stroke patients during a period of 2.5 years, there were 146 (23.8%) hyperacute ischemic stroke patients within 3 hours after onset. Even in the 29 cases of in-hospital stroke, the rate of early detection and management was only 27.6% (8 cases). Among the hyperacute stroke population, 56 (38.4%) patients were treated with the thrombolytic agent and 27 patients showed positive responses. Thrombolytic therapy was not tried in the remaining 90 patients. The most common reason was expectation of favorable outcome without thrombolysis. But among these patients, subsequent neurological worsening was noticed in 9 patients, particularly in those with vertebrobasilar stroke. CONCLUSIONS: Urgent notice and management of ischemic stroke needs to be more emphasized not only to the general public, but also to medical personnel. More close observation is especially needed in vertebrobasilar stroke cases (J Korean Neurol Assoc 19(5):447~451, 2001)
Humans ; National Institute of Neurological Disorders and Stroke ; Prognosis* ; Prospective Studies ; Stroke* ; Thrombolytic Therapy* ; Tissue Plasminogen Activator