BACKGROUND: Neurological syndromes often complicate the management of infective endocarditis. METHODS: We reviewed the neurological complications in 100 patients with infective endocarditis in a tertiary care hospital. RESULTS: Neurological complications occurred in 25 patients (25%). Ischemic infarctions occurred in 15 patients, hemorrhagic infarctions in 5, intracerebral hemorrhages in 12, subarachnoid hemorrhages in 4, and subdural hemorrhages in 2. Brain abscess was detected in 4 and seizures in 2 patients. Staphylococcus aureus endocarditis (p=0.01) and mitral valvular heart disease (p=0.015) correlated statistically with the development of neurological complications. The mortality rate was significantly higher in patients with neurological complications than those without neurological complications (p=0.00). Age, sex, and type of valve (native versus prosthetic) were not related to the complication rate. CONCLUSIONS: We concluded that (1) hemorrhagic complications occurred at a higher rate in this study than previous reports; (2) S.aureus infection and mitral valvular disease predicted the occurrence of neurological complications; and (3) neurological complications were related to mortality rates. (J Korean Neurol Assoc 19(3):202~206, 2001)
Brain Abscess ; Cerebral Hemorrhage ; Endocarditis ; Heart Diseases ; Heart Valve Diseases ; Hematoma, Subdural ; Humans ; Infarction ; Mortality ; Seizures ; Staphylococcus aureus ; Subarachnoid Hemorrhage ; Tertiary Healthcare

Homocystinuria is an inborn error of methionine metabolism and has several causes. Among the causes, cystathionine-b-synthase deficiency is the most common. The major clinical manifestations are ectopia lectis skeletal deformities, mental retardation and occlusive vascular disease A 16 year old girl was admitted with generalized seizure. She had a history of bilateral lens dislocation and thoracic scoliosis. Her brain MRI and MRA showed mass-like lesions at both frontal area and diffuses, stenosis of the right internal carotid artery She underwent a stereotaxic brain biopsy and cerebral angiography. Two days, after angiography, she was suddenly aggravated to show stuporous mentality and quadriplegia. FoIlow-up brain MRI showed newly developed acute ischemic lesions at both parietal area MR venography confirmed superior sagittal sinus thrombosis. Methionine and homocystine were markedly elevated in plasma and 24 hour urine. She recovered with anticoagulation and vitamin supplementation(folate and pyridoxine). Homocystinuria should be suspected in stroke patients of young age, especially if thy have nontraumatic lens dislocation or marfanoid features. We report a patient with homocystinuria complicated by cerebral venous sinus thrombosis which was aggrevated after cerebral angiography.
Adolescent ; Angiography ; Biopsy ; Brain ; Carotid Artery, Internal ; Cerebral Angiography ; Congenital Abnormalities ; Constriction, Pathologic ; Female ; Homocystine ; Homocystinuria* ; Humans ; Intellectual Disability ; Lens Subluxation ; Magnetic Resonance Imaging ; Metabolism ; Methionine ; Phlebography ; Plasma ; Quadriplegia ; Rabeprazole ; Scoliosis ; Seizures ; Sinus Thrombosis, Intracranial ; Stroke ; Stupor ; Superior Sagittal Sinus* ; Thrombosis* ; Vascular Diseases ; Vitamins

Homocystinuria is an inborn error of methionine metabolism and has several causes. Among the causes, cystathionine-b-synthase deficiency is the most common. The major clinical manifestations are ectopia lectis skeletal deformities, mental retardation and occlusive vascular disease A 16 year old girl was admitted with generalized seizure. She had a history of bilateral lens dislocation and thoracic scoliosis. Her brain MRI and MRA showed mass-like lesions at both frontal area and diffuses, stenosis of the right internal carotid artery She underwent a stereotaxic brain biopsy and cerebral angiography. Two days, after angiography, she was suddenly aggravated to show stuporous mentality and quadriplegia. FoIlow-up brain MRI showed newly developed acute ischemic lesions at both parietal area MR venography confirmed superior sagittal sinus thrombosis. Methionine and homocystine were markedly elevated in plasma and 24 hour urine. She recovered with anticoagulation and vitamin supplementation(folate and pyridoxine). Homocystinuria should be suspected in stroke patients of young age, especially if thy have nontraumatic lens dislocation or marfanoid features. We report a patient with homocystinuria complicated by cerebral venous sinus thrombosis which was aggrevated after cerebral angiography.
Adolescent ; Angiography ; Biopsy ; Brain ; Carotid Artery, Internal ; Cerebral Angiography ; Congenital Abnormalities ; Constriction, Pathologic ; Female ; Homocystine ; Homocystinuria* ; Humans ; Intellectual Disability ; Lens Subluxation ; Magnetic Resonance Imaging ; Metabolism ; Methionine ; Phlebography ; Plasma ; Quadriplegia ; Rabeprazole ; Scoliosis ; Seizures ; Sinus Thrombosis, Intracranial ; Stroke ; Stupor ; Superior Sagittal Sinus* ; Thrombosis* ; Vascular Diseases ; Vitamins

For the past 20 years, it has been suggested that B vitamins (vitamin B6, folate, vitamin B12) and antioxidant vitamins (vitamin A, vitamin C, vitamin E) can prevent cardiovascular disease. Many observational studies reported a consistent dose-related association between homocysteine levels and cardiovascular morbidity and mortality. Homocysteine can be easily lowered by supplementation of vitamin B6, folate, and vitamin B12. Because the vitamins are inexpensive and relatively safe, such therapy would be highly cost effective. However randomized clinical studies using vitamin B6, folate or vitamin B12 supplementation failed to show benefit in preventing cardiovascular disease despite adequate lowering of homocysteine. Similarly, the role of anti-oxidant vitamins was linked to prevention of cardiovascular disease by limiting oxidation of low density lipoprotein cholesterol. In large observational studies, higher intake of anti-oxidant vitamins from diet or supplement was associated with decreased risk of coronary artery disease in men and women. However, a series of large randomized trials demonstrated no benefit from these anti-oxidant vitamins. Instead, several meta-analyses showed that supplementation of carotene, vitamin C or vitamin E increased cardiovascular mortality or all cause mortality. Considering currently available evidences, vitamins taken in excess of the dose required to prevent deficiency states are not beneficial in preventing cardiovascular disease and may harm people.
Ascorbic Acid ; Cardiovascular Diseases ; Carotenoids ; Cholesterol ; Cholesterol, LDL ; Coronary Artery Disease ; Diet ; Female ; Folic Acid ; Homocysteine ; Humans ; Lipoproteins ; Male ; Stroke ; Vitamin B 12 ; Vitamin B 6 ; Vitamin B Complex ; Vitamin E ; Vitamins

OBJECTIVE: The purpose of this study was to compare the histogram analysis and visual scores in 3T MRI assessment of middle cerebral arterial wall enhancement in patients with acute stroke, for the differentiation of parent artery disease (PAD) from small artery disease (SAD). MATERIALS AND METHODS: Among the 82 consecutive patients in a tertiary hospital for one year, 25 patients with acute infarcts in middle cerebral artery (MCA) territory were included in this study including 15 patients with PAD and 10 patients with SAD. Three-dimensional contrast-enhanced T1-weighted turbo spin echo MR images with black-blood preparation at 3T were analyzed both qualitatively and quantitatively. The degree of MCA stenosis, and visual and histogram assessments on MCA wall enhancement were evaluated. A statistical analysis was performed to compare diagnostic accuracy between qualitative and quantitative metrics. RESULTS: The degree of stenosis, visual enhancement score, geometric mean (GM), and the 90th percentile (90P) value from the histogram analysis were significantly higher in PAD than in SAD (p = 0.006 for stenosis, < 0.001 for others). The receiver operating characteristic curve area of GM and 90P were 1 (95% confidence interval [CI], 0.86–1.00). CONCLUSION: A histogram analysis of a relevant arterial wall enhancement allows differentiation between PAD and SAD in patients with acute stroke within the MCA territory.
Arteries* ; Constriction, Pathologic ; Humans ; Magnetic Resonance Imaging ; Middle Cerebral Artery ; Parents* ; ROC Curve ; Stroke ; Tertiary Care Centers

BACKGROUND: Prehospital delay is a major obstacle for successful treatment of acute stroke. We investigated the annual change of prehospital delay and related factors in patients with acute ischemic stroke (AIS) or transient ischemic attack (TIA). METHODS: From prospective patient registry, demographic and clinical characteristics of patients who presented within 48 hours of symptom onset after AIS or TIA from 2005 to 2008 were analyzed. We compared the annual change of prehospital delay (time from symptom onset to hospital arrival) and the proportion of early arrival (EA-3, prehospital delay<3 h; EA-6, prehospital delay<6 h). We also investigated factors associated with prehospital delay and early arrival. RESULTS: Of 612 patients, 623 events of AIS or TIA were analyzed. The adjusted geometric mean (95% CI) of prehospital delay (hours) was 7.42 (6.07-9.06) in 2005, 8.18 (6.76-9.89) in 2006, 4.39 (3.50-5.51) in 2007, and 4.02 (3.10-5.22) in 2008 (p<0.01). The proportion of early arrival (year) was 23.6% (2005), 31% (2006), 58% (2007), 54% (2008) for EA-3 (p<0.001) and 38.8% (2005), 32.5% (2006), 51.6% (2007), 75% (2008) for EA-6 (p<0.001). Compared with 2006, the adjusted odds (95% CI) for early arrival were 1.54 (0.87-2.71) in 2005, 1.91 (1.11-3.30) in 2007, 2.29 (1.31-4.01) in 2008 for EA-3 and 1.37 (0.84-2.25) in 2005, 1.73 (1.06-2.81) in 2007, 2.03 (1.23-3.36) in 2008 for EA-6. Younger age, severe neurologic deficit, admission through emergency department, cardioembolic stroke, and TIA were also independently associated with early arrival. CONCLUSIONS: From 2005 to 2008, prehospital delay decreased and potential candidates for thrombolytic therapy increased significantly.
Emergencies ; Humans ; Ischemic Attack, Transient ; Neurologic Manifestations ; Stroke ; Thrombolytic Therapy

Atrial fibrillation (AF) is an emerging epidemic in both high-income and low-income countries, mainly because of global population aging. Stroke is a major complication of AF, and AF-related ischemic stroke is more disabling and more fatal than other types of ischemic stroke. However, because of concerns about bleeding complications, particularly intracranial hemorrhage, and the limitations of a narrow therapeutic window, warfarin is underused. Four large phase III randomized controlled trials in patients with non-valvular AF (RE-LY, ROCKET-AF, ARISTOTLE, and ENGAGE-AF-TIMI 48) demonstrated that new oral anticoagulants (NOACs) are superior or non-inferior to warfarin as regards their efficacy in preventing ischemic stroke and systemic embolism, and superior to warfarin in terms of intracranial hemorrhage. Among AF patients receiving warfarin, Asians compared to non-Asians are at higher risk of stroke or systemic embolism and are also more prone to develop major bleeding complications, including intracranial hemorrhage. The extra benefit offered by NOACs over warfarin appears to be greater in Asians than in non-Asians. In addition, Asians are less compliant, partly because of the frequent use of herbal remedies. Therefore, NOACs compared to warfarin may be safer and more useful in Asians than in non-Asians, especially in stroke patients. Although the use of NOACs in AF patients is rapidly increasing, guidelines for the insurance reimbursement of NOACs have not been resolved, partly because of insufficient understanding of the benefit of NOACs and partly because of cost concerns. The cost-effectiveness of NOACs has been well demonstrated in the healthcare settings of developed countries, and its magnitude would vary depending on population characteristics as well as treatment cost. Therefore, academic societies and regulatory authorities should work together to formulate a scientific healthcare policy that will effectively reduce the burden of AF-related stroke in this rapidly aging society.
Aging ; Anticoagulants* ; Asian Continental Ancestry Group* ; Atrial Fibrillation ; Delivery of Health Care ; Developed Countries ; Embolism ; Health Care Costs ; Hemorrhage ; Humans ; Insurance ; Intracranial Hemorrhages ; Population Characteristics ; Stroke* ; Warfarin

Previous studies have shown that patients with tandem occlusions involving extracranial internal carotid artery (ICA) and middle cerebral artery (MCA) have lower likelihood of recanalization by standard intravenous thrombolytic therapy. A 70-years-old man with a history of hypertension was admitted because of left hemiplegia and drowsiness which developed 47 minutes ago. On neurologic examination, he was drowsy and showed neglect syndrome as well as left hemiplegia. Brain CT angiography showed tandem occlusions at right extracranial ICA and proximal MCA. The administration of intravenous (IV) tissue plasminogen activator (tPA) did not improve his symptoms. We performed angioplasty and stenting for proximal ICA occlusion followed by mechanical thrombolysis for MCA occlusion. After the endovascular treatment, the MCA was recanalized and the patient recovered to show only mild left side weakness. This case shows successful treatment of hyperacute ischemic infarction from tendem occlusion of right MCA and proximal ICA with endovascular treatment following IV tPA thrombolysis.
Angiography ; Angioplasty ; Brain ; Carotid Artery, Internal ; Cerebral Infarction ; Hemiplegia ; Humans ; Hypertension ; Infarction ; Mechanical Thrombolysis ; Middle Cerebral Artery ; Neurologic Examination ; Sleep Stages ; Stents ; Thrombolytic Therapy ; Tissue Plasminogen Activator

BACKGROUND: A subanalysis study of the ENGAGE AF-TIMI 48 trial showed that cardiac troponin I, N-terminal proB-type natriuretic peptide, and D-dimer, were powerful predictors of cerebrovascular adverse events. We aimed to evaluate D-dimer and cardiac troponin I levels during the acute period of ischemic stroke in anticoagulation-naïve patients with non-valvular atrial fibrillation (NVAF) and also studied the association between these biomarkers and stroke severity. METHODS: Consecutive anticoagulation-naïve patients with acute ischemic stroke due to NVAF were enrolled within two days after each stroke event, and all patients were stratified into either moderate-to-severe or mild neurologic deficit groups using the National Institutes of Health Stroke Scale (NIHSS) at admission. RESULTS: A total of 98 patients were enrolled in this study. The median value for the D-dimer was above the upper limit of the normal reference range, but the troponin I value was within the normal range for all patients. After adjusting for CHA2DS2-VASc risk factors, the log-transformed values for D-dimer were positively correlated with an increasing NIHSS score (r=0.233; P=0.051). In the multivariate logistic analysis, the log-transformed D-dimer was positively associated with more severe strokes (odds ratio, 30.1; 95% confidence interval [CI], 1.9–486.2 and 29.7; 95% CI, 2.0–430.8 in the upper two quartiles respectively). The log-transformed values for troponin I did not correlate with the NIHSS score. CONCLUSION: D-dimer levels were higher and an independent risk factor for severe stroke in anticoagulation-naïve patients with NVAF related stroke. In contrast, troponin I levels were normal and were not associated with stroke severity.
Atrial Fibrillation ; Biomarkers ; Humans ; National Institutes of Health (U.S.) ; Neurologic Manifestations ; Reference Values ; Risk Factors ; Stroke ; Troponin I

Background: and Purpose Oral anticoagulants are needed in stroke patients with atrial fibrillation (AF) for the prevention of recurrent stroke. However, the risk of major events or bleeding may be greater in stroke patients than in those without, because the presence of cerebral atherosclerosis or small vessel disease may increase these risks. This study aimed to investigate the outcomes of apixaban-treated stroke patients with AF and assess whether these factors are associated with the outcome. Methods: This was a sub-analysis of stroke patients with AF enrolled in a prospective, open-label, multicenter, post-marketing surveillance study in South Korea, who were treated with apixaban and underwent magnetic resonance imaging (MRI) (Clinical trial registration: NCT01885598). Results: A total of 651 patients (mean age, 72.5±8.7 years) received apixaban for a mean duration of 82.7±37.4 weeks. Fifty-three bleeding events occurred in 39 patients (6.0%), and 10 (1.5%) experienced major bleeding. Seventeen patients (2.6%) had major events (stroke, n=15, 2.3%; all ischemic), systemic embolism (n=1, 0.2%), and death (n=3, 0.5%). MRI data showed no significant association between white matter ischemic changes and microbleeds, and major events or bleeding. Patients with cerebral atherosclerotic lesions had a higher rate of major events than those without (4.6% [n=10/219] vs. 1.7% [n=7/409], P=0.0357), which partly explains the increased prevalence of major outcomes in this group versus patients without stroke (0.7%, P=0.0002). Conclusions Apixaban is generally safe for patients with ischemic stroke. Increased primary outcomes in stroke patients may in part be attributed to the presence of cerebral atherosclerotic lesions, suggesting that further studies are needed to establish therapeutic strategies in this population.