OBJECTIVE: We aimed to investigate the relationship between adipokines and antioxidation enzyme and the risk of progression of symptomatic intracranial atherosclerotic stenosis (ICAS). METHODS: Of 409 patients who participated in the TOSS-2 (trial of cilostazol in symptomatic intracranial stenosis-2) study, 52 patients showed progression of symptomatic ICAS on magnetic resonance angiography at seven months after an index stroke. We randomly selected 20 patients with progression and 20 age- and sex-matched control patients. We serially collected blood sample initially, one month, and seven months after an index stroke. Then, multiplex analysis of biomarkers was performed for adiponectin, resistin, leptin, and superoxide dismutase-1, 2, 3. RESULTS: Demographic features and risk factors such as hypertension, diabetes, and smoking history were comparable between the two groups. Control group showed higher adiponectin levels at 7 months than progression group (P=0.05) and a significant in-creasing trend (P for trend=0.01). Resistin, leptin, and superoxide dismutase-1, 2, 3 levels were not different between the progression and control group initially, one month, and seven months after an index stroke. CONCLUSION: Increase of adiponectin level showed protective effect in the progression of ICAS. Resistin, leptin, and superoxide dismutase-1, 2, 3 levels are not different between the groups. Further large numbers of patients with longer follow-up studies are needed.
Adipokines* ; Adiponectin ; Biomarkers ; Constriction, Pathologic* ; Follow-Up Studies ; Humans ; Hypertension ; Leptin ; Magnetic Resonance Angiography ; Resistin ; Risk Factors ; Smoke ; Smoking ; Stroke ; Superoxide Dismutase ; Superoxides*

Reversible cerebral vasoconstriction syndrome (RCVS) is characterized by thunderclap headache and multiple reversible intracranial vasoconstrictions. Here we report a case of RCVS after exposure to ethylene oxide (EO) gas, which is a widely used sterilant. A 34-year-old woman presented with aphasia, right-arm weakness, and severe headache after inhaling EO gas. Brain imaging revealed multiple infarcts and multiple intracranial stenoses. The stenotic lesions completely regressed on follow-up CT angiography. This is the first report of RCVS after exposure to EO gas.
Adult ; Angiography ; Aphasia ; Constriction, Pathologic ; Ethylene Oxide* ; Female ; Follow-Up Studies ; Headache ; Headache Disorders, Primary ; Humans ; Inhalation* ; Neuroimaging ; Vasoconstriction*

Background: and PurposeThe impact of fluid-attenuated inversion recovery hyperintense vessels (FHVs) on outcomes in patients ineligible for recanalization therapy with large-vessel occlusion (LVO) is unclear. We investigated the impact of FHVs determined using the FHV– Alberta Stroke Program Early CT Score (ASPECTS) on clinical outcomes in patients with LVO stroke of mild-to-moderate severity ineligible for recanalization therapy. Methods: Sixty-eight consecutive patients with M1-middle cerebral artery occlusion who underwent magnetic resonance imaging within 24 hours of symptom onset and were ineligible for recanalization were included. Patients were dichotomized into a severe-FHV group (FHV-ASPECTS ≤4; n=33) and a mild-FHV group (FHV-ASPECTS >4; n=35), and multiple logistic regression analysis was used to examine the relationships of FHV scores with early neurological deterioration (END) and an unfavorable 3-month outcome (modified Rankin Scale score ≥3). Results: Mean age was 66.2±13.5 years (mean±SD), and 30 (44%) were female. The severe-FHV group had a larger infarct volume (median, 5.5 mL vs. 3 mL) and more frequently exhibited the susceptibility vessel sign (30% vs. 3%) than the mild-FHV group. Ipsilateral old nonlacunar infarct was more frequent in the mild-FHV group than in the severe-FHV group (37% vs. 15%). The severe-FHV group had a fivefold higher risk of END (odds ratio [OR] 5.02, 95% confidence interval [CI] 1.36–18.45) and unfavorable outcome (OR 5.97, 95% CI 1.18–33.31, p=0.03) compared with the mild-FHV group. Conclusions Greater FHV extent was associated with higher risk of END and unfavorable outcome in patients with LVO stroke of mild-to-moderate severity.

Background: and PurposeThe impact of fluid-attenuated inversion recovery hyperintense vessels (FHVs) on outcomes in patients ineligible for recanalization therapy with large-vessel occlusion (LVO) is unclear. We investigated the impact of FHVs determined using the FHV– Alberta Stroke Program Early CT Score (ASPECTS) on clinical outcomes in patients with LVO stroke of mild-to-moderate severity ineligible for recanalization therapy. Methods: Sixty-eight consecutive patients with M1-middle cerebral artery occlusion who underwent magnetic resonance imaging within 24 hours of symptom onset and were ineligible for recanalization were included. Patients were dichotomized into a severe-FHV group (FHV-ASPECTS ≤4; n=33) and a mild-FHV group (FHV-ASPECTS >4; n=35), and multiple logistic regression analysis was used to examine the relationships of FHV scores with early neurological deterioration (END) and an unfavorable 3-month outcome (modified Rankin Scale score ≥3). Results: Mean age was 66.2±13.5 years (mean±SD), and 30 (44%) were female. The severe-FHV group had a larger infarct volume (median, 5.5 mL vs. 3 mL) and more frequently exhibited the susceptibility vessel sign (30% vs. 3%) than the mild-FHV group. Ipsilateral old nonlacunar infarct was more frequent in the mild-FHV group than in the severe-FHV group (37% vs. 15%). The severe-FHV group had a fivefold higher risk of END (odds ratio [OR] 5.02, 95% confidence interval [CI] 1.36–18.45) and unfavorable outcome (OR 5.97, 95% CI 1.18–33.31, p=0.03) compared with the mild-FHV group. Conclusions Greater FHV extent was associated with higher risk of END and unfavorable outcome in patients with LVO stroke of mild-to-moderate severity.

BACKGROUND AND PURPOSE: An elevated intracellular calcium level is known to be a major initiator and activator of ischemic cell death pathway; however, in recent studies, elevated serum calcium levels have been associated with better clinical outcomes and smaller cerebral infarct volumes. The pathophysiological role played by calcium in ischemic stroke is largely unknown. METHODS: Acute stroke patients from a prospective stroke registry, consecutively admitted during October 2002-September 2008, were included. Significant associations between the modified Rankin scale distribution at discharge and serum calcium or albumin-corrected calcium were identified using ordinal logistic regression analysis. Cox proportional hazard models were used for survival analysis. RESULTS: Mean serum calcium and albumin-corrected calcium levels of the 1,915 participants on admission were 8.97+/-0.58 mg/dL and 9.07+/-0.49 mg/dL, respectively. Second [adjusted odds ratio 1.32 (95% confidence interval 1.07-1.61)] and third [1.24 (1.01-1.53)] tertiles of serum calcium level and the third [1.24 (1.01-1.53)] tertile of albumin-corrected calcium level were found to be independent risk factors for a poor discharge outcome. Significant relationships were observed with serum calcium [1.19 (1.03-1.38)] and albumin-corrected calcium [1.21(1.01-1.44)] as linear variables. However, only albumin-corrected calcium was associated with long-term mortality, third tertile [adjusted hazard ratio 1.40 (1.07-1.83)], and increase by 1 mg/dL [1.46 (1.16-1.84)]. CONCLUSIONS: Elevated albumin-corrected serum calcium levels are associated with a poorer short-term outcome and greater risk of long-term mortality after acute ischemic stroke.
Calcium* ; Cell Death ; Cerebral Infarction ; Humans ; Logistic Models ; Mortality* ; Odds Ratio ; Patient Outcome Assessment ; Proportional Hazards Models ; Prospective Studies ; Risk Factors ; Stroke*

BACKGROUND: Ventriculitis is a rare and critical infection of the central nervous system. Here, we report a case of ventriculitis by extended spectrum beta-lactamase (ESBL) producing Klebsiella pneumoniae , after acupuncture at the low back. CASE REPORT: A 72-year-old woman visited our center with fever, headache, and decreased mental status, after undergoing low back acupuncture. Brain imaging showed the fluid-debris level in the lateral ventricle, suggesting ventriculitis. ESBL producing Klebsiella pneumoniae were cultured from the cerebrospinal fluid. After the administration of antibiotics, although the ventriculitis was treated, the quadriplegia remained. CONCLUSIONS: This case stresses the importance of aseptic techniques during acupuncture.
Acupuncture ; Aged ; Anti-Bacterial Agents ; beta-Lactamases ; Central Nervous System ; Cerebral Ventriculitis ; Cerebrospinal Fluid ; Female ; Fever ; Headache ; Humans ; Klebsiella pneumoniae ; Klebsiella ; Lateral Ventricles ; Neuroimaging ; Quadriplegia

Despite recent advances in recanalization therapy, mechanical thrombectomy will never be a treatment for every ischemic stroke because access to mechanical thrombectomy is still limited in many countries. Moreover, many ischemic strokes are caused by occlusion of cerebral arteries that cannot be reached by intra-arterial catheters. Reperfusion using thrombolytic agents will therefore remain an important therapy for hyperacute ischemic stroke. However, thrombolytic drugs have shown limited efficacy and notable hemorrhagic complication rates, leaving room for improvement. A comprehensive understanding of basic and clinical research pipelines as well as the current status of thrombolytic therapy will help facilitate the development of new thrombolytics. Compared with alteplase, an ideal thrombolytic agent is expected to provide faster reperfusion in more patients; prevent re-occlusions; have higher fibrin specificity for selective activation of clot-bound plasminogen to decrease bleeding complications; be retained in the blood for a longer time to minimize dosage and allow administration as a single bolus; be more resistant to inhibitors; and be less antigenic for repetitive usage. Here, we review the currently available thrombolytics, strategies for the development of new clot-dissolving substances, and the assessment of thrombolytic efficacies in vitro and in vivo.

BACKGROUND AND PURPOSE: The CHADS2 (an acronym for congestive heart failure, hypertension, age > or =75 years, diabetes mellitus, and prior stroke or transient ischemic attack or thromboembolism) score is a widely used system for estimating the risk of stroke in patients with atrial fibrillation. However, how the CHADS2 score is related to stroke severity and outcome in patients with strokes due to atrial fibrillation has not yet been elucidated. METHODS: We enrolled patients with atrial fibrillation who visited our stroke center within 7 days after the onset of acute ischemic stroke between October 2002 and September 2008. CHADS2 scores were categorized into three groups: 0 points, low risk; 1 or 2 points, intermediate risk; and 3-6 points, high risk. Poor neurological state was defined as follows: a National Institutes of Health Stroke Scale (NIHSS) score of > or =2, and a modified Rankin Scale (mRS) score of > or =3 at discharge. Mortality information was ascertained as at December 2008. RESULTS: A cohort of 298 patients with atrial-fibrillation-related stroke was included in this study. A high-risk CHADS2 score at admission was a powerful predictor of poor neurological outcome [for NIHSS: odds ratio (OR), 4.17; 95% confidence interval (CI), 1.76-9.87; for mRS: OR, 2.97; 95% CI, 1.23-7.16] after controlling for all possible confounders. In addition, a high-risk CHADS2 score was an independent predictor of all causes of death during the follow-up [hazard ratio (HR), 3.01; 95% CI, 1.18-7.65] and vascular death (HR, 12.25; 95% CI, 1.50-99.90). CONCLUSIONS: Although the CHADS2 score was originally designed to distinguish patients with a future risk of stroke, our study shows that it may also be used to predict poor neurological outcome after atrial-fibrillation-related stroke.
Atrial Fibrillation ; Cause of Death ; Cohort Studies ; Diabetes Mellitus ; Follow-Up Studies ; Heart Failure ; Humans ; Hypertension ; Ischemic Attack, Transient ; National Institutes of Health (U.S.) ; Odds Ratio ; Stroke

Background: and Purpose We aimed to determine the relationships of 33 biomarkers of inflammation, oxidation, and adipokines with the risk of progression of symptomatic intracranial atherosclerotic stenosis (ICAS). Methods: Fifty-two of 409 patients who participated in the TOSS-2 (Trial of Cilostazol in Symptomatic Intracranial Stenosis-2) showed progression of symptomatic ICAS in magnetic resonance angiography at 7 months after an index stroke. We randomly selected 20 patients with progression as well as 40 age- and sex-matched control patients. We serially collected blood samples at baseline, 1 month, and 7 months after an index stroke. Multiplex analysis of biomarkers was then performed. Results: Demographic features and risk factors such as hypertension, diabetes, and smoking history were comparable between the two groups. Univariate analyses revealed that the levels of platelet-derived growth factor (PDGF)-AA [median (interquartile range)=1.64 (0.76–4.57) vs. 0.77 (0.51–1.71) ng/mL], PDGF-AB/BB [10.31 (2.60–25.90) vs. 2.35 (0.74–6.70) ng/mL], and myeloperoxidase [10.5 (7.5–22.3) vs. 7.8 (5.5–12.2) ng/mL] at 7 months were higher in the progression group. In the multivariate analysis using logistic regression, the PDGF AB/BB level at 7 months was independently associated with the progression of ICAS (p=0.02). Conclusions The PDGF-AB/BB level is associated with the progression of ICAS, and so may play a significant role in the progression of human ICAS.

BACKGROUND AND PURPOSE: The vertebral artery (VA) is important for the development of the transverse foramen (TF). Most studies of these structures have focused on anatomical anomalies. Therefore, we investigated quantitatively the association between the relative sizes of the TF and VA. METHODS: We recruited a consecutive series of subjects who underwent CT angiography to estimate the relative sizes of the VA and TF in axial source images. Two neurologists independently reviewed the axial CT images of 208 patients who had no history of transient ischemic attack or stroke. Averaged areas of the VA and TF were defined by the sum of the areas at each level from C3 to C6, divided by 4. Correlation analyses were adjusted for age, sex, and vascular risk factors. RESULTS: The mean age of the subjects was 53 years. The interobserver and intraobserver reliabilities of TF size were good. There was a linear relationship between the sizes of the VA and TF on each side (right side: r2=0.58, p<0.001; left side: r2=0.62, p<0.001). The area of the VA was significantly associated with that of the TF after adjusting for vascular risk factors. CONCLUSIONS: The size of the VA is strongly and linearly correlated with the size of the TF. These findings suggest that measurement of the TF and VA with CT angiography is a reliable method for evaluating VA diseases, and may provide new insight into the differentiation between VA hypoplasia and atherosclerosis of the VA.
Angiography ; Atherosclerosis ; Humans ; Ischemic Attack, Transient ; Stroke ; Vertebral Artery