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Repeated Thrombolytic Therapy in Patients with Recurrent Acute Ischemic Stroke.

Han Soo YOO ; Young Dae KIM ; Hye Sun LEE ; Dongbeom SONG ; Tae Jin SONG ; Byung Moon KIM ; Dong Joon KIM ; Dong Ik KIM ; Ji Hoe HEO ; Hyo Suk NAM

Journal of Stroke.2013;15(3):182-188.

BACKGROUND AND PURPOSE: Widespread use of thrombolytic treatments, along with improved chances of survival after an initial ischemic stroke, increases the possibility of repeated thrombolysis. There are few reports, however, regarding repeated thrombolysis in patients who have suffered acute ischemic stroke. We explored the number and outcome of patients with repeated thrombolytic therapy in the era of multimodal thrombolytic treatments. METHODS: We investigated patients with acute ischemic stroke who had received thrombolytic treatments for a period of 10 years. Number of thrombolysis was determined in each patient. Recanalization was defined as Thrombolysis in Cerebral Infarction grading > or =2a. Symptomatic hemorrhagic transformation was defined as any increase in the National Institutes of Health Stroke Scale score that could be attributed to intracerebral hemorrhage. A good outcome was defined as a modified Rankin scale score < or =2. RESULTS: Of the 437 patients who received thrombolytic treatments, only 7 underwent repeated thrombolysis (1.6%). The median age at the time of repeated thrombolytic therapy was 71 years old; 4 of the patients were female. All patients had 1 or more potential sources of cardiac embolism. Recanalization was achieved in all patients, in both the first and the second thrombolysis. No symptomatic intracranial hemorrhage occurred after repeated thrombolytic treatments. Five patients (71.4%) showed good outcomes at 3 months. CONCLUSIONS: Repeated thrombolysis for recurrent acute ischemic stroke appears to be safe and feasible. Among patients who experience recurrent acute ischemic stroke, thrombolytic therapy could be considered even if the patient has had previous thrombolytic treatments.
Cerebral Hemorrhage ; Cerebral Infarction ; Embolism ; Female ; Humans ; Intracranial Hemorrhages ; National Institutes of Health (U.S.) ; Recurrence ; Stroke ; Thrombolytic Therapy

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Robot-assisted Therapy in Stroke Rehabilitation.

Won Hyuk CHANG ; Yun Hee KIM

Journal of Stroke.2013;15(3):174-181.

Research into rehabilitation robotics has grown rapidly and the number of therapeutic rehabilitation robots has expanded dramatically during the last two decades. Robotic rehabilitation therapy can deliver high-dosage and high-intensity training, making it useful for patients with motor disorders caused by stroke or spinal cord disease. Robotic devices used for motor rehabilitation include end-effector and exoskeleton types; herein, we review the clinical use of both types. One application of robot-assisted therapy is improvement of gait function in patients with stroke. Both end-effector and the exoskeleton devices have proven to be effective complements to conventional physiotherapy in patients with subacute stroke, but there is no clear evidence that robotic gait training is superior to conventional physiotherapy in patients with chronic stroke or when delivered alone. In another application, upper limb motor function training in patients recovering from stroke, robot-assisted therapy was comparable or superior to conventional therapy in patients with subacute stroke. With end-effector devices, the intensity of therapy was the most important determinant of upper limb motor recovery. However, there is insufficient evidence for the use of exoskeleton devices for upper limb motor function in patients with stroke. For rehabilitation of hand motor function, either end-effector and exoskeleton devices showed similar or additive effects relative to conventional therapy in patients with chronic stroke. The present evidence supports the use of robot-assisted therapy for improving motor function in stroke patients as an additional therapeutic intervention in combination with the conventional rehabilitation therapies. Nevertheless, there will be substantial opportunities for technical development in near future.
Complement System Proteins ; Gait ; Hand ; Humans ; Robotics ; Spinal Cord Diseases ; Stroke ; Upper Extremity

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A Case of Delayed Neurological Recovery with Luxury Perfusion and a High Intracranial Arterial Calcification Burden.

Hong Il SUH ; Seon Wook LEE ; Young In EOM ; Jin Soo LEE

Journal of Stroke.2014;16(1):51-53.

No abstract available.
Perfusion*

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Serum 25-Hydroxyvitamin D Deficiency in Ischemic Stroke and Subtypes in Indian Patients.

Jaydip Ray CHAUDHURI ; K Rukmini MRIDULA ; Suvarna ALLADI ; A ANAMIKA ; M UMAMAHESH ; Banda BALARAJU ; A SWATH ; V C S Srinivasarao BANDARU

Journal of Stroke.2014;16(1):44-50.

BACKGROUND AND PURPOSE: Vitamin D deficiency is common across all age groups and may contribute to cardiovascular diseases. Serum 25-hydroxyvitamin D deficiency causing ischemic stroke has been documented in recent reports. AIM: To investigate the association of serum 25-hydroxyvitamin D deficiency with ischemic stroke and subtypes. METHODS: We recruited 250 consecutive ischemic stroke patients and 250 age and sex matched controls attending the Department of Neurology, at Yashoda hospital, Hyderabad, India, from January 2011 to December 2012. All ischemic stroke patients underwent stroke subtyping. We measured 25-hydroxyvitamin D by chemiluminescence test, serum calcium, phosphorus, alkaline phosphatase, and C-reactive protein (CRP) in cases and controls. RESULTS: Out of 250 stroke patients, 190 (76%) were men and mean age was 58.4+/-11.1 years (age range-26-89 years). 25-hydroxyvitamin D deficiency was observed in 122 (48.8%) stroke patients and 79 (31.6%) controls (P=0.001). Among stroke patients, serum 25-hydroxyvitamin D deficiency was found in 54.9% (50/91) of patients with large artery atherosclerosis, 54% (20/37) in cardioembolic stroke, 44.4% (20/45) in small artery diseases, 42.8% (15/35) in stroke of other determined etiology and 40.4% (17/42) in stroke of un-determined etiology. Multiple logistic regression analysis showed an independent association of 25-hydroxyvitamin D deficiency with ischemic stroke (odds ratio: 1.6; 95% CI 1.2-2.8). The association was strongest with large artery atherosclerosis (odds ratio: 2.4; 95% CI 1.6-3.5) and cardioembolic stroke (odds ratio: 2.0; 95% CI 1.0-3.2). CONCLUSIONS: We found that 25-hydroxyvitamin D deficiency had an independent association with ischemic stroke. The association was established in large artery arthrosclerosis and cardioembolic stroke.
Alkaline Phosphatase ; Arteries ; Atherosclerosis ; C-Reactive Protein ; Calcium ; Cardiovascular Diseases ; Humans ; India ; Logistic Models ; Luminescence ; Male ; Neurology ; Phosphorus ; Stroke* ; Vitamin D Deficiency

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Symptomatic Steno-Occlusion in Patients with Acute Cerebral Infarction: Prevalence, Distribution, and Functional Outcome.

Jihoon KANG ; Tai Hwan PARK ; Kyung Bok LEE ; Jong Moo PARK ; Youngchai KO ; Soo Joo LEE ; Keun Sik HONG ; Yong Jin CHO ; Ji Sung LEE ; Juneyoung LEE ; Byung Chul LEE ; Kyung Ho YU ; Dae Hyun KIM ; Jae Kwan CHA ; Jun LEE ; Myung Suk JANG ; Moon Ku HAN ; Hee Joon BAE

Journal of Stroke.2014;16(1):36-43.

BACKGROUND AND PURPOSE: Symptomatic steno-occlusion (SYSO) in acute ischemic stroke has a significant impact on treatment options and prognosis. However, the prevalence, distribution, clinical characteristics, and outcome of SYSO are not well known. METHODS: We retrospectively identified 3,451 patients hospitalized because of ischemic stroke within 24 hours of symptom onset at 9 stroke centers in South Korea. Patients who did not undergo magnetic resonance imaging were excluded. SYSO was defined as stenosis or occlusion of cerebral arteries with relevant ischemic lesions in the corresponding arterial territory. The number, location, and severity of SYSOs and their effects on functional outcome were analyzed. RESULTS: In total, 1,929 of 3,057 subjects (63.1%) had SYSO. The most frequently affected vessels were the middle cerebral artery (34.6%), extracranial internal carotid artery (14%), vertebral artery (12.4%), and basilar artery (8.7%). SYSO predicted poor outcome on the modified Rankin Scale 3-6 (odds ratio, 1.77; 95% confidence interval, 1.46-2.15) with adjustments. Involvement of 2 or more vessels was observed in 30.6% of patients with SYSO and independently increased the risk of poor outcome (odds ratio, 2.76; 95% confidence interval, 2.12-3.59). The severity of SYSO was associated with outcome and showed a significant dose-response trend (P<0.001). The effect of SYSO on outcome did not significantly differ by individual arterial location (P for contrast=0.21). CONCLUSIONS: Approximately 60% of patients with acute ischemic stroke had SYSO, and the severity and number were inversely correlated with outcome. The results suggest that SYSO could predict stroke outcome.
Basilar Artery ; Carotid Artery, Internal ; Cerebral Arteries ; Cerebral Infarction* ; Cerebrovascular Disorders ; Constriction, Pathologic ; Hospital Distribution Systems ; Humans ; Magnetic Resonance Imaging ; Middle Cerebral Artery ; Prevalence* ; Prognosis ; Republic of Korea ; Retrospective Studies ; Stroke ; Vertebral Artery

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Intracranial Atherosclerosis: Current Understanding and Perspectives.

Oh Young BANG

Journal of Stroke.2014;16(1):27-35.

The importance of intracranial atherosclerotic disease (ICAD) as a cause of stroke is underscored as compared to that of extracranial carotid stenosis and nonvalvular atrial fibrillation. Recent large clinical trials of ICAD, which evaluated the effectiveness of anticoagulation and stenting to prevent thromboembolism and restore hemodynamic compromise, failed to reduce major vascular events in patients with ICAD. These trials showed the importance of optimal control of risk factors to reduce major vascular events in these patients. Recent advances in risk factors for ICAD are summarized, together with possible reasons for race-ethnic differences in the prevalence of ICAD. In addition, the failure of the major clinical trials of ICAD may be caused by limitations in the understanding of ICAD. Unlike in patients with extracranial carotid stenosis or atrial fibrillation, stroke associated with ICAD occurs in association with various stroke mechanisms such as in situ thrombotic occlusion, artery-to-artery embolism, hemodynamic insufficiency, and branch occlusion. In clinical trials of ICAD, patients with all these types of ICAD were included. However, treatment effects may differ among the different types of ICAD. Treatment strategies might be selected based on clinical features (including the time after onset) and serologic and neuroimaging biomarkers (including diffusion-weighted image pattern and plaque images). Additional clinical trials considering these features are needed.
Atherosclerosis ; Atrial Fibrillation ; Biomarkers ; Carotid Stenosis ; Embolism ; Hemodynamics ; Humans ; Intracranial Arteriosclerosis* ; Neuroimaging ; Prevalence ; Risk Factors ; Stents ; Stroke ; Thromboembolism

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Recent Updates on Subcortical Ischemic Vascular Dementia.

Jee Hoon ROH ; Jae Hong LEE

Journal of Stroke.2014;16(1):18-26.

Vascular dementia (VaD) is a history-laden disease entity that dates back to the 19th century when arteriosclerotic brain atrophy due to hardening of the arteries was perceived as the major cause of senile dementia. Its existence had been overshadowed by the emergence of Alzheimer's disease (AD) in the past century and research on AD dominated the field of dementia. Interest in VaD has been revived in recent years as vascular lesions have been shown to make great contributions to the development of dementia, particularly in the elderly. VaD has now evolved into the concept of vascular cognitive impairment (VCI), which encompasses not only VaD but also AD with cerebrovascular disorder and VCI with no dementia. The concept of VCI is intended to maximize the therapeutic potential in dementia management because the vascular component may be amenable to therapeutic intervention particularly in the early stages of cognitive impairment. Subcortical ischemic vascular dementia (SIVD) is pathologically driven by severe stenosis and the occlusion of small vessels that culminate into white matter ischemia and multiple lacunar infarctions in the subcortical structures. The relatively slow progression of symptoms and clinical manifestations associated with cholinergic deficits often make the differentiation of SIVD from AD difficult. The recent development of in vivo amyloid imaging enabled further pathological breakdown of SIVD into pure SIVD and mixed dementia with subcortical ischemia based on the absence or existence of amyloid pathology in the brain. In this article, the authors reviewed the emerging concepts of VaD/VCI and the clinical manifestations, biomarkers, treatments, and preclinical models of SIVD based on the pathophysiologic mechanisms of the disease.
Aged ; Alzheimer Disease ; Amyloid ; Arteries ; Atrophy ; Biomarkers ; Brain ; Cerebrovascular Disorders ; Constriction, Pathologic ; Dementia ; Dementia, Vascular* ; Humans ; Ischemia ; Pathology ; Stroke, Lacunar

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Ischemic Stroke Subtype Classification: An Asian Viewpoint.

Bum Joon KIM ; Jong S KIM

Journal of Stroke.2014;16(1):8-17.

Proper classification of the causative mechanism of stroke is important for optimizing stroke treatment and assessing prognosis. The primary etiology of stroke differs according to race and ethnicity: emboli originating from the heart or extracranial large arteries are common in Western populations, whereas small-vessel occlusion or intracranial atherosclerosis is more prevalent in Asians. Intracranial atherosclerosis frequently leads to stroke by branch-artery occlusion, and the degree of stenosis in these cases is often <50%. Mild intracranial atherosclerotic stenosis may cause distal embolization, if the atherosclerotic plaque is sufficiently vulnerable. Moreover, high-resolution magnetic resonance imaging studies have identified small plaques causing infarction, even in patients with normal-appearing vascular findings. Such cases, which are prevalent in Asia, could not be classified as large-artery atherosclerosis by previous classification systems. Additionally, single subcortical infarctions, which are usually attributed to lipohyalinotic small-vessel disease, can have other causes, including microatheroma of perforators and atherothrombotic lesions at the parental artery. Single subcortical infarctions associated with parental artery disease or those bordering on the main vessel more often have atherosclerotic characteristics than do those associated with lipohyalinosis of the penetrating artery. In countries where intracranial atherosclerosis is common, such atherosclerotic single subcortical infarctions are predicted to be prevalent. These cases, however, could not be appropriately classified in previous systems. Further effort should be devoted to formulate ischemic stroke classification systems that adequately incorporate results of recent studies and reflect the underling pathologic mechanisms, especially in patients with single subcortical infarction and intracranial atherosclerosis.
Arteries ; Asia ; Asian Continental Ancestry Group* ; Atherosclerosis ; Cerebral Infarction ; Classification* ; Constriction, Pathologic ; Continental Population Groups ; Heart ; Humans ; Infarction ; Intracranial Arteriosclerosis ; Magnetic Resonance Imaging ; Parents ; Plaque, Atherosclerotic ; Prognosis ; Stroke*

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Facial Palsy and Nystagmus after Transvenous Embolization of a Carotid Cavernous Fistula.

Seong Il OH ; Young Seo KIM ; Young Jun LEE ; Hyeong Joong YI ; Hyun Young KIM

Journal of Stroke.2013;15(1):64-66.

No abstract available.
Caves ; Facial Paralysis ; Fistula

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Organized Comprehensive Stroke Center is Associated with Reduced Mortality: Analysis of Consecutive Patients in a Single Hospital.

Dae Hyun KIM ; Jae Kwan CHA ; Hyo Jin BAE ; Hyun Seok PARK ; Jae Hyung CHOI ; Myung Jin KANG ; Byoung Gwon KIM ; Jae Taeck HUH ; Sang Beom KIM

Journal of Stroke.2013;15(1):57-63.

BACKGROUND AND PURPOSE: Organized inpatient stroke care is one of the most effective therapies for improving patient outcomes. Many stroke centers have been established to meet this need, however, there are limited data on the effectiveness of these organized comprehensive stroke center (CSC) in the real-world setting. Our aim is to determine whether inpatient care following the establishment of CSC lowers mortality of patients with acute ischemic stroke (AIS). METHODS: Based on a prospective stroke registry, we identified AIS patients hospitalized before and after the establishment of a CSC. We observed all-cause mortality within 30 days from time of admission. Logistic regression was used to determine whether the establishment of the CSC affects independently the 30-day all-cause mortality. RESULTS: A total of 3,117 consecutive patients with AIS were admitted within seven days after the onset of the symptoms. Unadjusted 30-day mortality was lower for patients admitted to our hospital after the establishment of the CSC than before (5.9% vs. 8.2%, P=0.012). Advanced age, female gender, previous coronary artery disease, non-smoking, stroke subtype, admission on a holiday, referral from other hospitals, high NIHSS on admission, and admission before the establishment of CSC were associated with increased 30-day stroke case fatality. After adjustment for these factors, stroke inpatient care subsequent to the establishment of the CSC was independently associated with lower 30-day mortality (OR, 0.57; 95% CI, 0.412-0.795). CONCLUSIONS: Patients treated after the establishment of a CSC had lower 30-mortality rates than ever before, even adjusting for the differences in the baseline characteristics. The present study reveals that organized stroke care in a CSC might improve the outcome after AIS.
Coronary Artery Disease ; Female ; Holidays ; Humans ; Inpatients ; Logistic Models ; Prospective Studies ; Referral and Consultation ; Stroke

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