INTRODUCTION: The National Institutes of Health Stroke Scale (NIHSS), originally designed in the United States of America, contains items on dysphasia and dysarthria that are deemed culturally unsuitable for the Singapore context. We compared the error rates of dysphasia objects, dysphasia phrases and dysarthria words between the original and alternative items in a cohort of Singaporean subjects without dysphasia or dysarthria. METHODS: In this prospective study, 140 English-speaking Singaporean subjects without impairments of dysphasia or dysarthria had an assessment of NIHSS items 9 and 10 using the original and alternative items. Paired analyses were conducted for comparison of error rates. RESULTS: The error rates were high for four original dysphasia objects (Hammock: 62.9%, Cactus: 38.6%, Feather: 23.6%, Glove: 20.7%) and significantly lower for alternative items (Snail: 5%, Horse: 1.4%, Hanger: 1.4%, Car: 0%) (P < 0.001). For dysphasia phrases and dysarthria words, the error rates were low and there were no differences in error rates between the original and alternative items. CONCLUSION There are cultural issues with several dysphasia objects in the original NIHSS as evidenced by the high error rates, which were lowered with more culturally suitable alternatives. This study formed a basis to derive a more suitable version of the NIHSS for English-speaking subjects in Singapore.
Humans ; United States ; Animals ; Horses ; Stroke/diagnosis* ; Singapore ; Dysarthria/diagnosis* ; Prospective Studies ; National Institutes of Health (U.S.) ; Aphasia/diagnosis* ; Severity of Illness Index

PURPOSE: Although endovascular treatment is currently thought to only be suitable for patients who have pial arterial filling scores >3 as determined by multiphase computed tomography angiography (mpCTA), a cut-off score of 3 was determined by a study, including patients within 12 hours after symptom onset. We aimed to investigate whether a cut-off score of 3 for endovascular treatment within 6 hours of symptom onset is an appropriate predictor of good functional outcome at 3 months. MATERIALS AND METHODS: From April 2015 to January 2016, acute ischemic stroke patients treated with mechanical thrombectomy within 6 hours of symptom onset were enrolled into this study. Pial arterial filling scores were semi-quantitatively assessed using mpCTA, and clinical and radiological parameters were compared between patients with favorable and unfavorable outcomes. Multivariate logistic regression analysis was then performed to investigate the independent association between clinical outcome and pial collateral score, with the predictive power of the latter assessed using C-statistics. RESULTS: Of the 38 patients enrolled, 20 (52.6%) had a favorable outcome and 18 had an unfavorable outcome, with the latter group showing a lower mean pial arterial filling score (3.6±0.8 vs. 2.4±1.2, P=0.002). After adjusting for variables with a P-value of <0.1 in univariate analysis (i.e., age and National Institutes of Health Stroke Scale score at admission), pial arterial filling scores higher than a cut-off of 2 were found to be independently associated with favorable clinical outcomes (P=0.012). C-statistic analysis confirmed that our model had the highest prediction power when pial arterial filling scores were dichotomized at >2 vs. ≤2. CONCLUSION: A pial arterial filling cut-off score of 2 as determined by mpCTA appears to be more suitable for predicting clinical outcomes following endovascular treatment within 6 hours of symptom onset than the cut-off of 3 that had been previously suggested.
Angiography ; Humans ; Logistic Models ; National Institutes of Health (U.S.) ; Stroke ; Thrombectomy

BACKGROUND: Using data from a large national stroke registry, we aimed to investigate the incidence and determinants of in-hospital and post-discharge recovery after acute ischemic stroke and the independence of their occurrence. METHODS: In-hospital recovery was defined as an improvement of 4 points or > 40% in the National Institutes of Health Stroke Scale (NIHSS) score from admission to discharge. Post-discharge recovery was defined as any improvement in the modified Rankin Scale (mRS) score from discharge to 3 months after stroke onset. Two analytic methods (multivariate and multivariable logistic regression) were applied to compare the effects of 18 known determinants of 3-month outcome and to verify whether in-hospital and post-discharge recovery occur independently. RESULTS: During 54 months, 11,088 patients with acute ischemic stroke meeting the eligibility criteria were identified. In-hospital and post-discharge recovery occurred in 36% and 33% of patients, respectively. Multivariate logistic regression with an equality test for odds ratios showed that 7 determinants (age, onset-to-admission time, NIHSS score at admission, blood glucose at admission, systolic blood pressure, smoking, recanalization therapy) had a differential effect on in-hospital and post-discharge recovery in the way of the opposite direction or of the same direction with different degree (all P values < 0.05). Both in-hospital and post-discharge recovery occurred in 12% of the study population and neither of them in 43%. The incidence of post-discharge recovery in those with in-hospital recovery was similar to that in those without (33.8% vs. 32.7%, respectively), but multivariable analysis showed that these 2 types of recovery occurred independently. CONCLUSION: Our findings suggest that, in patients with acute ischemic stroke, in-hospital and post-discharge recovery may occur independently and largely in response to different factors.
Blood Glucose ; Blood Pressure ; Humans ; Incidence ; Logistic Models ; National Institutes of Health (U.S.) ; Odds Ratio ; Prognosis ; Registries ; Smoke ; Smoking ; Stroke

OBJECTIVE: In Parkinson's disease (PD), vitamin B12 levels are lower, and comorbid B12 deficiency has been associated with the development of neuropathy and early gait instability. Because little is known about B12 supplement use in PD, we sought to evaluate its use in a large PD cohort and, as an exploratory analysis, to determine whether baseline characteristics or disease progression differed according to B12 supplementation. METHODS: We utilized data collected as part of the National Institutes of Health Exploratory Trials in PD (NET-PD) Long-term Study (LS-1), a longitudinal study of 1,741 participants. We stratified subjects into 4 groups according to daily supplement use: no B12, multivitamin (MVI) containing < 100 μg B12, B12 ≥ 100 μg, and MVI + B12 ≥ 100 μg. Clinical outcomes were assessed at 3 years for each group using the Unified Parkinson's Disease Rating Scale (UPDRS), its subscores, and selected individual questions. RESULTS: Of the 1,147 participants who completed the 3-year visit, 41% took an MVI, 2% took B12, 3% took MVI + B12, and 54% reported taking no supplements. At 3 years, no significant differences in clinical outcomes were observed. However, there was a trend toward lower hazard ratios for developing sensory symptoms (UPDRS Item 17) in the MVI (p = 0.08) and B12 + MVI (p = 0.08) groups compared to that in the no supplement group. CONCLUSION: These results show that supplementation with vitamin B12 ≥ 100 μg is uncommon in early PD. The finding of a trend toward a lower hazard ratio for the development of sensory symptoms in those taking an MVI or B12 + MVI warrants further study.
Cohort Studies ; Disease Progression ; Gait ; Longitudinal Studies ; National Institutes of Health (U.S.) ; Neuroprotection ; Parkinson Disease ; Vitamin B 12 ; Vitamins

BACKGROUND: Acute ischemic stroke patients with malignant infarct cores were primarily treated with neurocritical care based on reperfusion and hypothermia. We evaluated the predictors for malignant progression and functional outcomes. METHODS: From January 2010 to March 2015 ischemic stroke patients with large vessel occlusion of the anterior circulation with infarct volume >82 mL on baseline diffusion weighted image (DWI) within 6 hours from onset, with National Institutes of Health Stroke Scale ≥15 were included. All patients were managed with intent for reperfusion and neurocritical care. Malignant progression was defined as clinical signs of progressive herniation. Predictive factors for malignant progression and outcomes of decompressive hemicraniectomy (DHC) were evaluated. RESULTS: In total, 49 patients were included in the study. Among them, 33 (67.3%) could be managed with neurocritical care and malignant progression was observed in the remainder. Decompressive surgery was performed in nine patients (18.4%). Factors predictive of malignant progression were initial DWI volumes (odds ratio [OR], 1.01; 95% confidence interval [CI], 1.00 to 1.02; P=0.046) and parenchymal hematoma (OR, 6.77; 95% CI, 1.50 to 30.53; P=0.013) on computed tomography taken at Day 1. Infarct volume of >210 mL predicted malignant progression with 56.3% sensitivity and 90.9% specificity. Among the malignant progressors, 77.7% resulted in grave outcomes even with DHC, while all patients who declined surgery died. CONCLUSION: Acute ischemic stroke patients with malignant cores between 82 to 209 mL can be primarily treated with neurocritical care based on reperfusion and hypothermia with feasible results. In patients undergoing surgical decompression due to malignant progression, the functional outcomes were not satisfactory.
Brain Edema ; Critical Care ; Decompression, Surgical ; Decompressive Craniectomy ; Diffusion ; Hematoma ; Humans ; Hypothermia ; Hypothermia, Induced ; Infarction, Middle Cerebral Artery ; National Institutes of Health (U.S.) ; Reperfusion ; Sensitivity and Specificity ; Stroke ; Thrombectomy

OBJECTIVE: To investigate longitudinal changes in language function in left-hemispheric ischemic stroke patients as well as factors that influence language recovery until 1 year after stroke onset.METHODS: We analyzed data from 235 patients with first-ever left-hemispheric ischemic stroke. All patients completed the Korean version of the Frenchay Aphasia Screening Test (K-FAST) at 7 days (T1), 3 months (T2), 6 months (T3), and 1 year (T4) after stroke onset. Repeated measures analysis of variance (ANOVA) was used to investigate changes in language function between time points. Subgroup analysis was performed according to the K-FAST scores at T1. Stroke lesion volume was assessed using diffusion tensor images, and involvement of language-related brain regions was examined. Multiple regression analysis was used to analyze factors influencing improvement of K-FAST score.RESULTS: The K-FAST scores at T1, T2, T3, and T4 differed significantly (p < 0.05). In the subgroup analysis, only the severe group showed continuous significant improvement by 1 year. Factors that negatively influenced improvement of language function were the age at onset, initial National Institutes of Health Stroke Scale (NIHSS) score, and initial K-FAST score, whereas education level and stroke lesion volume positively affected recovery. Involvement of language-related brain regions did not significantly influence long-term language recovery after ischemic stroke.CONCLUSION: Recovery of language function varied according to the severity of the initial language deficit. The age at stroke onset, education level, initial severity of aphasia, initial NIHSS score, and total stroke lesion volume were found to be important factors for recovery of language function.
Age of Onset ; Aphasia ; Brain ; Diffusion ; Education ; Humans ; Mass Screening ; National Institutes of Health (U.S.) ; Prognosis ; Rehabilitation ; Stroke Volume ; Stroke

OBJECTIVE: This study evaluated the outcomes of ischemic stroke patients according to delirium motor subtype.METHODS: This study included patients who were admitted to the stroke unit between August 2017 and March 2019 and met the DSM-5 diagnostic criteria for delirium. Patients were assessed twice weekly throughout their delirium episodes using the Korean version of the Delirium Motor Subtype Scale (K-DMSS) and the Korean version of the Delirium Rating Scale-Revised-98 (K-DRS-98). The clinical characteristics and short-term outcomes of the patients were also assessed.RESULTS: A total of 943 stroke patients were included; the rate of incident delirium was 10.18%. Of the 95 delirium patients, 34 were classified as the hyperactive subtype, 30 as the mixed subtype, 25 as the hypoactive and six as no subtype. Among the subtype groups, the hypoactive subtype had the highest initial scores on the National Institutes of Health Stroke Scale (NIHSS; 6.72±4.75, p=0.02) and the modified Rankin Scale (mRS; 3.96±1.24, p<0.01). Additionally, the mixed and hypoactive subtypes had longer durations (p<0.01) and more severe symptoms of delirium (p=0.03) than the other motor subtypes, and the hypoactive subtype group had a significantly longer hospital stay (36.88±27.71 days, p<0.01) than the other subtype groups. After adjusting for baseline covariates in a multiple linear regression analysis, these differences remained significant.CONCLUSION: The present results suggest that the motor subtype of delirium is associated with different characteristics and outcomes in ischemic stroke patients.
Delirium ; Humans ; Length of Stay ; Linear Models ; National Institutes of Health (U.S.) ; Stroke

OBJECTIVE: Anxiety is one of the most common complications in patients with stroke, but studies on its relationship to functional outcomes are limited and controversial. We investigated the association between post-stroke anxiety (PSA) and a 1-year trajectory of functional outcome.METHODS: A total of 423 patients were recruited within 2 weeks after a stroke (acute phase) during hospitalization. Of them, 306 (72.3%) completed follow-up examinations 1 year thereafter (chronic phase). Anxiety was evaluated using the Hospital Anxiety and Depression Scale-Anxiety subscale, and functional outcomes were measured using the National Institutes of Health Stroke Scale for stroke severity, the Barthel Index for activities of daily living (ADL), and the Mini-Mental State Examination for cognitive function at 2 weeks and 1 year. A range of demographic and clinical covariates were considered. The cross-sectional and longitudinal associations between PSA and functional outcomes were investigated.RESULTS: PSA at the acute phase was not associated with functional outcomes at the cross-sectional point, but predicted worsening of outcome on stroke severity and ADL 1 year after stroke. PSA at the chronic phase was cross-sectionally associated with poor functional outcomes in all three measures. All associations were independent of potential covariates.CONCLUSION: Screening for anxiety is recommended even during the acute phase of stroke, considering its independent detrimental effect on functional prognosis. Screening for anxiety during the chronic phase is also encouraged, as this may reflect the functional status of stroke.
Activities of Daily Living ; Anxiety ; Cognition ; Depression ; Follow-Up Studies ; Hospitalization ; Humans ; Longitudinal Studies ; Mass Screening ; National Institutes of Health (U.S.) ; Prognosis ; Stroke

BACKGROUND: This study aimed to evaluate the association between metabolic syndrome and depression severity based on the Patient Health Questionnaire 9 (PHQ-9) score in men aged >50 years.METHODS: In this study, we used data of 1,230 individuals from the Sixth Korea National Health and Nutrition Examination Survey (KNHANES VII-1) 2016 conducted by the Korea Centers for Disease Control and Prevention. We diagnosed metabolic syndrome in accordance with National Cholesterol Education Program-Adult Treatment Panel III guidelines using waist circumference, blood pressure, fasting serum triglyceride level, high-density lipoprotein cholesterol level, and fasting glucose level in men aged >50 years (mean±standard deviation: 64.6±8.8 years), and their PHQ-9 scores were classified as mild and severe (cutoff, 10).RESULTS: The mean waist circumference, fasting glucose level, triglyceride level, and high-density lipoprotein cholesterol level were 87.1±8.2 cm, 109.8±28.3 mg/dL, 155.9±123.9 mg/dL, and 46.5±12.2 mg/dL, respectively. The mean systolic and diastolic blood pressures were 124.7±15.9 mmHg and 76.2±10.7 mmHg, respectively. The mean body mass index, was 24.2±2.9 kg/m². The prevalence of metabolic syndrome was 43.7%. The mean PHQ-9 score was 2.0±3.3. The prevalence of severe depression with a score of >10 was 4.2%. Metabolic syndrome and depression were related (P<0.05). The adjusted odds ratio for metabolic syndrome was 0.5 (95% confidence interval [CI], 0.3–0.9). However, age (95% CI, 0.9–1.0), sleep duration during weekdays (95% CI, 0.9–1.0), and sleep duration during weekends (95% CI, 0.9–1.0) were not related.CONCLUSION: Metabolic syndrome was associated with depression in men aged >50 years in this study.
Blood Pressure ; Body Mass Index ; Centers for Disease Control and Prevention (U.S.) ; Cholesterol ; Depression ; Education ; Fasting ; Glucose ; Humans ; Korea ; Lipoproteins ; Male ; National Institutes of Health (U.S.) ; Nutrition Surveys ; Odds Ratio ; Prevalence ; Triglycerides ; Waist Circumference

OBJECTIVE: In patients with internal carotid artery (ICA) occlusion, collateral middle cerebral artery (MCA) flow has a protective role against ischemia. However, some of these patients may experience initial major neurological deficits and major worsening on following days. Thus, we investigated the safety and efficacy of endovascular treatment (EVT) for ICA occlusion with collateral MCA flow by comparing clinical outcomes of medical treatment versus EVT.METHODS: The inclusion criteria were as follows : 1) acute ischemic stroke with ICA occlusion and presence of collateral MCA flow on transfemoral cerebral angiography (TFCA) and 2) hospital arrival within 12 hours from symptom onset. The treatment strategy was made by the attending physician based on the patient’s clinical status and results of TFCA.RESULTS: Eighty-one patients were included (30 medical treatment, 51 EVT). The EVT group revealed a high incidence of intracranial ICA occlusion, longer ipsilesional MCA contrast filling time, and a similar rate of favorable clinical outcome despite a higher mean baseline the National Institutes of Health Stroke Scale (NIHSS) score. By binary logistic regression analysis, intravenous recombinant tissue plasminogen activator and EVT were independent predictors of favorable clinical outcome. In subgroup analysis based on stroke etiology, the non-atherosclerotic group showed a higher baseline NIHSS score, higher incidence of EVT, and a higher rate of distal embolization during EVT in comparison with the atherosclerotic group.CONCLUSION: In patients with ICA occlusion and collateral MCA flow, decisions regarding treatment strategy based on TFCA can help achieve favorable clinical outcomes. EVT strategy with respect to etiology of ICA occlusion might help achieve better angiographic outcomes.
Carotid Artery, Internal ; Cerebral Angiography ; Collateral Circulation ; Humans ; Incidence ; Ischemia ; Logistic Models ; Middle Cerebral Artery ; National Institutes of Health (U.S.) ; Stroke ; Thrombectomy ; Tissue Plasminogen Activator