BACKGROUND AND PURPOSE: A substantial proportion of patients with atrial fibrillation (AF) are not treated optimally; however, the inappropriateness of drug therapy has never been evaluated before or after a stroke event. We investigated the adherence to guidelines for therapy in AF patients hospitalized with acute ischemic stroke (AIS) before stroke onset and at discharge, with the aim of identifying the factors associated with inappropriate therapy. METHODS: AIS patients with AF hospitalized within 7 days of onset were identified from a prospective nine-center stroke registry database. Two cohorts were defined: patients diagnosed with AF prior to the stroke event (admission cohort) and patients diagnosed with AF at discharge from hospital (discharge cohort). Any of the following conditions were regarded as nonadherence to guidelines in this study: use of anticoagulant or nonuse of antithrombotics with CHADS2 score=0, nonuse of antithrombotics with CHADS2 score=1, or nonuse of anticoagulant with CHADS2 score > or =2. RESULTS: Overall, 406 patients were enrolled in the admission cohort and 518 in the discharge cohort. The rates of nonadherence before a stroke event and at discharge were 77.8% and 33.3%, respectively. These rates varied widely for both cohorts, with interhospital differences being statistically significant. Multivariable analysis revealed that old age, stroke history, and congestive heart failure were associated with nonadherence before stroke. At discharge, males, coronary heart disease, inappropriate antithrombotic use before stroke, and functional disability at discharge were associated with nonadherence. CONCLUSIONS: This study shows that antithrombotic use in AIS patients with AF might be not optimal before and after stroke in Korea.
Atrial Fibrillation* ; Cerebral Infarction ; Cohort Studies ; Coronary Disease ; Drug Therapy ; Drug Utilization Review ; Guideline Adherence ; Heart Failure ; Humans ; Korea* ; Male ; Morinda ; Observational Study* ; Prospective Studies ; Stroke*

On page 47, the definition of stroke progression was erroneously described in the previous version of article.

BACKGROUND AND PURPOSE: In a recent pooled analysis of randomized clinical trials (RCTs), intravenous tissue plasminogen activator (TPA) improves the outcome in patients aged > or =80 years. However, it is uncertain whether the findings are applicable to clinical practice in Asian populations. METHODS: From a multicenter stroke registry database of Korea, we identified patients with acute ischemic stroke who were aged > or = 80 years. Using multivariable analysis and propensity score (PS)-matched analyses, we assessed the effectiveness and safety of intravenous TPA within 4.5 hours. RESULTS: Among 2,334 patients who met the eligible criteria, 236 were treated with intravenous TPA (mean age, 83+/-5; median NIHSS, 13 [IQR, 8-17]). At discharge, the TPA group compared to the no-TPA group had a favorable shift on the modified Rankin Scale (mRS) score (multivariable analysis, OR [95% CI], 1.51 [1.17-1.96], P=0.002; PS-matched analysis, 1.54 [1.17-2.04], P=0.002) and was more likely to achieve mRS 0-1 outcome (multivariable analysis, 2.00 [1.32-3.03], P=0.001; PS-matched analysis, 1.59 [1.04-2.42], P=0.032). TPA treatment was associated with an increased risk of symptomatic intracranial hemorrhage (multivariable analysis, 5.45 [2.80-10.59], P<0.001; PS-matched analysis, 4.52 [2.24-9.13], P<0.001), but did not increase the in-hospital mortality (multivariable analysis, 0.86 [0.50-1.48], P=0.58; PS-matched analysis, 0.88 [0.52-1.47], P=0.61). CONCLUSIONS: In the setting of clinical practice, intravenous TPA within 4.5 hours improved the functional outcome despite an increased risk of symptomatic intracranial hemorrhage in very elderly Korean patients. The findings, consistent with those from pooled analysis of RCTs, strongly support the use of TPA for this population.
Aged* ; Asian Continental Ancestry Group ; Hospital Mortality ; Humans ; Intracranial Hemorrhages ; Korea ; Propensity Score ; Stroke* ; Thrombolytic Therapy ; Tissue Plasminogen Activator*

BACKGROUND AND PURPOSE: Estimating age- and sex-specific population attributable risks (PARs) of major risk factors for stroke may be a useful strategy to identify risk factors for targeting preventive strategies. METHODS: For this case-control matched study, consecutive patients aged 18-90 years and admitted to nine nationwide hospitals with acute ischemic stroke between December 2008 and June 2010, were enrolled as cases. Controls, individually matched by age and sex, were chosen from the 4th Korean National Health & Nutrition Examination Survey (2008-2010). Based on odds ratios and prevalence, standardized according to the age and sex structure of the Korean population, PARs of major risk factors were estimated according to age (young, < or = 45; middle-aged, 46-65; and elderly, > or = 66 years) and sex subgroups. RESULTS: In 4,743 matched case-control sets, smoking (PAR, 45.1%) was the greatest contributing risk factor in young men, followed by hypertension (28.5%). In middle-aged men, the greatest contributing factors were smoking (37.4%), hypertension (22.7%), and diabetes (14.6%), whereas in women the greatest factors were hypertension (22.7%) and stroke history (10.6%). In the elderly, hypertension was the leading factor in men (23.7%) and women (23.4%). Other noticeable factors were stroke history (men, 19.7%; women, 17.3%) and diabetes (men, 12.5%; women, 15.1%). In young women, risk factors with a PAR greater than 10% were not found. CONCLUSIONS: Smoking cessation in young people and hypertension and diabetes control in older people may be effective in reducing the burden of stroke on the population. In the elderly, secondary prevention could also be emphasized.
Aged ; Case-Control Studies ; Female ; Humans ; Hypertension ; Male ; Odds Ratio ; Prevalence ; Risk Factors* ; Secondary Prevention ; Smoke ; Smoking ; Smoking Cessation ; Stroke*

Characteristics of stroke cases, acute stroke care, and outcomes after stroke differ according to geographical and cultural background. To provide epidemiological and clinical data on stroke care in South Korea, we analyzed a prospective multicenter clinical stroke registry, the Clinical Research Center for Stroke-Fifth Division (CRCS-5). Patients were 58% male with a mean age of 67.2+/-12.9 years and median National Institutes of Health Stroke Scale score of 3 [1-8] points. Over the 6 years of operation, temporal trends were documented including increasing utilization of recanalization treatment with shorter onset-to-arrival delay and decremental length of stay. Acute recanalization treatment was performed in 12.7% of cases with endovascular treatment utilized in 36%, but the proportion of endovascular recanalization varied across centers. Door-to-IV alteplase delay had a median of 45 [33-68] min. The rate of symptomatic hemorrhagic transformation (HT) was 7%, and that of any HT was 27% among recanalization-treated cases. Early neurological deterioration occurred in 15% of cases and were associated with longer length of stay and poorer 3-month outcomes. The proportion of mRS scores of 0-1 was 42% on discharge, 50% at 3 months, and 55% at 1 year after the index stroke. Recurrent stroke up to 1 year occurred in 4.5% of patients; the rate was higher among older individuals and those with neurologically severe deficits. The above findings will be compared with other Asian and US registry data in this article.
Asian Continental Ancestry Group ; Humans ; Korea ; Length of Stay ; Male ; National Institutes of Health (U.S.) ; Stroke ; Tissue Plasminogen Activator

Chronic inflammatory demyelinating polyneuropathy (CIDP) has been rarely reported in systemic sclerosis (SSc). We describe the clinical, electrophysiological, and pathologic findings in a 73-year-old female with established limited cutaneous SSc who later developed CIDP. The patient had progressive limb weakness, sensory loss, and slow nerve conduction velocities. Sural nerve biopsy showed evidence of demyelination and remyelination. This case demonstrates that chronic demyelinating polyneuropathy can be an unusual manifestation of SSc, presumably resulting from an immune-mediated process.
Aged ; Autoimmunity ; Biopsy ; Demyelinating Diseases ; Extremities ; Female ; Humans ; Neural Conduction ; Polyneuropathies* ; Polyradiculoneuropathy, Chronic Inflammatory Demyelinating ; Scleroderma, Systemic* ; Sural Nerve

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

BACKGROUND AND PURPOSE: In order to improve inter-rater reliability and minimize diagnosis of undetermined etiology for stroke subtype classification, using a stroke registry, we developed and implemented a magnetic resonance imaging (MRI)-based algorithm for acute ischemic stroke subtype classification (MAGIC). METHODS: We enrolled patients who experienced an acute ischemic stroke, were hospitalized in the 14 participating centers within 7 days of onset, and had relevant lesions on MR-diffusion weighted imaging (DWI). MAGIC was designed to reflect recent advances in stroke imaging and thrombolytic therapy. The inter-rater reliability was compared with and without MAGIC to classify the Trial of Org 10172 in Acute Stroke Treatment (TOAST) of each stroke patient. MAGIC was then applied to all stroke patients hospitalized since July 2011, and information about stroke subtypes, other clinical characteristics, and stroke recurrence was collected via a web-based registry database. RESULTS: The overall intra-class correlation coefficient (ICC) value was 0.43 (95% CI, 0.31-0.57) for MAGIC and 0.28 (95% CI, 0.18-0.42) for TOAST. Large artery atherosclerosis (LAA) was the most common cause of acute ischemic stroke (38.3%), followed by cardioembolism (CE, 22.8%), undetermined cause (UD, 22.2%), and small-vessel occlusion (SVO, 14.6%). One-year stroke recurrence rates were the highest for two or more UDs (11.80%), followed by LAA (7.30%), CE (5.60%), and SVO (2.50%). CONCLUSIONS: Despite several limitations, this study shows that the MAGIC system is feasible and may be helpful to classify stroke subtype in the clinic.
Arteries ; Atherosclerosis ; Classification* ; Diagnosis ; Humans ; Magic ; Magnetic Resonance Imaging ; Recurrence ; Stroke* ; Thrombolytic Therapy

BACKGROUND: For the improvement in stroke care, we have campaigned for stroke warning signs and its symptoms. However, few reports on the validation of symptom selection in the campaign have been published till now. METHODS: Based on the prospective stroke registry, patients were identified, who were hospitalized with stroke within 7 days from the stroke onset and had relevant lesions on their brain images. One presenting symptom was selected in each patient through review of electronic medical records by an investigator, and those collected symptoms were classified into 5 symptom categories or the unclassified. Those 5 symptom categories were developed and are being used in the stroke awareness campaign in 2009 by the Korean Stroke Society (KSS). RESULTS: A total of 3027 patients (age, 66.57+/-12.6 years; male, 58.2%) were enrolled in our study. The rate of frequency of each categorized symptom was 54.9% for unilateral numbness or weakness, 27.5% for confusion or speech disturbance, 2.8% for visual disturbance, 10.5% for dizziness or gait disturbance, 2.3% for severe headache, and 2.0% for the unclassified. Ninety-eight percent of stroke patients were classified into one of the 5 symptom categories. Confusion or speech disturbance was associated with the shorter pre-hospital delay, whereas dizziness or gait disturbance with the longer delay. Dizziness was the most frequent symptom in TIA, and so was severe headache in hemorrhagic stroke. CONCLUSIONS: Our study shows that the 5 stroke warning symptoms of the KSS campaign represent well the presenting symptoms of Korean patients with acute stroke or TIA.
Brain ; Dizziness ; Electronic Health Records ; Gait ; Headache ; Humans ; Hypesthesia ; Male ; Prospective Studies ; Research Personnel ; Stroke

Acute neuropathic complications rarely develop in patients with inflammatory bowel disease. A case of acute peripheral neuropathy that developed only 4 weeks after a diagnosis of Crohn's disease (CD) is reported herein. Peripheral neuropathy can be a rare extraintestinal manifestation of CD. Early recognition and proper management of the neurologic complications are crucial for preventing the associated morbidity.
Crohn Disease* ; Diagnosis ; Humans ; Inflammatory Bowel Diseases ; Peripheral Nervous System Diseases* ; Polyneuropathies