Abstract WP210: Transthoracic Echocardiographic Predictor for Long-Term Outcomes in Real-World Korean Patients With Atrial Fibrillation-Related Stroke: A Multi-Center Cohort Study

Background: While transthoracic echocardiography (TTE) is performed to find out potential embolic sources and certain cardiac abnormalities as a routine workup of stroke, clinical implication of echocardiographic findings for long-term outcomes in atrial fibrillation (AF)-related stroke patients has been unknown.

Methods: This was a sub-study of K-ATTENTION (Korean ATrial fibrillaTion EvaluatioN regisTry in Ischemic strOke patieNts), a multicenter-based cohort composed of prospective stroke registries from 11 tertiary centers. All stroke survivals enrolled in this study underwent TTE during hospitalization. Echocardiographic findings included left atrial (LA) diameter, left ventricular ejection fraction (LVEF), LV end-diastolic dimension (LVEDV), stenosis and regurgitation of mitral and aortic valves, and peak trans-mitral filling velocity/mean mitral annular velocity during early diastole (E/e’ ratio). Indexed-LA size was acquired as dividing LA size by body surface area. LV systolic function was grouped into normal (LVEF≥55%), mild (55%>LVEF>40%), and severe (LVEF≤40%). Level of E/e’ ratio associated with LV filling pressure was divided into normal (<8), borderline (8-15) and increased (≥15). Outcomes of interest were recurrent stroke, coronary artery disease, and vascular, and all-cause death. We used Cox regression multivariable analyses adjusted by confounding factors.

Results: A total of 1952 patients were finally included. Over a mean follow-up of 1.72±1.31 years, 140 patients had recurrent stroke, 36 had coronary artery disease, and of 236 fatalities, 33 died of a vascular cause. Multivariable analyses demonstrated that severe LV systolic dysfunction was associated with a higher risk of coronary artery disease (hazard ratio [HR] 3.80, 95% confidence interval [CI] 1.53-9.41), vascular death (HR 3.59, 95% CI 1.42-9.10) and all-cause death (HR 2.29, 95% CI 1.47-3.56).

Conclusions: LV ejection fraction could be important predictor for long-term outcomes in AF-related stroke.

Abstract TP519: The Effect of Different Oral Anticoagulants on Vascular Outcomes in Stroke With Atrial Fibrillation: A Real-world Data

Background and Purpose: Little is known about the different effect of outcomes and factors associated with vascular outcomes in stroke patients with atrial fibrillation in real world practice setting especially in Korea. In this study, we investigated the effect of each oral anticoagulants on vascular outcomes using K-ATTENTION (Korean ATrial fibrillaTion EvaluatioN regisTry in Ischemic strOke patieNts) study.

Methods: Consecutive data of acute stroke patients with atrial fibrillation were collected from 11 centers in Korea from January 2013 to December 2015. Eligibility of inclusion was acute stroke within 7 days from the onset of stroke and diagnosis of non-valvular or valvular atrial fibrillation. Vascular outcomes included ischemic stroke, hemorrhagic stroke, death of any cause, and major adverse cerebro/cardiovascular events (MACE). To describe the effect of each oral anticoagulants on vascular outcomes, we performed time-dependent Cox’s regression analyses with the class of oral anticoagulant as a time dependent covariate. For stroke, hemorrhagic stroke, and any stroke, death was considered as competing risk.

Results: Among 3213 stroke patients included in K-ATTENTION study, a total 3033 stroke patients (mean age 73.45 ± 9.93 years old, female 48.5%) were included. Mean CHA2DS2-VASc score was 4.89 ± 1.37. During the study period, a total of 161 ischemic strokes, 46 hemorrhagic strokes, 199 any strokes, 556 death and 720 MACE were captured. Time-dependent Cox’s regression analysis revealed that use of oral anticoagulants [vitamin K antagonist (VKA), dabigatran, rivaroxaban, or apixaban] was associated with significantly lower risk of death and MACE compared with no oral anticoagulants use. Although, there was no difference among oral anticoagulants for ischemic stroke, hemorrhagic stroke, or any stroke when compared with no oral anticoagulants, dabigatran showed a trend of reduced risk of any stroke (HR 0.48, 95%CI 0.23 - 1.01, p = 0.0545).

Conclusion: This real-world data revealed that the use of oral anticoagulants was associated with the reduced risk of MACE and death. However, for ischemic stroke and hemorrhagic stroke, the results were not conclusive. Dabigatran showed a trend of reduced risk of any stroke.

Abstract WP227: White Matter Hyperintensities and Recurrent Stroke Risk in Stroke Patients With Small-Vessel Disease Burden

Background and Purpose: Although white matter hyperintensities (WMH) on magnetic resonance imaging (MRI) are linked to an increased risk of infarct growth, the impact of WMH severity on the long-term risk of recurrent stroke is currently unknown. This study aimed to evaluate the association between WMH severity and the risk of recurrent vascular events among ischemic stroke patients with small-vessel disease (SVD).

Methods: Data from participants (n = 1,454) in the PreventIon of CArdiovascular Events in iSchemic Stroke Patients with High Risk of Cerebral HemOrrhage trial were reviewed. The severity of WMH in baseline brain MRI scans was assessed using the Fazekas scale. The association between WMH severity and stroke (ischemic or hemorrhagic) and major vascular events (MVEs, a composite of stroke, myocardial infarction, or vascular death) was assessed.

Results: Study patients were having significant burden of SVD; Fazekas score 0 (n=2), 1 (n = 426), 2 (n = 650), and 3 (n = 376) and median Fazekas scale was 2 (mean follow-up 1.9 ± 1.3 years). The stroke incidence rate per 100 person-years was 2.6% in the Fazekas 0-1 group, 3.6% in Fazekas 2, and 7.0% in Fazekas 3, and the rates for MVEs were 3.3%, 4.3%, and 7.6%, respectively. Compared with the Fazekas 0-1 group, the Fazekas 3 group was associated with a higher risk of stroke (adjusted hazard ratio, 2.69; 95% confidence interval, 1.61–4.50; P < 0.001), ischemic stroke (2.56; 1.44–4.55; P = 0.001), hemorrhagic stroke (3.26; 1.04–10.25; P = 0.043), and MVEs (2.27; 1.43–3.61; P = 0.001).

Conclusions: In this study of Asian patients with SVD who had experienced a non-cardioembolic stroke or transient ischemic attack, advanced WMH (Fazekas 3) was independently associated with a greater than 2-fold increased risk of recurrent stroke during the 2-year follow-up period, when compared with the milder WMH group (Fazekas ≤ 1). Increasing WMH severity may, therefore, be a useful prognostic indicator of patients at high risk of recurrent vascular events.

Cerebral Microbleeds in the Patients With Acute Stroke Symptoms

Background: Some patients with acute stroke symptoms do not show hyperintensities on diffusion-weighted image (DWI). A few case reports have indicated that acutely developed cerebral microbleeds (CMBs) might cause focal symptoms. This study sought to investigate the incidence and characteristics of symptomatic CMBs in the patients with acute stroke symptoms but without DWI ischemic lesions.

Methods: We enrolled the patients with acute stroke symptoms who underwent magnetic resonance imaging including DWI and gradient echo (GRE) sequences within 7 days after symptom onset, at our prospective stroke registry. We then identified patients without DWI-positive ischemic lesions but with CMBs in the relevant brain regions.

Results: Between January 2005 and February 2012, we identified 235 DWI-negative transient ischemic attack (n = 221) and stroke (n = 14) patients from 2129 consecutive patients at our registry. In total, 16 patients had CMBs corresponding to the focal symptoms. Among these 16 patients, 12 patients showed a hyperintense rim on DWI around a microbleed suspected to be related to focal symptoms; of the 12 patients, 7 experienced stroke symptoms for more than 24 h. However, the symptoms in the remaining patients (5 patients with the hyperintense rim and 4 patients without the hyperintense rim) improved within 24 h.

Conclusion: Symptomatic microbleeds are infrequent but not rare in the patients with acute stroke symptoms. Perihematomal edema around an acute CMB can cause a hyperintense rim on DWI. Our results suggest that a combination of DWI and GRE imaging can help diagnose acute symptomatic CMBs.

Differences between the Molecular Mechanisms Underlying Ruptured and Non-Ruptured Carotid Plaques, and the Significance of ABCA1

Background and Purpose

Carotid plaques are a strong risk factor for ischemic stroke, and plaque rupture poses an even higher risk. Although many studies have investigated the pathogenic mechanisms of carotid plaque formation, few have studied the differences in molecular mechanisms underlying the rupture and non-rupture of carotid plaques. In addition, since early diagnosis and treatment of carotid plaque rupture are critical for the prevention of ischemic stroke, many studies have sought to identify the important target molecules involved in the rupture. However, a target molecule critical in symptomatic ruptured plaques is yet to be identified.

Methods

A total of 79 carotid plaques were consecutively collected, and microscopically divided into ruptured and non-ruptured groups. Quantitative polymerase chain reaction array, proteomics, and immunohistochemistry were performed to compare the differences in molecular mechanisms between ruptured and non-ruptured plaques. Enzyme-linked immunosorbent assay was used to measure the differences in ATP-binding cassette subfamily A member 1 (ABCA1) levels in the serum.

Results

The expression of several mRNAs and proteins, including ABCA1, was higher in ruptured plaques than non-ruptured plaques. In contrast, the expression of other proteins, including β-actin, was lower in ruptured plaques than non-ruptured plaques. The increased expression of ABCA1 was consistent across several experiments, ABCA1 was positive only in the serum of patients with symptomatic ruptured plaques.

Conclusions

This study introduces a plausible molecular mechanism underlying carotid plaque rupture, suggesting that ABCA1 plays a role in symptomatic rupture. Further study of ABCA1 is needed to confirm this hypothesis.

Basilar Artery Plaque and Pontine Infarction Location and Vascular Geometry

Background and Purpose

Subclinical atherosclerotic plaques are common in patients with pontine infarctions (PIs) but without basilar artery (BA) stenosis. We hypothesized that BA plaque locations may differ by PI type and vertical location as well as vertebrobasilar artery geometry.

Methods

Ninety-six patients with PI but without BA stenosis on magnetic resonance imaging (MRI) and magnetic resonance angiography were enrolled. PIs were classified by type (paramedian, deep, or lateral) and vertical location (rostral, middle, or caudal). Patients underwent high-resolution MRI to evaluate BA plaque location (anterior, posterior, or lateral). The mid-BA angle on anteroposterior view and angle between the BA and dominant vertebral artery (BA-VA angle) on lateral view were measured.

Results

The PIs were paramedian (72.9%), deep (17.7%), and lateral (9.4%) type with a rostral (32.3%), middle (42.7%), and caudal (25.0%) vertical location. The BA plaque locations differed by PI type (P=0.03) and vertical location (P<0.001); BA plaques were most frequent at the posterior wall in paramedian (37.1%) and caudal (58.3%) PIs and at the lateral wall in lateral (55.5%) and middle (34.1%) PIs. The BA-VA and mid-BA angles differed by BA plaque and PI vertical location; the greatest BA-VA angle was observed in patients with posterior plaques (P<0.001) and caudal PIs (P<0.001). Greatest mid-BA angles were observed with lateral BA plaques (P=0.03) and middlelocated PIs (P=0.03).

Conclusions

Greater mid-BA angulation may enhance lateral plaque formation, causing lateral and middle PIs, whereas greater BA-VA angulation may enhance posterior plaque formation, causing paramedian or caudal PIs.

Role of Hyperintense Acute Reperfusion Marker for Classifying the Stroke Etiology

Purpose

The hyperintense acute reperfusion marker (HARM) is a delayed enhancement of the subarachnoid or subpial space observed on post-contrast fluid-attenuated inversion recovery (FLAIR) images and is associated with permeability changes to the blood–brain barrier in acute stroke. We investigated the relationship between HARM and stroke etiology based on the Trial of ORG 10172 in Acute Stroke Treatment (TOAST) classification. In addition, we evaluated the relationship between HARM and stroke locations with respect to vascular territories and anatomic compartments.

Materials and methods

We recruited 264 consecutive patients (109 women; mean age 68.63 years) who were diagnosed with acute ischemic stroke and underwent brain magnetic resonance imaging (MRI) including post-contrast FLAIR and DWI within 7 days of symptom onset from May 2015 to March 2016 for this retrospective study. Post-contrast FLAIR images were obtained 5 min after gadolinium administration. The mean time interval between the onset of stroke symptoms and MRI acquisition in total included patients was 18 h and 7 min (median 12 h and 57 min, range 2–127 h). We analyzed the overall incidence and distribution patterns of HARM in acute ischemic stroke cases and compared the relative incidence and distribution patterns of HARM between the subgroups of stroke etiology based on conventional TOAST classification. We obtained odds ratio (OR) of HARM in different stroke locations based on vascular territories and anatomical compartments. This study was approved by our institutional review board.

Results

Among the 264 patients, 67 (25.38%) patients were HARM positive and 197 (74.62%) patients were HARM negative. There was significant difference in HARM incidence among the stroke subgroups (p < 0.001). Small vessel occlusion (SVO) was associated with the HARM-negative group (p < 0.001), while large artery atherosclerosis (LAA) and cardioembolism (CE) were associated with the HARM-positive group (p = 0.001). Also, regional pattern of HARM on the same vascular territory as the acute infarction was dominantly demonstrated regardless of stroke etiology. The OR for HARM from middle cerebral artery (MCA) infarction was 1.868 [95% confidence interval (CI): 1.025–3.401]. The OR for HARM from cortical infarction was 9.475 (95% CI: 4.754–18.883) compared to other anatomic compartments.

Conclusion

The presence of the HARM was significantly associated with embolic infarctions including LAA and CE. Conversely, SVO was exclusively associated with the absence of the HARM. Second, MCA and cortical infarction showed a more pronounced HARM compared to infarctions at other vascular territories and anatomic compartments. According to the results in the current study, we speculate that the presence of HARM on post-contrast FLAIR images was associated with specific stroke causes especially in embolic causes.

Factors Influencing Decision Making for Carotid Endarterectomy versus Stenting in the Very Elderly

As the population ages worldwide, the number of elderly patients with carotid stenosis is also increasing. There have been many large clinical trials comparing carotid endarterectomy (CAE) versus stenting, but the inclusion criteria (i.e., symptomatic or asymptomatic), stenting methods (i.e., protection device), and primary end point (i.e., the definition of myocardial infarction and follow-up period) were different between trials. Therefore, the interpretation of those results is difficult and requires attention. When it comes to age, the patients older than 80 years were excluded or stratified to a high risk group in previous landmark trials. However, a recent guideline recommended that endarterectomy may be associated with lower stroke risk compared with carotid artery stenting in patients older than 70 years with symptomatic carotid disease. The annual risk of stroke in individuals with asymptomatic carotid stenosis is about 1-3% but the risk is about 4-12% with symptomatic stenosis without carotid intervention. Although the outcome of CAE is better than that of carotid stenting in patients older than 70 years, the perioperative risk is higher in older patients. Therefore, it is important to classify high risk patients and consider underlying disability and life expectancy of very elderly patients before deciding whether to undergo a carotid intervention. In addition, we should also consider that the stroke rate with intensive medical treatment is unknown and is currently being investigated in randomized controlled trials. Intensive medical treatment includes high intensity statins, diabetes and blood pressure control, and aggressive antiplatelet treatment. The aim of this review is to report the factors that may be responsible for the variability in the treatment of carotid stenosis, particularly in the elderly population. This will allow the readers to integrate the current available evidence to individualize the treatment of carotid stenosis in this challenging population.

Acute Hemiparesis in a Healthy Elderly Woman: Where and What Is the Lesion?

Hemiparesis may be the result of lesions in the contralateral pyramidal tract in the brain or, less frequently, in the ipsilateral pyramidal tract in the upper cervical spinal cord. However, although rare, multiple lesions that simultaneously occur in both of these regions may be the cause of acute hemiparesis, and the clinical symptoms can often be misdiagnosed as a stroke. In addition, the correct diagnosis of these multiple central nervous system (CNS) lesions is very challenging if they are caused by infection from an unexpected microorganism. We evaluated an elderly healthy woman who presented with acute hemiparesis and multiple brain and spinal cord lesions that were confirmed to occur from an infection with Propionibacterium acnes. In this report, the differential diagnosis and histopathological findings are discussed for these multiple CNS lesions in this healthy woman.

Syndrome of inappropriate antidiuretic hormone secretion associated with seronegative neuromyelitis optica spectrum disorder

The syndrome of inappropriate antidiuretic hormone secretion (SIADH) is a potential cause of hyponatremia of the central nervous system (CNS). Although SIADH has been reported to be associated with many other central nervous disorders, its association with neuromyelitis optica (NMO) or NMO spectrum disorders are rare. NMO is a demyelinating disorder characterized by optic neuritis and transverse myelitis. Aquaporin-4 (AQP4), which is the target antigen for a NMO autoantibody, is the predominant CNS water channel. However, some NMO patients show seronegative AQP4 antibody results. The spectrum of NMO has been changed, and new findings about the disease have been reported. Here, we report a case of seronegative NMO spectrum disorder associated with SIADH.

Predictors of Hemorrhage Volume after Intravenous Thrombolysis

BACKGROUND

Symptomatic intracerebral hemorrhage (sICH) is one of the most feared complications after administration of intravenous recombinant tissue plasminogen activator (IV rtPA). The aim of this study was to determine correlations between hemorrhage volume (HV) after IV rtPA treatment and risk factors for sICH.

METHODS

We analyzed 318 patients from the stroke registries of 4 hospitals in Korea. We confirmed hemorrhage by computed tomography (CT) or magnetic resonance imaging within 36 hours. Patient groups were classified by HV (0, 0-10, 10-25, and greater than 25 mL). Based on the HV, we evaluated the following: (1) predictors for hemorrhage; (2) rates of sICH according to various sICH definitions; and (3) 3-month functional outcomes after IV rtPA treatment.

RESULTS

Among the 318 patients, hemorrhage occurred in 72 patients. HV was significantly correlated with atrial fibrillation (OR = 3.38, 95% CI = 1.87-6.09), early CT changes (OR = 3.17, 95% CI = 1.69-5.93), and dense artery sign (OR = 1.90, 95% CI = 1.07-3.39). Compared with the groups with HV less than 25 mL, patients with an HV of greater than 25 mL were more likely to have higher mortality rates (33.3% versus 11.8%) and worse outcomes at 3 months (good: 8.3% versus 50.3%; excellent: 0% versus 33.7%).

CONCLUSIONS

HV after IV rtPA is an important predictor of clinical outcomes. Atrial fibrillation, early CT changes, and dense artery sign were significantly associated with large HVs; therefore, these patient factors might be considered before and after thrombolytic treatment.

Paradoxical development of neovascular glaucoma following carotid angioplasty and stenting

This report describes a very rare ocular complication of carotid intervention. A 74-year-old patient presented with left-sided weakness and was diagnosed with right cerebral border-zone infarctions caused by severe stenosis of the right proximal internal carotid artery. Staged carotid intervention (balloon angioplasty followed by stenting) was successfully performed. However, neovascular glaucoma developed following carotid angioplasty and stenting. We concluded that although carotid angioplasty and stenting improves vision in patients with ischemic oculopathy, it can rarely induce paradoxical visual deterioration such as development or aggravation of neovascular glaucoma.

Protocol of the Stroke in Korean Young Adults Study: A Multicenter Case-Control Study and Prospective Cohort Study

BACKGROUND

The incidence of ischemic stroke in young adults has been rising over recent decades, but there is still limited information on its risk factors, etiologies, and outcomes. Because these patients generally participate in social life, risk factors associated with lifestyle may have a great impact and need to be identified.

METHODS

The SKY (Stroke in Korean Young Adults) study is a multicenter case-control study and a prospective cohort study in 8 tertiary medical centers in the Republic of Korea. The case subjects are patients aged 18-44 years with first-ever ischemic stroke occurring within 1 month of stroke onset, and the control subjects are age- and gender-matched community controls. Our aim is to include 470 cases and 470 controls. The main objective of our study is to determine the risk factors and the causes of ischemic stroke in Korean young adults. Both well-documented risk factors and little-known lifestyle-related risk factors such as lifestyle habits and psychological distress including job strain will be evaluated by comparing cases and controls using a structured questionnaire. Secondary objectives are to determine the risks of mortality, recurrent vascular events, and poststroke epilepsy in these patients. Conditional logistic regression analysis will be used to estimate odds ratios and 95% confidence intervals.

CONCLUSIONS

The SKY study is designed to obtain more insights into relatively little-known risk factors in young Korean adults with ischemic stroke. The results may also help identify the frequencies of uncommon etiologies and outcomes in these patients.

Preoperative Coronary Stenosis Is a Determinant of Early Vascular Outcome after Carotid Endarterectomy

BACKGROUND AND PURPOSE

The benefit of carotid endarterectomy (CEA) is directly influenced by the risk of perioperative adverse outcomes. However, patient-level risks and predictors including coronary stenosis are rarely evaluated, especially in Asian patients. The aim of this study was to determine the relationship between the vascular risk factors underlying CEA, including coronary stenosis, and postoperative outcome.

METHODS

One hundred and fifty-three consecutive CEAs from our hospital records were included in this analysis. All patients underwent coronary computed tomography angiography before CEA. Data were analyzed to determine the vascular outcomes in patients with mild-to-moderate vs. severe coronary stenosis and high vs. standard operative risk, based on the criteria for high operative risk defined in the Stenting and Angioplasty with Protection in Patients at High Risk for Endarterectomy (SAPPHIRE) trial. The vascular outcome was defined as the occurrence of postoperative (≤30 days) stroke, myocardial infarction (MI), or death.

RESULTS

An adverse vascular outcome occurred in 8 of the 153 CEAs, with 6 strokes, 2 MIs, and 3 deaths. The vascular outcome differed significantly between the groups with mild-to-moderate and severe coronary stenosis (p=0.024), but not between the high- and standard-operative-risk groups (stratified according to operative risk as defined in the SAPPHIRE trial). Multivariable analysis adjusting for potent predictors revealed that severe coronary stenosis (odds ratio, 6.87; 95% confidence interval, 1.20-39.22) was a significant predictor of the early vascular outcome.

CONCLUSIONS

Severe coronary stenosis was identified herein as an independent predictor of an adverse early vascular outcome.

Basilar plaque on high-resolution MRI predicts progressive motor deficits after pontine infarction

BACKGROUND

The association between progressive motor deficits (PMD) in acute pontine infarction and basilar stenosis is unclear. High resolution MRI (HRMRI) is an emerging tool for basilar artery evaluation and might provide more accurate information. We aimed to analyze the association between basilar plaque assessed by HRMRI and PMD after acute pontine infarction.

METHODS

We identified consecutive patients with unilateral pontine infarction within 24 h of stroke onset. All the patients underwent diffusion weighted MRI, MR angiography and HRMRI within 24 h of admission. PMD was defined as an increase in National Institutes of Health Stroke Scale score by ≥1 during hospitalization. Factors potentially associated with PMD were validated by multivariate analyses.

RESULTS

Of a total of 87 patients, 63 (72%) had paramedian pontine infarction (PPI) and PMD was observed in 28 (32%) patients. Apparent basilar plaque assessed by HRMRI was more frequent in those with PMD than in those without PMD (52% versus 33%, p<0.001). In contrast, the frequency of basilar stenosis (>30%) assessed by MR angiography was similar regardless of PMD. In the patients with PPI, PMD was associated with hypertension and apparent plaque on HRMRI. After adjusting covariates, PMD was independently associated with apparent plaque on HRMRI (OR, 9.1; 95% CI 1.4-58.9).

CONCLUSIONS

Our results suggest that basilar plaque assessed by HRMRI is associated with PMD in patients with acute unilateral pontine infarction. Since basilar stenosis may be underestimated by MR angiography, HRMRI may provide additional information for predicting PMD and evaluating basilar artery stenosis.

Abstract T P156: Awareness Of Atrial Fibrillation And Appropriate Antithrombotic Treatment Will Attenuate Stroke Severity And Improve Clinical Outcome In Acute Ischemic Stroke Patients With Atrial Fibrillation

Background: Ischemic stroke due to atrial fibrillation (AF) is markedly increasing in Korea. Appropriate use of oral anticoagulants for the patients with AF is very important. We elucidated the relationship between international normalized ratio (INR) values on stroke severity and clinical outcomes in patients with acute ischemic stroke and AF.

Methods: Study subjects were extracted from prospectively-designed stroke registries of three academic hospitals from 2003 to 2013. We selected 2,303 patients with AF who visited our hospital within 7 days after onset. Persistent or paroxysmal AF is confirmed by electrocardiography or Holter monitoring. We adopted INR values extracted in emergency room, and the initial stroke severity and functional outcome were assessed by baseline and discharge National Institutes of Health Stroke Scale (NIHSS) and modified Rankin Scale.

Results: One thousand three hundred two patients (50.1%) were aware of their AF before admission. The awareness was markedly lower than that of hypertension (88.7%) and diabetes (88.1%). After exclusion of the patients who did not know their medication history, 48.5% were not on antithrombotic treatment, 17.1% on warfarin, 25.8% on mono antiplatelet treatment, 4.1% on dual or triple antiplatelet therapy, and 4.5% on warfarin and antiplatelet. Besides, the patients who were taking warfarin with a therapeutic INR (2.0~3.0) were only 68 (3.0%). Admission and discharge NIHSS score was significantly lower in the group of patients taking warfarin (median 6, interquartile range [2,13]). Admission and discharge NIHSS scores were lowest in the group of patients with optimal INR level (admission NIHSS; INR<1.5, 8[3,14]; INR=1.5-2.0, 5.5[2,13]; INR=2.0-3.0, 4[2,10], INR ≥3.0, 5.5[2,15.75], p=0.026 and discharge NIHSS; INR<1.5, 4[1,11]; INR=1.5-2.0, 3[1,10.25]; INR=2.0-3.0, 2[0,7.75]; INR ≥3.0, 2.5[1,11.25], p=0.024)

Conclusion: Awareness of AF has been poor and underuse or inappropriate use of warfarin was widespread. Suboptimal (INR=1.5-2.0) or optimal (INR=2.0-3.0) use of warfarin can be associated with lower initial stroke severity and clinical outcome. Therefore, the education about appropriate anticoagulation is needed for the general public and health professionals.

Increased VEGF and decreased SDF-1α in patients with silent brain infarction are associated with better prognosis after first-ever acute lacunar stroke

BACKGROUND

Pre-existing silent brain infarctions (SBIs) have been reported to be associated with better outcomes after first-ever symptomatic ischemic stroke, although the mechanism of this remains unclear. We investigated the association between SBIs, outcomes of acute lacunar infarction, and biomarkers including vascular endothelial growth factor (VEGF), stromal cell-derived factor-1α (SDF-1α), macrophage migration inhibitory factor (MIF), and high-mobility group box-1 (HMGB1).

METHODS

A total of 68 consecutive patients diagnosed with first-ever lacunar infarction (<20 mm) within 24 hours of symptom onset were included in this study. Clinical, laboratory, and imaging data were obtained. Plasma levels of VEGF, SDF-1α, MIF, and HMGB1 were assessed using Enzyme-Linked Immunosorbent Assay kits.

RESULTS

SBIs were noted in 31 of the 68 patients. Although the initial National Institutes of Health Stroke Scale scores were not related with the presence of SBIs (P = .313), patients with SBIs had better outcomes at 3 months (P = .029). Additionally, plasma VEGF levels were higher (P = .035) and SDF-1α levels were lower (P < .001) in patients with SBIs. Logistic regression analysis indicated that VEGF and SDF-1α were independently associated with the presence of SBIs.

CONCLUSIONS

SBIs are associated with favorable outcomes in patients with first-ever acute lacunar infarction and higher levels of VEGF, and lower levels of SDF-1α in these patients may contribute to their more favorable prognosis.

Sleep disturbances and predictive factors in caregivers of patients with mild cognitive impairment and dementia

Background and Purpose

We examined the characteristics of sleep disturbances and sleep patterns in the caregivers of patients with amnestic mild cognitive impairment (aMCI) and dementia.

Methods

We prospectively studied 132 patients (60 with aMCI and 72 with dementia) and their caregivers, and 52 noncaregiver controls. All caregivers and controls completed several sleep questionnaires, including the Pittsburgh Sleep Quality Index (PSQI). The patients were administered neuropsychological tests and the neuropsychiatric inventory to evaluate their behavioral and neuropsychiatric symptoms of dementia (BPSD).

Results

The PSQI global score was 6.25±3.88 (mean±SD) for the dementia caregivers and 5.47±3.53 for the aMCI caregivers. The Insomnia Severity Index (ISI) and short form of the Geriatric Depression Scale (GDS-S) predicted higher PSQI global scores in aMCI caregivers, and higher scores for the ISI, Epworth Sleepiness Scale (ESS), and GDS-S in dementia caregivers. BPSD, including not only agitation, depression, and appetite change in dementia patients, but also depression, apathy, and disinhibition in aMCI patients, was related to impaired sleep quality of caregivers, but nighttime behavior was not. Age and gender were not risk factors for disturbed sleep quality.

Conclusions

Dementia and aMCI caregivers exhibit impaired quality of sleep versus non-caregivers. ISI, GDS-S, and ESS scores are strong indicators of poor sleep in dementia caregivers. In addition, some BPSD and parts of the neuropsychological tests may be predictive factors of sleep disturbance in dementia caregivers.

Abstract T MP35: Difference in Long-Term Survival After Carotid Endarterectomy Between Standard and High Risk Patients

Background: Large randomized controlled trials have shown that carotid endarterectomy (CEA) in carefully selected patients reduced the risk of stroke and death compared to existing medical therapy alone. Early and long-term mortality after CEA and the predictive factors of major adverse events (MAEs) should be considered when deciding on this procedure.

Methods: We enrolled the patients who underwent consecutive CEA procedures. Perioperative (≤30 days) and long-term outcome in standard-risk (SR) and high-risk (HR) procedures was obtained. MAE was defined as the occurrence of stroke, death, or myocardial infarction out to 174 months.

Results: A total of 247 patients underwent 271 CEA procedures. Of these, 157 patients had SR and 90 patients had HR. The 30-day rate of death, myocardial infarction, or stroke was 4.5% among all patients (3.2% for SR vs. 6.7% for HR). Kaplan-Meier analysis showed significant lower survival rate in HR patients (p=0.002). At 5 year, survival rate was 68.1% in SR patients and 28.6% in HR patients, respectively. The most single significant predictor of MAE was coronary artery disease (HR, 3.1; 95% CI, 1.8-5.5).

Conclusion: In this study of patients underwent CEA, a substantial reduction in long-term survival was observed in high risk patients compared with standard risk patients. Therefore, evaluation and treatment for coronary disease is strongly recommended before and after CEA.