Clinical Outcomes of Posterior Versus Anterior Circulation Infarction With Low National Institutes of Health Stroke Scale Scores

Background and Purpose—

We compared baseline characteristics and outcomes at 3 months between patients with minor anterior circulation infarction (ACI) versus minor posterior circulation infarction (PCI), including the influence of large vessel disease on outcomes.

Methods—

This study is an analysis of a prospective multicenter registry database in South Korea. Eligibility criteria were patients with ischemic stroke admitted within 7 days of stroke onset, lesions in either anterior or posterior circulation, and National Institutes of Health Stroke Scale score of ≤4 at baseline. Patients were divided into 4 groups for further analysis: minor ACI with and without internal carotid artery/middle cerebral artery large vessel disease and minor PCI with and without vertebrobasilar large vessel disease.

Results—

A total of 7178 patients (65.2±12.6 years) were analyzed in this study, and 2233 patients (31.1%) had disability (modified Rankin Scale score 2–6) at 3 months. Disability was 32.3% in minor PCI and 30.3% in minor ACI ( P =0.07), and death was 1.3% and 1.5%, respectively ( P =0.82). In a multivariable logistic regression analysis, minor PCI was significantly associated with disability at 3 months when compared with minor ACI (odds ratio, 1.23; 95% confidence interval, 1.09–1.37; P <0.001). In pairwise comparisons, minor PCI with vertebrobasilar large vessel disease was independently associated with disability at 3 months, compared with the other 3 groups.

Conclusions—

Our study showed that minor PCI exhibited more frequent disability at 3 months than minor ACI. Especially, the presence of vertebrobasilar large vessel disease in minor PCI had a substantially higher risk of disability. Our results suggest that minor PCI with vertebrobasilar large vessel disease could require more meticulous care and are important targets for further study.

Usefulness of 3-dimensional stereotactic surface projection FDG PET images for the diagnosis of dementia

To compare diagnostic performance and confidence of a standard visual reading and combined 3-dimensional stereotactic surface projection (3D-SSP) results to discriminate between Alzheimer disease (AD)/mild cognitive impairment (MCI), dementia with Lewy bodies (DLB), and frontotemporal dementia (FTD).[F]fluorodeoxyglucose (FDG) PET brain images were obtained from 120 patients (64 AD/MCI, 38 DLB, and 18 FTD) who were clinically confirmed over 2 years follow-up. Three nuclear medicine physicians performed the diagnosis and rated diagnostic confidence twice; once by standard visual methods, and once by adding of 3D-SSP. Diagnostic performance and confidence were compared between the 2 methods.3D-SSP showed higher sensitivity, specificity, accuracy, positive, and negative predictive values to discriminate different types of dementia compared with the visual method alone, except for AD/MCI specificity and FTD sensitivity. Correction of misdiagnosis after adding 3D-SSP images was greatest for AD/MCI (56%), followed by DLB (13%) and FTD (11%). Diagnostic confidence also increased in DLB (visual: 3.2; 3D-SSP: 4.1; P < 0.001), followed by AD/MCI (visual: 3.1; 3D-SSP: 3.8; P = 0.002) and FTD (visual: 3.5; 3D-SSP: 4.2; P = 0.022). Overall, 154/360 (43%) cases had a corrected misdiagnosis or improved diagnostic confidence for the correct diagnosis.The addition of 3D-SSP images to visual analysis helped to discriminate different types of dementia in FDG PET scans, by correcting misdiagnoses and enhancing diagnostic confidence in the correct diagnosis. Improvement of diagnostic accuracy and confidence by 3D-SSP images might help to determine the cause of dementia and appropriate treatment.

Cognitive remediation for individuals with psychosis: efficacy and mechanisms of treatment effects

BACKGROUND

The popularity of cognitive remediation (CR) interventions for individuals with psychosis is in part based on the well-established link between cognition and functioning and the assumption that by targeting cognition, function can improve. While numerous trials have reported CR's efficacy, it is still not considered an evidence-based treatment. Importantly, little is known about the mechanisms through which it may affect functioning.

METHOD

In this study, we evaluated CR's proximal and distal effects, and examined potential mechanisms. A total of 75 individuals with psychotic disorders were randomized to a combination of strategy-based and drill-and-practice CR or wait-list control, with assessments of training task performance, neurocognition, functional capacity, symptoms and functioning conducted at baseline, end of the 2-month intervention, and 2-month follow-up.

RESULTS

Compared with treatment as usual, CR was associated with large post-training improvements on training tasks targeting attention, visuospatial memory, and verbal learning and memory, with persisting group differences at the 2-month follow-up. These generalized to mostly large improvements on neuropsychological measures targeting visuospatial memory, verbal learning and memory, delayed verbal memory and verbal working memory. While there were no CR-associated improvements on measures of functional capacity, symptoms, or a self-report measure of independent living skills, there was an effect on an interviewer-rated measure of functioning (Quality of Life Scale), which appeared primarily driven by the Intrapsychic Foundations subscale. Finally, for those randomized to CR, there were significant, medium-sized correlations between training task improvement, neuropsychological improvement and functioning measures.

CONCLUSIONS

This suggests a complex, multifactorial relationship between CR, and cognitive and functional change.

Late-onset bulky naevocytoma of the perineum masquerading as a malignant melanoma

Bulky naevocytoma of the perineum is a very rare variant of giant congenital melanocytic naevus (GCMN). It presents as a bulky naevocytic tumour in the perineal region with characteristic histological findings, such as extensive areas with a neural appearance called 'lames foliacees', formation of a pseudofollicular structure and extension of naevus cells between collagen bundles in a row called 'Indian-file' pattern. We report a case of late-onset bulky naevocytoma of the perineum in a 13-year-old girl. The patient presented with two bulky, pedunculated, heavily pigmented masses in the vulvar area that developed in a pre-existing GCMN lesion, which began around puberty and caused severe gait disturbance. Given the possibility of malignant transformation, we conducted staged reduction surgery of the tumour masses, which were found to be intradermal naevi without evidence of malignancy. The patient's gait disturbance improved markedly after surgery.

Impact of the Penumbral Pattern on Clinical Outcome in Patients with Successful Endovascular Revascularization

BACKGROUND

In patients with acute ischemic stroke, the impact of penumbral patterns on clinical outcomes after endovascular treatment (EVT) remains controversial. We aimed to establish whether penumbral patterns are associated with clinical outcome after successful recanalization with EVT while adjusting for onset to revascularization time.

MATERIALS AND METHODS

Using a web-based, multicenter, prospective stroke registry database, we identified patients with acute ischemic stroke who underwent perfusion and diffusion magnetic resonance imaging (MRI) before EVT, had anterior circulation stroke, received EVT within 12 hours of symptom onset, and had successful revascularization confirmed during EVT. Based on pretreatment MRI, patients were stratified as having a favorable or nonfavorable penumbral pattern. Onset to revascularization time was dichotomized by median value. Primary outcome was functional independence (modified Rankin Scale score ≤2) at 90 days.

FINDINGS

Among 121 eligible patients from three university hospitals, 104 (86.0%) had a favorable penumbral pattern, and the median time to revascularization was 271 minutes (interquartile range, 196-371). The functionally independent patient proportion was higher in those with a favorable penumbral pattern than in those without (53.8% versus 5.9%; P <.001), but was not different between early and late revascularization groups (49.2% versus 45.0%; P = .65). The favorable penumbral pattern was associated with functional independence after adjusting confounders (odds ratio, 23.25; 95% confidence interval: 1.58-341.99; P = .02). Time to revascularization did not modify the association (P for interaction, .53).

CONCLUSION

A favorable penumbral pattern is associated with improved functional independence in patients with endovascular revascularization, and the association was not time-dependent.

Overexpression of caveolin-1 attenuates brain edema by inhibiting tight junction degradation

Cerebral edema from the disruption of the blood-brain barrier (BBB) after cerebral ischemia is a major cause of morbidity and mortality as well as a common event in patients with stroke. Caveolins (Cavs) are thought to regulate BBB functions. Here, we report for the first time that Cav-1 overexpression (OE) decreased brain edema from BBB disruption following ischemic insult. Edema volumes and Cav-1 expression levels were measured following photothrombosis and middle cerebral artery occlusion (MCAO). Endothelial cells that were transduced with a Cav-1 lentiviral expression vector were transplanted into rats. BBB permeability was quantified with Evans blue extravasation. Edema volume was determined from measures of the extravasation area, brain water content, and average fluorescence intensity after Cy5.5 injections. Tight junction (TJ) protein expression was measured with immunoblotting. Cav-1 expression levels and vasogenic brain edema correlated strongly after ischemic insult. Cav-1 expression and BBB disruption peaked 3 d after the MCAO. In addition, intravenous administration of endothelial cells expressing Cav-1 effectively increased the Cav-1 levels 3 d after the MCAO ischemic insult. Importantly, Cav-1 OE ameliorated the vasogenic edema by inhibiting the degradation of TJ protein expression in the acute phase of ischemic stroke. These results suggested that Cav-1 OE protected the integrity of the BBB mainly by preventing the degradation of TJ proteins in rats. These findings need to be confirmed in a clinical setting in human subjects.

Prestroke Antiplatelet Effect on Symptomatic Intracranial Hemorrhage and Functional Outcome in Intravenous Thrombolysis

Background and Purpose

About 30%-40% of stroke patients are taking antiplatelet at the time of their strokes, which might increase the risk of symptomatic intracranial hemorrhage (SICH) with intravenous tissue plasminogen activator (IV-TPA) therapy. We aimed to assess the effect of prestroke antiplatelet on the SICH risk and functional outcome in Koreans treated with IV-TPA.

Methods

From a prospective stroke registry, we identified patients treated with IV-TPA between October 2009 and November 2014. Prestroke antiplatelet use was defined as taking antiplatelet within 7 days before the stroke onset. The primary outcome was SICH. Secondary outcomes were discharge modified Rankin Scale (mRS) score and in-hospital mortality.

Results

Of 1,715 patients treated with IV-TPA, 441 (25.7%) were on prestroke antiplatelet. Prestroke antiplatelet users versus non-users were more likely to be older, to have multiple vascular risk factors. Prestroke antiplatelet use was associated with an increased risk of SICH (5.9% vs. 3.0%; adjusted odds ratio [OR] 1.79 [1.05-3.04]). However, at discharge, the two groups did not differ in mRS distribution (adjusted OR 0.90 [0.72-1.14]), mRS 0-1 outcome (34.2% vs. 33.7%; adjusted OR 1.27 [0.94-1.72), mRS 0-2 outcome (52.4% vs. 52.9%; adjusted OR 1.21 [0.90-1.63]), and in-hospital mortality (6.1% vs. 4.2%; adjusted OR 1.19 [0.71-2.01]).

Conclusions

Despite an increased risk of SICH, prestroke antiplatelet users compared to non-users had comparable functional outcomes and in-hospital mortality with IV-TPA therapy. Our results support the use of IV-TPA in eligible patients taking antiplatelet therapy before their stroke onset.

Histopathological analysis of 2,4,5-trinitrobenzene sulphonic acid (TNBS)-induced mouse colitis

<p>Ulcerative colitis is one of the chronic diseases that results in inflammation of colon in humans. In this Visual experiment we demonstrate the histopathology of TNBS induced colitis model of mouse. The experiment involves following steps: a) Selection of mouse model, b) Induction of colitis, c) Paraffin sectioning of colon tissue, d) Hematoxylin and Eosin staining, and d) Microscopic observation.</p><p><strong>Video Clips</strong></p><p><a href="https://www.youtube.com/v/LIs8SU8odRo">Part 1:</a> 13 min 14 sec</p><p><a href="https://www.youtube.com/v/hjD1OTGrAsE">Part 2:</a> 3 min 13 sec</p>

Neuroprotective effects of systemic cerebral endothelial cell transplantation in a rat model of cerebral ischemia

Human cerebral microvascular endothelial cell line (hCMEC)/D3 cells, which are from a stable clonal cell line of human immortalized cerebral endothelial cells, were intra-arterially transplanted through the common carotid artery in a rat model of photochemical-induced cerebral ischemia. Their therapeutic effects on infarct size, blood-brain barrier (BBB) breakdown, and outcome were examined. The hCMEC/D3 cells were genetically modified with the firefly luciferase gene for in vivo imaging post-transplantation. Transplanted hCMEC/D3 cells were identified in the infarcted brain by bioluminescence imaging at 1 day after transplantation. Compared with the control group, the hCMEC/D3-transplanted group showed reduced infarct size on day 3, reduced Evans blue dye leakage on day 1 indicating decreased BBB breakdown, and early recovery from Rotarod test neurological deficits. The hCMEC/D3-transplanted group also showed decreased levels of matrix metalloproteinase (MMP)-9, which were inversely correlated with TIMP-1 levels on post-transplantation days 1 and 3. The expression of tumor necrosis factor-α and interleukin-1β were markedly diminished in the hCMEC/D3-transplanted group compared with controls. The systemically transplanted cells selectively migrated and integrated into the ischemically lesioned area, which accelerated neurological recovery. This new cerebral endothelial cell-based therapy may hold promise for clinical trials in patients with ischemic stroke.

Regulation of Caveolin-1 Expression Determines Early Brain Edema After Experimental Focal Cerebral Ischemia

Background and Purpose—

Most patients with cerebral infarction die of brain edema because of the breakdown of the blood–brain barrier (BBB) in ischemic tissue. Caveolins (a group of proteins) are key modulators of vascular permeability; however, a direct role of caveolin-1 (Cav-1) in the regulation of BBB permeability during ischemic injury has yet to be identified.

Methods—

Cav-1 expression was measured by immunoblotting after photothrombotic ischemia. A direct functional role of Cav-1 in cerebral edema and BBB permeability during cerebral ischemia was investigated by genetic manipulation (gene disruption and re-expression) of Cav-1 protein expression in mice.

Results—

There was a significant correlation between the extent of BBB disruption and the Cav-1 expression. In Cav-1–deficient (Cav-1 −/− ) mice, the extent of BBB disruption after cerebral ischemia was increased compared with wild-type (Cav-1 +/+ ) mice, whereas the increase in cerebral edema volume was ameliorated by lentiviral-mediated re-expression of Cav-1. Furthermore, Cav-1 −/− mice had significantly higher degradation of tight junction proteins and proteolytic activity of matrix metalloproteinase than Cav-1 +/+ mice. Conversely, re-expression of Cav-1 in Cav-1 −/− mice restored tight junction protein expression and reduced matrix metalloproteinase proteolytic activity.

Conclusions—

These results indicate that Cav-1 is a critical determinant of BBB permeability. Strategies for regulating Cav-1 represent a novel therapeutic approach to controlling BBB disruption and subsequent neurological deterioration during cerebral ischemia.

Drip, Ship, and On-Demand Endovascular Therapy for Acute Ischemic Stroke

BACKGROUND

The "drip and ship" approach can facilitate an early initiation of intravenous thrombolysis (IVT) for acute ischemic stroke (AIS) at community hospitals. New endovascular treatment modalities, such as stent retrieval, have further improved the rate of safe and successful recanalization. We assessed the clinical outcomes of on-demand endovascular therapy in patients with AIS who were transported to a comprehensive stroke center under the "drip and ship" paradigm.

METHODS

This retrospective study evaluated prospectively registered patients with acute large vessel occlusions in the anterior circulation who underwent endovascular recanalization after IVT at our regional comprehensive stroke center between January 2011 and April 2014. Clinical outcomes and neuroradiological findings were compared between patients who received IVT at the center (direct visit, DV) and at a community hospital (drip and ship, DS).

RESULTS

Baseline characteristics such as age, initial National Institutes of Health Stroke Scale (NIHSS) score, and risk factors for stroke were similar, and most patients underwent endovascular therapy with a Solitaire stent (81.9% vs. 89.3% for DV and DS, respectively, P = 0.55). The average initial NIHSS score was 12.15 ± 4.1 (12.06 vs. 12.39 for DV and DS, respectively, P = 0.719). The proportions of long-term favorable outcomes (modified Rankin Scale score ≤ 2 at 90 days) and successful recanalization (Thrombolysis in Cerebral Ischemia score ≥ 2b) were not significantly different (P = 0.828 and 0.158, respectively). The mortality rates and occurrences of symptomatic intracerebral hemorrhage were not significantly different (P = 0.999 and 0.267, respectively).

CONCLUSIONS

The "drip and ship" approach with subsequent endovascular therapy is a feasible treatment concept for patients with acute large vessel occlusion in the anterior circulation that could help improve clinical outcomes in patients with AIS.

Abstract TP304: Use, Time Delay and Outcomes of the Drip-and-Ship Thrombolysis Paradigm for Patients With Acute Ischemic Stroke

Introduction: The utilization of drip-and-ship thrombolysis paradigm, clinical characteristics and outcomes of patients treated with the paradigm could vary with regional stroke care system.

Hypothesis: We hypothesized that clinical characteristics and functional outcomes of patients treated with drip-and-ship paradigm would be different from those of patients treated via direct visit.

Methods: From a multicenter stroke registry, we identified acute ischemic stroke patients treated with tPA who arrived hospital within 6 hours from the symptom onset. Functional outcomes at three months after the stroke were classified as favorable (modified Rankin Scale score [mRS] 0 to 1) or unfavorable (mRS 2-6). Using multivariable analysis, we compared the modified Rankin scale (mRS) score at 3 months and symptomatic intracranial hemorrhages (SICH) between patients treated with drip-and-ship paradigm and those treated via direct visit.

Results: Among 1,843 patients who met the eligible criteria, 244 patients (13.2%; 95% CI, 11.7-14.9) were treated using drip-and-ship paradigm. Patients treated with drip-and-ship paradigm had shorter onset to needle time compared with patients treated via direct visit (median[IQR], 110 minutes[79-150] vs 126 minutes[90-173], p<0.001). After multivariable analysis, patients treated with drip-and-ship paradigm had significantly greater risk of unfavorable functional outcome (mRS 2-6) at 3 months after the stroke compared with patients treated via direct visit (OR 2.15; 95% CI, 1.50-3.08; p < 0.001). SICH also occurred more frequently in patients treated with drip-and-ship paradigm (OR 1.78; 95% CI, 1.02-3.12; p =0.04). Of 1,843 patients, 509 patients (27.6%, 71 patients with drip-and-ship paradigm and 438 patients via direct visit) received subsequent endovascular recanalization therapy. The use of drip-and-ship paradigm caused approximately 105 minute delay in onset to groin puncture time compared with those treated via direct visit (305 minutes[260-345] vs 200 minutes[155-245], p<0.001).

Conclusions: Drip-and-ship thrombolysis paradigm was used in less than 15% of patients treated with tPA, and use of the paradigm caused a significant delay in onset to groin puncture time for endovascular therapy.

Abstract WP76: Utility of Individual NIH Stroke Scale Items as a Predictor of Functional Outcomes in Acute Ischemic Stroke Patients Presenting With Mild Neurologic Deficits

Introduction: Predicting outcomes of acute stroke patients initially presenting with mild neurologic deficits is important in making decision for thrombolytic therapy. Previous researches with a small sample size have failed to find specific items of NIH Stroke Scale or clinical syndromes to be predictive of functional outcome.

Hypothesis: We hypothesized that certain items of the NIH Stroke Scale or their combinations would be independently associated with unfavorable functional outcome after mild stroke

Methods: Using a multicenter stroke registry database, we identified patients with acute ischemic stroke who presented within 4.5 hours of symptom onset and had initial NIH Stroke Scale scores ≤ 5. Functional outcomes at three months after the stroke were classified as favorable (modified Rankin Scale score [mRS] 0 to 1) or unfavorable (mRS 2-6). The individual NIH Stroke Scale items were dichotomized as absent (0) or present (≥1) for the analysis. The NIH Stroke Scale items and the total score were tested for predicting the outcomes in multivariable models adjusting for demographics and clinical characteristics. Area under the ROC curve (AUC) was used to assess the performance of multivariable models.

Results: Among 2,209 patients who met the eligible criteria, 588 patients (26.6%) exhibited unfavorable functional outcome (mRS 2-6) at three months. The most frequently present items were item 10 (dysarthria, 37.5%), item 4 (facial palsy, 21.1%), item 8 (sensory, 15.0%), and items indicating limb paralysis. Among 15 items of NIH Stroke Scale, all items except for item 8 (sensory) and item 11 (extinction) were significantly associated with unfavorable functional outcomes in bivariate analysis (P <0.05), and many of them remained significant in multivariable analyses. In multivariable analyses, the model including the total NIH Stroke Scale scores exhibited similar AUC (0.759; 95% CI, 0.740 -0.776; P=0.75 for pairwise comparison) compared to the model with all NIH Stroke Scale items (0.758; 0.739 - 0.775) in predicting functional outcomes after the stroke.

Conclusions: Simply using the total score was as effective as using all NIH Stroke Scale items in predicting outcomes of patients presented with mild stroke symptom.

Clinical assessment of lipid profiles in live kidney donors

BACKGROUND

Abnormal serum lipid profiles are an issue in chronic kidney disease (CKD), but the clinical ramifications of dyslipidemia in live kidney donors are unclear. Thus, we explored the relationship between serum lipids and residual renal function in living donors post-nephrectomy.

METHODS

Charts of living donors who underwent nephrectomy between January 2010 and March 2013 were reviewed, targeting those with 6-month follow-up examinations at minimum. Altogether, 282 donors were studied, examining total cholesterol (TC), triglyceride (TG), low-density lipoprotein (LDL), and high-density lipoprotein (HDL) levels assayed before donation by standard techniques. Median follow-up time was 14 months. The relationship between postoperative renal function and allograft biopsy results was assessed. Recursive partitioning was applied to identify optimal cut-off points for each parameter.

RESULTS

Median (interquartile range) serum TC, TG, LDL, and HDL levels were 183 (161-205) mg/dL, 86 (63-131) mg/dL, 108 (92-128) mg/dL, and 53 (44-62) mg/dL, respectively. The glomerular filtration rate at last follow-up was associated with TC (r = -0.187; P = .002) and LDL (r = -0.172; P = .005) levels, but showed no correlation with TG and HDL. Root nodes of TC and LDL determinations in recursive partitioning were 170.5 mg/dL and 80.5 mg/dL, respectively, serving as thresholds for further evaluation. On logistic regression analysis, the likelihood of CKD (glomerular filtration rate < 60 mL/min/1.73 m(2)) at last follow-up was greater in donors with elevated TC and LDL levels (odds ratio = 1.96 and 3.33; P = .021 and .029, respectively).

CONCLUSION

Kidney donors with serum TC and LDL elevations require close observation, given their demonstrable predisposition to CKD after donation.

Impact of metabolic syndrome on postdonation renal function in living kidney donors

INTRODUCTION

Optimization of kidney donor selection is critical to ensure recovery of the donor. The goal of this study was to determine the influence of metabolic syndrome on renal histology and perioperative renal function in living kidney donors.

PATIENTS AND METHODS

Between January 2010 and March 2013, a total of 363 living kidney donors who underwent donor nephrectomy at our institution were enrolled. Metabolic syndrome was diagnosed in patients according to the National Cholesterol Education Program's Adult Treatment Panel III, and renal histology of implantation biopsy specimens and perioperative renal function were compared in participants with or without metabolic syndrome. Using multivariate regression analysis, the goal was to identify which component of metabolic syndrome induces chronic histologic changes and delayed renal function recovery.

RESULTS

We identified 30 donors (8.45%) with metabolic syndrome. Donors with metabolic syndrome were older (48.4 ± 9.2 years vs 39.7 ± 11.4 years; P < .001) and more likely to have chronic histologic changes (36.8% vs 9.7%; P = .001) than subjects without metabolic syndrome. Results of the multivariate regression analysis indicated that obesity, hyperglycemia, and hypertriglyceridemia were independently associated with chronic histologic changes. Perioperative renal function was correlated with the presence of metabolic syndrome rather than with chronic histologic changes, and patients with metabolic syndrome were more likely to experience delayed renal function recovery. Linear regression models found that the sum of the metabolic components correlated with renal function 6 months postoperatively, but among all risk factors, only obesity was significantly associated with the occurrence of delayed renal function recovery (odds ratio, 2.67; P = .001).

CONCLUSIONS

Although metabolic syndrome in living kidney donors is characterized by chronic histologic changes, perioperative renal function is affected by the syndrome itself rather than by the histologic changes. Obesity is the most important metabolic factor for predicting delayed renal function recovery in living kidney donors, providing an important clinical indicator of postoperative renal function in these patients.

Clinical Implications of Changes in Individual Platelet Reactivity to Aspirin Over Time in Acute Ischemic Stroke

BACKGROUND AND PURPOSE

Time-dependent changes in individual platelet reactivity have been detected in patients with coronary artery disease. Therefore, we sought to evaluate the time-dependent changes in platelet reactivity to aspirin during the acute stage after ischemic stroke and the clinical implications of variable patient responses to aspirin in acute ischemic stroke.

METHODS

We conducted a single-center, prospective, observational study. The acute aspirin reaction unit (ARU) was measured after 3 hours of aspirin loading, with higher values indicating increased platelet reactivity despite aspirin therapy. The follow-up ARU was measured on the fifth day of consecutive aspirin intake. The numeric difference between the follow-up ARU and the acute ARU was defined as ΔARU and was stratified into quartiles. Early neurological deterioration was regarded as an early clinical outcome.

RESULTS

Both the acute ARU (476±69 IU) and the follow-up ARU (451±68 IU) were measured in 349 patients in this study. Early neurological deterioration was observed in 72 patients (20.6%). Changes in aspirin platelet reactivity over time showed an approximately Gaussian distribution. The highest ΔARU quartile was independently associated with early neurological deterioration (odds ratio, 3.19; 95% confidence interval, 1.43-7.10; P=0.005) by multivariate logistic regression analysis.

CONCLUSIONS

The results of our study showed that the increase in platelet reactivity to aspirin over time is independently associated with early neurological deterioration in patients with acute ischemic stroke. In addition, during the acute stage of ischemic stroke, serial platelet reactivity assays may be more useful than a single assay for identifying the clinical implications of aspirin platelet reactivity after ischemic stroke.

Thyroid status and cognitive function in euthyroid patients with early Parkinson's disease

BACKGROUND

Alterations in thyroid hormone (TH) levels may be related to the pathogenesis of mild cognitive impairment (MCI) and dementia. Cognitive deficits are common in Parkinson's disease (PD) patients. The aim of this study was to investigate whether variations within the normal ranges of thyroid function are related to cognitive function in early PD without dementia.

METHODS

Eighty-four euthyroid patients with early PD underwent evaluation of their thyroid status, including measures of thyroid-stimulating hormone (TSH), total triiodothyronine (tT3) and free thyroxine (fT4), and comprehensive neuropsychological tests.

RESULTS

The 46 patients of the PD-MCI group did not differ in the serum levels of TH compared to the 38 patients of the PD-normal cognition group. fT4 levels were inversely associated with the Mini-Mental State Examination (MMSE) score and neuropsychological tests of attention and visuospatial and executive function. TSH and tT3 levels were not related to cognitive performances. After controlling for demographic and clinical variables, multiple regression analyses indicated statistically significant associations between fT4 concentrations and MMSE score and neuropsychological tests of executive function.

CONCLUSIONS

This study supports a relationship between the thyroid status and cognitive function in euthyroid early PD patients, with higher concentrations of fT4 being associated with a poor performance of executive function.

Comparison of the Brain Volume in Essential Tremor and Parkinson's Disease Tremor Using an Automated Segmentation Method

BACKGROUND

Essential tremor (ET) and Parkinson's disease (PD) are common neurological disorders in elderly people, and some features of ET and PD may overlap. Quantitative analysis of brain atrophy may be useful in differentiating neurodegenerative disorders. The aim of this study was to identify the volumetric differences of subcortical structures in patients with ET and PD tremor using an automated segmentation method.

METHODS

Volumetric MRIs were obtained in 45 patients with ET, 45 patients with PD tremor, and 45 age- and sex-matched control subjects. The volume of the different brain structures was measured by the automated segmentation method (FreeSurfer).

RESULTS

Volumetric data obtained with automated segmentation of cerebral regions showed a significant atrophy of the cerebellum in patients with ET. Cerebellar atrophy of ET patients was more significant in the white matter than in the grey matter, and it was noted only in patients with ET having a head tremor. No volumetric differences were found between the PD group and the control group.

CONCLUSION

Our study suggests that volumetric differences in subcortical structures using whole brain segmentation method may help to differentiate ET from PD tremor.

Clinical outcomes of patients with acute minor stroke receiving rescue IA therapy following early neurological deterioration

Background

Patients presenting with minor ischemic stroke frequently have early neurological deterioration (END) and poor final outcome. The optimal management of patients with END has not been determined.

Objective

To investigate rescue IA therapy (IAT) when patients with acute minor ischemic stroke develop END.

Methods

This was a retrospective study of consecutively registered patients with acute minor stroke and END. ‘END’ was defined as an increase in National Institutes of Health Stroke Scale (NIHSS) scores by 1 or more points (or development of new neurological symptoms) and ‘ΔEND−NIHSS’ was defined as numerical difference between NIHSS scores at the time of END and before END. Rescue IAT following END was adjusted for the covariates to evaluate the association between IAT and favorable outcome at 3 months.

Results

Among 982 patients with acute minor ischemic stroke, END occurred in 232 (23.6%). Of the 209 patients with END with full data available, 87 (41.6%) had favorable outcomes at 3 months. Rescue IAT following END was performed in 28 (13.4%). Favorable 3-month outcomes were seen in 50% of patients undergoing rescue IAT, including 8/19 (42.1%) undergoing rescue IAT beyond 8 h. By multivariate logistic regression analysis, rescue IAT following END was independently associated with favorable outcome at 3 months (OR=10.9; 95% CI 3.06 to 38.84; p<0.001).

Conclusions

The results suggest that rescue IAT may be safe and effective when END occurs in selected patients with acute minor ischemic stroke. Further prospective and randomized studies are needed to confirm our results.

The HIF-1 inhibitor YC-1 decreases reactive astrocyte formation in a rodent ischemia model

Astrocytes become reactive after central nervous system injury, re-expressing glial fibrillary acidic protein (GFAP), vascular endothelial growth factor (VEGF), and nestin. Hypoxia-inducible transcription factor alpha (HIF-1α) is an important transcription factor for several genes including the VEGF and nestin genes, the expression of which generate reactive astrocytes and cause gliosis after cerebral ischemia. To evaluate the role of HIF-1α in reactive astrocyte formation, we applied the potent HIF-1α inhibitor YC-1 to a focal cerebral ischemia model and analyzed the expression of HIF-1α, VEGF, nestin, and GFAP. Quantitative real-time reverse transcription polymerase chain reaction and western blot analyses demonstrated that the expression of HIF-1α and its downstream genes (VEGF and nestin) were markedly attenuated in the YC-1-treated group versus the control group (HIF-1α, VEGF: p < 0.01; nestin: p < 0.05). GFAP expression was also effectively inhibited in the YC-1-treated group (p < 0.05). Immunohistochemical evaluations showed that GFAP-positive (GFAP+) cells in the YC-1-treated group were sparse in the peri-infarct area, while an immunofluorescence assay revealed that the number of VEGF+/GFAP+ and nestin+/GFAP+ reactive astrocytes were decreased in the YC-1-treated group (p < 0.05). These results demonstrate that HIF-1α suppression decreases the formation of reactive astrocytes and gliosis that occur following focal ischemia.

Aspirin resistance in the acute stages of acute ischemic stroke is associated with the development of new ischemic lesions

BACKGROUND

Aspirin is a primary antiplatelet agent for the secondary prevention of ischemic stroke. However, if aspirin fails to inhibit platelet function, as is expected in acute ischemic stroke (AIS), it may increase the rate of early clinical events. Therefore, we sought to determine whether aspirin resistance in the acute stage was associated with early radiological events, including new ischemic lesions (NILs).

METHODS

This study was a single-center, prospective, observational study conducted between April 2012 and May 2013. Aspirin 300 mg was initially administered followed by maintenance doses of 100 mg daily. The acute aspirin reaction unit (aARU) was consistently measured after 3 hours of aspirin loading. An aARU value ≥550 IU was defined as biological aspirin resistance (BAR). NILs on follow-up diffusion-weighted imaging (DWI) were defined as lesions separate from index lesions, which were not detected on the initial DWI.

RESULTS

A total of 367 patients were analyzed in this study. BAR in aARU was detected in 60 patients (16.3%). On follow-up DWI, 81 patients (22.1%) had NILs, which were frequently in the same territory as the index lesions (79%), pial infarcts (61.7%), and located within the cortex (59.3%). BAR was independently associated with NILs on follow-up DWI (adjusted OR 2.00, 95% CIs 1.01-3.96; p = 0.047).

CONCLUSION

In conclusion, BAR in aARU could be associated with NILs on follow-up DWI in AIS. Therefore, a further prospective study with a longer follow-up period is necessary to evaluate the clinical implications of aARU in AIS.