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Krekeler BN, Schieve HJP, Khoury J, Ding L, Haverbusch M, Alwell K, Adeoye O, Ferioloi S, Mackey J, Woo D, Flaherty M, La Rosa FDLR, Demel S, Star M, Coleman E, Walsh K, Slavin S, Jasne A, Mistry E, Kleindorfer D, Kissela B. Health Factors Associated With Development and Severity of Poststroke Dysphagia: An Epidemiological Investigation. J Am Heart Assoc 2024; 13:e033922. [PMID: 38533959 PMCID: PMC11179757 DOI: 10.1161/jaha.123.033922] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Accepted: 01/31/2024] [Indexed: 03/28/2024]
Abstract
BACKGROUND Dysphagia after stroke is common and can impact morbidity and death. The purpose of this population-based study was to determine specific epidemiological and health risk factors that impact development of dysphagia after acute stroke. METHODS AND RESULTS Ischemic and hemorrhagic stroke cases from 2010 and 2015 were identified via chart review from the GCNKSS (Greater Cincinnati Northern Kentucky Stroke Study), a representative sample of ≈1.3 million adults from southwestern Ohio and northern Kentucky. Dysphagia status was determined on the basis of clinical assessments and necessity for alternative access to nutrition via nasogastric or percutaneous endoscopic gastrostomy tube placement. Comparisons between patients with and without dysphagia were made to determine differences in baseline characteristics and premorbid conditions. Multivariable logistic regression determined factors associated with increased risk of dysphagia. Dysphagia status was ascertained from 4139 cases (1709 with dysphagia). Logistic regression showed that increased age, Black race, higher National Institutes of Health Stroke Scale score at admission, having a hemorrhagic stroke (versus infarct), and right hemispheric stroke increased the risk of developing dysphagia after stroke. Factors associated with reduced risk included history of high cholesterol, lower prestroke modified Rankin Scale score, and white matter disease. CONCLUSIONS This study replicated previous findings of variables associated with dysphagia (older age, worse stroke, right-sided hemorrhagic lesions), whereas other variables identified were without clear biological rationale (eg, Black race, history of high cholesterol, and presence of white matter disease) and should be investigated in future studies to determine biological relevance and potential influence in stroke recovery.
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Affiliation(s)
- Brittany N. Krekeler
- Department of Otolaryngology‐Head and Neck SurgeryUniversity of Cincinnati College of MedicineCincinnatiOHUSA
- Department of Neurology and Rehabilitation MedicineUniversity of Cincinnati College of MedicineCincinnatiOHUSA
| | | | - Jane Khoury
- Division of Biostatistics and Epidemiology, Cincinnati Children’s Hospital Medical Center, Department of PediatricsUniversity of Cincinnati College of MedicineCincinnatiOHUSA
| | - Lili Ding
- Division of Biostatistics and Epidemiology, Cincinnati Children’s Hospital Medical Center, Department of PediatricsUniversity of Cincinnati College of MedicineCincinnatiOHUSA
| | - Mary Haverbusch
- Department of Neurology and Rehabilitation MedicineUniversity of Cincinnati College of MedicineCincinnatiOHUSA
| | - Kathleen Alwell
- Department of Neurology and Rehabilitation MedicineUniversity of Cincinnati College of MedicineCincinnatiOHUSA
| | - Opeolu Adeoye
- Department of Emergency MedicineWashington University School of MedicineSt. LouisMOUSA
| | - Simona Ferioloi
- Department of Neurology and Rehabilitation MedicineUniversity of Cincinnati College of MedicineCincinnatiOHUSA
| | - Jason Mackey
- Department of NeurologyIndiana University School of MedicineIndianapolisINUSA
| | - Daniel Woo
- Department of Neurology and Rehabilitation MedicineUniversity of Cincinnati College of MedicineCincinnatiOHUSA
| | - Matthew Flaherty
- Department of Neurology and Rehabilitation MedicineUniversity of Cincinnati College of MedicineCincinnatiOHUSA
| | - Felipe De Los Rios La Rosa
- Department of Neurology and Rehabilitation MedicineUniversity of Cincinnati College of MedicineCincinnatiOHUSA
- Baptist Health South FloridaMiami Neuroscience InstituteMiamiFLUSA
| | - Stacie Demel
- Department of Neurology and Rehabilitation MedicineUniversity of Cincinnati College of MedicineCincinnatiOHUSA
| | | | - Elisheva Coleman
- Department of NeurologyUniversity of Chicago MedicineChicagoILUSA
| | - Kyle Walsh
- Department of Neurology and Rehabilitation MedicineUniversity of Cincinnati College of MedicineCincinnatiOHUSA
| | - Sabreena Slavin
- Department of NeurologyUniversity of Kansas Medical CenterKansas CityKSUSA
| | - Adam Jasne
- Department of NeurologyYale School of MedicineNew HavenCTUSA
| | - Eva Mistry
- Department of Neurology and Rehabilitation MedicineUniversity of Cincinnati College of MedicineCincinnatiOHUSA
| | - Dawn Kleindorfer
- Department of Neurology and Rehabilitation MedicineUniversity of Cincinnati College of MedicineCincinnatiOHUSA
- Department of NeurologyUniversity of MichiganAnn ArborMIUSA
| | - Brett Kissela
- Department of Neurology and Rehabilitation MedicineUniversity of Cincinnati College of MedicineCincinnatiOHUSA
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Krekeler BN, Schieve HJP, Khoury J, Ding L, Haverbusch M, Alwell K, Adeoye O, Ferioloi S, Mackey J, Woo D, Flaherty M, De Los Rios La Rosa F, Demel S, Star M, Coleman E, Walsh K, Slavin S, Jasne A, Mistry E, Kleindorfer D, Kissela B. Health factors associated with development and severity of post-stroke dysphagia: an epidemiological investigation. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.08.29.23294807. [PMID: 37693442 PMCID: PMC10491359 DOI: 10.1101/2023.08.29.23294807] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/12/2023]
Abstract
Background and Purpose Dysphagia is a common post-stroke occurrence and has been shown to impact patients' morbidity and mortality. The purpose of this study was to use a large population-based dataset to determine specific epidemiological and patient health risk factors that impact development and severity of dysphagia after acute stroke. Methods Using data from the Greater Cincinnati Northern Kentucky Stroke Study, GCNKSS, involving a representative sample of approximately 1.3 million people from Southwest Ohio and Northern Kentucky of adults (age ≥18), ischemic and hemorrhagic stroke cases from 2010 and 2015 were identified via chart review. Dysphagia status was determined based on bedside and clinical assessments, and severity by necessity for alternative access to nutrition via nasogastric (NG) or percutaneous endoscopic gastrostomy (PEG) tube placement. Comparisons between patients with and without dysphagia were made to determine differences in baseline characteristics and pre-morbid conditions. Multivariable logistic regression was used to determine factors associated with increased risk of developing dysphagia. Results Dysphagia status was ascertained from 4139 cases (1709 with dysphagia). Logistic regression showed: increased age, Black race, higher NIHSS score at admission, having a hemorrhagic stroke (vs infarct), and right hemispheric stroke increased risk of developing dysphagia after stroke. Factors associated with reduced risk included history of high cholesterol, lower pre-stroke mRS score, and white matter disease. Conclusions This study replicated many previous findings of variables associated with dysphagia (older age, worse stroke, right sided hemorrhagic lesions), while other variables identified were without clear biological rationale (e.g. Black race, history of high cholesterol and presence of white matter disease). These factors should be investigated in future, prospective studies to determine biological relevance and potential influence in stroke recovery.
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Fekete K, Tóth J, Horváth L, Márton S, Héja M, Csiba L, Árokszállási T, Bagoly Z, Sulina D, Fekete I. Neurophysiological Examinations as Adjunctive Tool to Imaging Techniques in Spontaneous Intracerebral Hemorrhage: IRONHEART Study. Front Neurol 2021; 12:757078. [PMID: 34777228 PMCID: PMC8578792 DOI: 10.3389/fneur.2021.757078] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Accepted: 09/23/2021] [Indexed: 11/13/2022] Open
Abstract
Introduction: Intracerebral hemorrhage (ICH) is a devastating disease, which may lead to severe disability or even death. Although many factors may influence the outcome, neurophysiological examinations might also play a role in its course. Our aim was to examine whether the findings of electroencephalography (EEG) and transcranial magnetic stimulation (TMS) can predict the prognosis of these patients. Methods: Between June 1 2017 and June 15 2021, 116 consecutive patients with ICH were enrolled prospectively in our observational study. Clinical examinations and non-Contrast computed tomography (NCCT) scan were done on admission for ICH; follow-up NCCT scans were taken at 14 ± 2 days and at 3 months ± 7 days after stroke onset. EEG and TMS examinations were also carried out. Results: Of the patients in the study, 65.5% were male, and the mean age of the study population was 70 years. Most patients had a history of hypertension, 50.8% of whom had been untreated. In almost 20% of the cases, excessive hypertension was measured on admission, accompanied with >10 mmol/L blood glucose level, whereas their Glasgow Coma Scale was 12 on average. Presence of blood in the ventricles or subarachnoid space and high blood and perihematomal volumes meant poor prognosis. Pathological EEG was prognostic of a worse outcome. With TMS examination at 14 days, it might be possible to estimate outcome in a univariate model and the absence, or reduction of the amplitude of the motor evoked potentials was associated with poor prognosis. Conclusion: Together with the clinical symptoms, the volume of bleeding, perihematomal edema (or their combined volume), and neurophysiological examinations like EEG and TMS play an important role in the neurological outcome of patients with ICH. This might affect the patients' rehabilitation plans in the future, since with the help of the examinations the subset of patients with potential for recovery could be identified.
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Affiliation(s)
- Klára Fekete
- Department of Neurology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Judit Tóth
- Department of Radiology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - László Horváth
- Department of Pharmaceutical Surveillance and Economics, Faculty of Pharmacy, University of Debrecen, Debrecen, Hungary
| | - Sándor Márton
- Institute of Political Science and Sociology, Faculty of Arts, University of Debrecen, Debrecen, Hungary
| | - Máté Héja
- Department of Neurology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - László Csiba
- Department of Neurology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary.,MTA-DE Cerebrovascular and Neurodegenerative Research Group, University of Debrecen, Debrecen, Hungary
| | - Tamás Árokszállási
- Department of Neurology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Zsuzsa Bagoly
- MTA-DE Cerebrovascular and Neurodegenerative Research Group, University of Debrecen, Debrecen, Hungary.,Division of Clinical Laboratory Sciences, Department of Laboratory Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Dóra Sulina
- Department of Neurology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - István Fekete
- Department of Neurology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
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Wang M, Xie Y, Zhao S, Wang Y, Cui J, Chang S. Association of alcohol consumption with prognosis of ischemic stroke by subtype in different follow-up periods: a hospital-based study in China. Postgrad Med 2020; 133:154-159. [PMID: 33522353 DOI: 10.1080/00325481.2020.1805945] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVES Alcohol consumption is a risk factor for stroke. However, there are no available data on the effect of alcohol consumption on the long-term outcome of ischemic stroke in China. Therefore, this study aimed to explore the association of alcohol consumption with the prognosis of ischemic stroke by subtype in different follow-up periods after stroke. METHODS This 12-month follow-up study recruited 3830 acute ischemic stroke patients from Tianjin, China, between 2016 and 2018. Patients were categorized into two groups according to their consumption of alcohol. Differences in mortality, recurrence, and dependency rates at 3 and 12 months after stroke were compared between both groups. RESULTS The mortality, recurrence, and dependency rates at 12 months after stroke were significantly higher in patients who previously consumed alcohol than in those without previous alcohol consumption (all P < 0.005). A similar trend was observed for mortality rate at 3 months after stroke (P < 0.001). The risk of death at 3 months after an atherothrombotic stroke decreased by 63.4% (relative risk [RR], 0.366; 95% confidence interval [CI], 0.144-0.935) among patients who previously consumed alcohol compared with those who never consumed alcohol. Moreover, for patients with small artery disease classified according to the Trial of ORG 10,172 in Acute Stroke Treatment (TOAST), the recurrence and dependency rates at 12 months after stroke decreased by 49.2% (RR, 0.508; 95% CI, 0.259-0.996) and 49.5% (RR, 0.505; 95% CI, 0.258-0.990), respectively, among patients who consumed alcohol. CONCLUSIONS Previous alcohol consumption decreased the risk of death at 3 months after stroke among patients with atherothrombotic stroke according to the TOAST classification. Furthermore, for patients with small artery disease (according to TOAST classification), alcohol consumption significantly decreased the risk of recurrence and dependency at 12 months after stroke. This study highlights an urgent need to quantify the association of alcohol consumption with outcomes after stroke in China to improve stroke prognosis.
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Affiliation(s)
- Min Wang
- Department of Neurology, Dongying People's Hospital, Dongying, Shandong Province, China
| | - Yuanli Xie
- Department of Neurology, Dongying People's Hospital, Dongying, Shandong Province, China
| | - Suzhen Zhao
- Department of Oncology, Dongying People's Hospital, Dongying, Shandong Province, China
| | - Yucui Wang
- Department of Neurology, Dongying People's Hospital, Dongying, Shandong Province, China
| | - Jingjing Cui
- Department of Neurology, Dongying People's Hospital, Dongying, Shandong Province, China
| | - Shihui Chang
- Department of Neurology, Dongying People's Hospital, Dongying, Shandong Province, China
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Han J, Mao W, Ni J, Wu Y, Liu J, Bai L, Shi M, Tu J, Ning X, Wang J. Rate and Determinants of Recurrence at 1 Year and 5 Years After Stroke in a Low-Income Population in Rural China. Front Neurol 2020; 11:2. [PMID: 32038470 PMCID: PMC6989474 DOI: 10.3389/fneur.2020.00002] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Accepted: 01/02/2020] [Indexed: 01/07/2023] Open
Abstract
Recurrent stroke is becoming an increasingly important public health issue owing to the increased risk of disability and death. However, population-based studies investigating the rate of recurrent stroke in China are rare. We explored the rate and determinants of recurrent stroke within 1 and 5 years after the initial stroke in a rural population in China. Data for stroke events were obtained from the Tianjin Brain Study, conducted between 1992 and 2016. The age-standardized rates of recurrent stroke within the first year and the first 5 years after the initial stroke were calculated for this period. Determinants of recurrent stroke were assessed using Cox regression analyses. The overall age-standardized rate of recurrent stroke within 1 year was 5.7% (men, 6.9%; women, 4.6%); within 5 years, the overall recurrent stroke rate was 22.5% (men, 24.0%; women, 20.2%). The recurrence rate increased with advancing age and decreased with increased educational attainment. Age ≥65 years and a history of alcohol consumption were independent risk factors for recurrent stroke within 1 year after the incident stroke, after adjusting for age, sex, education, hypertension, diabetes, smoking, and alcohol consumption. However, the risk of recurrent stroke within 5 years after the incident stroke was positively associated with male sex, age ≥65 years, a lower level of education, known diabetes, and alcohol consumption, after adjusting for the previously indicated covariates. These findings suggest a crucial need to address risk factor management among stroke patients to reduce the burden of stroke, especially among low-income populations. Furthermore, a multicenter, large sample, nationwide study is urgently needed.
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Affiliation(s)
- Jing Han
- Department of Neurology, Tianjin Medical University General Hospital, Tianjin, China
| | - Wenjing Mao
- Department of Neurology, Tianjin Medical University General Hospital, Tianjin, China.,Department of Neurology, The Affiliated Hospital of North China University of Science and Technology, Tangshan, China
| | - Jingxian Ni
- Department of Neurology, Tianjin Medical University General Hospital, Tianjin, China.,Laboratory of Epidemiology, Tianjin Neurological Institute, Tianjin, China.,Tianjin Neurological Institute, Key Laboratory of Post-Neuroinjury Neuro-repair and Regeneration in Central Nervous System, Ministry of Education and Tianjin City, Tianjin, China
| | - Yanan Wu
- Department of Neurology, Tianjin Medical University General Hospital, Tianjin, China.,Laboratory of Epidemiology, Tianjin Neurological Institute, Tianjin, China.,Tianjin Neurological Institute, Key Laboratory of Post-Neuroinjury Neuro-repair and Regeneration in Central Nervous System, Ministry of Education and Tianjin City, Tianjin, China
| | - Jie Liu
- Department of Neurology, Tianjin Medical University General Hospital, Tianjin, China.,Laboratory of Epidemiology, Tianjin Neurological Institute, Tianjin, China.,Tianjin Neurological Institute, Key Laboratory of Post-Neuroinjury Neuro-repair and Regeneration in Central Nervous System, Ministry of Education and Tianjin City, Tianjin, China
| | - Lingling Bai
- Department of Neurology, Liaocheng People's Hospital, Liaocheng, China
| | - Min Shi
- Department of Neurology, Tianjin Medical University General Hospital, Tianjin, China.,Laboratory of Epidemiology, Tianjin Neurological Institute, Tianjin, China.,Tianjin Neurological Institute, Key Laboratory of Post-Neuroinjury Neuro-repair and Regeneration in Central Nervous System, Ministry of Education and Tianjin City, Tianjin, China
| | - Jun Tu
- Department of Neurology, Tianjin Medical University General Hospital, Tianjin, China.,Laboratory of Epidemiology, Tianjin Neurological Institute, Tianjin, China.,Tianjin Neurological Institute, Key Laboratory of Post-Neuroinjury Neuro-repair and Regeneration in Central Nervous System, Ministry of Education and Tianjin City, Tianjin, China
| | - Xianjia Ning
- Department of Neurology, Tianjin Medical University General Hospital, Tianjin, China.,Laboratory of Epidemiology, Tianjin Neurological Institute, Tianjin, China.,Tianjin Neurological Institute, Key Laboratory of Post-Neuroinjury Neuro-repair and Regeneration in Central Nervous System, Ministry of Education and Tianjin City, Tianjin, China
| | - Jinghua Wang
- Department of Neurology, Tianjin Medical University General Hospital, Tianjin, China.,Laboratory of Epidemiology, Tianjin Neurological Institute, Tianjin, China.,Tianjin Neurological Institute, Key Laboratory of Post-Neuroinjury Neuro-repair and Regeneration in Central Nervous System, Ministry of Education and Tianjin City, Tianjin, China
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Li B, Li D, Liu JF, Wang L, Li BZ, Yan XJ, Liu W, Wu K, Xiang RL. "Smoking paradox" is not true in patients with ischemic stroke: a systematic review and meta-analysis. J Neurol 2019; 268:2042-2054. [PMID: 31664548 PMCID: PMC8179908 DOI: 10.1007/s00415-019-09596-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Revised: 10/17/2019] [Accepted: 10/18/2019] [Indexed: 11/05/2022]
Abstract
Background Ischemic stroke (IS) is a common cause of death from vascular diseases. Studies have found that smoking increases the risk of ischemic stroke, but the association of smoking with the outcome of IS remains unclear. This meta-analysis aims to investigate the effect of smoking on the prognosis of IS. Methods We searched four electronic databases including PubMed, EMBASE, Cochrane library and Web of science for papers, published before January 2019. In this meta-analysis, Review Manager 5.3 software was used to calculate for the pooled estimate effect, as well as the inverse-variance method for pooled mean difference (MD) and odds ratio (OR) of incidence in two groups of population. Results A total of 14,789 citations were identified during the literature search, 21 studies were included in the meta-analyses after screening. The full-adjusted OR of poor prognostic outcome in smoking and nonsmoking patients with stroke was pooled as 0.96 (95% CI 0.77–1.21), suggested that smoking or not has no impact on prognosis of IS. The pooled MD of onset age between smoking and nonsmoking IS patients was − 10.05 (− 12.91, − 7.19), indicated that smoking causes first onset of IS to occur 10 years earlier. Conclusions This meta-analysis showed that smoking was not a protective factor for poor prognosis of IS. Smoking patients with IS are 10 years younger than nonsmoking patients at time of the first onset of stroke.
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Affiliation(s)
- Bo Li
- Department of Neurology, Beijing Hepingli Hospital, No.18 North Street Hepingli, Dongcheng District, Beijing, 100013, China.
| | - Dan Li
- Department of Neurology, Beijing Hepingli Hospital, No.18 North Street Hepingli, Dongcheng District, Beijing, 100013, China
| | - Jing-Feng Liu
- Department of Neurology, Beijing Hepingli Hospital, No.18 North Street Hepingli, Dongcheng District, Beijing, 100013, China
| | - Lin Wang
- Department of Neurology, Beijing Hepingli Hospital, No.18 North Street Hepingli, Dongcheng District, Beijing, 100013, China
| | - Bao-Zhu Li
- Department of Neurology, Beijing Hepingli Hospital, No.18 North Street Hepingli, Dongcheng District, Beijing, 100013, China
| | - Xiu-Juan Yan
- Department of Neurology, Beijing Hepingli Hospital, No.18 North Street Hepingli, Dongcheng District, Beijing, 100013, China
| | - Wei Liu
- Department of Neurology, Beijing Hepingli Hospital, No.18 North Street Hepingli, Dongcheng District, Beijing, 100013, China
| | - Kun Wu
- Department of Neurology, Beijing Hepingli Hospital, No.18 North Street Hepingli, Dongcheng District, Beijing, 100013, China
| | - Ruo-Lan Xiang
- Department of Physiology and Pathophysiology, Key Laboratory of Molecular Cardiovascular Sciences, Ministry of Education, and Beijing Key Laboratory of Cardiovascular Receptors Research, Peking University School of Basic Medical Sciences, No.38 Xueyuan Road, Haidian District, Beijing, 100191, China.
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Zheng Q, Li Y, Zhang L, Yao Q, Zhang J, Li M, Wang J, Zhu C. [Association between drinking and all-cause mortality in patients with ischemic stroke]. NAN FANG YI KE DA XUE XUE BAO = JOURNAL OF SOUTHERN MEDICAL UNIVERSITY 2019; 39:422-427. [PMID: 31068285 DOI: 10.12122/j.issn.1673-4254.2019.04.07] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To investigate the association between alcohol drinking and all-cause death in patients with ischemic stroke. METHODS Between January, 2010 and July, 2018, consecutive patients with first-episode ischemic stroke admitted in the West China Hospital, Sichuan University were enrolled, and all the patients were followed up every 3 months.Chi-square test was used to compare the differences in the baseline characteristics between the pre-stroke drinkers and the nondrinkers.The Cox regression model was used to analyze the effects of drinking status, drinking years, drinking frequency, average single alcohol intake before stroke and drinking status during the follow-up period on the mortality of patients after discharge. RESULTS A total of 855 patients with ischemic stroke were enrolled, and deaths occurred in 140 of these patients.Chi-square test showed significant differences in gender (P < 0.001), weekly physical exercise time (P=0.035), smoking (P < 0.001), and heart disease (P < 0.001) between the pre-stroke drinkers and nondrinkers.Multivariate Cox regression analysis showed that drinking during the follow-up period (P=0.001), drinking for less than 28 years before stroke (P=0.035) and a moderate drinking frequency (5 to 20 times per month for males and 4 to 9 times per month for females; P=0.030) were associated with a lowered risk of death after discharge.No significant effects of pre-stroke drinking status or average single alcohol intake were found on death after ischemic stroke. CONCLUSIONS The drinking years and drinking frequency before stroke and drinking status during the follow-up period are related to the all-cause mortality in patients with ischemic stroke.Investigations of the more specific variables of drinking behaviors during the follow-up period are needed to further clarify the association between drinking and death after ischemic stroke.
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Affiliation(s)
- Qianwen Zheng
- Department of Epidemiology and Health Statistics, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu 610041, China
| | - Yawen Li
- Department of Epidemiology and Health Statistics, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu 610041, China
| | - Lu Zhang
- Department of Epidemiology and Health Statistics, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu 610041, China
| | - Qiang Yao
- Department of Epidemiology and Health Statistics, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu 610041, China
| | - Jing Zhang
- Department of Epidemiology and Health Statistics, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu 610041, China
| | - Mier Li
- Department of Epidemiology and Health Statistics, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu 610041, China
| | - Ju Wang
- Department of Epidemiology and Health Statistics, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu 610041, China
| | - Cairong Zhu
- Department of Epidemiology and Health Statistics, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu 610041, China
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Recurrence Rate and Relevant Associated Factors of Stroke among Patients with Small Artery Occlusion in Northern China. Sci Rep 2019; 9:2834. [PMID: 30808986 PMCID: PMC6391422 DOI: 10.1038/s41598-019-39207-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Accepted: 01/14/2019] [Indexed: 12/22/2022] Open
Abstract
Small artery occlusion (SAO) is responsible for 31.3% of all ischemic strokes in China. However, reports regarding the recurrence rate of SAO in China are rare. We aimed to assess the recurrence rate and factors associated with SAO in China. All consecutive patients with SAO hospitalized at Tianjin Huanhu Hospital from 2005 to 2014 were recruited. We assessed the association between stroke subtype, severity, and disease history with recurrence at 3, 12, and 36 months of onset using multivariate logistic regression analysis. A total of 2,524 SAO patients were included in this study, including 1696 (67.2%) men and 828 (32.8%) women. The recurrence rates were 3.1% at 3 months, 12.7% at 12 months, and 36.5% at 36 months. Compared with women, men had a higher risk of recurrence at 3 months after SAO (P = 0.003). Old age and severity of stroke were also associated with a higher risk of recurrence (P < 0.05). Patients with an elevated C-reactive protein had a higher risk of recurrence at 12 months (P = 0.003). On the other hand, the risk of recurrence at 12 months was 39% lower in patients who consumed alcohol than in those who did not (P = 0.037). Hypertension, atrial fibrillation, and obesity were independent risk factors of recurrence at 36 months. These findings suggest that modification of risk factors in patients with SAO, particularly men, is essential for reducing the rate of recurrence and the overall burden of stroke in China.
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Hoyer C, Schmidt HL, Kranaster L, Alonso A. Impact of psychiatric comorbidity on the severity, short-term functional outcome, and psychiatric complications after acute stroke. Neuropsychiatr Dis Treat 2019; 15:1823-1831. [PMID: 31308675 PMCID: PMC6614829 DOI: 10.2147/ndt.s206771] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Accepted: 05/03/2019] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND AND PURPOSE The comorbidity of psychiatric disorders and cerebrovascular disease appears to be complex with underlying bidirectional influences. Hitherto, research has focused mainly on the evaluation of stroke risk in particular psychiatric disorders; only a few studies have assessed their role in the acute natural history of stroke. The aim of this study was to provide a perspective on psychiatric premorbidity and its impact on stroke severity, psychiatric complications during the initial treatment phase, and the short-term functional outcome of stroke. PATIENTS AND METHODS We retrospectively studied the impact of a predocumented psychiatric diagnosis (PDPD) on stroke severity, short-term functional outcome, and psychiatric complications in a sample of 798 patients consecutively admitted for acute ischemic or hemorrhagic stroke by performing a chart review. Group comparisons (PDPD vs non-PDPD) with adjustment for covariates were carried out either using multivariate analysis of variance or logistic regression analysis. RESULTS More severe strokes (ie, mean National Institute of Health Stroke Scale score on admission 10.1±7.9 vs 7.5±7.4; F(10,796)=18.5, p<0.0001) and higher prevalence of poor outcome (73.7 vs 54.9%; OR: 2.6, standard error: 0.5, z=4.82, p<0.0001) was found in patients with a documented psychiatric diagnosis at the time of stroke, as well as a higher rate of psychiatric complications during the initial treatment phase (46.7 vs 28.9%; OR: -0.78, z=4.59, p<0.0001). CONCLUSION Our data have clinical implications in that they call for identification of psychiatric premorbidity or comorbidity through careful history-taking and particularly close monitoring for psychiatric complications with respect to their potentially negative impact on outcome after stroke.
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Affiliation(s)
- Carolin Hoyer
- Department of Neurology, Universitätsmedizin Mannheim, University of Heidelberg, Mannheim, Germany
| | - Hanna Luise Schmidt
- Department of Neurology, Universitätsmedizin Mannheim, University of Heidelberg, Mannheim, Germany
| | - Laura Kranaster
- Department of Psychiatry and Psychotherapy, Central Institute of Mental Health, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Angelika Alonso
- Department of Neurology, Universitätsmedizin Mannheim, University of Heidelberg, Mannheim, Germany
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Clinical outcomes of acute ischemic stroke patients treated by direct catheter-based trombectomy depending on their baseline characteristics. COR ET VASA 2018. [DOI: 10.1016/j.crvasa.2017.12.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Vallés J, Santos MT, Latorre AM, Tembl J, Salom J, Nieves C, Lago A, Moscardó A. Neutrophil extracellular traps are increased in patients with acute ischemic stroke: prognostic significance. Thromb Haemost 2017; 117:1919-1929. [DOI: 10.1160/th17-02-0130] [Citation(s) in RCA: 103] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2017] [Accepted: 06/16/2017] [Indexed: 12/14/2022]
Abstract
SummaryNeutrophil extracellular traps (NETs) are networks of DNA, histones, and proteolytic enzymes produced by activated neutrophils through different mechanisms. NET formation is promoted by activated platelets and can in turn activate platelets, thus favoring thrombotic processes. NETs have been detected in venous and arterial thrombosis, but data in stroke are scarce. The aim of this study was to evaluate NETs in the plasma of patients with acute ischemic stroke and their potential association with baseline clinical characteristics, stroke severity, and one-year clinical outcomes. The study included 243 patients with acute ischemic stroke. Clinical and demographic data and scores of stroke severity (NIHSS and mRs) at onset and discharge were recorded. Markers of NETs (cell-free DNA, nucleosomes, and citrullinated histone 3 (citH3)), were determined in plasma. Patients were followed-up for 12 months after the ischemic event. NETs were significantly elevated in the plasma of patients with acute ischemic stroke when compared to healthy subjects. NETs were increased in patients who were over 65 years of age and in those with a history of atrial fibrillation (AF), cardioembolic stroke, high glucose levels, and severe stroke scores at admission and discharge. In multivariate analysis, elevated levels of citH3, the most specific marker of NETs, at onset were independently associated with AF and all-cause mortality at oneyear follow-up. NETs play a role in the pathophysiology of stroke and are associated with severity and mortality. In conclusion, citH3 may constitute a useful prognostic marker and therapeutic target in patients with acute stroke.
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Ingeman A, Andersen G, Thomsen RW, Hundborg HH, Rasmussen HH, Johnsen SP. Lifestyle Factors and Early Clinical Outcome in Patients With Acute Stroke. Stroke 2017; 48:611-617. [DOI: 10.1161/strokeaha.116.015784] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2016] [Revised: 11/02/2016] [Accepted: 12/05/2016] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
We examined the associations of individual and combined lifestyle factors with early adverse stroke outcomes.
Methods—
A total of 82 597 patients were identified from nationwide registries. Lifestyle factors at the time of stroke admission included body mass index (kg/m
2
), smoking habits, and alcohol intake, which were grouped (healthy, moderately healthy, moderately unhealthy, and unhealthy). The associations between lifestyle and outcomes were examined using multivariable regression.
Results—
A total of 18.3% had a severe stroke, 7.8% pneumonia, 12.5% urinary tract infection, and 9.9% died within 30 days. The association between lifestyle, stroke severity, and mortality, respectively, differed according to sex. Unhealthy lifestyle was associated with lower risk of severe stroke (adjusted odds ratio [OR], 0.73; 95% confidence interval [CI], 0.63–0.84) and 30-day mortality among men (adjusted OR, 0.71; 95% CI, 0.58–0.87), but not among women (severe stroke: adjusted OR, 1.14; 95% CI, 0.85–1.55, and mortality: adjusted OR, 1.34; 95% CI, 0.90–1.99). No sex differences were found for pneumonia and urinary tract infection. Unhealthy lifestyle was not associated with a statistically significant increased risk of developing in-hospital pneumonia (adjusted OR, 1.30; 95% CI, 0.98–1.73) or urinary tract infection (adjusted OR, 0.98; 95% CI, 0.72–1.33). Underweight was associated with a higher 30-day mortality (men: adjusted OR, 1.71; 95% CI, 1.50–1.96, and women: adjusted OR, 1.46; 95% CI, 1.34–1.60).
Conclusions—
Healthy lifestyle was not associated with a lower risk of adverse stroke outcomes, in particularly among men. However, underweight may be a particular concern being associated with an increased risk of adverse outcomes among both sexes.
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Affiliation(s)
- Annette Ingeman
- From the Department of Clinical Epidemiology (A.I., R.W.T., H.H.H., S.P.J.) and Department of Neurology (G.A.), Aarhus University Hospital, Denmark; and Centre for Nutrition and Bowel Disease, Aalborg University Hospital, Denmark (H.H.R.)
| | - Grethe Andersen
- From the Department of Clinical Epidemiology (A.I., R.W.T., H.H.H., S.P.J.) and Department of Neurology (G.A.), Aarhus University Hospital, Denmark; and Centre for Nutrition and Bowel Disease, Aalborg University Hospital, Denmark (H.H.R.)
| | - Reimar W. Thomsen
- From the Department of Clinical Epidemiology (A.I., R.W.T., H.H.H., S.P.J.) and Department of Neurology (G.A.), Aarhus University Hospital, Denmark; and Centre for Nutrition and Bowel Disease, Aalborg University Hospital, Denmark (H.H.R.)
| | - Heidi H. Hundborg
- From the Department of Clinical Epidemiology (A.I., R.W.T., H.H.H., S.P.J.) and Department of Neurology (G.A.), Aarhus University Hospital, Denmark; and Centre for Nutrition and Bowel Disease, Aalborg University Hospital, Denmark (H.H.R.)
| | - Henrik H. Rasmussen
- From the Department of Clinical Epidemiology (A.I., R.W.T., H.H.H., S.P.J.) and Department of Neurology (G.A.), Aarhus University Hospital, Denmark; and Centre for Nutrition and Bowel Disease, Aalborg University Hospital, Denmark (H.H.R.)
| | - Søren P. Johnsen
- From the Department of Clinical Epidemiology (A.I., R.W.T., H.H.H., S.P.J.) and Department of Neurology (G.A.), Aarhus University Hospital, Denmark; and Centre for Nutrition and Bowel Disease, Aalborg University Hospital, Denmark (H.H.R.)
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Szepesi R, Csokonay Á, Murnyák B, Kouhsari MC, Hofgárt G, Csiba L, Hortobágyi T. Haemorrhagic transformation in ischaemic stroke is more frequent than clinically suspected - A neuropathological study. J Neurol Sci 2016; 368:4-10. [PMID: 27538593 DOI: 10.1016/j.jns.2016.06.055] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2016] [Revised: 06/01/2016] [Accepted: 06/24/2016] [Indexed: 11/18/2022]
Abstract
OBJECTIVES The vast majority of literature on the frequency of the haemorrhagic transformation of ischaemic stroke is based on imaging studies. The purpose of the present study was to assess the added value of autopsy and neuropathological analysis in a neurology centre with emphasis on acute stroke care. METHODS We retrospectively analysed the findings of 100 consecutive brain autopsies followed by detailed clinical correlation. RESULTS The clinical diagnosis was confirmed by neuropathology in every patient with intracerebral haemorrhage and with non-cerebrovascular neurological disorders (e.g. primary tumours, metastases, infections). At admission 64 patients (age 62years, SD 6.5) were diagnosed with acute ischaemic stroke. In 10 of these patients (16%) haemorrhagic transformation was diagnosed clinically by a second CT. In 24 cases (38%) haemorrhagic transformation was detected only at autopsy. The distribution of haemorrhagic transformation in our material was the following: small petechiae in 26.5%, more confluent petechiae in 29.4%, ≤30% of the infarcted area with some mild space-occupying effect in 29.4% and >30% of the infarcted area with significant space-occupying effect or clot remote from infarcted area in 14.7%. Most of the PH1-2 transformations developed in thrombolysed patients and all of the PH2 type transformations were diagnosed already clinically. CONCLUSIONS We demonstrated that haemorrhagic transformation is frequent and often undiscovered in vivo. Our findings underline the importance of post-mortem neuropathological examination also in the era of advanced imaging techniques and prove that autopsy is the ultimate yardstick of our diagnostic and therapeutic efforts. The high number of haemorrhagic transformations diagnosed only after death is an important novel finding with clinical implications.
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Affiliation(s)
- Rita Szepesi
- Department of Neurology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Ákos Csokonay
- Division of Neuropathology, Institute of Pathology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Balázs Murnyák
- Division of Neuropathology, Institute of Pathology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Mahan C Kouhsari
- Division of Neuropathology, Institute of Pathology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Gergely Hofgárt
- Department of Neurology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - László Csiba
- Department of Neurology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Tibor Hortobágyi
- Division of Neuropathology, Institute of Pathology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary.
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Alcoholic Beverage Consumption and Chronic Diseases. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2016; 13:ijerph13060522. [PMID: 27231920 PMCID: PMC4923979 DOI: 10.3390/ijerph13060522] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/13/2016] [Revised: 05/12/2016] [Accepted: 05/16/2016] [Indexed: 12/12/2022]
Abstract
Epidemiological and experimental studies have consistently linked alcoholic beverage consumption with the development of several chronic disorders, such as cancer, cardiovascular diseases, diabetes mellitus and obesity. The impact of drinking is usually dose-dependent, and light to moderate drinking tends to lower risks of certain diseases, while heavy drinking tends to increase the risks. Besides, other factors such as drinking frequency, genetic susceptibility, smoking, diet, and hormone status can modify the association. The amount of ethanol in alcoholic beverages is the determining factor in most cases, and beverage types could also make an influence. This review summarizes recent studies on alcoholic beverage consumption and several chronic diseases, trying to assess the effects of different drinking patterns, beverage types, interaction with other risk factors, and provide mechanistic explanations.
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Pham TL, Blizzard L, Srikanth V, Thrift AG, Lien NTK, Thang NH, Gall SL. Case-fatality and functional status three months after first-ever stroke in Vietnam. J Neurol Sci 2016; 365:65-71. [PMID: 27206877 DOI: 10.1016/j.jns.2016.03.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2015] [Revised: 02/18/2016] [Accepted: 03/07/2016] [Indexed: 11/15/2022]
Abstract
BACKGROUND To provide novel information on outcomes after first-ever stroke in Vietnam, case-fatality and functional status were assessed 3months after stroke onset. METHODS First-ever stroke patients admitted to the stroke unit of a tertiary teaching hospital in Ho Chi Minh City, Vietnam were recruited, examined and interviewed. Functional status was assessed on the modified Rankin Scale (mRS) at admission and again at 3months. RESULT We recruited 450 consecutive first-ever stroke patients (99.6% participation, 47.9% female, mean age 62.5 [SD 14.0] years, 76.2% ischaemic stroke). Three-month observed case-fatality was 10.4%. Under plausible assumptions about deaths among non-recruited participants, the estimated case-fatality would be higher (16.4%) Those who had died were mostly older patients compromised by comorbidities and pre-existing disability, and who had severe impairment or severe disability due to stroke at the time of admission. At 3-month follow-up of 376 patients, 34% had least severe disability (mRS=0/1), 39% had intermediate disability and 28% had most severe disability (mRS=4/5). Those with least severe disability were mostly men younger than 65years of age and principally with ischemic stroke. Those with most severe disability were predominantly women aged ≥65years and those with severe disability, mainly attributable to intracerebral haemorrhage. At 3months, 50% had better functional status than at stroke onset, and 27% had poorer function. CONCLUSION Case-fatality was relatively low in this study, possibly because of cultural preferences for end-of-life care at home. The dependency burden was relatively high, placing pressure on the healthcare system and society.
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Affiliation(s)
- Tran L Pham
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Australia; Pham Ngoc Thach University of Medicine, Ho Chi Minh City, Viet Nam
| | - Leigh Blizzard
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Australia.
| | - Velandai Srikanth
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Australia; Stroke and Ageing Research Centre, School of Clinical Sciences, Monash University, Melbourne, Australia
| | - Amanda G Thrift
- Stroke and Ageing Research Centre, School of Clinical Sciences, Monash University, Melbourne, Australia; Stroke Division, The Florey Institute of Neuroscience and Mental Health, Heidelberg, Australia
| | - Nguyen T K Lien
- Stroke Unit, Cerebrovascular Disease Department, 115 People's Hospital, Ho Chi Minh City, Viet Nam
| | - Nguyen H Thang
- Stroke Unit, Cerebrovascular Disease Department, 115 People's Hospital, Ho Chi Minh City, Viet Nam
| | - Seana L Gall
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Australia
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Lee JH, Lee JY, Ahn SH, Jang MU, Oh MS, Kim CH, Yu KH, Lee BC. Smoking is Not a Good Prognostic Factor following First-Ever Acute Ischemic Stroke. J Stroke 2015; 17:177-91. [PMID: 26060805 PMCID: PMC4460337 DOI: 10.5853/jos.2015.17.2.177] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2015] [Revised: 03/24/2015] [Accepted: 03/25/2015] [Indexed: 12/21/2022] Open
Abstract
Background and Purpose There is evidence that smoking increases stroke risk; however, the effect of smoking on functional outcome after stroke is unclear. The aim of this study was to explore the effect of smoking status on outcome following acute ischemic stroke. Methods We assessed 1,117 patients with first-ever acute cerebral infarction and no prestroke disability whose functional outcome was measured after three months. A poor outcome was defined as a modified Rankin Scale score of ≥2. Smoking within one month prior to admission was defined as current smoking. Our analysis included demographics, vascular risk factors, initial National Institutes of Health Stroke Scale (NIHSS) score, stroke subtype, onset-to-admission time, thrombolytic therapy, initial blood pressure, and prognostic blood parameters as covariates. Results At baseline, current smokers were predominantly male, approximately 10 years younger than non-smokers (mean age, 58.6 vs. 68.3 years), and less likely to have hypertension and atrial fibrillation (53.9% vs. 65.4% and 8.7% vs. 25.9%, respectively), with a lower mean NIHSS score (4.6 vs. 5.7). The univariate analyses revealed that current smokers had a better functional outcome and significantly fewer deaths at three months follow-up when compared with non-smokers (functional outcome: 64.0% vs. 58.4%, P=0.082; deaths: 3.0% vs. 8.4%, P=0.001); however, these effects disappeared after adjusting for covariates (P=0.168 and P=0.627, respectively). Conclusions In this study, smoking was not associated with a good functional outcome, which does not support the paradoxical benefit of smoking on functional outcome following acute ischemic stroke.
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Affiliation(s)
- Ju-Hun Lee
- Department of Neurology, Hallym University Medical Center, Hallym Neurological Institute, Hallym University College of Medicine, Anyang, Korea
| | - Ju Young Lee
- Department of Neurology, Hallym University Medical Center, Hallym Neurological Institute, Hallym University College of Medicine, Anyang, Korea
| | - So Hyun Ahn
- Department of Neurology, Hallym University Medical Center, Hallym Neurological Institute, Hallym University College of Medicine, Anyang, Korea
| | - Min Uk Jang
- Department of Neurology, Hallym University Medical Center, Hallym Neurological Institute, Hallym University College of Medicine, Anyang, Korea
| | - Mi Sun Oh
- Department of Neurology, Hallym University Medical Center, Hallym Neurological Institute, Hallym University College of Medicine, Anyang, Korea
| | - Chul-Ho Kim
- Department of Neurology, Hallym University Medical Center, Hallym Neurological Institute, Hallym University College of Medicine, Anyang, Korea
| | - Kyung-Ho Yu
- Department of Neurology, Hallym University Medical Center, Hallym Neurological Institute, Hallym University College of Medicine, Anyang, Korea
| | - Byung-Chul Lee
- Department of Neurology, Hallym University Medical Center, Hallym Neurological Institute, Hallym University College of Medicine, Anyang, Korea
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