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Diabetes mellitus (DM) predisposes individuals to vascular injury, leading to poor outcomes after ischemic stroke and symptomatic hemorrhagic transformation (SHT) after thrombolytic and endovascular treatment (EVT). Metformin (MET), an oral antidiabetic drug, has shown potential neuroprotective effects, but its impact on stroke prognosis in DM patients undergoing EVT remains unclear. In a multicenter study, 231 patients with DM undergoing EVT for acute ischemic stroke were enrolled. Prior MET use was identified, and patients were stratified into MET+ and MET− groups. Demographics, clinical data, and outcomes were compared between groups. Multivariate analysis was used to assess the effect of MET on stroke prognosis. Of the enrolled patients, 59.3% were previously on MET. MET+ patients had lower initial infarct volumes and NIHSS scores compared to MET-taking patients. Multivariate analysis showed that MET+ was associated with a lower risk of stroke progression and SHT (with stroke progression as follows: odd ratio [OR] 0.24, 95% confidence interval [CI] [0.12–0.48], p < 0.001; SHT: OR 0.33, 95% CI [0.14–0.75], p = 0.01) and was also associated with better 3-month functional outcomes (mRS 0–2) after EVT. Prestroke MET use in DM patients undergoing EVT is associated with improved stroke prognosis, including reduced risk of stroke progression and SHT and better functional outcomes. These findings suggest the potential neuroprotective role of MET in this population and highlight its clinical utility as an adjunctive therapy in the management of ischemic stroke. Further research is warranted to elucidate the underlying mechanisms and to optimize MET therapy in this setting. [ABSTRACT FROM AUTHOR]

Foot drop can have a variety of causes, including the common peroneal nerve (CPN) injuries, and is often difficult to diagnose. We aimed to develop a deep learning-based algorithm that can classify foot drop with CPN injury in patients with knee MRI axial images only. In this retrospective study, we included 945 MR image data from foot drop patients confirmed with CPN injury in electrophysiologic tests (n = 42), and 1341 MR image data with non-traumatic knee pain (n = 107). Data were split into training, validation, and test datasets using a 8:1:1 ratio. We used a convolution neural network-based algorithm (EfficientNet-B5, ResNet152, VGG19) for the classification between the CPN injury group and the others. Performance of each classification algorithm used the area under the receiver operating characteristic curve (AUC). In classifying CPN MR images and non-CPN MR images, EfficientNet-B5 had the highest performance (AUC = 0.946), followed by the ResNet152 and the VGG19 algorithms. On comparison of other performance metrics including precision, recall, accuracy, and F1 score, EfficientNet-B5 had the best performance of the three algorithms. In a saliency map, the EfficientNet-B5 algorithm focused on the nerve area to detect CPN injury. In conclusion, deep learning-based analysis of knee MR images can successfully differentiate CPN injury from other etiologies in patients with foot drop. [ABSTRACT FROM AUTHOR]

This study aimed to investigate the association between cerebral small vessel disease (CSVD) burden and infarct growth rate (IGR) in patients with large vessel occlusion (LVO) stroke who underwent endovascular treatment (EVT). A retrospective analysis was conducted on a cohort of 495 patients with anterior circulation stroke who received EVT. CSVD burden was assessed using a CSVD score based on neuroimaging features. IGR was calculated from diffusion-weighted imaging (DWI) lesion volumes divided by the time from stroke onset to imaging. Clinical outcomes included stroke progression and functional outcomes at 3 months. Multivariate analyses were performed to assess the relationship between CSVD burden, IGR, and clinical outcomes. The fast IGR group had a higher proportion of high CSVD scores than the slow IGR group (24.4% vs. 0.8%, p < 0.001). High CSVD burden was significantly associated with a faster IGR (odds ratio [95% confidence interval], 26.26 [6.26–110.14], p < 0.001) after adjusting for confounding factors. High CSVD burden also independently predicted stroke progression and poor functional outcomes. This study highlights a significant relationship between CSVD burden and IGR in LVO stroke patients undergoing EVT. High CSVD burden was associated with faster infarct growth and worse clinical outcomes. [ABSTRACT FROM AUTHOR]

The need for developing a simple and effective assessment tool for muscle mass has been increasing in a rapidly aging society. This study aimed to evaluate the feasibility of the surface electromyography (sEMG) parameters for estimating muscle mass. Overall, 212 healthy volunteers participated in this study. Maximal voluntary contraction (MVC) strength and root mean square (RMS) values of motor unit potentials from surface electrodes on each muscle (biceps brachii, triceps brachii, biceps femoris, rectus femoris) during isometric exercises of elbow flexion (EF), elbow extension (EE), knee flexion (KF), knee extension (KE) were acquired. New variables (MeanRMS, MaxRMS, and RatioRMS) were calculated from RMS values according to each exercise. Bioimpedance analysis (BIA) was performed to determine the segmental lean mass (SLM), segmental fat mass (SFM), and appendicular skeletal muscle mass (ASM). Muscle thicknesses were measured using ultrasonography (US). sEMG parameters showed positive correlations with MVC strength, SLM, ASM, and muscle thickness measured by US, but showed negative correlations with SFM. An equation was developed for ASM: ASM = −26.04 + 20.345 × Height + 0.178 × weight − 2.065 × (1, if female; 0, if male) + 0.327 × RatioRMS(KF) + 0.965 × MeanRMS(EE) (SEE = 1.167, adjusted R2 = 0.934). sEMG parameters in controlled conditions may represent overall muscle strength and muscle mass in healthy individuals. [ABSTRACT FROM AUTHOR]

Background: Standard autonomic testing includes a 10-minute head-up tilt table test to detect orthostatic hypotension. Although this test can detect delayed orthostatic hypotension (dOH) between 3 and 10 minutes of standing, it cannot detect late-onset dOH after 10 minutes of standing. Methods: To determine whether Valsalva maneuver responses can identify patients who would require prolonged head-up tilt table test to diagnose late-onset dOH; patients with immediate orthostatic hypotension (onset <3 minutes; n=176), early-onset dOH (onset between 3 and 10 minutes; n=68), and late-onset dOH (onset >10 minutes; n=32) were retrospectively compared with controls (n=114) with normal head-up tilt table test and composite autonomic scoring scale score of 0. Results: Changes in baseline systolic blood pressure at late phase 2 (∆SBPVM2), heart rate difference between baseline and phase 3 (∆HRVM3), and Valsalva ratio were lower and pressure recovery time (PRT) at phase 4 was longer in late-onset dOH patients than in controls. Differences in PRT and ∆HRVM3 remained significant after correcting for age. A PRT ≥2.14 s and ∆HRVM3 ≤15 bpm distinguished late-onset dOH from age- and sex-matched controls. Patients with longer PRT (relative risk ratio, 2.189 [1.579–3.036]) and lower ∆HRVM3 (relative risk ratio, 0.897 [0.847–0.951]) were more likely to have late-onset dOH. Patients with longer PRT (relative risk ratio, 1.075 [1.012–1.133]) were more likely to have early-onset than late-onset dOH. Conclusions: Long PRT and short ∆HRVM3 can help to identify patients who require prolonged head-up tilt table test to diagnose late-onset dOH. [ABSTRACT FROM AUTHOR]

The measurement of skeletal muscle mass is essential for the diagnosis of sarcopenia. Muscle ultrasonography has emerged as a useful tool for evaluating sarcopenia because it can be used to assess muscle quality and quantity. This study investigated whether muscle ultrasonography is effective for estimating appendicular skeletal muscle mass (ASM) and screening for sarcopenia. This study prospectively enrolled 212 healthy volunteers aged 40–80 years. ASM was measured using the bioelectrical impedance analysis. Muscle thickness (MT) and echo-intensity (EI) were measured in four muscles (biceps brachii, BB; triceps brachii, TB; rectus femoris, RF; biceps femoris, BF) on the dominant hand. A hold-out cross-validation method was used to develop and validate the ASM prediction equation. In the model development group, the ASM prediction equations were deduced as follows: estimated ASM for men (kg) = 0.167 × weight (kg) + 0.228 × height (cm) + 0.143 × MT of BF (mm)– 0.822 × EI to MT ratio of BB– 28.187 (R2 = 0.830) and estimated ASM for women (kg) = 0.115 × weight + 0.215 × height (cm) + 0.139 × MT of RF–0.638 × EI to MT ratio of BB– 23.502 (R2 = 0.859). In the cross-validation group, the estimated ASM did not significantly differ from the measured ASM in both men (p = 0.775; intraclass correlation coefficient [ICC] = 0.948) and women (p = 0.516; ICC = 0.973). In addition, multiple logistic regression analysis revealed that the ratios of EI to MT in the BF and RF muscles in men and MT in the BB muscle in women could be valuable parameters for sarcopenia screening. Therefore, our study suggests that muscle ultrasound could be an effective tool for estimating ASM and screening sarcopenia. [ABSTRACT FROM AUTHOR]

Step length is a critical hallmark of health status. However, few studies have investigated the modifiable factors that may affect step length. An exploratory, cross-sectional study was performed to evaluate the surface electromyography (sEMG) and body impedance analysis (BIA) parameters, combined with individual demographic data, to predict the individual step length using the GAITRite® system. Healthy participants aged 40–80 years were prospectively recruited, and three models were built to predict individual step length. The first model was the best-fit model (R2 = 0.244, p < 0.001); the root mean square (RMS) values at maximal knee flexion and height were included as significant variables. The second model used all candidate variables, except sEMG variables, and revealed that age, height, and body fat mass (BFM) were significant variables for predicting the average step length (R2 = 0.198, p < 0.001). The third model, which was used to predict step length without sEMG and BIA, showed that only age and height remained significant (R2 = 0.158, p < 0.001). This study revealed that the RMS value at maximal strength knee flexion, height, age, and BFM are important predictors for individual step length, and possibly suggesting that strengthening knee flexor function and reducing BFM may help improve step length. [ABSTRACT FROM AUTHOR]

• Shear wave elastography (SWE) and high-definition (HD) color provide useful supportive information for the evaluation of carpal tunnel syndrome (CTS). • SWE discriminated CTS severity, and detected CTS patients with normal nerve conduction study results. • 50.12-kPa for median nerve (MN) stiffness at the wrist and 1.91 for the MN stiffness ratio are cutoff values for CTS diagnosis. The diagnostic values of measuring median nerve (MN) stiffness and vascularity with shear wave elastography (SWE) and high-definition (HD) color were investigated in carpal tunnel syndrome (CTS). Seventy patients (123 wrists) with CTS and thirty-five healthy volunteers (70 wrists) were enrolled. Based on nerve conduction studies (NCS), the patients were subdivided into NCS-negative, mild-to-moderate, and severe CTS groups. MN and abductor pollicis brevis (APB) SWE and MN HD color were performed on a longitudinal plane. The mild-to-moderate and severe CTS groups showed increased MN stiffness at the wrist and MN stiffness ratio (wrist-to forearm) compared with the control (p < 0.001). The NCS-negative CTS group showed increased MN stiffness at the wrist (p = 0.022) and MN stiffness ratio (p = 0.032) compared with the control. The severe CTS group showed increased MN stiffness at the wrist compared with the mild-to-moderate CTS group (p = 0.034). The cutoff-values in diagnosing NCS-confirmed CTS were 50.12 kPa for MN stiffness at the wrist, 1.91 for MN stiffness ratio, and grade 1 for HD color. SWE and HD color are good supportive tools in diagnosing and assessing severity in CTS. SWE and HD color demonstrated that MN in CTS was associated with increased stiffness and hypervascularity. [ABSTRACT FROM AUTHOR]

Objective: This study aimed to investigate the utility of facial nerve ultrasonography in the functional and structural assessment of early-stage Bell's palsy and the prognostic value of facial nerve ultrasonography in Bell's palsy.Study Design: Prospective longitudinal study.Setting: Single center, a university-affiliated neurology clinic.Subjects and Methods: Patients with unilateral Bell's palsy who had visited our clinic within 3 days of symptom onset were enrolled in this study. Demographic information and House-Brackmann grade were collected. Electrophysiologic studies and facial nerve ultrasonography were then performed. The facial nerves on each side were scanned longitudinally with a 5- to 12-MHz probe. The diameter of the facial nerves with and without the sheath was measured at the proximal and distal portions. Follow-up examinations, including House-Brackmann grade analysis, electrophysiologic studies, and facial nerve ultrasonography, were performed after 2 months.Results: Fifty-four patients with unilateral Bell's palsy were enrolled, and 22 underwent the follow-up examinations. The diameters of the facial nerves were larger on the affected side than on the unaffected side at the proximal and distal portions (P < .01). On the affected side, the enlarged facial nerve at the proximal portion had decreased in size after 2 months (P < .05). The initial ultrasonography findings were positively correlated with the initial severity of Bell's palsy, but they did not predict prognosis.Conclusion: Ultrasonography could be a useful tool for evaluating the facial nerve in Bell's palsy. Nevertheless, further studies are needed to demonstrate its prognostic value. [ABSTRACT FROM AUTHOR]

Adequate nutritional support and high body mass index (BMI) are good prognostic factors for disease progression and survival in amyotrophic lateral sclerosis (ALS). However, whether the composition of body weight, such as body fat percentage, has an independent effect on ALS prognosis remains unclear. The clinical data of 53 ALS patients were collected by medical record review. The data included: disease onset, sex, age, time of diagnosis, survival duration, presence of percutaneous endoscopic gastrostomy (PEG), nasogastric tube, tracheostomy, and availability of oral intake throughout the course of the disease, and interval measurement values of body mass by bioelectrical impedance analysis (BIA). The interval change (∆) of the BIA parameters was calculated by subtracting the follow-up values from the baseline values. Change in body fat percentage/interval between BIA measurements (months) (hazard ratio [HR] = 0.374, p = 0.0247), and availability of oral food intake (HR = 0.167, p = 0.02), were statistically significant for survival duration in multivariate hazard proportional regression analysis. Survival analysis and Kaplan–Meier curves showed similar results. Higher average monthly change in body fat percentage and availability of oral food intake are prognostic factors in ALS survival. [ABSTRACT FROM AUTHOR]

Introduction: Although white matter hyperintensity (WMH) shares similar vascular risk and pathology with small vessel occlusion (SVO) stroke, there were few studies to evaluate the impact of the burden of WMH volume on early and delayed stroke outcomes in SVO stroke., Materials and Methods: Using a multicenter registry database, we enrolled SVO stroke patients between August 2013 and November 2022. The WMH volume was estimated by automated methods using deep learning (VUNO Med-DeepBrain, Seoul, South Korea), which was a commercially available segmentation model. After propensity score matching (PSM), we evaluated the impact of WMH volume on early neurological deterioration (END) and poor functional outcomes at 3-month modified Ranking Scale (mRS), defined as mRS score >2 at 3 months, after an SVO stroke., Results: Among 1,718 SVO stroke cases, the prevalence of subjects with severe WMH (Fazekas score ≥ 3) was 68.9%. After PSM, END and poor functional outcomes at 3-month mRS (mRS > 2) were higher in the severe WMH group (END: 6.9 vs. 13.5%, p < 0.001; 3-month mRS > 2: 11.4 vs. 24.7%, p < 0.001). The logistic regression analysis using the PSM cohort showed that total WMH volume increased the risk of END [odd ratio [OR], 95% confidence interval [CI]; 1.01, 1.00-1.02, p = 0.048] and 3-month mRS > 2 (OR, 95% CI; 1.02, 1.01-1.03, p < 0.001). Deep WMH was associated with both END and 3-month mRS > 2, but periventricular WMH was associated with 3-month mRS > 2 only., Conclusion: This study used automated methods using a deep learning segmentation model to assess the impact of WMH burden on outcomes in SVO stroke. Our findings emphasize the significance of WMH burden in SVO stroke prognosis, encouraging tailored interventions for better patient care., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2024 Lee, Suh, Sohn, Kim, Han, Sung, Yu, Lim and Lee.)

Background: Appropriate evaluation and management of dysphagia are essential in neurological disorders. However, there is currently a lack of a simple yet reliable method for dysphagia evaluation., Aim: This study aimed to investigate the usefulness of new dynamic M-mode ultrasonography (US) parameters of suprahyoid muscle (SHM) to evaluate dysphagia., Design: Prospective observational, cross-sectional study., Setting: Inpatient setting at neurology department of tertiary medical center., Population: A total of 89 patients with dysphagia and 175 healthy volunteers were enrolled in the study. Patients were subdivided into mild and severe dysphagia groups depending on the need for dietary changes and disease classification, which included amyotrophic lateral sclerosis, peripheral neuromuscular diseases, and stroke., Methods: Dynamic M-mode US was performed during swallowing to obtain the SHM thickness (the baseline thickness of the SHM), SHM displacement (peak-to-peak amplitude of SHM movement), SHM difference (SHM displacement - SHM thickness), SHM ratio (SHM displacement/SHM thickness), peak-to-peak time, and total duration. A videofluoroscopic swallowing study (VFSS) was performed., Results: Significant differences were found in SHM displacement and SHM difference according to dysphagia severity (P<0.001). The SHM ratio, total duration (P<0.001), and peak-to-peak time (P=0.001) differed significantly according to the patients' underlying diseases. The pharyngeal delay time and penetration-aspiration scale from the VFSS demonstrated significant negative correlations with SHM displacement and difference (P<0.001). By combining SHM difference and total duration, patients with dysphagia could be distinguished from healthy controls, with the highest negative predictive value of 95.6%., Conclusions: Dynamic M-mode US of the SHM provided added value in evaluating the severity of dysphagia and differentiating swallowing mechanics of dysphagia related to underlying neurological disorders., Clinical Rehabilitation Impact: Dynamic M-mode US of the SHM can serve as a supportive tool for rapid screening and repetitive follow-up of patients with dysphagia, which would contribute to dysphagia rehabilitation in patients with various neurological disorders.

Competing Interests: The authors have no potential conflicts of interest to disclose.

Objectives: The WHO recommends that adults engage in regular moderate-to-vigorous physical activities (MVPAs) and muscle-strengthening activities (MSA), and minimise sedentary behaviour. This study aimed to determine the association of occupation with MVPA, MSA and sedentary behaviour in middle-aged Korean workers., Design and Setting: A cross-sectional study using data from the seventh Korea National Health and Nutrition Examination Survey (2016-2018)., Participants: Workers aged between 40 and 69 years in Korea (n=6359)., Outcome Measures: Population-weighted proportions not meeting the MVPA (＜150 min/week) and MSA (＜2 days/week) guidelines, and with high sedentary behaviour (＞7 hours/day) were calculated, and their associations with sociodemographic and work-related variables were assessed using multiple logistic regression analyses. Additionally, the estimated time spent on MVPA, MSA and sedentary behaviour according to the occupation categories (white-collar, pink-collar and blue-collar) was calculated using analysis of covariance (ANCOVA)., Results: The MVPA level did not show a significant difference across the occupation categories. Blue-collar workers showed significantly lower MSA participation than white-collar and pink-collar workers (male, p=0.006; female, p=0.004; by ANCOVA). High sedentary behaviour was significantly associated with white-collar occupations (p<0.001 by ANCOVA). Longer working hours were negatively associated with MVPA (OR=1.01, 95% CI 1.01 to 1.02) and MSA (OR=1.01, 95% CI 1.00 to 1.02). Workers with higher stress were less likely to participate in MSA (male: OR=1.43, 95% CI 1.10 to 1.86; female: OR=1.39, 95% CI 1.08 to 1.80). Self-employed workers showed lower MVPA levels than employees (male: OR=1.26, 95% CI 1.09 to 1.47; female: OR=1.36, 95% CI 1.13 to 1.64). Daily workers compared with full-time workers (OR=0.38, 95% CI 0.24 to 0.59) and temporary workers compared with regular workers (OR=0.75, 95% CI 0.59 to 0.95) were associated with less sedentary behaviour in men., Conclusion: A number of work-related factors were associated with PA levels and sedentary behaviour in middle-aged workers. The workplace is one of the critical elements to intervene in health promotion strategies., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background and Purpose: Amyotrophic lateral sclerosis (ALS) is a neurodegenerative disease that mainly affects the pyramidal motor system. However, recent studies have suggested that degeneration of the extramotor system plays a role in the disability experienced by patients with ALS. We investigated the local shape changes and mean volumes of the subcortical nuclei in sporadic ALS patients with preserved cognition., Methods: The participants comprised 32 patients with ALS and 43 age- and sex-matched healthy controls. Three-dimensional T1-weighted structural images were acquired. Surface-based vertex analysis was performed with fully automated segmentation of both amygdalae, hippocampi, caudate nuclei, nuclei accumbens, putamina, pallida, and thalami, and the brainstem. The scalar distances from the mean surfaces of the individual subcortical nuclei were compared between groups, and correlations of the local shape distances with initial Amyotrophic Lateral Sclerosis Functional Rating Scale Revised (ALS-FRS-R) scores and the delta FRS-R and with the disease duration were analyzed., Results: ALS patients showed regional shape contractions on the lateral surfaces of both pallida, the lateroposterior surface of the right putamen, and the anterior basal surface of the right accumbens. Delta FRS-R scores were negatively correlated with local shape distances in the right hippocampus and the putamina. However, the initial ALS-FRS-R score and disease duration were not correlated with local shape distances., Conclusions: Subcortical gray-matter structures are involved in the neurodegenerative process of ALS before cognitive impairment becomes evident., Competing Interests: The authors have no potential conflicts of interest to disclose., (Copyright © 2020 Korean Neurological Association.)

Background and Purpose: Many elderly patients are unable to actively stand up by themselves and have contraindications to performing the head-up tilt test (HUTT). We aimed to develop screening algorithms for diagnosing orthostatic hypotension (OH) before performing the HUTT., Methods: This study recruited 663 patients with orthostatic intolerance (78 with and 585 without OH, as confirmed by the HUTT) and compared their clinical characteristics. Univariate and multivariate analyses were performed to investigate potential predictors of an OH diagnosis. Machine-learning algorithms were applied to determine whether the accuracy of OH prediction could be used for screening OH without performing the HUTT., Results: Differences between expiration and inspiration (E-I differences), expiration:inspiration ratios (E:I ratios), and Valsalva ratios were smaller in patients with OH than in those without OH. The univariate analysis showed that increased age and baseline systolic blood pressure (BP) as well as decreased E-I difference, E:I ratio, and Valsalva ratio were correlated with OH. In the multivariate analysis, increased baseline systolic BP and decreased Valsalva ratio were found to be independent predictors of OH. Using those variables as input features, the classification accuracies of the support vector machine, k -nearest neighbors, and random forest methods were 84.4%, 84.4%, and 90.6%, respectively., Conclusions: We have identified clinical parameters that are strongly associated with OH. Machine-learning analysis using those parameters was highly accurate in differentiating OH from non-OH patients. These parameters could be useful screening factors for OH in patients who are unable to perform the HUTT., Competing Interests: The authors have no potential conflicts of interest to disclose., (Copyright © 2020 Korean Neurological Association.)