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The etiology or rate of recurrent ischemic stroke according to dosing methods including drug adherence in patients taking non-vitamin K antagonist oral anticoagulants (NOACs) remain uncertain. We investigated the association between dosing methods including drug adherence achieved with NOACs and the presence of major vessel occlusion (MVO) in patients with ischemic stroke with non-valvular atrial fibrillation (NVAF). From July 2013 through December 2016, 120 patients with recurrent ischemic stroke with NVAF on NOACs were retrospectively analyzed. Patients taking non-standard doses of NOACs were divided into the missed dose group that discontinued NOACs for ≥48 h prior to arrival, and the under-dose group that used lower doses of NOACs. A logistic regression analysis was performed to determine the association between MVO and dosing methods including drug adherence. There were 60 (50.0%), 39 (32.5%), and 21 (17.5%) patients, respectively, in the standard dose, under-dose, and missed dose groups. Twelve patients (20.0%) in the standard dose group, 15 (38.5%) in the under-dose group, and 13 (61.9%) in the missed dose group had MVO. MVO was significantly higher in the missed dose group than in the standard dose and under-dose groups (P = 0.002). In patients with ischemic stroke with NVAF, who are on NOACs, anticoagulation caused by missed or lowered doses of NOACs was significantly associated with MVO in patients with recurrent cardioembolic stroke.

Non-valvular atrial fibrillation patients receiving non-vitamin K antagonist oral anticoagulants (NOACs) have half the incidence of intracerebral hemorrhage (ICH) compared to those receiving warfarin. However, the differences in outcomes of NOAC-associated ICH (NICH) and warfarin-associated ICH (WICH) remain controversial. In this study, we investigated the clinical outcome and radiologic findings of ICH in Asian patients receiving NOACs or warfarin. We retrospectively reviewed the medical records of 544 ICH patients admitted to our hospital from January 2013 through December 2017, and compared the baseline demographics, clinical characteristics, ICH-related radiologic findings, and clinical outcome between the WICH and NICH groups. WICH and NICH were diagnosed in 46 and 13 patients, respectively. Lesions were located more frequently in the supratentorial deep area (45.7% and 46.2%) than the lobar area (30.4% and 30.8%) or brainstem and cerebellum (23.9% and 23.1%) in the WICH and NICH groups, respectively. The hematoma expansion and concomitant intraventricular hemorrhage (IVH) rate was significantly higher in the WICH group than in the NICH group (58.7% versus 7.7%, P = 0.001 and 50.0% versus 15.4%, P = 0.030, respectively). Hematoma expansion (odds ratio [OR]: 50.546; 95% confidence interval [CI]: 2.763–924.748; P = 0.008) and concomitant IVH (OR: 9.240; 95% CI: 1.450–58.892; P = 0.019) were independently associated with mortality at three months, after adjustment for confounding variables. Our results indicate that the radiological findings and clinical outcome at three months in patients with ICH are more favorable in those receiving NOAC therapy than in those receiving warfarin treatment.

Acute ischemic stroke is a disease with multiple etiologies. Classifying the mechanism of acute ischemic stroke is therefore fundamental for treatment and secondary prevention. The TOAST classification is currently the most widely-used system, but it has limitations of often classifying unknown causes and inadequate inter-rater reliability. Therefore, we tried to develop a 3D-convolutional neural network(CNN) based algorithm for stroke lesion segmentation and subtype classification using only diffusion and adc information of acute ischemic stroke patients. The recruited patients were 2251 patients with acute ischemic stroke who visited Chungbuk National University Hospital from February 2013 – July 2019. Our segmentation model for lesion segmentation in the training set achieved a Dice score of 0.843±0.009. The subtype classification model achieved an average accuracy of 81.9%, and each subtype was Large artery astherosclerosis (LAA) = 81.6%, Cardioembolism (CE) = 86.8%, Small vessel occlusion (SVO) = 72.9%, and Control = 86.3%. In conclusion, the proposed method shows great potential for identification of diffusion lesion segmentation and stroke subtype classification. As deep learning systems gradually develop, it would be useful in clinical practice and application.

Background: In general, disease severity has been found to be associated with abnormal chloride levels in critically ill patients, but hyperchloremia is associated with mixed results regarding patient-centered clinical outcomes. We aimed to investigate the impact of maximum serum chloride concentration on the clinical outcomes of critically ill patients with large hemispheric infarction (LHI).Methods: We conducted a retrospective observational cohort study using prospective institutional neurocritical care registry data from 2013 to 2018. Patients with LHIs involving over two-thirds of middle cerebral artery territory, with or without infarction of other vascular territories, and a baseline National Institutes of Health Stroke Scale score of ≥13 were assessed. Those with a baseline creatinine clearance of Results: Of 90 patients, 20 (22.2%) died in-hospital. Patients who died in-hospital had significantly higher maximum serum chloride levels than did those who survived up to hospital discharge (139.7 ± 8.1 vs. 119.1 ± 10.4 mmol/L; p < 0.001). After adjusting for age, sex, and Glasgow coma scale score, each 5-mmol/L increase in maximum serum chloride concentration was independently associated with an increased risk of in-hospital mortality (adjusted odds ratio (aOR), 4.34; 95% confidence interval [CI], 1.98–9.50; p < 0.001). Maximum serum chloride level was also an independent risk factor for 3-month mortality (aOR, 1.99 [per 5 mmol/L increase]; 95% CI, 1.42–2.79; p < 0.001) and AKI occurrence (aOR, 1.57 [per 5 mmol/L increase]; 95% CI, 1.18–2.08; p = 0.002).Conclusions: High maximum serum chloride concentrations were associated with poor clinical outcomes in critically ill patients with LHI. This study highlights the importance of monitoring serum chloride levels and avoiding hyperchloremia in this patient population.

Contrast leakage on non-enhanced brain computed tomography (CT) is a common phenomenon after diagnostic or interventional cerebral angiography in patients with acute ischemic stroke. Contrast leakage is known to be related to the loosening of the blood-brain barrier. Sometimes, the contrast leakage on non-enhanced brain CT has been mistaken for intracranial hemorrhage. Differentiating the contrast leakage from the intracranial hemorrhage on non-enhanced brain CT is a very important issue, because subsequent treatment after intravenous thrombolysis (IVT) or intra-arterial thrombolysis would depend on the result of brain CT after thrombolysis. Recently, we experienced a case of contrast leakage mimicking intraventricular hemorrhage in a patient with IVT. The contrast leakage into the lateral ventricles after IVT is not a common phenomenon. We describe here our case.

Objectives: To validate a visual rating scale reflecting sub-regional patterns of putaminal hypointensity in susceptibility-weighted imaging of patients with multiple system atrophy (MSA).Methods: Using a visual rating scale (from G0 to G3), 2 examiners independently rated putaminal hypointensities of 37 MSA patients and 21 control subjects. To investigate the correlation with the scales, R2* values and the volume of the entire putamen were measured.Results: MSA patients with parkinsonian variant had significantly higher scores than those with cerebellar variant. Visual rating scores in MSA were correlated with R2* values [General estimating equation (GEE), Wald chi-square = 25.89, corrected p < 0.001] and volume (Wald chi-square = 75.44, corrected p < 0.001). They correlated with UPDRS motor scores. Binary logistic regression analyses revealed that the visual rating scale was a significant predictor for discriminating MSA patients from controls [multivariate model adjusted for age and sex, odds ratio 52.722 (corrected p = 0.009)]. Pairwise comparison between areas under the curve (AUCs) revealed that the visual rating scale demonstrated higher accuracy than R2* values [difference between AUCs; univariate model = 0.247 (corrected p < 0.001); multivariate model = 0.186 (corrected p = 0.003)]. There were no significant differences in clinical characteristics between the high-iron group, defined as putamen with visual rating scale ≥ G2 and R2* values ≥ third quartile, and the remaining patients.Conclusion: The visual rating scale, which reflects quantitative iron content and atrophy of the putamen as well as motor severities, could be useful for the discrimination and evaluation of patients with MSA.

Heat stroke is a life-threatening disease characterized by hyperthermia and neurological dysfunction. The central nervous system is highly sensitive to hyperthermia, which causes neurological complications due to the involvement of the cerebellum, basal ganglia, anterior horn cells, and peripheral nerves. Several studies reported about clinical symptoms and brain image findings of heat stroke. Isolated cranial nerve dysfunction caused by lacunar infarction is an extremely rare condition in patient with heat stroke. We experienced a rare case of trochlear nerve palsy due to midbrain infarction caused by heat stroke.

Background Psychological aspect and quality of life should be considered in treating patients with psoriasis. Objective We sought to ascertain which clinical characteristics including presence of exposed lesions are associated with impairment of health-related quality of life (HRQoL) in patients with psoriasis. Methods The EPI-PSODE study was a nationwide, multicenter, cross-sectional study conducted in Korea that included 1260 adult patients with psoriasis. In addition to clinical characteristics including presence of exposed lesions, data were collected using the Psoriatic Arthritis (PsA) Screening and Evaluation (PASE), Dermatology Life Quality Index (DLQI), MOS 36-Item Short-Form Health Survey (SF-36), Work Productivity and Activity Impairment Questionnaire Psoriasis (WPAI: PSO) and Medication Satisfaction Questionnaire (MSQ). Results Patients with a DLQI score > 5 (n = 990) were younger, had an earlier onset of psoriasis, scored higher on the Psoriasis Area and Severity Index (PASI), had higher body surface area (BSA) and had higher PASE scores than patients with DLQI ≤ 5 (n = 266). The group of patients with exposed lesions (n = 871) were younger and male predominance, earlier onset of psoriasis, longer disease duration, higher PASI/BSA score and a higher proportion with drinking and smoking history each than the group of patients without exposed lesions (n = 389). Presence of exposed lesions negatively influenced DLQI, 36-Item Short-Form Health Survey (SF-36) (mental component), presenteeism, total work productivity impairment and total activity impairment in the WPAI: PSO. In multiple regression model, PASI score was the only variable which was significantly associated with all HRQoL measures. Presence of exposed lesions was a significant factor affecting DLQI and SF-36 (mental). Conclusion The presence of exposed lesions has a negative impact on quality of life, mental health and work productivity. Therefore, effective treatments are particularly needed for psoriasis patients with exposed lesions.

Received February 17, 2015 Revised April 17, 2015 Accepted April 17, 2015 Address for correspondence: Jae Wook Cho, MD Department of Neurology, Pusan National University School of Medicine, 20 Geumo-ro, Mulgeum-eup, Yangsan 626-770, Korea Tel: +82-55-360-3014 Fax: +82-55-360-2152 E-mail: sleep.cho@gmail.com 일산화탄소중독은 가장 흔하게 발생하는 가스중독이지만 증 상과 징후가 모호하거나 다양하다. 두통, 어지럼, 근위약감, 구 역, 구토, 의식소실 등이 나타날 수 있는데 이 중 두통은 가장 흔하고 초기에 발생하는 증상이다. 하지만 일산화탄소 만성노 출에 의한 두통은 전형적인 양상이 없고 신경학적 이상 소견을 동반하는 경우가 많지 않아 두통만 호소할 경우 일산화탄소 유 발 두통이라 진단하기가 쉽지 않다. 급성 일산화탄소중독에 대 한 보고는 많았으나 만성노출로 인한 두통에 대한 국내문헌 보 고는 아직 없다. 저자들은 장기간 일산화탄소에 노출되어 발생 한 두통 환자를 경험하여 보고한다.

Received June 22, 2015 Revised June 24, 2015 Accepted June 26, 2015 Address for correspondence Jae Wook Cho, MD Department of Neurology, Pusan National University Yangsan Hospital, 20 Geumo-ro, Mulgeum-eup, Yangsan 626-770, Korea Tel: +82-55-360-2122 Fax: +82-55-360-2152 E-mail: sleep.cho@gmail.com We present a patient who complained of excessive daytime sleepiness (EDS), which started three years ago. She had no other medical, neurological, and psychiatric disorders. Nocturnal polysomnography did not indicate any sleep disorders, which might cause daytime EDS, such as obstructive sleep apnea. The following multiple sleep latency test was not compatible for narcolepsy. Her laboratory findings were remarkable for subclinical hypothyroidism, although free T4 and T3 were within reference rage, she had elevated thyroid stimulating hormone. After four weeks of levothyroxine treatment, her EDS resolved. The hypersomnolence, as a presenting symptom of subclinical hypothyroidism, was optimally treated after thyroid hormone replacement. J Sleep Med 2015;12(1):23-25

Early neurological deterioration (END) and poor outcome frequently occur in lenticulostriate artery (LSA) infarction due to branch atheromatous disease (BAD). We evaluate whether the tissue plasminogen activator (tPA) can prevent END and improve the outcome by comparing with anti-platelet treatment in LSA infarction due to BAD. We enrolled the patients with LSA infarction due to BAD who arrived at the hospital within 24h from onset, and divided those into two groups by whether tPA was given or not. END and good outcome (modified Rankin score: 0-1) at 3months were examined between two groups. Consecutive 35 patients of LSA infarction due to BAD enrolled in this study. Nine patients were given tPA (tPA group) and 26 patients antiplatelets only (non-tPA group). Patients in tPA group showed no symptomatic hemorrhage. END occurred in 68.6% (24/35) of all patients, 66.7% (6/9) of tPA group and 69.2% (18/26) of non-tPA group (p=0.886). The proportion of good outcome at 3months were 25.7% in all patients, 22.2% (2/9) in tPA group and 26.9% (7/26) in non-tPA (p=0.781). tPA did not adequately prevent END, and did not show better outcome in LSA infarction due to BAD compared with antiplatelet therapy only. More effective treatment strategies are needed for prevention of END and favourable outcome in BAD.

Background Basal cell carcinoma (BCC) is by far the most common cancer in white populations. In addition, recent reports have demonstrated an increasing incidence of BCC in Korea. We have observed a significant number of early-onset BCC cases in which the disease occurred in patients younger than 50 years. Objective To investigate the clinicopathological characteristics of early-onset BCC in an Asian population, specifically in Koreans. Methods One hundred and five patients with early-onset BCC were enrolled from a total of 1047 BCC patients who underwent surgery between January 1997 and December 2014 (942 patients over the age of 50 years were designated as the control group). Results Early-onset BCC accounted for 10.03% of all 1047 cases and the incidence over time displayed an incremental trend. The early-onset group displayed similar results as the control group, with a predominance of female BCC patients and the majority of tumours displaying the following characteristics: small in size, occurring in sun-exposed areas and belonging to the noduloulcerative clinical subtype and nodular histopathological subtype. In comparison with a previous study in a Western population, the incidence of the disease in non-exposed areas of the body, as well as the proportion of tumours of the superficial histological subtype, were lower in Asian patients. Conclusion Although the clinicopathological characteristics of BCC are well-known, these characteristics have not been determined for early-onset BCC in an Asian population. Therefore, this study is the first report on early-onset BCC in Asians, specifically in a Korean patient group.

Summary Background Psoriasis and seborrhoeic dermatitis are common erythematous-squamous dermatoses that may present with scaly erythematous patches on the scalp. Owing to the similar clinicopathological features of these dermatoses, their differentiation poses a diagnostic challenge, particularly when the lesions on the scalp are isolated. Objectives To evaluate the usefulness of dermoscopy in the clinical differentiation of scalp psoriasis and seborrhoeic dermatitis. Methods This was a retrospective observational study to evaluate the characteristic dermoscopic features of scalp psoriasis and seborrhoeic dermatitis. The study included a total of 96 patients with lesions; these patients were recruited from two tertiary teaching hospitals in Korea (Pusan National University Hospital and Kyungpook National University Hospital). Among these, 55 patients had scalp psoriasis and 41 patients had seborrhoeic dermatitis. Results The most significant dermoscopic features of scalp psoriasis were red dots and globules, twisted red loops, and glomerular vessels. In contrast, seborrhoeic dermatitis was characterized by arborizing vessels and atypical red vessels with the absence of red dots and globules. Featureless areas devoid of any particular vascular patterns were also frequently observed in seborrhoeic dermatitis. Dermoscopic findings of red lines and other vascular patterns were not considered useful for differentiation because these were uncommon features in both diseases. Although scales were observed commonly in both diseases, there was no significant difference in the frequency and characteristics of the scales when they were observed using dermoscopy. Conclusions Our study shows that the investigation of vascular patterns by using dermoscopy can be valuable for the clinical diagnosis and differentiation of scalp psoriasis and seborrhoeic dermatitis.