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Cerebral infarction in cancer patients is often caused by thrombosis due to hypercoagulability, and in some cases, caused by direct tumor embolism. We report the case of cerebral infarction due to direct tumor embolism mixed with thrombus. Biopsy of blood clots obtained during thrombectomy is important for diagnosis. If there is a high risk of thrombosis among cancer patients with cerebral infarction, the use of appropriate antithrombotic agents along with maintaining a certain level of platelets should be considered.

Background and ObjectivesWe evaluated the association between admission glycated hemoglobin (HbA1c) and subsequent risk of composite vascular events, including stroke, myocardial infarction (MI), and vascular death, in patients with acute ischemic stroke and diabetes.MethodsPatients who had a TIA or an acute ischemic stroke within 7 days of symptom onset and diabetes were included in a retrospective cohort design using the stroke registry of the Clinical Research Center for Stroke in Korea. The association between admission HbA1c and composite vascular events, including stroke, MI, and vascular death, during 1-year follow-up was estimated using the Fine-Gray model. The risk of composite vascular events according to the ischemic stroke subtype was explored using fractional polynomial and linear-quadratic models.ResultsOf the 18,567 patients, 1,437 developed composite vascular events during follow-up. In multivariable analysis using HbA1c as a categorical variable, the risk significantly increased at a threshold of 6.8%–7.0%. The influence of admission HbA1c level on the risk of composite vascular events was pronounced particularly among those in whom fasting glucose at admission was ≤130 mg/dL. The optimal ranges of HbA1c associated with minimal risks for composite vascular events were lowest for the small vessel occlusion subtype (6.6 [95% confidence internal [CI], 6.3–6.9]) compared to the large artery atherosclerosis (7.3 [95% CI, 6.8–7.9]) or the cardioembolic subtype (7.4 [95% CI, 6.3–8.5]).DicussionIn patients with ischemic stroke and diabetes, the risks of composite vascular events were significantly associated with admission HbA1c. The optimal range of admission HbA1c was below 6.8%–7.0% and differed according to the ischemic stroke subtype.

Rationale Very early stage blood pressure (BP) levels may affect outcome in stroke patients who have successfully undergone recanalization following intra-arterial treatment, but the optimal target of BP management remains uncertain. Aim We hypothesized that the clinical outcome after intensive BP-lowering is superior to conventional BP control after successful recanalization by intra-arterial treatment. Sample-size estimates We aim to randomize 668 patients (334 per arm), 1:1. Methods and design We initiated a multicenter, prospective, randomized, open-label trial with a blinded end-point assessment (PROBE) design. After successful recanalization (thrombolysis in cerebral infarction score ≥ 2 b), patients with elevated systolic BP level, defined as the mean of two readings ≥ 140 mmHg, will be randomly assigned to the intensive BP-lowering (systolic BP Study outcomes The primary efficacy outcomes are from dichotomized analysis of modified Rankin Scale (mRS) scores at three months (mRS scores: 0–2 vs. 3–6). The primary safety outcomes are symptomatic intracerebral hemorrhage and death within three months. Discussion The OPTIMAL-BP trial will provide evidence for the effectiveness of active BP control to achieve systolic BP Clinical trial registration ClinicalTrials.gov Identifier: NCT04205305.

Reversible cerebral vasoconstriction syndrome (RCVS) has several trigger factors, including physical exertion, pregnancy, and the intake of vasoconstrictive agents. These triggers activate the sympathetic nervous system and induce vasoconstriction, thereby leading to an ischemic or hemorrhagic stroke. In this study, we describe case of RCVS in a 73-year-old woman who complained of sudden bilateral leg weakness after taking cyclophosphamide for anti-neutrophil cytoplasmic antibody associated vasculitis. She was diagnosed with concurrent cerebral hemorrhage and cerebral infarction with multiple intracranial vasoconstrictions on imaging analyses.

People living near abandoned mines are at increased risk of exposure to toxic metals. We surveyed 4500 inhabitants with the mean age of 68.5 years old (male: 1768, female: 2732) living near 104 abandoned metal mines from 2013 to 2017 (the 2nd phase health survey in Korea). We conducted personal interviews, blood and urine sampling, and analyzed the concentrations of lead (Pb) and cadmium (Cd) in whole blood and Cd in urine using a graphite furnace atomic absorption spectrometer. The geometric means of blood Pb, blood Cd, and urine Cd were 2.27 μg/dL, 1.42 μg/L, and 1.66 μg/g creatinine, respectively. The level of metal exposure was lower than that reported from the first phase health survey in Korea (2008‒2011) but was higher than in the general population of Korea. Blood Pb was higher in males while blood Cd and urine Cd were significantly higher in females. Blood Pb was highest in the 40‒59 age group, while blood and urine Cd levels continuously increased until age 80 or older. The Cd levels in blood and urine were affected by consumption of locally produced rice and duration of residence near abandoned mines. Furthermore, negative correlations were observed between blood Pb and blood and urine Cd levels. Additionally, 252 of the 4500 subjects exceeded the thresholds of blood Cd or urine Cd levels. Together, these findings suggest that Cd has more sustainable and adverse health effects on the abandoned mine inhabitants, who are mostly aged. Therefore, continuous biomonitoring and risk assessment to environmental health risks are necessary for environmental pollution control and health promotion.

There is a paucity of studies on the influence of alcohol intake among non-drinkers. We evaluated the association between an increase in alcohol consumption and primary prevention of major adverse cardiovascular events (MACE) among non-drinkers. Data collected by the National Health Insurance Service in the Korea between 2007 and 2013 were analysed. A total of 112,403 subjects were included and followed up from 1 January 2011 to 31 December 2013. Increases in alcohol consumption, measured as glasses per day, at the second medical check-up, were categorized into maintenance of nondrinking (0), > 0– ≤ 1, > 1– ≤ 2, > 2– ≤ 4, and > 4. Hazard ratios (HRs) for MACE and all-cause mortality on increase in alcohol consumption were calculated. Compared to that in non-drinkers at the second check-up, the risk of MACE significantly decreased among the subjects with an increase in alcohol consumption to ≤ 1 glass per day (HR 0.79, 95% CI 0.68–0.92). However, a light increase in alcohol consumption did not reduce the risk of stroke or all-cause mortality (stroke, HR 0.83, 95% CI 0.68–1.02; all-cause mortality, HR 0.89, 95% CI 0.73–1.09). Compared to continual non-drinkers, those who drank > 2 glass per day had higher risk for death due to external causes (aHR 2.06, 95% CI 1.09–3.90). The beneficial effect of light increments in alcohol consumption on the occurrence of MACE may have resulted from the inappropriate inclusion of sick quitters, who maintained a nondrinking status, in the reference group.

OBJECTIVE To evaluate whether prestroke glucose control is associated with functional outcomes in patients with acute large vessel occlusive stroke and diabetes who underwent intra-arterial thrombectomy (IAT). RESEARCH DESIGN AND METHODS From the Clinical Research Center for Stroke–Korea registry, we included patients with emergent large vessel occlusive stroke with diabetes who underwent IAT between January 2009 and March 2020. The association between the HbA1c level at admission and functional outcomes (modified Rankin Scale at 3 months after the index stroke) was assessed. RESULTS A total of 1,351 patients were analyzed. Early neurological deterioration was more common in patients with higher levels of HbA1c at admission (P = 0.02 according to HbA1c quintiles, P = 0.003 according to an HbA1c cutoff value of 7.0%) than in those with lower HbA1c levels. Higher HbA1c levels at admission were significantly associated with decreased odds of favorable functional outcomes at a threshold of 7.0–7.1%. The association was consistently observed in subgroups divided according to age, sex, stroke subtype, occlusion site, degree of recanalization, thrombolysis modalities, time from symptom onset to groin puncture, and treatment period. CONCLUSIONS Prestroke glucose control with a target HbA1c of ≤7.0% may be beneficial for neurological recovery in patients with diabetes undergoing IAT for large vessel occlusive stroke, regardless of stroke subtype, bridging intravenous thrombolysis, occlusion site, degree of recanalization, and treatment period.

Background: Acute dizziness is a common symptom among patients visiting emergency medical centers. Extensive neurological examinations aimed at delineating the cause of dizziness often require experience and specialized training. We tried to diagnose central dizziness by machine learning using only basic clinical information.Methods: Patients were enrolled who had visited an emergency medical center with acute dizziness and underwent diffusion-weighted imaging. The enrolled patients were dichotomized as either having central (with a corresponding central lesion) or non-central dizziness. We obtained patient demographics, risk factors, vital signs, and presentation (non-whirling type dizziness or vertigo). Various machine learning algorithms were used to predict central dizziness. The area under the receiver operating characteristic curve (AUROC) was measured to evaluate diagnostic accuracy. The SHapley Additive exPlanations (SHAP) value was used to explain the importance of each factor.Results: Of the 4,481 visits, 414 (9.2%) were determined as central dizziness. Central dizziness patients were more often older and male and had more risk factors and higher systolic blood pressure. They also presented more frequently with non-whirling type dizziness (79 vs. 54.4%) than non-central dizziness. Catboost model showed the highest AUROC (0.738) with a 94.4% sensitivity and 31.9% specificity in the test set (n = 1,317). The SHAP value was highest for previous stroke presence (mean; 0.74), followed by male (0.33), presentation as non-whirling type dizziness (0.30), and age (0.25).Conclusions: Machine learning is feasible for classifying central dizziness using demographics, risk factors, vital signs, and clinical dizziness presentation, which are obtainable at the triage.

Background: Clinical-diffusion mismatch (CDM) and perfusion-diffusion mismatch (PDM) are used to select patients for endovascular thrombectomy (EVT) in the late-window period. As CDM well reflects true penumbra, we hypothesized that patients with CDM and PDM would respond better to EVT than those with PDM only at the late-window period. Methods: Acute ischemic stroke patients who received EVT 6–24 h after stroke onset were included. PDM (perfusion-/diffusion-weighted image (DWI) lesion volume >1.8) was used to select candidates for EVT in this time-period in our center. CDM was defined according to the DAWN trial criteria. Response to EVT was compared between patients with and without CDM. Early neurological improvement (ENI) was defined as improvement >4 points on National Institutes of Health Stroke Scale (NIHSS) score 1 day after EVT. Multivariable analysis was performed to investigate independent factors associated with ENI. The correlation between DWI lesion volume and NIHSS score was investigated in those with and without CDM. Results: Among 94 patients enrolled, all patients had PDM and 44 (46.3%) had CDM. Forty-eight patients (51.1%) showed ENI. The prevalence of hypertension, initial NIHSS score, improvement in NIHSS score after EVT, and prevalence of ENI were greater in patients with CDM than those without. ENI was independently associated with onset-to-door time (odds ratio [95% confidence interval]: 0.998 [0.997–1.000]; p = 0.042), complete recanalization (23.912 [2.238–255.489]; p = 0.009), initial NIHSS score (1.180 [1.012–1.377]; p = 0.034), and the presence of CDM (5.160 [1.448–18.386]; p = 0.011). The correlation between DWI lesion volume and initial NIHSS score was strong in patients without CDM (r = 0.731) but only moderate in patients with CDM (r = 0.355). Conclusion: Patients with both CDM and PDM had a better response to late-window EVT than those with PDM only.

Background: Optimal blood pressure (BP) management after intraarterial thrombectomy (IAT) has yet to be thoroughly elucidated. We assessed whether maintaining a systolic BP (SBP) of ≤130 mm Hg for 24 h following IAT was associated with better outcomes in patients with successful recanalization. Methods: Patients presenting with large vessel occlusion within 4 h from symptom onset underwent IAT based on multiphase computed tomography angiography, and those achieving successful recanalization were included in this retrospective analysis. Patients were dichotomized based on a 24-h mean SBP after IAT >130 or ≤130 mm Hg, and functional outcomes were compared at 3 months. At 3 months, 24-h mean SBPs were compared based on recanalization degree, baseline collateral status, stroke mechanism, and occlusion site. Results: The proportion of favorable outcomes at 3 months (modified Rankin Scale [mRS] 0–2) was significantly lower in patients with a mean SBP >130 mm Hg over the 24 h after IAT (40.5 vs. 66.7%, p = 0.02). The distribution of mRS varied significantly among patients with complete recanalization, poor baseline collateral status (pial arterial filling score 0–3), cardioembolic stroke, or middle cerebral artery occlusion, with higher mRS values associated with higher mean SBPs. A mean SBP >130 mm Hg during the 24 h after IAT was associated with worse functional outcomes after multivariable adjustment (OR 2.66; 95% CI 1.11–6.41; p= 0.03). Conclusion: Stricter BP control during the 24 h following IAT may improve clinical outcomes in patients with large vessel occlusion who achieved successful recanalization.

BACKGROUND AND PURPOSE The identification of high-risk patent foramen ovale (PFO) is important for selecting suitable patients for PFO closure to prevent recurrent stroke in those with cryptogenic stroke. We aimed to evaluate the predictability of transcranial Doppler (TCD) in diagnosing high-risk PFO compared with that of transesophageal echocardiography (TEE), which is not feasible for some stroke patients. METHODS We retrospectively reviewed the data of 461 cryptogenic stroke patients who underwent TEE and TCD for PFO evaluation. High-risk PFO on TEE was defined as PFO with atrial septal aneurysm (phasic septal excursion ≥10 mm) or large PFO (≥2 mm). Spencer grading of right-to-left shunt was used to classify the amount of shunt on TCD. RESULTS PFO on TEE was observed for 242 (52.5%) patients, and high-risk PFO was detected for 123 (26.7%) patients. However, PFO on TCD was observed for 336 (72.9%) patients. Among patients with significant shunt (Spencer grade III or higher) who underwent TCD after Valsalva maneuver (VM), 60.0% of patients had high-risk PFO. However, only 5.3% of patients had high-risk PFO among those without significant shunt. Receiver operating characteristic curves showed that significant shunt after VM had higher predictability (AUC = .876, 95% CI: .843-.905) for detecting the high-risk PFO compared with the predictability based on significant shunt at rest (AUC = .718, 95% CI: .674-.759). (P

OBJECTIVE We aimed to present neurological profiles and clinical outcomes of patients with acute neurological symptoms, which developed during hospitalization with nonneurological illness. METHODS We organized the neurological alert team (NAT), a neurological rapid response team, to manage in-hospital neurological emergencies. In this registry-based study, we analyzed the clinical profiles and outcomes of patients who were consulted to the NAT. We also compared the 3-month mortality of patients with acute neurological symptoms with that of patients without acute neurological symptoms. RESULTS Among the 85,507 adult patients, 591 (0.7%) activated the NAT. The most common reason for NAT activation was stroke symptoms (37.6%), followed by seizures (28.6%), and sudden unresponsiveness (24.0%). The most common diagnosis by the NAT neurologists was metabolic encephalopathy (45.5%), followed by ischemic stroke (21.2%) and seizures or status epilepticus (21.0%). Patients with NAT activation had high rates in mortality before hospital discharge (22.5%) and at 3 months (34.7%), transfer to intensive care units (39.6%), and length of hospital stay (43.1 ± 57.1 days). They also had high prevalence of poor functional status (78.1%) and recurrence of neurological symptoms at 3 months (27.2%). In a Cox proportional hazards model, patients with in-hospital neurological emergencies had a hazard ratio of 13.2 in terms of mortality at 3 months (95% confidence interval, 11.5-15.3; P < 0.001). CONCLUSIONS Occurrence of acute neurological symptoms during hospital admission was associated with high rate of mortality and poor functional status. These results call for enhanced awareness and hospital-wide strategies for managing in-hospital neurological emergencies.

Background Little is known about newly developed stroke in patients admitted to the intensive care unit (ICU). Objective This study aimed to investigate characteristics and outcomes of newly developed stroke in patients admitted to the non-neurological intensive care units (ICU-onset stroke, IOS). Methods A consecutive series of adult patients who were admitted to the non-neurological ICU were included in this study. We compared neurological profiles, risk factors, and mortality rates between patients with IOS and those without IOS. Results Of 18,604 patients admitted to the ICU for non-neurological illness, 218 (1.2%) developed stroke (ischemic, n = 182; hemorrhagic, n = 36). The most common neurological presentation was altered mental status (n = 149), followed by hemiparesis (n = 55), and seizures (n = 28). The most common etiology of IOS was cardioembolism (50% [91/182]) for ischemic IOS and coagulopathy (67% [24/36]) for hemorrhagic IOS. In multivariable analysis, the Acute Physiology and Chronic Health Evaluation II (APACHE II) score (adjusted odds ratio [AOR] = 1.04, 95% CI = 1.03−1.06, P

Background and Purpose— We evaluated whether hemoglobin concentration at admission was associated with stroke recurrence and composite vascular events (stroke, myocardial infarction, and vascular death) in acute ischemic stroke. Methods— We collected data from patients with acute ischemic stroke or transient ischemic attack from a multicenter stroke registry database in Korea. The association of hemoglobin concentration with 1-year stroke recurrence and composite vascular events was evaluated with respect to age, presence of cerebral artery stenosis, stroke severity, and stroke subtype. Results— Hemoglobin levels were inversely associated with stroke recurrence and composite vascular events. One-year rates of stroke recurrence and composite vascular events were significantly higher in patients with anemia or moderate anemia. In multivariable analyses, moderate anemia remained an independent predictor of stroke recurrence (adjusted hazard ratio, 1.43 [95% CI, 1.16–1.75]) and composite vascular events (adjusted hazard ratio, 1.26 [95% CI, 1.07–1.48]). Moderate anemia increased the risk of composite vascular events in patients with mild-to-moderate stroke severity (National Institutes of Health Stroke Scale score P =0.01 for interaction). Conclusions— Hemoglobin concentration could be an independent predictor of stroke recurrence and composite vascular events.

Introduction: We evaluated whether the optimal cutoff of blood pressure to reduce cardiovascular risk is different according to hemoglobin (Hb) concentration and its changing pattern using the National Health Insurance Service-Health Screening Cohort. Methods: The study population consisted of individuals who underwent both 2002-2003 and 2004-2005 health examinations. Individuals who were diagnosed with cardiovascular disease or who died before index date of 1 January 2006 were excluded. The primary outcome of the study was the association between systolic blood pressure (SBP) and MACE (composite of myocardial infarction, stroke, and cardiovascular death) according to Hb concentration. Hazard ratios (HR) were calculated using Cox regression analysis adjusted for age and sex. Results: A total of 290573 were included in the analysis. During the follow up period from 1 January 2006 to 31 December 2013, a total of 18292 experienced MACE. There was a significant interaction between SBP and Hb concentration with regard to cardiovascular diseases (p for interaction= 0.07). Among the subjects with Hb Conclusion: The threshold of SBP which increases cardiovascular risk may be different according to the hemoglobin concentration and change pattern of hemoglobin.

Background: Blood pressure variability (BPV) is associated with target organ damage progression and increased cardiovascular events, including stroke. The aim of this study was to evaluate the associations between short-term BPV during acute periods and recanalization degree, early neurological deterioration (END) occurrence, and functional outcomes in acute ischemic stroke patients who had undergone intra-arterial thrombectomy (IAT). Methods: We retrospectively analyzed 303 patients with large vessel occlusive stroke who underwent IAT. The following BPV parameters, measured over 24 and 48 h after IAT, were compared: the mean, SD, coefficient of variation (CV), variation independent of the mean (VIM) for both the systolic BP (SBP) and diastolic BP, and the proportion of nocturnal SBP risers. Results: BPV parameters decreased with higher recanalization degree. The mean SBP (SBPmean) over 24 and 48 h after IAT, and the SD of SBP (SBPSD), CV of SBP (SBPCV), and VIM of SBP (SBPVIM) during the 48 h following the procedure had significant associations with recanalization degree. Patients with END had higher BPV than that of those without END, and the difference was more evident for incomplete recanalization. Increased BPV was associated with a shift toward poor functional outcome at 3 months after adjustment, including recanalization degree (OR range for significant parameters, 1.26–1.64, p = 0.006 for 48 h SBPmean, p = 0.003 for 48 h SBPCV, otherwise p < 0.002). Conclusions: Short-term BPV over 24 and 48 h after IAT in acute ischemic stroke patients was related to recanalization degree, and END occurrence, and may be an independent predictor of clinical outcome.

We investigated the association between early recanalization degree after intravenous thrombolysis (IVT), occurrence of hemorrhagic transformation, and functional outcome. We also evaluated whether recombinant tissue plasminogen activator (rTPA) dosing error could influence the outcome. Patients with ischemic stroke with major vessel occlusion (n=256) who underwent IVT were included. Recanalization status (no recanalization, partial recanalization, and complete recanalization) was confirmed by subsequent magnetic resonance or conventional angiography. Association between early recanalization degree and favorable outcome (modified Rankin Scale score ≤2) was evaluated using logistic regression analysis. Early partial recanalization was achieved in 33 (12.9%), and complete recanalization in 7 (2.7%) patients. Patients with the highest quintile of rTPA dosage achieved complete recanalization more frequently than the lower four quintiles (8.0% vs 2.0%, P=0.03). Hemorrhagic transformation tended to occur more frequently in patients with complete recanalization as compared with patients with partial recanalization (57.1% vs 21.2%, P=0.15). The proportion of favorable outcome was significantly lower in patients with the highest quintile of rTPA dosage used as compared with the patients with lower four quintiles (40.8%, 57.0%, P=0.04). In multivariable analysis, partial recanalization was significantly associated with favorable outcome (adjusted odds ratio, 3.15; 95% CI, 1.06-9.35), but complete recanalization was not. Early partial recanalization after IVT may be an indicator of favorable outcome with low occurrence of any hemorrhagic transformation.

// Se Young Jang 1, * , Gyeonghwa Kim 2, * , Soo Young Park 1 , Yu Rim Lee 1 , Sang Hoon Kwon 1 , Hyeong Seok Kim 1 , Jun Sik Yoon 1 , Jun Seob Lee 1 , Young-Oh Kweon 1 , Heon Tak Ha 3 , Jae Min Chun 3 , Young Seok Han 3 , Won Kee Lee 4 , Jun Young Chang 5 , Jung Gil Park 6 , Byungheon Lee 2 , Won Young Tak 1 and Keun Hur 2 1 Department of Internal Medicine, Kyungpook National University School of Medicine, Daegu, Republic of Korea 2 Department of Biochemistry and Cell Biology, Cell and Matrix Research Institute, School of Medicine, Kyungpook National University, Daegu, Republic of Korea 3 Department of Surgery, Kyungpook National University School of Medicine, Daegu, Republic of Korea 4 Biostatistics, Medical Research Collaboration Center in Kyungpook National University Hospital, Kyungpook National University School of Medicine, Daegu, Republic of Korea 5 Department of Neurology, Gyeongsang National University Changwon Hospital, Changwon, Republic of Korea 6 Department of Internal Medicine, College of Medicine, Yeungnam University, Daegu, Republic of Korea * These authors contributed equally to this work Correspondence to: Keun Hur, email: KeunHur@knu.ac.kr Won Young Tak, email: wytak@knu.ac.kr Keywords: hepatocellular carcinoma, long noncoding RNA ATB, survival, prognosis, epithelial mesenchymal transition Received: June 28, 2017 Accepted: September 04, 2017 Published: September 20, 2017 ABSTRACT Hepatocellular carcinoma (HCC) is a worldwide health problem and it is important to understand the mechanistic roles of the biomolecules involved in its pathogenesis. Long non-coding RNAs (lncRNAs) are frequently and aberrantly expressed in various human cancers and are known to play a role in cancer pathogenesis. The aim of this study was to analyze the expression of lncRNA-ATB in HCC and investigate the implications for prognoses. In total, 100 samples of HCC tissues and their corresponding, adjacent, non-cancerous liver tissues were collected. Total RNAs were extracted and the expression levels of lncRNA-ATB were measured by qRT-PCR. The association of lncRNA expression with clinicopathological features and patient survival were then analyzed. LncRNA-ATB was significantly upregulated in HCC tissues compared with the levels in corresponding non-cancerous tissues. Expression of lncRNA-ATB was significantly associated with portal vein thrombosis, intrahepatic or extrahepatic metastases, mUICC stage, and the BCLC stage. Large tumors (> 5 cm, HR = 3.851, 95% CI = 1.431–10.364, p = 0.008) and higher lncRNA-ATB expression (HR = 4.158, 95% CI = 1.226–14.107, p = 0.022) were the significant prognostic factors for overall survival. With this novel evidence of the involvement of lncRNA-ATB in HCC pathogenesis and clinical features, lncRNA-ATB can be concluded to have potential as a biomarker for the prognosis of HCC and as a targeted therapy for afflicted patients.

Background: Admission to an intensive care unit (ICU) specialized for brain and spine injury patients is associated with improved outcome. We investigated the effects of the first dedicated, combined neurological and neurosurgical ICU (NeuroICU) in Korea on patient outcomes. Methods: The first dedicated NeuroICU in Korea was established in March 2013. We retrospectively analyzed the clinical data and compared the outcomes between patients admitted to the ICU before and after NeuroICU establishment. The predicted mortality of NeuroICU patients was calculated using their Acute Physiology and Chronic Health Evaluation II scores. Patients’ functional outcomes were evaluated using their modified Rankin scale (mRS) scores at 6 months after ICU admission, which were obtained from medical records or telephone interviews. Results: We included 2487 patients, 1572 and 915 of whom were admitted prior to and after NeuroICU establishment, respectively. The demographic characteristics, Glasgow Coma Scale scores, and disease proportions did not differ significantly between the groups. The length of ICU stay and the number of days on ventilation were significantly lower in NeuroICU patients than they were in general ICU patients ( P = .024, P = .001). Intensive care unit mortality was significantly lower in NeuroICU patients (7.3% vs 4.7%, P = .012). The predicted mortality was obtained from 473 NeuroICU patients. The mortality ratio (observed mortality/predicted mortality) was 0.34 (8.9%/26.1%), and 228 (48.1%) patients showed good functional recovery (mRS, 0-2). Conclusion: Our findings suggest that admission to a dedicated NeuroICU significantly improves the neurological outcomes of patients with brain and spine injuries, including their postoperative care, in Korea.

Summary Background and purpose To determine whether status of dominant vertebral artery could affect clinical outcome in patients with symptomatic basilar artery occlusion (BAO). Methods We reviewed patients with symptomatic BAO who underwent endovascular treatment at the institute between January 2007 and July 2014. Patients were categorized into 2 groups according to functional outcome and baseline characteristics, treatment related factors were compared. Variables including clinical and imaging parameters were also compared according to the dominant V1 lesion. Results Fifty-nine of 101 patients underwent endovascular treatment and 23 patients (39.0%) showed favorable outcome (modified Rankin score ≤3 at 3 month). Younger age, male sex, lower baseline NIHSS score, higher PC-ASPECTS, absence of hemorrhagic transformation, shorter procedure time, and complete recanalization were associated with favorable outcome. Procedure time tended to be longer in patients with dominant V1 lesion (130.0; range, 105.0–179.0 vs. 101.5; range, 48.0–138.0, P = 0.05). Among patients with large artery disease (LAD), higher initial NIHSS, and clinical manifestation of decreased mental status were significantly associated with dominant V1 lesion. Endovascular procedure time tended to be longer, distal basilar occlusion tended to be more frequent, and proportion of the patients with complete recanalization tended to be less in patient with dominant V1 lesion. Poor outcome tended to be more frequent in dominant V1 lesion with LAD (88.9% vs. 42.9%, P = 0.05). These findings were comparable in patients who underwent mechanical thrombectomy. Conclusion Dominant V1 steno-occlusion may be associated with poor functional outcome in patients with the symptomatic BAO. Status of dominant VA and various treatment strategy should be considered when performing endovascular treatment for recanalization in patients with symptomatic BAO.

Early diagnosis and management of cerebral edema in acute liver failure is important to reduce neurological complication and mortality. Ammonia-induced astrocyte swelling and increased blood brain barrier permeability via transmembrane dysfunction are major mechanisms of cerebral edema in acute liver failure. Conventional therapy can be used to lower intracranial pressure. In addition, various treatment options are available to reduce serum ammonia level. Herein, we described the pathophysiology, monitoring, and management of cerebral edema in acute liver failure.

A large number of malicious software communicate with C & C (Command and Control) servers to download resources for malicious actions or to receive commands to perform desired attacks. Malware needs to know C & C servers' IP addresses to communicate with, and these IP addresses are usually obtained through DNS (Domain Name System) communications by sending domain names to DNS servers instead of using hard-coded IP addresses in order to avoid analysis and detection. In this process, malware usually uses DGA (Domain Generation Algorithm) to hide domain names of C & C servers and to make difficult to block C & C servers or domain names. Although DGA techniques have been studied extensively, most of previous studies have been based on the analysis of the domain names generated by DGA focusing on the characteristics of the strings. However, this kind of analysis methods has difficulties to detect some domain names generated by DGA with creative criteria. In this paper, we have conducted research to detect malicious code generated by DGA based on the value of flags included in the DNS communication process, deviating from the existing research focusing on domain name only.

Introduction: Light to moderate amount of alcohol intake may have preventive effect on cardiovascular disease. Even though the benefit of light to moderate alcohol consumption, nondrinkers are not advised to start drinking. The purpose of our study is to evaluate the association between alcohol consumption increment and primary prevention of major adverse cardiovascular events (MACE), such as stroke, coronary artery disease, or cardiovascular death, among nondrinkers. Methods: The National Health Insurance Service (NHIS) data collected from 2007 to 2013 was used for the analysis. Among the subjects who completed data on their drinking status both the first (2007-2008) and the second (2009-2010) medical checkup, the subjects who respond not to drink at all at the first NHIS medical checkup were included. Alcohol increment, measured by glass per day at the second medical checkup, was categorized into 0, 0< ≤1, 1< ≤ 2, 2< ≤4, >4. Hazard ratios (HRs) and 95% confidence interval (CI) for alcohol increment and MACE occurrence were calculated using Cox regression analysis. Results: Among 284511 subjects who performed both first and second medical checkup, nondrinker was 115870 (40.7%). Compared with the group who maintain nondrinking at the second checkup, the risk of MACE significantly decreased among the subjects with alcohol increment equal or less than 1 glass per day (HR 0.78, 95% CI 0.64-0.93). The risk of stroke, coronary artery disease, and all cause death were also decreased only the group with alcohol increment equal or less than 1 glass per day (stroke, HR 0.89, 95% CI 0.60-0.99; coronary artery disease, HR 0.74, 95% CI 0.56-0.98; all cause death, HR 0.75, 95% CI 0.58-0.97). The protective effect of light alcohol increment (0< ≤1) on MACE was not maintained among the subgroup with female, history of hypertension, current smoking. Conclusion: Light alcohol increment equal or less than 1 glass per day from nondrinking significantly reduced the risk of MACE occurrence.

Background and Purpose: We evaluated the effect of 24 h blood pressure variability (BPV) on clinical outcomes in acute ischemic stroke patients with successful recanalization after endovascular recanalization therapy (ERT). Methods: Patients with anterior circulation occlusion were evaluated if they underwent ERT based on multiphase computed tomography angiography and achieved successful recanalization (≥thrombolysis in cerebral ischemia 2b). Collateral degrees were dichotomized based on the pial arterial filling score, with a score of 0-3 defined as a poor collateral status. BPV parameters include mean, standard deviation, coefficient of variation, and variation independent of the mean (VIM) for systolic blood pressure (SBP), diastolic blood pressure (DBP), mean blood pressure, and pulse rate (PR). These parameters were measured for 24 h after ERT and were analyzed according to occlusion sites and stroke mechanisms. Associations of BPV parameters with clinical outcomes were investigated with stratification based on the baseline collateral status. Results: BPV was significantly different according to the occlusion sites and stroke mechanisms, and higher BPV was observed in patients with internal carotid artery occlusion or cardioembolic occlusion. After adjustment for confounders, most BPV parameters remained significant to predict functional outcomes at 3 months in patients with poor collateral circulation. However, no significant association was found between BPV parameters and clinical outcomes in patients with good collateral circulation. Conclusion: Postreperfusion BP management by decreasing BPV may have influence on improving clinical outcome in cases of poor collateral circulation among patients achieving successful recanalization after ERT.

This study aimed to measure lead (Pb) and cadmium (Cd) exposure levels in residents living near a zinc (Zn) smelter in Seokpo-myeon, Bonghwa-gun, South Korea, and identify factors affecting exposure. Residents aged ≥20 years living within 3 km and ≥30 km away from the smelter were classified as the exposure group (n = 549), and the control group (n = 265), respectively. Data were obtained through a questionnaire survey. Blood Pb levels in the exposure group (4.19 µg/dL) were higher than in the control group (2.70 µg/dL). The exposure group (1.32 µg/L) also had higher urinary Cd concentrations than the control group (0.80 µg/L). Male sex, older age, previous work at the smelter, smoking, and proximity to the smelter were associated with higher blood Pb levels on multivariate analysis, urinary Cd concentration was significantly higher in women, those who were older, those with experience of working in a Zn smelter or mine, those with proximity to the Zn smelter, and those who consumed locally grown vegetables. In conclusion, Zn smelters are major source of Pb and Cd pollution and require ongoing public health management to prevent potential adverse health effects.

Strategy for secondary prevention of ischemic stroke depends on the mechanism of stroke. The aim of this study was to compare the stroke mechanism according to the location and severity of middle cerebral artery (MCA) disease.We analyzed acute ischemic stroke patients within 7 days of onset with symptomatic MCA disease. The location of MCA disease was classified into proximal MCA M1 (pMCA) and distal MCA M1/proximal M2 (dMCA). The mechanism of stroke was categorized according to the pattern of ischemic lesion: local branch occlusion, artery-to-artery embolism/hemodynamic infarction, in situ-thrombosis, or a combined mechanism. The mechanism and imaging characteristics of stroke were compared according to the location and severity. The factors associated with the stroke mechanism were also investigated.A symptomatic MCA disease was observed in 126 patients (74 pMCA and 52 dMCA). The mechanism of stroke differed according to the location (p 0.001); the combined mechanism was most common in pMCA disease (54.1%), especially in those who presented with MCA occlusion and with a susceptible vessel sign. Artery-to-artery embolism/hemodynamic infarction was most common in dMCA disease (46.2%). A longer length of stenosis was observed in local branch occlusion than in other mechanisms (p = 0.04) and was an independent factor associated with local branch occlusion (OR=1.631, 95% CI=1.161-2.292; p = 0.005).The mechanism of stroke differed according to the location of MCA disease: occlusion caused by plaque rupture with combined mechanism of stroke type was predominant in pMCA. Longer length of stenosis was associated with local branch occlusion.

Background and purpose The use of decompressive hemicraniectomy (DHC) for the treatment of malignant cerebral edema can decrease mortality rates. However, this benefit is not sufficient to justify its use in elderly patients. We investigated the effects of therapeutic hypothermia (TH) on safety, feasibility, and functional outcomes in elderly patients with malignant middle cerebral artery (MCA) infarcts. Methods Elderly patients 60 years of age and older with infarcts affecting more than two-thirds of the MCA territory were included. Patients who could not receive DHC were treated with TH. Hypothermia was started within 72 hours of symptom onset and was maintained for a minimum of 72 hours with a target temperature of 33°C. Modified Rankin Scale (mRS) scores at 3 months following treatment and complications of TH were used as functional outcomes. Results Eleven patients with a median age of 76 years and a median National Institutes of Health Stroke Scale score of 18 were treated with TH. The median time from symptom onset to initiation of TH was 30.3±23.0 hours and TH was maintained for a median of 76.7±57.1 hours. Shivering (100%) and electrolyte imbalance (82%) were frequent complications. Two patients died (18%). The mean mRS score 3 months following treatment was 4.9±0.8. Conclusions Our results suggest that extended use of hypothermia is safe and feasible for elderly patients with large hemispheric infarctions. Hypothermia may be considered as a therapeutic alternative to DHC in elderly individuals. Further studies are required to validate our findings.

Background and Purpose Recent advances in intra-arterial techniques and thrombectomy devices lead to high rate of recanalization. However, little is known regarding the effect of the evolvement of endovascular revascularization therapy (ERT) in acute basilar artery occlusion (BAO). We compared the outcome of endovascular mechanical thrombectomy (EMT) versus intra-arterial fibrinolysis (IAF)-based ERT in patients with acute BAO. Methods After retrospectively reviewed a registry of consecutive patients with acute ischemic stroke who underwent ERT from September 2003 to February 2015, 57 patients with acute BAO within 12 hours from stroke onset were enrolled. They were categorized as an IAF group (n=24) and EMT group (n=33) according to the primary technical option. We compared the procedural and clinical outcomes between the groups. Results The time from groin puncture to recanalization was significantly shorter in the EMT group than in the IAF group (48.5 [25.3 to 87.8] vs. 92 [44 to 179] minutes; P=0.02) The rate of complete recanalization was significantly higher in the EMT group than in the IAF group (87.9% vs 41.7%; P

Background There have been no prospective studies on the clinical features, etiologies, and outcome of transient ischemic attack (TIA) in Korea. The aim of this study was to identify variables that can discriminate TIA from TIA mimics. Also we evaluated the characteristic of TIA patients according to the presence of diffusion-weighted imaging (DWI) lesion. Methods Patients were categorized into TIA and TIA mimics according to the result of an initial workup. TIA patients were divided according to the presence of DWI lesions. Baseline demographics, risk factors, laboratory results, initial blood pressure, imaging findings, recurrence rate of TIA or stroke at 3 months, and initial neurologic manifestations were prospectively collected and compared. Results We evaluated a total of 252 patients (212 with TIA and 40 with TIA mimics). Steno-occlusion of the relevant artery (odds ratio [OR], 22.39; 95% confidence interval [CI], 2.03-246.73) and cardioembolic risk (OR, 32.15; 95% CI, 1.12-922.97) were significantly associated with TIA. Amnesia (OR, .001; 95% CI, .00-.05) and consciousness disturbance (OR, .003; 95% CI, .00-.06) favored TIA mimics. Perfusion defect (OR, 5.56; 95% CI, 2.90-10.68) and cardioembolic risk (OR, 2.68; 95% CI, 1.14-6.32) were significantly associated with DWI lesion. Recurrence did not significantly differ according to the presence of a lesion on DWI (positive, 4.9%; negative, 7.8%; P = .41). Conclusion Steno-occlusive disease and cardioembolic risk were independently associated with TIA. Perfusion defect and cardioembolic risk predicted positive DWI lesion. The value of various imaging modalities for predicting TIA etiology needs further evaluation.

BACKGROUND AND PURPOSE: The functional recovery after the lateral medullary infarction (LMI) is usually good. Little is known about the prognostic factors associated with poor outcome following acute LMI. The aim of this study was to identify the factors associated with poor long-term outcome after acute LMI, based on experiences at a single center over 11 years. METHODS: A consecutive series of 157 patients with acute LMI who were admitted within 7 days after symptom onset was evaluated retrospectively. Clinical symptoms were assessed within 1 day after admission, and outcomes were evaluated over a 1-year period after the initial event. The lesions were classified into three vertical types (rostral, middle, and caudal), and the patients were divided into two groups according to the outcome at 1 year: favorable [modified Rankin Scale (mRS) score ≤1] and unfavorable (mRS score ≥2). RESULTS: Of the 157 patients, 93 (59.2%) had a favorable outcome. Older age, hypertension, dysphagia, requirement for intensive care, and pneumonia were significantly more prevalent in the unfavorable outcome group. The frequencies of intensive care (13%) and mortality (16.7%) were significantly higher in the rostral lesion (p=0.002 and p=0.002). Conditional logistic regression analysis revealed that older age and initial dysphagia were independently related to an unfavorable outcome at 1 year [odds ratio (OR)=1.04, 95% confidence interval (95% CI)=1.001-1.087, p=0.049; OR=2.46, 95% CI=1.04-5.84, p=0.041]. CONCLUSIONS: These results suggest that older age and initial dysphagia in the acute phase are independent risk factors for poor long-term prognosis after acute LMI.

Background: Acute carotid-T occlusion results in both low recanalization rates and poor outcomes. We investigated clinical outcomes and recanalization in a rare case of thrombolytic therapy. Methods: A consecutive series of patients with acute carotid-T occlusion who were treated with either bridging intravenous (IV) plus intra-arterial (IA) thrombolysis or IA alone were analyzed. Complete recanalization was defined as a thrombolysis in cerebral infarction (TICI) grade of 3. A favorable outcome was defined as a modified Rankin Scale (mRS) score of ≤2. Results: Of the 40 patients, 6 (15%) had favorable outcomes, and 34 (85%) had poor outcomes. Favorable outcomes were significantly associated with a lower National Institutes of Health Stroke Scale (NIHSS) score after revascularization treatment and higher rates of complete recanalization (p < 0.01, p < 0.024, respectively). Complete recanalization was achieved in all patients with favorable clinical outcomes and 5 (83%) patients had received combined IV/IA thrombolysis (p = 0.381). Conclusions: The results suggest that complete recanalization for acute carotid-T occlusion improves clinical outcomes. In that regard, bridging IV/IA thrombolysis may be more efficacious than IA alone.

We report 2 cases of central retinal artery occlusion with concomitant ipsilateral cerebral infarction after cosmetic facial injections and a literature review. The 2 patients were two healthy women, in which cosmetic facial injections with autologous fat and filler were performed, respectively. The patients had no light perception at the final visit and their conditions led to memory retrieval disturbance in case 1 and right arm weakness, dysarthria, facial palsy, and ophthalmoplegia in case 2. Neuroimaging showed multifocal small infarctions in the ipsilateral frontal lobe with occlusion of the ophthalmic artery in case 1 and multiple infarctions in the ipsilateral anterior and middle cerebral artery territories with subsequent hemorrhagic transformation in case 2. Poor visual prognosis and neurological complications can occur in healthy adults undergoing cosmetic facial injection, and all patients should be informed of this risk before the procedure.

Background and objective Symptomatic basilar artery stenosis (BAS) is associated with high risk of ischemic stroke recurrence. We aimed to investigate whether statin therapy might prevent the progression of symptomatic BAS and stroke recurrence. Methods We retrospectively analyzed the data of patients with acute ischemia with symptomatic BAS, which was assessed using magnetic resonance angiogram (MRA) imaging on admission day, and 1 year later (or the day of the clinical event). The clinical endpoints were recurrent ischemic stroke and its composites, transient ischemic attack, coronary disease, and vascular death. Results Of the 153 patients with symptomatic BAS, 114 (74.5%) were treated with a statin after experiencing a stroke. Statin therapy significantly prevented the progression of symptomatic BAS (7.0% vs 28.2%) and induced regression (22.8% vs 15.4%) compared to non-statin users (p = 0.002). There were 31 ischemic stroke incidences and 38 composite vascular events. Statin users showed significantly lower stroke recurrence (14.9% vs 35.9%, p = 0.05) and composite vascular events (17.5% vs 46.2%; odds ratio [OR], 0.29; 95% confidence interval [CI], 0.13–0.64) than those not using statins did. Recurrent stroke in the basilar territory and composite vascular events were more common in patients with progression of BAS than they were in other patients (OR, 5.16; 95% CI, 1.63–16.25 vs OR, 4.2; 95% CI, 1.56–11.34). Conclusion Our study suggests that statin therapy may prevent the progression of symptomatic BAS and decrease the risk of subsequent ischemic stroke. Large randomized trials are needed to confirm this result.

Background: We have evaluated whether anemia at admission is associated with ischemic stroke recurrence and composite outcome events (stroke, myocardial infarction, and vascular death) according to the age, presence of cerebral artery stenosis, stroke subtype, and initial severity of stroke. Methods: All 27145 patients with transient ischemia attack or acute ischemic stroke admitted between April 2008 and November 2014 from the stroke registry of the fifth section of the Clinical Research Center for Stroke (CRCS-5) were selected. The association between anemia and 1-year stroke recurrence, composite outcome events according to age, presence of cerebral artery stenosis, stroke mechanism, and initial severity of stroke were evaluated. Results: The cumulative 1-year stroke recurrence rate, composite outcome events were significantly higher in patients with anemia than without anemia ( 7.2% vs. 4.8%, p Conclusion: Anemia is an independent predictor of 1-year ischemic stroke recurrence, composite outcome events of stroke, myocardial infarction, and vascular death. Our data suggests that more attention should be paid to the anemic patients with mild to moderate neurological deficit, small vessel occlusion subtype, and stroke of other determined etiology.

Background: The purpose of the study is to evaluate whether prestroke glycemic control is associated with functional outcome in patients with acute ischemic stroke after endovascular treatment. Methods: We reviewed the acute ischemic stroke patients who underwent endovascular recanalization in the participating centers between April 2008 and March 2015 from the Clinical Research Center for Stroke-5th division (CRCS-5) registry. The relationship between the level of HbA1c on admission and functional outcome at 3 month, stroke recurrence and composite outcome (stroke, myocardial infarction, or vascular death) occurrence were assessed. Results: All 829 study subjects were classified as 4 groups according to quartiles of HbA1c on admission: 1 st quartile (HbA1c ≤5.6%), 2 nd quartile (5.6% < HbA1c ≤5.9%), 3 rd quartile (5.9% < HbA1c ≤6.5%), 4 th quartile (HbA1c >6.5%). END occurred more frequently in the highest quartile of HbA1c (P=0.02). Among the components of END, the frequency of symptomatic hemorrhagic transformation occurred more often in the group with higher quartiles (P=0.03), while stroke recurrence or recurrence was not significantly different according to the quartiles of HbA1c (P=0.27). After adjusting for significant variables (age, sex, initial NIHSS, diabetes, complete recanalization, procedure time, occurrence of END, P6.5% was still inversely associated with favorable functional outcome at 3 month (adjusted OR 0.48, 95% CI 0.25-0.93 as quartiles, adjusted OR 0.40, 95% CI 0.22-0.73 as a dichotomized variable). No significant heterogeneities were observed according to the age, diagnosis of diabetes on admission, stroke subtype, recanalization degree, and reperfusion time. The cumulative risk of both stroke recurrence and composite even rates were not significantly different according to the quartiles of HbA1c on admission (P=0.64, P=0.19, respectively). Conclusion: Prestroke glycemic control is associated with occurrence of symptomatic hemorrhagic ransformaion and functional outcome in patients with acute ischemic stroke after endovascular treatment. More stringent glycemic control of HbA1c below or equal to 6.5 % may have beneficial effect on neurological recovery after stroke.

We have performed stenting in 11 patients with symptomatic vertebral arterial orifice stenosis refractory to medical treatment or impairment in anterior circulation. Three of the 11 patients experienced asymptomatic severe in-stent restenosis or occlusion. Bare metal stents were used in those three patients, two of whom received revascularization therapy. Development of sufficient cervical collateral channels reconstituting the distal vertebral artery was the common feature in patients with asymptomatic in-stent restenosis. In selecting appropriate stents, consideration of mechanical strength and drug-eluting properties of a stent according to characteristics of the target vessel is important to reduce the risk of in-stent restenosis. Any decision to perform revascularization should be based on the presence of abundant cervical collaterals as well as clinical symptoms of vertebrobasilar ischemia.

Background: Acute aortic dissection typically manifests severe abrupt chest or back pain which can be accompanied by various neurologic symptoms. However, in case without typical pain, the accurate diagnosis is very difficult. Case Report: A 77-year old female patient presented with symptoms of right cerebral hypoperfusion such as altered mental status, left sided hemiplegia and hypesthesia, tonic-clonic movement and right sided gaze deviation. Initial brain CT angiography revealed a dissection of ascending aorta and intramural hematoma compressing the origin of common carotid artery. Perfusion brain CT showed the prolonged time to peak and mean transit time for right cerebral hemisphere. Emergent replacement of ascending aorta and hemiarch was done without complication. Conclusion: Cerebral hemispheric hypoperfusion could be initial manifestations of the aortic dissection. Aortic dissection should be discriminated in a patient with neurologic deficit accompanied by atypical systemic symptoms. J Neurocrit Care 2014;7(1):44-47

†‡ * † ‡ Decompressive hemicraniectomy followed by subsequent therapeutic hypothermia can reduce mortality in patients with malignant cerebral infarction without significantly increasing risk. We report three cases of malignant cerebral infarction treated with hemicraniectomy followed by hypothermia. Case 1 received elective decompressive surgery and hypothermia. Case 2 developed subsequent cerebral infarction with uncal herniation. Therefore, emergent decompressive surgery and hypothermia was performed in this case. Despite surgery and hyperosmolar therapy, case 3 received hypothermia treatment for refractory increased intracranial pressure. All patients survived with a score of 4 or 5 on the modified Rankin scale. Therefore, we suggest that application of hypothermia after hemicraniectomy is safe and feasible. Several possible modifications can be made to improve the management strategy in order to increase the benefits of hypothermia treatment.

BACKGROUND Carotid cavernous fistula (CCF) is an abnormal communication between the carotid artery and the cavernous sinus. The pathogenesis of spontaneous CCF remains unclear, although sinus thrombosis is known to be a predisposing factor for dural arteriovenous fistula. Because spontaneous CCFs are mainly of the dural type, we considered that thrombogenic conditions, such as, protein S deficiency might be associated with CCF. CASE REPORT A 42-year-old woman complained of conjunctival injection and retro-orbital pain that first appeared 1-month before visiting our hospital. She had no history of head trauma or intracranial surgery. Exophthalmos and chemosis were observed in her left eye, which also had lower visual acuity and higher intraocular pressure than the right eye. Magnetic resonance images and cerebral angiography revealed a left dural CCF. Her protein S was low, at 41% (normal range: 70-140%), but other hematologic values related to coagulation were normal. Her symptoms were relieved after initial transvenous coil embolization. However, a newly developed sixth-nerve palsy was detected 4 days after initial embolization. Follow-up angiography revealed a minimal shunt, and thus transvenous coil embolization was repeated. Two days later, the ophthalmoplegia started reducing, and 1-month later it had almost disappeared. CONCLUSIONS To the best of our knowledge, this is the first report of spontaneous dural CCF in a Korean patient with concurrent protein S deficiency. Interestingly, transient sixth-nerve palsy developed after transvenous coil embolization in this patient. This additional symptom caused by the residual fistula was relieved after additional transarterial embolization.

Background: Alzheimer’s disease (AD) is associated with vascular risk factors; brain ischemia facilitates the pathogenesis of AD. Recent studies have suggested that the reduction of AD risk with statin was achieved by decreased amyloidogenic amyloid precursor protein. Methods: We used mitochondrial transgenic neuronal cell (cybrid) models to investigate changes in the levels of intracellular hypoxia inducible factor 1α (HIF-1α )a ndβ-site amyloid precursor protein cleaving enzyme (BACE) in the presence of simvastatin. Sporadic AD (SAD) and age-matched control (CTL) cybrids were exposed to 2 % O2 and incubated with 1 μ Mo r 10μM simvastatin. Results: There was no significant difference between cell survival by 1 or 10 μM simvastatin in both SAD and CTL cybrids. In the presence of 1 μM simvastatin, intracellular levels of HIF-1α and BACE decreased by 40–70 % in SAD, but not CTL cybrids. However, 10 μM simvastatin increased HIF-1α and BACE expression in both cybrid models. Conclusion: Our results suggest demonstrate differential dose-dependent effects of simvastatin on HIF-1α and BACE in cultured Alzheimer’s disease cybrid cells.

Importance Thromboembolism is the most common complication in coiling for an unruptured aneurysm and is frequent in patients with high on-treatment platelet reactivity (HTPR) who are prescribed a standard antiplatelet preparation for its prevention. Objective To evaluate the effect of a modified antiplatelet preparation compared with a standard preparation in patients with HTPR undergoing coiling. Design, Setting, and Participants A prospective randomized open-label active-control trial with blinded outcome assessment at the Seoul National University Bundang Hospital from May 27, 2013, to April 7, 2014. Patients with HTPR were randomly assigned (1 to 1) to the standard or modified preparation group. Patients without HTPR were assigned to the non-HTPR group. A total of 228 patients undergoing coiling for unruptured aneurysms were enrolled and allocated to the study, 126 in the HTPR group (63 to the standard preparation group and 63 to the modified preparation group) and 102 to the non-HTPR group. Intent-to-treat analysis was performed. Interventions The modified preparation (HTPR to aspirin, 300 mg of aspirin and 75 mg of clopidogrel bisulfate; and HTPR to clopidogrel, 200 mg of cilostazol added to the standard regimen) was performed before coiling in the modified preparation group. Standard preparation (100 mg of aspirin and 75 mg of clopidogrel) was maintained in the standard preparation and non-HTPR groups. Main Outcomes and Measures The primary outcome was a thromboembolic event defined as thromboembolism during coiling and a transient ischemic attack or ischemic stroke within 7 days after coiling. The principal secondary outcome was a bleeding complication according to Thrombolysis in Myocardial Infarction bleeding criteria within 30 days after coil embolization. Results The thromboembolic event rate was low in the modified preparation group (1 of 63 [1.6%]) compared with the standard preparation group (7 of 63 [11.1%]; adjusted risk difference, −11.7% [95% CI, −21.3% to −2.0%]; P = .02), which had a higher thromboembolic risk than the non-HTPR group (1 of 102 [1.0%]; adjusted risk difference, 8.6% [95% CI, 1.0% to 16.3%]; P = .03). All bleeding complications were of minimal grade according to Thrombolysis in Myocardial Infarction bleeding criteria. The bleeding rate was not different between the modified (6 of 63 [9.5%]) and standard (4 of 63 [6.3%]) preparation groups (adjusted risk difference, 5.6% [95% CI, −4.2% to 15.4%]; P = .26). Conclusions and Relevance Modified antiplatelet preparation for patients with HTPR compared with standard antiplatelet preparation reduced the thromboembolic event rate in coiling for an unruptured aneurysm without increasing bleeding. Trial Registration Clinical Research Information Service Identifier:KCT0000804.

Purpose The study aims to classify schools based on traffic pollutants and their complex sources, to assess the environment, to determine the state of allergic diseases among students using the International Study of Asthma and Allergies in children (ISAAC) questionnaire, and to assess their connection to air pollutants. Materials and Methods A total of seven schools were divided into three categories according to the characteristics of their surrounding environments: three schools in traffic-related zones, two schools in complex source zones I (urban), and two schools in complex source zones II (industrial complex). ISAAC questionnaires were administered and the 4404 completed questionnaires were analyzed. Results The frequency of asthma treatment during the past 12 months showed a significant increase (p