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Background: The efficacy and safety of intravenous alteplase administered 34. 5 h after acute ischemic stroke have been demonstrated. However, whether responses differ between low-dose and standard-dose alteplase during this time window and whether certain subgroups benefit more remain unknown. Patients and Methods: The current analysis was based on a multicenter matched-cohort study conducted in Taiwan. The treatment group comprised 378 patients receiving intravenous alteplase 34.5 h after stroke onset, and the control group comprised 378 age- and sex-matched patients who did not receive alteplase treatment during the same period. Standard- and low-dose alteplase was administered to patients at the physician's discretion. Results: Overall, patients receiving alteplase exhibited more favorable outcomes than did controls [34.0 vs. 22.7%; odds ratio (OR): 1.75, 95% confidence interval (CI): 1.27–1.42], and the effectiveness was consistent in all subgroups. Although patients in the standard-dose group (n = 182) were younger than those in the low-dose (n = 192) group, the proportions of patients with favorable outcomes (36.3 vs. 31.8%; OR: 1.22, 95% CI: 0.80–1.88) and symptomatic hemorrhage (2.8 vs 4.2%; OR: 0.65, 95% CI: 0.21–2.02) were consistently comparable in a covariate-adjusted model and an age-matched cohort. In the subgroup analysis, patients with cardioembolism, atrial fibrillation, and hypercholesterolemia were more likely to achieve favorable outcomes after receiving standard-dose than low-dose alteplase. Conclusion: In the 34.5-h time window, the effectiveness and safety of standard-dose and low-dose alteplase may be comparable. A standard dose may be selected for patients with cardioembolism, atrial fibrillation, or hypercholesterolemia. [ABSTRACT FROM AUTHOR]

Objective  The endoscopic endonasal approach (EEA) has been shown to be an effective means to access sellar lesions. However, there are limited studies centered on evaluating olfactory function after surgery. In this study, we assessed the pre- and postoperative olfactory function of patients who underwent EEA for sellar and suprasellar lesions. The impact of nasoseptal flap use on olfaction was further analyzed. Study Design  A retrospective study. Setting  A tertiary-care referral center in Taiwan. Participants  Patients with sellar and suprasellar lesions who underwent EEA and pre- and postoperative olfaction assessment from August 2015 to March 2018 were included in the study. Main Outcome Measures  The patients' olfactory function was examined pre-and postoperatively using the Sniffin' Sticks odor identification test. Data regarding demographics, olfactory scores, pathology, reconstructive technique, graft usage, and extent of resection were retrieved. Results  A total of 106 patients (36 males and 70 females) were enrolled, with a mean age of 51 years. There were 76 pituitary tumors, 12 Rathke's cleft cysts, 7 craniopharyngiomas, 7 meningiomas, and 4 other lesions. The nasoseptal flap was used in 39 patients for skull base reconstruction, and these patients had no statistically significant change between pre- and postoperative olfactory scores (p  = 0.283). Moreover, a statistically significant improvement of olfactory scores was found in patients in whom the nasoseptal flap was not used. Conclusion  Olfactory function may be reliably preserved after EEA, with or without nasoseptal flap harvest and use. [ABSTRACT FROM AUTHOR]

Ischemic stroke is the most common type of cerebrovascular event and is responsible for approximately 85% of all strokes in Taiwan. Neurons contain high concentrations of polyamines, which are prone to various pathological states in the brain and are perturbed after cerebral ischemia. Acrolein, an α,β-unsaturated aldehyde, has been suggested as the primary culprit of neuronal damage in stroke patients. However, the mechanism by which acrolein induces neuronal damage during ischemic stroke is not clear. Urinary 3-hydroxypropyl mercapturic acid (3-HPMA), an acrolein-glutathione (GSH) metabolite, plasma acrolein-protein conjugates (Acr-PC) and plasma GSH levels were analyzed to correlate disease severity and prognosis of stroke patients compared with control subjects. In vivo middle cerebral artery occlusion (MCAO) animal models and an in vitro oxygen glucose deprivation (OGD) stroke model were used to investigate the mechanisms of acrolein-induced neuronal damage. A deregulated acrolein metabolism, including significantly increased plasma Acr-PC levels, decreased urinary 3-HPMA levels and decreased plasma GSH levels, was found in stroke patients compared to control subjects. We further observed that acrolein was produced during ischemia resulting in brain damage in in vivo MCAO animal model. The induction of acrolein in neuronal cells during OGD occurred due to the increased expression of spermidine/spermine N1-acetyltransferase (SSAT) by NF-kB pathway activation. In addition, acrolein elicited a vicious cycling of oxidative stress resulting in neurotoxicity. Finally, N -acetylcysteine effectively prevented OGD-induced neurotoxicity by scavenging acrolein. Overall, our current results demonstrate that acrolein is a culprit of neuronal damage through GSH depletion in stroke patients. The mechanism underlying the role of acrolein in stroke-related neuronal damage occurs through SSAT-induced polyamine oxidation by NF-kB pathway activation. These results provide a novel mechanism of neurotoxicity in stroke patients, aid in the development of neutralizing or preventive measures, and further our understanding of neural protection. Unlabelled Image • A deregulated acrolein metabolism is found in stroke patients. • Acrolein is produced resulting in brain damage in MCAO animal model. • Acrolein occurs through SSAT-induced polyamine oxidation by NF-kB pathway. • Acrolein elicits a vicious cycling of oxidative stress resulting in neurotoxicity. • N -acetylcysteine prevents OGD-induced neurotoxicity by scavenging acrolein. [ABSTRACT FROM AUTHOR]

The reported incidence and risk factors mediating seizures in Alzheimer's disease (AD) have been extremely inconsistent and relevant data is lacking in Asia. We investigated the incidence rate and risk of seizures in AD and in a large, nationwide cohort from Han Chinese. A retrospective population-based study was conducted on the data from Taiwan's National Health Insurance Research Database from 2000 to 2010. To reduce selection bias, we applied propensity scores, wherein 981 patients with AD were matched to 3835 non-AD controls from a pool of 1000,000 randomly sampled cohort dataset. This approach was based on age, sex, comorbidities and previous brain conditions. Incidence rate, cumulative incidence and hazard ratios (HRs) were estimated. During the 10-year follow-up period (mean follow-up time, 4.02 years), 44 out of 937 AD patients (4.7%) developed seizures. The incidence rate in the AD cohort (11.9 per 1000 person-years) was higher than that in the matched cohort (5.7 per 1000 person-years), with an adjusted HR of 1.85 (95% confidence interval [CI], 1.20–2.83, p = 0.005). The mean duration from the diagnosis of AD to the occurrence of seizure is 3.6 years. The Cox regression analysis revealed that AD itself is a significant predictor after adjustment for confounders (HR = 2.01, 95% CI, 1.40–2.90, p < 0.001). Moreover, age is an independent predictor, with an adjusted HR of 1.03 (95% CI, 1.00–1.05, p = 0.019). In conclusion, seizure occurrence in AD is more common than in the matched cohort. Notably, advanced age carries a higher risk for development of seizures in patients with AD. [ABSTRACT FROM AUTHOR]

Background Insufficient evidence is available for patients with acute ischemic stroke with atrial fibrillation (AF) to determine the efficacy and safety of different dosages of intravenous thrombolysis treatment. This study examined clinical outcomes in Chinese patients with stroke with and without AF after intravenous thrombolysis treatment with different intravenous thrombolysis doses. Methods and Results This multicenter, prospective cohort study recruited 2351 patients with acute ischemic stroke (1371 with AF and 980 without AF) treated with intravenous thrombolysis using alteplase. The Totaled Health Risks in Vascular Events score is a validated risk-scoring tool used for assessing patients with acute ischemic stroke with and without AF. We evaluated favorable functional outcome at day 90 and symptomatic intracranial hemorrhage within 24 to 36 hours and outcomes of the patients receiving different doses of alteplase. Compared with the non-AF group, the AF group exhibited a 2- to 3-fold increased risk of symptomatic intracranial hemorrhage according to the National Institute of Neurological Disorders and Stroke standard (relative risk [RR], 2.10 [95% CI, 1.35-3.26]). Favorable functional outcome at 90 days and symptomatic intracranial hemorrhage rates according to the European Cooperative Acute Stroke Study II and the Safe Implementation of Thrombolysis in Stroke-Monitoring Study standards did not significantly differ between the AF and non-AF groups. In addition, the low-dose alteplase subgroup exhibited an increased risk of symptomatic intracranial hemorrhage according to the National Institute of Neurological Disorders and Stroke standard (RR, 2.84 [95% CI, 1.63-4.96]). A validation study confirmed these findings after adjustment for scores determined using different stroke risk-scoring tools. Conclusions Different alteplase dosages did not affect functional status at 90 days in the AF and non-AF groups. Thus, the adoption of low-dose alteplase simply because of AF is not recommended.

Familial hypercholesterolemia (FH) is a common genetic disorder characterized by a lifelong elevated low-density lipoprotein cholesterol (LDL-C) level. The relationship between FH and ischemic stroke is still controversial. We enrolled ischemic stroke patients prospectively in our neurological ward, and divided them into two groups according to LDL-C levels with a threshold of 130 mg/dl. Targeted sequencing was performed in all stroke patients for LDLR, APOB , and PCSK9 genes. The fifty-eight high-LDL subjects were older, prevalence of previous myocardial infarction/stroke history was lower, and the first stroke age was older compared with values in the sixty-three low-LDL cases. The prevalence of FH in Han-Chinese stroke patients was 5.0%, and was 10.3% in those with a higher LDL-C level. We identified six carriers, who had higher percentages of large vessel stroke subtype (66.7% vs. 15.4%) and transient ischemic attack (33.3% vs. 3.8%), previous myocardial infarction/stroke history (50.0% vs. 11.5%), statin use (50.0% vs. 11.5%), and increased carotid intima-media thickness (IMT) (0.9-1.2mm vs.0.7-9.0mm) compared with the other hypercholesterolemic patients without pathogenic variants. Ischemic stroke patients carrying FH pathogenic variants seemed to have a higher risk for large artery stroke and transient ischemic attack. The IMT exam could be useful to screen for FH in hypercholesterolemic stroke patients.

Objective: Intracranial vertebrobasilar artery dissection (iVBD) is an important etiology for posterior circulation ischemic stroke (PCS); however, its long-term functional outcome has been seldom reported. The present study aimed to elucidate the functional outcomes and the predictors of poor functional recovery at 1-year after iVBD-caused PCS., Methods: Patients with iVBD-caused PCS who had been recruited in the Stroke Registry of Taipei Veterans General Hospital between January 1, 2012 to February 28, 2014 were included. Multivariate analysis was used to detect predictors for poor 1-year functional recovery [modified Rankin Scale (mRS) ≥ 4]., Results: Sixty patients [age: 66.3±15.1 years; 45(75%) men] were included. At 1-year after stroke, 61.7% of patients had good functional status (mRS 0-1); however, 21.6% of patients were disabled (mRS≥4). Multivariate analyses showed that older age, cigarette-smoking history and low basilar-artery (BA) flow velocity were significantly associated with poor functional recovery independent of stroke severity at admission. The results also revealed a synergistic effect of cigarette-smoking and low BA flow on poor 1-year functional recovery: patients with both, a history of cigarette-smoking and low BA flow (≤24cm/s) had an odds ratio of 276.1 (p=0.007) leading to poor 1-year functional recovery, versus patients with neither cigarette-smoking history nor low BA flow., Conclusions: Our results suggest that adequate blood flow may be key to functional recovery after iVBDcaused PCS. Methods to improve blood flow and tissue perfusion after iVBD-caused PCS should be considered in the future clinical studies with the purpose to improve functional recovery in these patients.

Purpose: To develop and validate a scale of social functioning for people with epilepsy (PWE)-the Social and Occupational Functioning Scale for Epilepsy (SOFSE)., Methods: According to the literature review and opinions from a panel of experts, PWE, and caregivers, a total of 31 questions were compiled. Questionnaires were analyzed from 172 adults with epilepsy., Key Findings: The final scale had 30 items in six dimensions. The results showed that internal consistency coefficients and test-retest reliabilities for each dimension ranged from 0.70 to 0.84 and 0.72 to 0.89, respectively. Retest reliability for the total SOFSE score was 0.92. Seven factors were extracted through principal factor analysis. Moreover, criterion-related validity was demonstrated by the significant correlations between the SOFSE and the following measures: the Mini Mental Status Examination (r = 0.60, p < 0.001), the Quality of Life in Epilepsy-31 (r = 0.53, p < 0.001), and the Global Severity Index of the Symptom Checklist-90-Revised (r = -0.66, p < 0.001). Finally, the differences in functional competence among patients also supported the discriminant validity of the inventory., Significance: The SOFSE is a brief, psychometrically sound, and easy-to-administer measure of social functioning for use in busy clinical settings., (Wiley Periodicals, Inc. © 2013 International League Against Epilepsy.)

Vasovagal syncope is an uncommon complication during acupuncture. However, convulsive syncope during acupuncture treatment in older individuals is seldom reported in the literature. Two older patients who experienced convulsive syncope during acupuncture treatment at Taipei Veterans Hospital, Taipei, Taiwan, from January 2000 to December 2002 are reported. These cases are instructive to acupuncturists. Although acupuncture treatment is generally safe in most situations, one needs to be cautious in delivering acupuncture to older and debilitated individuals.