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Ceftazidime is a widely used third-generation cephalosporin. We report a case of ceftazidime-induced nonconvulsive status epilepticus in a patient with renal failure. A 56-year-old man experienced the gradual development of altered mentation after a diabetic foot ulcer was treated with ceftazidime. Rhythmic sharply contoured triphasic waves were evident in all electroencephalography leads. The clinical and electrographical seizures ceased after introducing antiepileptic drugs and discontinuing ceftazidime. This case demonstrates that altered mentality and nonconvulsive status epilepticus can be caused by ceftazidime in patients with renal dysfunction. J Korean Neurol Assoc 33(3):183-185, 2015

Referred pain has been observed in some patients after cordotomy, wherein noxious stimulus applied to a region rendered analgesic by cordotomy produces pain at a spot different from the one where the noxious stimulus is applied. We report a patient who had intramedullary spinal cord metastasis of extraskeletal small cell osteosarcoma, a rare form of metastatic disease, and experienced contralateral referred pain.Initially, the patient had a mass in the left posterior neck region and later developed a large extradural mass at the C3-C7 level. The masses were excised, and the histological findings led to a diagnosis of small cell osteosarcoma. He underwent chemotherapy and radiation therapy. He experienced numbness in his left leg; subsequently, the numbness slowly spread up the thigh to the left side of the abdomen. When pinched in the numb area on the left side of the body, he felt as though he had been pinched in both that area and the corresponding area on the right side. A magnetic resonance imaging scan showed an enhancing lesion in the right side of the cord at the C6-C7 level.An intramedullary spinal cord metastasis can arise from primary extraskeletal small cell osteosarcoma and cause contralateral referred pain, especially in a mirror-image location. Contralateral referred pain may be caused by a subsidiary pathway comprising ascending chains of short neurons that link the dorsal horn neurons longitudinally and latitudinally.

Background: The beneficial effects of endovascular therapy (EVT) in acute ischemic stroke have been demonstrated in recent clinical trials using new-generation thrombectomy devices. However, the comparative effectiveness and safety of preceding intravenous thrombolysis (IVT) in this population has rarely been evaluated. Methods: From a prospective multicenter stroke registry database in Korea, we identified patients with acute ischemic stroke who were treated with EVT within 8 h of onset and admitted to 14 participating centers during 2008-2013. The primary outcome was a modified Rankin Scale (mRS) score at 3 months. Major secondary outcomes were successful recanalization defined as a modified Treatment in Cerebral Ischemia score of 2b-3, functional independence (mRS score 0-2), mortality at 3 months, and symptomatic hemorrhagic transformation (SHT) during hospitalization. Multivariable logistic regression analyses using generalized linear mixed models were performed to estimate the adjusted odds ratios (ORs) of preceding IVT. Results: Of the 639 patients (male, 61%; age 69 ± 12; National Institutes of Health Stroke Scale score of 15 [11-19]) who met the eligibility criteria, 458 received preceding IVT. These patients showed lower mRS scores (adjusted common OR, 1.38 [95% CI 0.98-1.96]). Preceding IVT was associated with successful recanalization (1.96 [1.23-3.11]) and reduced 3-month mortality (0.58 [0.35-0.97]) but not with SHT (0.96 [0.48-1.93]). Conclusion: In patients treated with EVT within 8 of acute ischemic stroke onset, preceding IVT may enhance survival and successful recanalization without additional risk of SHT, and mitigate disability at 3 months.

We undertook a population-based, case-control study to examine a dose-response relationship between alcohol intake and risk of ischemic stroke in Koreans who had different alcoholic beverage type preferences than Western populations and to examine the effect modifications by sex and ischemic stroke subtypes.Cases (n = 1,848) were recruited from patients aged 20 years or older with first-ever ischemic stroke. Stroke-free controls (n = 3,589) were from the fourth and fifth Korean National Health and Nutrition Examination Survey and were matched to the cases by age (±3 years), sex, and education level. All participants completed an interview using a structured questionnaire about alcohol intake.Light to moderate alcohol intake, 3 or 4 drinks (1 drink = 10 g ethanol) per day, was significantly associated with a lower odds of ischemic stroke after adjusting for potential confounders (no drinks: reference;1 drink: odds ratio 0.38, 95% confidence interval 0.32-0.45; 1-2 drinks: 0.45, 0.36-0.57; and 3-4 drinks: 0.54, 0.39-0.74). The threshold of alcohol effect in women was slightly lower than that in men (up to 1-2 drinks in women vs up to 3-4 drinks in men), but this difference was not statistically significant. There was no statistical interaction between alcohol intake and the subtypes of ischemic stroke (p = 0.50). The most frequently used alcoholic beverage was one native to Korea, soju (78% of the cases), a distilled beverage with 20% ethanol by volume.Our findings suggest that light to moderate distilled alcohol consumption may reduce the risk of ischemic stroke in Koreans.

Background and purpose About 30%-40% of stroke patients are taking antiplatelet at the time of their strokes, which might increase the risk of symptomatic intracranial hemorrhage (SICH) with intravenous tissue plasminogen activator (IV-TPA) therapy. We aimed to assess the effect of prestroke antiplatelet on the SICH risk and functional outcome in Koreans treated with IV-TPA. Methods From a prospective stroke registry, we identified patients treated with IV-TPA between October 2009 and November 2014. Prestroke antiplatelet use was defined as taking antiplatelet within 7 days before the stroke onset. The primary outcome was SICH. Secondary outcomes were discharge modified Rankin Scale (mRS) score and in-hospital mortality. Results Of 1,715 patients treated with IV-TPA, 441 (25.7%) were on prestroke antiplatelet. Prestroke antiplatelet users versus non-users were more likely to be older, to have multiple vascular risk factors. Prestroke antiplatelet use was associated with an increased risk of SICH (5.9% vs. 3.0%; adjusted odds ratio [OR] 1.79 [1.05-3.04]). However, at discharge, the two groups did not differ in mRS distribution (adjusted OR 0.90 [0.72-1.14]), mRS 0-1 outcome (34.2% vs. 33.7%; adjusted OR 1.27 [0.94-1.72), mRS 0-2 outcome (52.4% vs. 52.9%; adjusted OR 1.21 [0.90-1.63]), and in-hospital mortality (6.1% vs. 4.2%; adjusted OR 1.19 [0.71-2.01]). Conclusions Despite an increased risk of SICH, prestroke antiplatelet users compared to non-users had comparable functional outcomes and in-hospital mortality with IV-TPA therapy. Our results support the use of IV-TPA in eligible patients taking antiplatelet therapy before their stroke onset.

Background and Purpose— The association between family history of stroke and stroke recurrence remains unclear. Methods— Using a web-based multicenter stroke registry database, information on history of stroke in first-degree relatives was collected prospectively for acute ischemic stroke patients who were hospitalized within 7 days of onset. The collected information was categorized as follows: type of the affected relative(s) with stroke (paternal, maternal, sibling, or 2 or more) and age of the relative’s stroke onset ( Results— Among 7642 patients, 937 (12.3%) had a history of stroke in their first-degree relatives and 475 (6.2%: 201 within and 274 after 3 weeks from index stroke) experienced stroke recurrence (median follow-up, 365 days). In multivariable Cox proportional hazard models, overall family history was not associated with stroke recurrence (hazard ratio, 1.08; 95% confidence interval, 0.81–1.43). However, the details of their family histories, including relative’s age at stroke onset ( Conclusions— This study suggests that elevated risks of recurrent stroke are associated with having relatives with early-onset stroke and siblings with stroke histories, implying that additional precautions may be needed in such populations.

Background: The widespread use of drip-and-ship strategy in acute ischemic stroke (AIS) is confined by the safety concerns during transfer. However, recent development of endovascular therapy (EVT) might add the advantage of higher recanalization rate to this strategy. We evaluated the effectiveness and safety of drip-and-ship versus conventional (front-door) strategy of preceding intravenous thrombolysis (IVT) in large artery occlusion stroke patients receiving EVT. Method: From a prospective multicenter stroke registry (CRCS-5) database, we identified AIS patients treated with IVT and EVT within 8 h of onset and admitted to the 14 participating centers between 2008 and 2013. Safety outcomes were symptomatic intracranial hemorrhage (sICH), and 3-month mortality. Effectiveness outcome was a 3-month modified Rankin Scale (mRS) score. We performed multivariable logistic regression analysis using generalized estimating equation to estimate adjusted odds ratio (OR) and 95% confidence interval (CI) of the drip-and-ship versus the front-door. Results: Of 16929 AIS patients registered during 64 months, 480 were treated with IVT and EVT within 8 h, and 61 (13%) were categorized into drip-and-ship group. Mean onset to IVT and IVT to EVT times were 117±51 and 187±69 minutes in drip-and-ship strategy and 127±59 and 75±38 minutes in front-door strategy, respectively. Forty-eight drip-and-ship cases were matched to 146 front-door cases by age and initial NIH stroke scale (NIHSS). Compared to the front-door cases, the drip-and-ship cases were more likely to be a habitual smoker, and treated with standard dose alteplase. sICH developed in 5.5% of the front-door strategy and 10.4% of the drip-and-ship strategy (p=0.146). After adjustment for age, initial NIHSS, pre-stroke mRS score, and variables with p Conclusion: The drip-and-ship strategy did not improve functional recovery at 3 months, and the safety issues might still exist in patients receiving EVT. However, there is a possible underestimation of initial stroke severity in drip and ship patients.

Background: Association between family history of stroke and stroke recurrence remains unclear. Methods: Using a web-based multicenter stroke registry database, information on history of stroke in first-degree relatives was collected prospectively in ischemic stroke patients hospitalized within 7 day of onset. Collected information was categorized as follows: type of affected relatives with stroke (paternal, maternal, sibling, or two or more) and age of relative’s stroke onset in relative (< 50, 50∼59, 60∼69, and ≥ 70). Stroke recurrence was captured prospectively using predetermined protocol. Subgroup analysis was performed using categories based on patient’s age at the index stroke. Results: Among 7,642 patients, 937 (12.3%) had history of stroke in their first-degree relatives, and 475(6.2%) experienced stroke recurrence (median follow-up, 365 days). In multivariate Cox proportional hazard models, overall family history was not associated with stroke recurrence (hazard ratio [HR], 1.06; 95% confidence interval [CI], 0.80-1.41). However, the details of family history, including relative’s age at stroke onset < 50 (HR, 2.15; 95% CI, 1.01-4.57) and stroke history in sibling (HR, 1.67; 95% CI, 1.09-2.57) were independently associated with stroke recurrence after adjusting for possible confounders. The associations seemed to be stronger in stroke of young adults (age, Conclusion: This study suggests that having relative with early onset stroke and sibling with history of stroke increase the risk of recurrent stroke and imply that additional precautions may be needed in such population.

Background and Purpose: Heavy alcohol consumption increases the risk for all strokes, whereas moderate regular alcohol consumption is associated with a lower risk for ischemic stroke. The effect of binge drinking on ischemic stroke has not been well known. We undertook a population-based case-control study and the purpose of this study was to evaluate the effect of the binge drinking on ischemic stroke risk. Methods: Cases were recruited from patients aged 20 over and hospitalized due to first-ever ischemic stroke which was confirmed by diffusion-weighted MRI. Stroke-free controls, obtained from the database of the 4-5th Korean National Health and Nutrition Examination Survey, were matched with the cases by age, sex and education level. All participants completed an interview using a structured questionnaire about alcohol intake. A binge drinking pattern was defined as consuming 6 or more drinks (> 60g of pure alcohol) of the same alcoholic beverage in 1 session. We confined this analysis to male subjects and non-drinkers in past year and were excluded. A conditional logistic regression models were adjusted for age, hypertension, diabetes, coronary artery disease, hyperlipidemia, body mass index and smoking habit. The frequent drinking was defined as 4 times or more a week. Results: Case (n=682) and control (n=1592) were included in this analysis. The binge drinking habit was found in 365 (53.5%) of the cases and 495 (31.1%) of the controls. Compared with non-binge drinkers, the odd ratio for ischemic stroke among binge drinkers was 2.96 (95% CI, 2.18-4.03) after adjusting the confounders. Compared with non-binge drinkers, the harmful association with ischemic stroke in occasional binge drinkers who drank less than 4 times a week (OR 2.31, 95%CI 1.61-3.31) and in frequent binge drinker who drank 4 times or more a week (OR 4.25, 95%CI 2.79-6.48). Conclusions: This result suggests that a binge drinking habit may have a harmful effect on ischemic stroke.

Introduction: Predicting outcomes of acute stroke patients initially presenting with mild neurologic deficits is important in making decision for thrombolytic therapy. Previous researches with a small sample size have failed to find specific items of NIH Stroke Scale or clinical syndromes to be predictive of functional outcome. Hypothesis: We hypothesized that certain items of the NIH Stroke Scale or their combinations would be independently associated with unfavorable functional outcome after mild stroke Methods: Using a multicenter stroke registry database, we identified patients with acute ischemic stroke who presented within 4.5 hours of symptom onset and had initial NIH Stroke Scale scores ≤ 5. Functional outcomes at three months after the stroke were classified as favorable (modified Rankin Scale score [mRS] 0 to 1) or unfavorable (mRS 2-6). The individual NIH Stroke Scale items were dichotomized as absent (0) or present (≥1) for the analysis. The NIH Stroke Scale items and the total score were tested for predicting the outcomes in multivariable models adjusting for demographics and clinical characteristics. Area under the ROC curve (AUC) was used to assess the performance of multivariable models. Results: Among 2,209 patients who met the eligible criteria, 588 patients (26.6%) exhibited unfavorable functional outcome (mRS 2-6) at three months. The most frequently present items were item 10 (dysarthria, 37.5%), item 4 (facial palsy, 21.1%), item 8 (sensory, 15.0%), and items indicating limb paralysis. Among 15 items of NIH Stroke Scale, all items except for item 8 (sensory) and item 11 (extinction) were significantly associated with unfavorable functional outcomes in bivariate analysis (P Conclusions: Simply using the total score was as effective as using all NIH Stroke Scale items in predicting outcomes of patients presented with mild stroke symptom.

Introduction: The utilization of drip-and-ship thrombolysis paradigm, clinical characteristics and outcomes of patients treated with the paradigm could vary with regional stroke care system. Hypothesis: We hypothesized that clinical characteristics and functional outcomes of patients treated with drip-and-ship paradigm would be different from those of patients treated via direct visit. Methods: From a multicenter stroke registry, we identified acute ischemic stroke patients treated with tPA who arrived hospital within 6 hours from the symptom onset. Functional outcomes at three months after the stroke were classified as favorable (modified Rankin Scale score [mRS] 0 to 1) or unfavorable (mRS 2-6). Using multivariable analysis, we compared the modified Rankin scale (mRS) score at 3 months and symptomatic intracranial hemorrhages (SICH) between patients treated with drip-and-ship paradigm and those treated via direct visit. Results: Among 1,843 patients who met the eligible criteria, 244 patients (13.2%; 95% CI, 11.7-14.9) were treated using drip-and-ship paradigm. Patients treated with drip-and-ship paradigm had shorter onset to needle time compared with patients treated via direct visit (median[IQR], 110 minutes[79-150] vs 126 minutes[90-173], p Conclusions: Drip-and-ship thrombolysis paradigm was used in less than 15% of patients treated with tPA, and use of the paradigm caused a significant delay in onset to groin puncture time for endovascular therapy.

Although a positive association between body mass index (BMI) and stroke incidence has been reported, having a higher BMI is known to be advantageous in surviving and recovering from stroke. The association between adiposity and stroke incidence is more evident for measures of abdominal obesity than for general obesity. The aim of our study was to compare BMI, waist circumference, and waist-height ratio (WHR) as predictors of 3-month functional outcome in stroke patients. The BMI, waist circumference, and WHR of acute stroke patients were divided into sex-specific quartiles. A total of 605 female and 727 male patients were included. For BMI, male patients in the second quartile were more likely to have a favorable functional outcome compared with those in the lowest quartile (adjusted OR 1.64, 95% CI 1.02–2.62). For waist circumference (adjusted OR for top quartile vs. lowest quartile 1.79, 95% CI 1.14–2.82) and WHR (adjusted OR for second quartile vs. lowest quartile 1.99, 95% CI 1.22–3.25), male patients in the two top quartiles were more likely to have a favorable functional outcome compared with those in the respective lowest quartile. BMI and WHR showed similar relationships to a favorable functional outcome, with a favorable functional outcome occurring most often among male patients in the second quartiles. In women, however, obesity was not related to functional outcome. In conclusion, general obesity measured by BMI and abdominal obesity measured by WHR showed similar effects on the functional outcome after stroke in men.

Enterococci are uncommon etiologic agents of central nervous system infections. We describe a case of nosocomial encephalitis and concurrent cerebellitis associated with Enterococcus faecium in a man, with extranodal natural killer/T-cell lymphoma, nasal type, who underwent high-dose chemotherapy and autologous peripheral blood stem cell transplantation. Brain magnetic resonance images showed lesions in the bihemispheral cerebellar cortex with swelling and several small lesions in both cerebral hemispheres. The blood and cerebrospinal fluid cultures were positive for vancomycin-resistant E. faecium. Vancomycin-resistant E. faecium can cause encephalitis and concurrent cerebellitis in an immunocompromised patient who underwent autologous peripheral blood stem cell transplantation.

Left ventricular (LV) mass and LV geometry are well-established measures of hypertension chronicity and severity, have a prognostic value on cardiovascular morbidity and mortality, and are related to asymptomatic cerebral small-artery disease (SAD) and largeartery disease (LAD). The aim of the present study was to clarify the different effects of LV mass and LV geometry on underlying SAD compared with its effects on underlying LAD in ischemic stroke patients. Four hundred three ischemic stroke patients underwent echocardiography to determine LV mass index and relative wall thickness. Brain magnetic resonance imaging, angiography, and carotid magnetic resonance angiography were preformed to detect LAD (≥50% stenosis) and SAD (leukoaraiosis, microbleeds, and old lacunar infarction) in the brain. Multivariate analyses showed that the LV mass index was highly associated with underlying SAD but not with underlying LAD. Among the various subtypes of SAD, only cerebral microbleeds were closely related to the LV mass index. Concentric LV hypertrophy was not related to the presence of either SAD or LAD. Subgroup analyses revealed that, among the various subtypes of SAD, only cerebral microbleeds were associated with concentric LV hypertrophy. In conclusion, cerebral microbleeds may imply more advanced target organ damage than underlying LAD and ischemic subtypes of SAD.

Focal motor status epilepticus (FMSE) is often associated non-ketotic hyperglycemia (NKH). There are no previous reports describing FMSE with NKH that was accompanied by an acute cerebral infarction and its long term follow-up result. We describe the case of a patient having focal motor status epilepticus (FMSE) associated with non-ketotic hyperglycemia (NKH) and acute cerebral infarction who later developed recurrent unprovoked seizures. A small acute infarct was observed in the left frontal subcortical area on diffusion-weighted images (DWI). FMSE was initially controlled with short term antiepileptic drugs and strict glucose control. Two years later, recurrent seizures occurred, and long-term antiepileptic drug treatment was administered. DWI should be considered for acute cerebral infarction in patients having FMSE associated with NKH, and careful follow-up should be conducted for such patients.

Early initiation of heparin therapy for treatment of stroke is not only associated with an improved outcome, but also with the risk of hemorrhagic transformation. We compared the efficacy of three unfractionated heparin bolus regimens (0 U/kg, 30 U/kg, or 80 U/kg) in achieving a therapeutic activated partial thromboplastin time over the first 6-hour period in a cohort of 54 patients admitted with transient ischemic attack or stroke. Patients treated with the low bolus dose (30 U/kg) were more often within the therapeutic range for activated partial thromboplastin time at two hours after the initial bolus than patients treated with the other regimens. The percentage of therapeutic activated partial thromboplastin time results within the first six hours of treatment was greater in the group treated with the low bolus dose. Using the low bolus dose may reduce complication rates and improve clinical outcomes in the future clinical trials.

Objective:Clopidogrel napadisilate has better chemical stability than clopidogrel bisulfate. Our trial’s objective was to compare the efficacy and safety of clopidogrel napadisilate with clopidogrel bisulfate in participants with ischemic stroke.Research design and methods:The study was a phase 4, 4 week, randomized, parallel-group, non-inferiority trial. Patients with ischemic stroke were randomized to receive either clopidogrel napadisilate 75 mg or clopidogrel bisulfate 75 mg. The primary study endpoint was change from baseline in P2Y12 percentage inhibition at week 4. The primary analysis was conducted in the per-protocol population. Non-inferiority was confirmed if the lower limit of the 95% confidence interval (CI) of the treatment difference was greater than or equal to −9.0% points.Results:Sixty-one participants were randomly assigned clopidogrel napadisilate and 60 were randomly assigned clopidogrel bisulfate. Thirty-nine participants in the clopidogrel napadisilate group and 39 in the clopidogrel bisulfate group were analyzed for the primary endpoint. At 4 weeks, mean P2Y12 percentage inhibition had increased in both treatment groups. The estimated mean change from baseline was 22.3% with clopidogrel napadisilate and 21.4% with clopidogrel bisulfate; the estimated treatment difference of 0.9% (95% CI, −8.6 to 10.4) confirmed the non-inferiority of clopidogrel napadisilate to clopidogrel bisulfate.Conclusions:Clopidogrel napadisilate was non-inferior to clopidogrel bisulfate as assessed by change in P2Y12 percentage inhibition. Rates of adverse events were similar between the two groups. Therefore, clopidogrel napadisilate is a useful alternative option for the dosing of ischemic stroke patient populations.

Background and Purpose— Selecting among different antiplatelet strategies when patients experience a new ischemic stroke while taking aspirin is a common clinical challenge, currently addressed by a paucity of data. Methods— This study is an analysis of a prospective multicenter stroke registry database from 14 hospitals in South Korea. Patients with acute noncardioembolic stroke, who were taking aspirin for prevention of ischemic events at the time of onset of stroke, were enrolled. Study subjects were divided into 3 groups according to the subsequent antiplatelet therapy strategy pursued; maintaining aspirin monotherapy (MA group), switching aspirin to nonaspirin antiplatelet agents (SA group), and adding another antiplatelet agent to aspirin (AA group). The primary study end point was the composite of stroke (ischemic and hemorrhagic), myocardial infarction, and vascular death up to 1 year after stroke onset. Results— A total of 1172 patients were analyzed for this study. Antiplatelet strategies pursued in study patients were MA group in 212 (18.1%), SA group in 246 (21.0%), and AA group in 714 (60.9%). The Cox proportional hazards regression analysis showed that, compared with the MA group, there was a reduction in the composite vascular event primary end point in the SA group (hazard ratio, 0.50; 95% confidence interval, 0.27–0.92; P =0.03) and in the AA group (hazard ratio, 0.40; 95% confidence interval, 0.24–0.66; P Conclusions— This study showed that, compared with maintaining aspirin, switching to or adding alternative antiplatelet agents may be better in preventing subsequent vascular events in patients who experienced a new ischemic stroke while taking aspirin.

Background Patients with acute ischemic stroke (AIS) are at high risk of subsequent vascular events. The aim of this study was to estimate rates of recurrent stroke, myocardial infarction (MI), and major vascular events during the first year after AIS in Korea. Methods Through a multicenter stroke registry in Korea, 12,227 consecutive cases of AIS were identified between November 2010 and May 2013 and were followed up for recurrent stroke, MI, and major vascular events up to 1 year after stroke. Results Cumulative 30-day, 90-day and 1-year rates were 2.7%, 3.9%, and 5.7% for recurrent stroke; .1%, .3%, and .5% for MI; and 8.1%, 10.6%, and 13.7% for major vascular events, indicating that the early period is at high risk of recurrent stroke and major vascular events. The risk of recurrent stroke was substantially higher than the risk of MI: 13.0 times at 90 days and 11.4 times at 1 year. Compared to those with small-vessel occlusion (SVO), those with ischemic stroke subtypes other than SVO had a higher risk of recurrent stroke as well as major vascular events. Other common independent predictors for recurrent stroke and major vascular events were diabetes and prior stroke history. Conclusions During the first year after AIS, one in 18 had recurrent stroke and one in 7 major vascular events. More than two thirds of recurrent stroke and three quarters of major vascular events developed within 90 days in a Korean cohort of stroke patients. Better prevention strategies are required for high-risk patients during this high-risk period.

Background Experimental studies suggest that pre-stroke statin treatment has a dual effect of neuroprotection during ischemia and neurorestoration after ischemic injury. The aim of this study was to evaluate the effect of pre-stroke statin use on initial stroke severity and early clinical outcome. Methods We used a prospective database enrolling patients with acute ischemic stroke from 12 hospitals in Korea between April 2008 and January 2012. Primary endpoint was the initial stroke severity as measured by the National Institutes of Health Stroke Scale (NIHSS) score. Secondary endpoints were good outcome (modified Rankin Scale [mRS], 0–2) and overall mRS distribution at discharge. Multivariable regression model and propensity score (PS) matching were used for statistical analyses. Results Among the 8340 patients included in this study, 964 patients (11.6 %) were pre-stroke statin users. The initial NIHSS score (mean [95 % CI]) was lower among pre-stroke statin users vs. non-users in multivariable analysis (5.7 [5.2–6.3] versus 6.4 [5.9–6.9], p = 0.002) and PS analysis (5.2 [4.7–5.7] versus 5.7 [5.4–6.0], p = 0.043). Pre-stroke statin use was associated with increased achievement of mRS 0–2 outcome (multivariable analysis: OR [95 % CI], 1.55 [1.25–1.92], p

Background and Purpose— The low-dose (0.6 mg/kg) alteplase strategy to treat acute ischemic stroke patients became widespread in East Asian countries, without rigorous testing against standard-dose (0.9 mg/kg) alteplase treatment. Our aim was to investigate the comparative effectiveness and safety of the low-dose versus standard-dose intravenous alteplase strategy. Methods— A total of 1526 acute ischemic stroke patients who qualified for intravenous alteplase and treated within 4.5 hours were identified from a prospective, multicenter, and nationwide stroke registry database. Primary outcomes were a modified Rankin scale score of 0 to 1 at 3 months after stroke and occurrence of symptomatic hemorrhagic transformation. Inverse probability of low-dose alteplase weighting by propensity scores was used to remove baseline imbalances between the 2 groups, and variation among centers were also accounted using generalized linear mixed models with a random intercept. Results— Low-dose intravenous alteplase was given to 450 patients (29.5%) and standard-dose intravenous alteplase to 1076 patients (70.5%). Low-dose alteplase treatment was comparable to standard-dose therapy according to the following adjusted outcomes and odds ratios (95% confidence intervals): modified Rankin scale score 0 to 1 at 3 months and 0.95 (0.68–1.32); modified Rankin scale 0 to 2 at 3 months and 0.84 (0.62–1.15); symptomatic hemorrhagic transformation and 1.05 (0.65–1.70); and 3-month mortality and 0.54 (0.35–0.83). The associations were unchanged when the analysis was limited to those without endovascular recanalization. Conclusions— The low-dose alteplase strategy was comparable to the standard-dose treatment in terms of the effectiveness and safety.

Background and PurposezzA substantial proportion of patients with atrial fibrillation (AF) are not treated optimally; however, the inappropriateness of drug therapy has never been evaluated before or after a stroke event. We investigated the adherence to guidelines for ther apy in AF patients hospitalized with acute ischemic stroke (AIS) before stroke onset and at discharge, with the aim of identifying the factors associated with inappropriate therapy. MethodszzAIS patients with AF hospitalized within 7 days of onset were identified from a prospective nine-center stroke registry database. Two cohorts were defined: patients diag nosed with AF prior to the stroke event (admission cohort) and patients diagnosed with AF at discharge from hospital (discharge cohort). Any of the following conditions were regarded as nonadherence to guidelines in this study: use of anticoagulant or nonuse of antithrombotics with CHADS2 score=0, nonuse of antithrombotics with CHADS2 score=1, or nonuse of anticoagulant with CHADS2 score ≥2. ResultszzOverall, 406 patients were enrolled in the admission cohort and 518 in the discharge cohort. The rates of nonadherence before a stroke event and at discharge were 77.8% and 33.3%, respectively. These rates varied widely for both cohorts, with interhospital differ ences being statistically significant. Multivariable analysis revealed that old age, stroke histo ry, and congestive heart failure were associated with nonadherence before stroke. At discharge, males, coronary heart disease, inappropriate antithrombotic use before stroke, and functional disability at discharge were associated with nonadherence. ConclusionszzThis study shows that antithrombotic use in AIS patients with AF might be not optimal before and after stroke in Korea.

Background: The low-dose (0.6 mg/Kg) alteplase strategy to treat acute ischemic stroke patients became widespread in East Asian countries, without rigorous testing against the concurrent standard-dose (0.9 mg/Kg) regimen. The aim of the current study was to investigate the comparative effectiveness and safety of low-dose alteplase treatment against standard dose regimen. Methods: A total of 1572 acute ischemic stroke patients who arrived within 4.5 hours from their last seen normal and treated with alteplase between November 2009 and March 2013 were identified from a prospective, multicenter and nationwide stroke registry database containing 15814 case records. Acute stroke management including the decision on the dose of alteplase was performed according to the current guideline and the attending physicians’ discretion. Inverse probability of low-dose strategy weighting (IPTW) by the propensity score was primarily utilized to remove baseline imbalance between the two doses. Results: From a total of 1572 cases who met the eligibility criteria, low-dose alteplase was infused in 464 (29.5%) subjects and standard-dose in 1108 (70.5%) cases. Low-dose group showed shorter onset-to-arrival delay, higher NIHSS score at arrival, and more frequent endovascular treatment. The balance between alteplase doses were adequately balanced using IPTW technique, and the low-dose alteplase treatment was not associated with a mRS score of 0 - 1 at 3 months and with symptomatic HT or 3-month mortality (see Figure A). When the analyses were limited to the subgroup without endovascular treatment, the neutral associations with mRS score 0 - 1 and symptomatic HT were retained but the odds for 3-month mortality was significantly lower in the low-dose alteplase group (see Figure B). Conclusion: The low-dose alteplase strategy was as comparable as the standard-dose treatment in terms of the effectiveness and safety, also with possibly decreasing 3-month mortality.

Objective: This study aimed to describe clinical outcomes in patients treated with intravenous (IV) tPA according to evidence of previous Intracranial hemorrhage (ICH) and investigate the associations between previous ICH and clinical outcomes. Methods: Using a prospective multicenter stroke registry database, we identified acute ischemic stroke patients who were hospitalized to the 14 participating centers between January 2011 and July 2013 and were treated with IV tPA within 4.5 h of onset. Presence of previous ICH was screened using the formal radiologic reports or the clinical history of ICH from the registry database. If suspected, previous ICH was confirmed through direct review of brain MRI. As clinical outcomes, modified Rankin scale (mRS) 0-1 at discharge, mortality during hospitalization and symptomatic hemorrhagic transformation (sHT) were collected. sHT was defined according to the definition of SITS-MOST trial. Results: Among 1495 patients who were treated with IV tPA, 70 (4.7%) had evidence of previous ICH. sHT developed in 69 (4.6%) of all subjects; 7.1% (n=5) of 70 patients with previous ICH and 4.5% (n=64) of 1425 without previous ICH (p=0.25 on Fisher’s exact test). Hospital Mortality and mRS 0-1 at discharge was observed in 5.6% and 26.6% of all subjects and in 8.6% and 22.9% of those with previous ICH and 5.4% and 26.7% in those without it (p=0.28 on Fisher’s exact test and p=0.47 on Pearson’s chi-squared test, respectively). Multivariable logistic regression analysis with adjustment for age, initial National Institute of Health Stroke Scale, initial glucose and tPA dose showed that previous ICH was not associated with sHT, mortality during hospitalization and having discharge mRS 0-1 (p’s >0.4). Review of MRI on 5 patients who had previous ICH and developed sHT after IV tPA demonstrated that, in 4 cases, location of sHT was different from where previous ICH had developed, but in 1 case sHT occurred exactly where previous ICH had developed. Conclusions: This study shows that previous ICH may not increase the risk of sHT and death and aggravate functional outcome at discharge. However, it should be noted that the retrospective nature and small sample size of this study limit the generalization of its results.

Background: Since the introduction of intravenous (IV) heparin for the treatment of acute ischemic stroke in 1941, its use has been an area of great controversy among neurologists. Current American Heart Association guideline does not recommend IV heparin for the treatment of acute ischemic stroke. We sought to obtain updated information regarding the practices of Korean neurologists with regard to acute heparin use. Methods: Based on a prospective multicenter stroke registry database (CRCS-5), we collected patients with acute ischemic stroke, arrived within 7 days of symptom onset, from 2008 to 2013. Patient’s demographics, medical history and stroke characteristics were compared between IV heparin user and non-user. Results: Total of 23,425 patients from 12 regional stroke centers or university hospitals across the nation was analyzed. The mean age was 67.8 years and 58.1% was male. Median initial NIHSS score was 4 (interquartile range, 2 - 9). Large artery atherosclerosis was the most common cause of acute ischemic stroke (37.1%), followed by cardioembolism (21.9%), and small-vessel occlusion (18.9%). During the study period, use of IV heparin decreased; 9.7% in 2008; 10.9% in 2009; 9.4% in 2010; 6.0% in 2011; 4.7% in 2012; 4.3% in 2013 (p for trend < 0.001). The most prominent reduction was observed between 2010 and 2011, just after the first release of the Korean Stroke Guidelines in October, 2009. Cardioembolism (17.1%) and stroke of two or more causes (15.3%) were associated with IV heparin, and the decrease of IV heparin use in these stroke subtypes was a major contributor of the decrease in general. Age (age ≥ 75, 7.5%; age

We aimed to examine whether direct access to hospitals offering intravenous thrombolysis is associated with functional outcomes in patients with acute ischemic stroke treated with intravenous thrombolysis. We enrolled patients who received intravenous thrombolysis within 4.5hours of symptom onset using a prospective multicenter registry database. Patients referred directly from the field to organized stroke centers were compared with those who were transferred from non-thrombolysis-capable hospitals in terms of clinical outcomes at 90days after intravenous recombinant tissue plasminogen activator treatment. We also investigated onset-to-door time and onset-to-needle time according to admission mode. A total of 820 patients (mean age of 67.3years and median National Institutes of Health Stroke Scale score of 9) were enrolled. Seventeen percent of patients with AIS who received intravenous thrombolytic therapy at 12 hospitals (n=142) were transferred from other hospitals. The direct admission group had a shorter median onset-to-admission time (63 versus 121minutes, P

Background One third of patients presenting with initially mild strokes have unfavorable outcomes, and the efficacy of intravenous thrombolysis ( IVT ) in this population has not been proven. This study aimed to evaluate the comparative effectiveness of standard care with IVT versus without IVT in mild stroke patients. Methods and Results Using a multicenter stroke registry database, we identified patients with acute ischemic stroke who presented within 4.5 hours of symptom onset and had initial National Institutes of Health Stroke Scale scores ≤5. Multivariable logistic analysis and propensity score matching were used to adjust for baseline imbalances between the patients who did and did not receive IVT . Adjusted odds ratios and 95% CI s of IVT were estimated for 3‐month modified Rankin Scale scores of 0 to 1 and symptomatic. Of 13 117 patients with stroke who were hospitalized between April 2008 and May 2012, 1386 met the eligibility criteria, and 194 (14.0%) were treated with IVT . For a modified Rankin Scale of 0 to 1 at 3 months, the adjusted odds ratios were 1.96 (95% CI , 1.28 to 3.00; P =0.002) by multivariable logistic analysis and 1.68 (1.10 to 2.56; P =0.02) by propensity score matching analysis, respectively. There was a statistically nonsignificant excess of symptomatic hemorrhagic transformation (odds ratios=3.76 [0.95 to 16.42; P =0.06] and 4.81 [0.84 to 49.34; P =0.09]), respectively. Conclusions In this observational registry‐based study, standard care with IVT is more effective than not receiving IVT in mild ischemic stroke patients, and there is a statistically nonsignificant risk of symptomatic hemorrhagic transformation.

Cerebral small-vessel disease is an important cause of a hemorrhagic stroke (HS) or a certain type of ischemic stroke (IS). Using magnetic resonance imaging, the frequency and the pattern of ischemic lesions between an HS group and an IS group were compared. Sixty-eight patients with HS and 104 patients with IS as a control group were enrolled in this study. The rate of grade 2 and 3 periventricular white matter lesions (WML) in the HS group was similar to that in the IS group. However, grade 2 and 3 lacunes (LAC) were more frequent in the HS group. These results show that the incidence of concomitant silent LAC is different from that of WML in HS patients. This suggests that the pathophysiology of WML and that of LAC is different and that the pathophysiology of HS is closely associated with that of LAC.

Background and Purpose— We aimed to generate rigorous graphical and statistical reference data based on volumetric measurements for assessing the relative severity of white matter hyperintensities (WMHs) in patients with stroke. Methods— We prospectively mapped WMHs from 2699 patients with first-ever ischemic stroke (mean age=66.8±13.0 years) enrolled consecutively from 11 nationwide stroke centers, from patient (fluid-attenuated-inversion-recovery) MRIs onto a standard brain template set. Using multivariable analyses, we assessed the impact of major (age/hypertension) and minor risk factors on WMH variability. Results— We have produced a large reference data library showing the location and quantity of WMHs as topographical frequency-volume maps. This easy-to-use graphical reference data set allows the quantitative estimation of the severity of WMH as a percentile rank score. For all patients (median age=69 years), multivariable analysis showed that age, hypertension, atrial fibrillation, and left ventricular hypertrophy were independently associated with increasing WMH (0–9.4%, median=0.6%, of the measured brain volume). For younger (≤69) hypertensives (n=819), age and left ventricular hypertrophy were positively associated with WMH. For older (≥70) hypertensives (n=944), age and cholesterol had positive relationships with WMH, whereas diabetes mellitus, hyperlipidemia, and atrial fibrillation had negative relationships with WMH. For younger nonhypertensives (n=578), age and diabetes mellitus were positively related to WMH. For older nonhypertensives (n=328), only age was positively associated with WMH. Conclusions— We have generated a novel graphical WMH grading (Kim statistical WMH scoring) system, correlated to risk factors and adjusted for age/hypertension. Further studies are required to confirm whether the combined data set allows grading of WMH burden in individual patients and a tailored patient-specific interpretation in ischemic stroke-related clinical practice.

Despite recent technical advances in endovascular recanalization, there is skepticism regarding its clinical effectiveness compared with intravenous thrombolysis for treating acute ischemic stroke. We aimed to delineate its effectiveness and safety and their change over time.Using a prospective, multicenter stroke registry database, we identified 872 patients with ischemic stroke who underwent recanalization therapy with intravenous thrombolysis alone (IVT; n = 533) or endovascular recanalization with or without intravenous thrombolysis (EVT; n = 339) between April 2008 and January 2012. All subjects had National Institute of Health Stroke Scale score of 10 or more and arrived at the hospital within 4.5 hours of onset. Propensity score was used to address baseline imbalances between treatment groups, but balance adjustment was not performed for subgroup analyses.The primary outcome was modified Rankin Scale score of 0-2 at discharge. The year-by-year effectiveness and safety of EVT and IVT were compared. Before 2010, the primary outcome was not associated with the recanalization method. However, in 2011, EVT increased the odds of having a primary outcome compared with IVT (adjusted odds ratio [OR], 1.87; 95% confidence interval [CI], 1.08-3.23). In 2011, EVT was superior to IVT regarding the achievement of a favorable outcome at 3 months after stroke (OR, 1.99; 95% CI, 1.10-3.59). The odds of in-hospital mortality and 3-month mortality were not different over 4 years.There might have been a change in the effectiveness of endovascular recanalization compared with intravenous thrombolysis, but the results remain tentative until prospectively evaluated.

BACKGROUND AND PURPOSE In order to improve inter-rater reliability and minimize diagnosis of undetermined etiology for stroke subtype classification, using a stroke registry, we developed and implemented a magnetic resonance imaging (MRI)-based algorithm for acute ischemic stroke subtype classification (MAGIC). METHODS We enrolled patients who experienced an acute ischemic stroke, were hospitalized in the 14 participating centers within 7 days of onset, and had relevant lesions on MR-diffusion weighted imaging (DWI). MAGIC was designed to reflect recent advances in stroke imaging and thrombolytic therapy. The inter-rater reliability was compared with and without MAGIC to classify the Trial of Org 10172 in Acute Stroke Treatment (TOAST) of each stroke patient. MAGIC was then applied to all stroke patients hospitalized since July 2011, and information about stroke subtypes, other clinical characteristics, and stroke recurrence was collected via a web-based registry database. RESULTS The overall intra-class correlation coefficient (ICC) value was 0.43 (95% CI, 0.31-0.57) for MAGIC and 0.28 (95% CI, 0.18-0.42) for TOAST. Large artery atherosclerosis (LAA) was the most common cause of acute ischemic stroke (38.3%), followed by cardioembolism (CE, 22.8%), undetermined cause (UD, 22.2%), and small-vessel occlusion (SVO, 14.6%). One-year stroke recurrence rates were the highest for two or more UDs (11.80%), followed by LAA (7.30%), CE (5.60%), and SVO (2.50%). CONCLUSIONS Despite several limitations, this study shows that the MAGIC system is feasible and may be helpful to classify stroke subtype in the clinic.

We aimed to describe the current status and clinical outcomes of recanalization therapy for internal carotid artery occlusion (ICAO) presenting as acute ischemic stroke.Using a nationwide stroke registry database in Korea, we identified consecutive ischemic stroke patients with ICAO hospitalized within 12 hours of onset between March 2010 and November 2011.ICAO accounted for 10.6% (322 of 3028) of acute ischemic strokes within 12 hours of onset. Among the 322 ICAO patients, 53% underwent recanalization therapy, 41% intravenous thrombolysis (IVT) alone, and 59% endovascular treatment (EVT). Twenty-two percent of those with mild deficits (National Institutes of Health Stroke Scale4) and 50% of those 80 years of age or more received recanalization therapy. Compared with no treatment, recanalization therapy was not significantly associated with a favorable outcome (3-month modified Rankin scale, 0-2) (adjusted odds ratio [OR], 1.77; 95% confidence interval [CI], .80-3.91; P = .16). However, compared with IVT, EVT significantly improved the odds of favorable outcome (OR, 2.86; 95% CI, 1.19-6.88; P = .02) without significant increase of symptomatic intracranial hemorrhage (OR, 2.18; 95% CI, .42-11.43; P = .36) and 3-month mortality (OR, .53; 95% CI, .23-1.18; P = .12). Successful recanalization rate (Thrombolysis in Cerebral Infarction ≥2a) by EVT was 76%.In Korea, one tenth of acute ischemic stroke was caused by ICAO, and about 50% were treated by recanalization therapy. EVT was widely used as a recanalization modality (about 60% of cases) despite lack of evidence. However, its effectiveness and safety were acceptable.

Background: Intracranial arterial stenosis (ICAS) is a major cause of ischemic stroke in Asians. Despite the clinical importance of ICAS, the literature on the natural history of ICAS has been less enlightening. The aims of our study were to evaluate a long-term natural course of symptomatic and asymptomatic ICAS. Methods: 102 subjects (37 symptomatic and 65 asymptomatic) underwent follow-up MR angiography (MRA) with a median time interval between initial and follow-up MRA of 5.7 years (range 3.6-8.5 years). For each patient, the extent of stenosis of five arteries (both middle cerebral arteries, both intracranial internal carotid arteries, and basilar artery) was classified according to five grades, by consensus: normal, mild (signal reduction Results: Mean (Standard deviation) age at initial MRA was 63.5 (9.6) and 54% were men. The progression rate of ICAS differed significantly between symptomatic and asymptomatic patients (22 vs. 8%, p < 0.01), indicating a 3-fold risk of progression for symptomatic stenosis compared with asymptomatic stenosis [odds ratio (OR) 3.27, 95% confidence interval (CI) 1.08-9.95]. After adjustment for propensity score, the OR was 4.84 (95% CI, 1.40-16.7). In the matched cohort, the relative risk of stenosis progression was 5.20 for symptomatic stenosis (95% CI 1.00-27.23) compared with asymptomatic stenosis. Conclusion: We found a greater risk of progression for symptomatic stenosis compared with asymptomatic stenosis.

Background: Heavy alcohol intake has consistently been identified as a risk factor for all type of stroke, whereas the effect of moderate drinking is less certain. Previous researches have limitation in declaring the dose-response relationship between alcohol intake and stroke because of the heterogeneity of stroke subtypes, the potential different effects across sex, race/ethnic group and the amounts of alcohol consumed. Objective: To determine the dose-response relationship between alcohol intake and risk of ischemic stroke in Korean population. Methods: We undertook a prospective multicenter matched case-control study in 9 hospitals between January 2011 and January 2012. Cases were patients hospitalized due to first-ever ischemic stroke within 7 days of onset, confirmed by diffusion-weighted MRI. Controls, obtained from the database of the 4th Korean National Health and Nutrition Examination Survey (KNHANES IV-V, between 2007-2010), had no history of stroke, and were matched with cases for age (± 3 years), sex and education level. All participants completed an interview using structured questionnaire about alcohol intake and past medical history. Results: During the study period, 1848 cases (mean age, 66.1 years; male, 58.9%) were enrolled and were matched to 3589 controls. Conditional logistic regression analysis found that light to moderate alcohol intake, up to 3-4 drinks (drink=10g ethanol) per day, was significantly protective for ischemic stroke after adjusting for hypertension, diabetes, hyperlipidemia, current smoking and body mass index ( Conclusion: Our findings suggest that light to moderate alcohol intake is associated with reduced risk of ischemic stroke and the margin of its protective effect may be different between men and women in the Korean population.

Background: Experimental studies suggest that prestroke statin treatment has dual effect of neuroprotection during ischemia and neurorestoration after ischemic injury. However, human clinical stroke studies of small to modest sample sizes have shown inconsistent results regarding these effects. Methods: We analyzed the Clinical Research Center for Stroke-5 data set for patients hospitalized with acute ischemic stroke in 12 academic hospitals between April 1, 2008 and January 31, 2012. Primary endpoint was the initial stroke severity as measured by the National Institutes of Health Stroke Scale (NIHSS) score. Secondary endpoints were mRS 0-2 proportion and overall distribution of mRS outcomes at discharge. Propensity score (PS) analysis were used to adjust baseline characteristics between statin users and non-users in addition to multivariable analyses. Results: Among 8,340 patients included in this study (age, 67±13 years; men, 59.6%; initial median NIHSS score [interquartile range, IQR], 3 [2-7]), 964 patients (11.6%) were taking statins before the index stroke. Prestroke statin users had significantly lesser initial NIHSS score than that of non-users (unadjusted mean [95% CI], 4.6 [4.3-4.9] versus 5.4[5.3-5.6], p Conclusions: Prestroke statin use was independently associated with lesser stroke severity at presentation and better early functional outcome, suggesting dual effect of neuroprotection and neurorestoration in human clinical strokes.

Background: There is skepticism in clinical practice about the comparative effectiveness of endovascular recanalization compared to intravenous thrombolysis for acute ischemic stroke, and there is a paucity of information about effectiveness and safety trends. Methods: We identified 872 acute ischemic stroke patients who underwent recanalization therapy with intravenous thrombolysis only (IVT; n=533) or endovascular recanalization with or without intravenous thrombolysis (EVT; n=339) from a prospective, multicenter stroke registry database between April 2008 and January 2012. All study subjects had NIHSS score ≥10 and arrived within 4.5 hours of onset. Inverse probability of EVT weighting by propensity score was used to remove baseline imbalance between treatment groups. Primary outcome was mRS score 0 – 2 at the time of discharge. Year-by-year effectiveness and safety of EVT over IVT were estimated with further adjustment by age, NIHSS score, onset to arrival time, duration of hospitalization and treatment year. Results: Before 2010, the primary outcome was not associated with treatment modality. However in 2011, EVT increased the odds of better primary outcome compared to IVT (adjusted OR, 1.87; 95% CI, 1.08 – 3.23). Also in year 2011, EVT became superior to IVT for mRS score 0 – 2 (1.99; 1.10 – 3.59) at 3 months after stroke. The odds of mortality during admission and at 3 month and symptomatic hemorrhagic transformation were not different between recanalization methods throughout the study period (see Figure). Subgroup analyses showed that effect estimates from EVT were significantly modified by total stroke volume of hospital (higher in ≥30 stroke cases per month) and time from onset to arrival (higher in ≥2-hour delay). Conclusion: Over time, endovascular recanalization has become superior to intravenous thrombolysis for improvement of clinical outcomes in acute ischemic stroke.

Background: One third of patients with initially mild strokes have unfavorable outcome, and the efficacy of intravenous thrombolysis (IVT) in those patients has not proven. This study aimed to evaluate the comparative effectiveness of IVT over no thrombolysis in patients with mild ischemic stroke presenting within 4.5 hours of onset. Methods: From a multicenter prospective stroke registry database, we identified acute ischemic stroke patients (1) who were aged 18 years or more, (2) whose neuroimaging confirmed relevant acute ischemic lesions, (3) who were presented within 4.5 hours of onset, and (4) whose initial NIHSS scores were 5 points or less. Matching and inverse probability of treatment weighting (IPTW) by propensity score (PS) were used to remove baseline imbalance between the IVT and no treatment groups. Further adjustments for potential confounders were made in the IPTW analysis. The adjusted odds ratios (ORs) and their 95% confidence intervals (CIs) of IVT compared to no treatment were calculated for 3-month modified Rankin Scale (mRS) 0-1 (primary efficacy outcome), the full distribution of mRS scores (sedoncary efficacy outcome, by an ordinal logistic regression analysis), and symptomatic hemorrhagic transformation (sHT, safety outcome). Results: Between April 2008 and May 2012, 13,117 stroke patients were hospitalized to the 12 participating centers. Among them, 1,386 subjects met the eligibility criteria, and 194 (14.0%) were treated with IVT. The proportions of 3-month mRS 0-1 were not different between the IVT and no treatment groups (71% vs. 75%, p=0.18), but those of sHT were different (4.1% vs. 0.5%, p The adjusted ORs (95% CIs, p values) were 1.46 (0.95-2.25, 0.08) by PS-matching and 1.47 (0.77-2.82, 0.24) by IPTW for 3-month mRS 0-1; 1.05 (0.73-1.49, 0.80) by PS-matching and 1.09 (0.65-1.81, 0.75) for an increment of 3-month mRS score; and 7.47 (1.52-36.64, 0.01) by PS-matching and 3.85 (0.82-18.06, 0.09) by IPTW for sHT. Conclusion: This comparative effectiveness analysis based on the large multicenter stroke registry database failed to prove the superiority of intravenous thrombolysis over no treatment in patients with mild ischemic stroke.

Background: Although the benefit of intravenous recombinant tissue plasminogen activator (IV-TPA) has been proved in patients with 3-4.5 hour after stroke from a randomized trial and observational studies, in which most subjects were Western population. We aimed to determined the safety and efficacy of IV-TPA within the 3- to 4.5-hour window in Korean population. Methods: Using a prospective, web-based registry of consecutive patients with acute stroke or transient ischemic attack (TIA) admitted to 12 academic hospitals in Korea, we enrolled 616 patients receiving IV-TPA therapy within 3 hours and 107 within 3-4.5 hours after stroke onset for this study. Functional outcome measured by modified Rankin scale (mRS) at 3 months after stroke was compared between the two time window cohorts. Symptomatic intracranial hemorrhage (SICH) defined as any apparently extravascular blood in the brain or within the cranium associated with 4 points or more increase in the National Institutes of Health Stroke Scale (NIHSS) score or leading to death was evaluated for safety. Odds ratios (OR) and 95% confidence intervals (CI) was calculated to present the probability of achieving each outcome for patients treated within 3-4.5 hours compared to those treated within 3 hours. Results: The excellent outcome (mRS 0-1) was less often achieved in the 3-4.5 hours cohort than in the within 3 hours cohort (39.3% vs 42.9%), but the difference was not statistically significant after adjusting for age, sex, baseline NIHSS score, weight, glucose, center (adjusted OR [95% CI], 1.26 [0.60-2.65]). The proportion of mRS 0-2 at 3 months (48.6% vs55.7%) was not also different between two groups (adjusted OR [95% CI], 0.80 [0.41-1.54]). The rate of SICH was higher in the 3-4.5 hours cohort than in the within 3 hours cohort (4.7% vs 3.1%), but the difference was not statistically significant (adjusted OR [95% CI], 0.81 [0.20-3.35]). Conclusion: This study shows that IV-TPA therapy within the 3- to 4.5-hour window after ischemic stroke is safe and effective in Korean patients.

Journal of Stroke 2015;17(1):38-53 http://dx.doi.org/10.5853/jos.2015.17.1.38 On page 47, the definition of stroke progression was erroneously described in the previous version of article, and the correct definition of “stroke progression” is as following; Corrected Table 5 Table 5. Definitions of outcome variables in the CRCS-5 registry END event in neurologically stable patients ≥ 24 hours • May be attributable to peri-lesional edema • For cases with ≤ 24 hours after onset, END events not attributable to recurrent stroke

Vitamin B6 is closely associated with functions of the nervous, immune, and endocrine systems. Its deficiency may result in neurological disorders including convulsions and epileptic encephalopathy. Until today, this has only been reported in infants, children, and critically ill adult patients. We report a case of a 36year-old man with chronic alcoholism who presented with seizures after gastrointestinal disturbance. His seizures persisted even after treatment with antiepileptic drugs, but eventually disappeared after administration of pyridoxine. Hence, vitamin B6 deficiency may cause seizures in adult patients with chronic alcoholism.