Differences of Mortality and Dependence Between Stroke Unit and General Ward Care in Acute Ischemic Stroke Patients

Background: There is strong evidence for the efficacy of stroke unit (SU) care, which has become a common practice in other developed countries but is available only in a small number of centers in Korea. This late introduction of SU care in Korea can be at least partly attributed to doubts about its benefits on patient outcomes compared to general ward (GW) care in our routine practice. Methods: Based on a prospective stroke registry, we identified 1,300 acute stroke patients hospitalized in either SUs (n=195) or GWs (n=1,105) from January 2004 to June 2008. Clinical outcomes such as fatality and disability rates were compared using propensity score matching in the total cohort. Additional statistical adjustments were performed using stepwise logistic regression analyses with the backward elimination method for potential confounders. Results: The baseline characteristics did not differ significantly between patients admitted to SUs (n=195) and their matched controls (n=386). The 3-month dependency rate was 17.4% in SUs and 21.0% in GWs (p=0.31), and the case fatality rates were 1.5% and 8.0% (p<0.001), respectively. Adjusted odds ratios for SU care were 0.49 for dependency (95% confidence interval [CI]=0.22-1.08) and 0.17 for death (95% CI=0.04-0.83). Conclusions: This study showed that SU care reduces fatality rates and improves functional outcomes, which indicates the need to implement more SUs in Korea.N

Validation of Five Cardinal Symptoms Used for Stroke Awareness Campaign

Background: For the improvement in stroke care, we have campaigned for stroke warning signs and its symptoms. However, few reports on the validation of symptom selection in the campaign have been published till now. Methods: Based on the prospective stroke registry, patients were identified, who were hospitalized with stroke within 7days from the stroke onset and had relevant lesions on their brain images. One presenting symptom was selected in each patient through review of electronic medical records by an investigator, and those collected symptoms were classified into 5 symptom categories or the unclassified. Those 5 symptom categories were developed and are being used in the stroke awareness campaign in 2009 by the Korean Stroke Society (KSS). Results: A total of 3027 patients (age, 66.57±12.6 years; male, 58.2%) were enrolled in our study. The rate of frequency of each categorized symptom was 54.9% for unilateral numbness or weakness, 27.5% for confusion or speech disturbance,2.8% for visual disturbance, 10.5% for dizziness or gait disturbance, 2.3% for severe headache, and 2.0% for the unclassified. Ninety-eight percent of stroke patients were classified into one of the 5 symptom categories. Confusion or speech disturbance was associated with the shorter pre-hospital delay, whereas dizziness or gait disturbance with the longer delay. Dizziness was the most frequent symptom in TIA, and so was severe headache in hemorrhagic stroke. Conclusions: Our study shows that the 5 stroke warning symptoms of the KSS campaign represent well the presenting symptoms of Korean patients with acute stroke or TIA.N

Development of a Stroke Prediction Model for Korean

Background: Assessing an individuals risk of stroke can be a starting point for stroke prevention. The aim of this study was to develop a stroke prediction model that can be applied to the Korean population, using the best available current knowledge. Methods: A sex- and age-specific stroke prediction model that is applicable specifically to Koreans was developed using Gails breast cancer prediction model, which is based on competing risk theory. Results: The relative risks for major stroke risk factors, including hypertension, diabetes, hypercholesterolemia, atrial fibrillation, ischemic heart disease, previous stroke, obesity, and smoking status, were obtained from a recent systematic review of stroke risk factors among Koreans. The results were incorporated into the concept of a proportional hazard regression model. For baseline age- and sex-specific hazard rates for stroke, we employed Jees 10-year stroke-risk prediction model with its reference categories for predictor variables. Death-certificate data from the Korea National Statistical Office were used to calculate competing risks of stroke in our model. Conclusions: Our prediction model for stroke incidence may be useful for predicting an individuals risk of stroke based on his/her age, sex, and risk factors. This model will contribute to the development of individualized risk-specific guidelines for the prevention of stroke.N

Emergency Superficial Temporal Middle Cerebral Artery Bypass Surgery for Acute Symptomatic Middle Cerebral Artery Occlusion With Hemodynamic Disturbance

The role of surgical revascularization for patients with ischemic stroke remains controversial. During acute phase of large artery occlusive ischemic stroke, extracranial?intracranial (EC-IC) bypass, such as superficial temporal-middle cerebral aretery (STA-MCA) bypass sugery, has been rarely performed. We report a case of successful emergency STA-MCA bypass surgery to stop the neurologic deterioration and improve the hemodynamic compromise in a patient with acute symptomatic MCA occlusion associated with hypoperfusion.N

The Long-term Incidence of Recurrent Stroke: Single Hospital-based Cohort Study

Background: Recurrent stroke is a major cause of morbidity and mortality among stroke survivors. However, studies of the long-term prognosis after acute stroke are very rare, especially in Asia. This study aimed to provide estimates of recurrent stroke rates by age, gender, and subtype of stroke in an unselected cohort of patients hospitalized to a community-based general hospital due to acute stroke. Methods: Based on a prospective stroke registry, acute stroke patients were enrolled within 7 days of symptom onset and followed retrospectively or prospectively for up to 3 years. Information was gathered about stroke recurrence and other vascular events. The cumulative risk of recurrent stroke was calculated using the Kaplan-Meier method. Results: Two-thousand and sixty-eight patients were enrolled in this study. The cumulative risks of stroke recurrence were 2.3%, 5.5%, 8.6%, and 10.0% at 90 days and 1, 2, and 3 years, respectively. The prevalence of stroke recurrence increased with age and the presence of previous stroke history (p<0.001), but not with gender or stroke subtype. Conclusions: To the best of our knowledge, this is the first cohort study of stroke recurrence in Korea. Its limitation of being a single hospital-based study warrants community- or multicenter-based cohort studies to identify high-risk groups for stroke recurrence.N

Outcome and Prognostic Factor of Isolated Anterior Cerebral Artery Territory Infarction

Background: Isolated anterior cerebral artery (ACA) territory infarction is uncommon and there have been no prospective out-come studies in Korea. Methods: From September 2004 to August 2005, patients with isolated ACA territory infarction ad-mitted within 7 days of symptom onset from 4 university hospitals were collected prospectively. We analyzed clinical and lab-oratory characteristics, stroke subtypes, stroke severity, and medical complications by a predetermined protocol. The out-come was measured by the modified Rankin Scale (mRS) at 3-months after stroke onset and classified as good (mRS score of 0 to 3) or poor (mRS score of 4 to 6) outcome. Results: Thirty-seven (2.9%) patients were identified to have isolated ACA ter-ritory infarction among 1,254 patients with acute ischemic stroke. Mean age was 67 years (range 45 to 83) and female were 22 (59%). Stroke subtypes were large-artery atherosclerosis in 57%, cardioembolism in 22%, undetermined in 19%, and small-vessel occlusion in 3%. The median National Institutes of Health Stroke Scale (NIHSS) score at admission was 4 (range 0 to 28). Neurological progression was developed in 9 patients (24%) and medical complications in 13 patients (35%). At 3 months after the stroke onset, 27 patients (72%) showed good outcome and 10 patients (27%) showed poor outcome. On univariate a-nalysis, medical complication, and NIHSS scores at admission were significantly associated with good outcome. Multivar-iate analysis revealed NIHSS scores at admission was independent predictor of functional outcome at 3 months. Conclusion: The overall prognosis of isolated ACA infarction was favorable and NIHSS scores at admission were important prognostic factor. (Korean J Stroke 2009;11:19-24)N

Analysis of 10,811 Cases with Acute Ischemic Stroke from Korean Stroke Registry: Hospital-Based Multicenter Prospective Registration Study

Background: Although several hospital-based stroke studies were published, there has not been any reliable data representing the clinical characteristics of stroke in Korea. We analyzed the clinical characteristics of patients with ischemic stroke registered in the Korean Stroke Registry (KSR), which is the largest prospective hospital-based nation-wide stroke registry in Korea. Methods: The KSR provided standardized protocols for collecting data, which includes the data of demographics, subtypes of stroke, risk factors, and neurological outcome at discharge. The brain imaging studies, including CT or MRI, were performed in all cases. Results: KSR registered 10,811 patients of acute ischemic stroke between Nov. 2002 and Jun. 2004. The large-artery atherosclerosis was the most common subtype (37.3%), followed by small vessel occlusion (30.8%). Hypertension (65.4%) was the most common risk factor, followed by smoking (34.5%) and diabetes (28.3%). Although most of the hypertensive and diabetic patients had been diagnosed before the stroke, less than 45.4% and 32.5% of them were under regular control. The steno-occlusive lesion of extracranial carotid artery was only 29.3% and the ratio of intra- to extracranial artery disease was more than 2 in KSR. Only 20.5% of patients were admitted within 3 hours after stroke onset and 2.1% were treated with intravenous thrombolysis. In-hospital case-fatality was 5.2%, which is relatively comparable to those of previous studies. Conclusions: The KSR provided informative data in understanding the clinical characteristics of ischemic stroke in Korea. Further analysis of KSR will facilitate clinical trials and development of guidelines for the management of stroke patients.N