Background and purpose: Previous studies have reported that early hospital arrival improves clinical outcomes in patients with acute ischemic stroke; however, whether early arrival is associated with favorable outcomes regardless of reperfusion therapy and the type of stroke onset time is unclear. Thus, we investigated the impact of onset-to-door time on outcomes and evaluated the predictors of pre-hospital delay after ischemic stroke. Methods: Consecutive acute ischemic stroke patients who arrived at the hospital within five days of onset from September 2019 to May 2020 were selected from the prospective stroke registries of Seoul National University Hospital and Chung-Ang University Hospital of Seoul, Korea. Patients were divided into early (onset-to-door time, ≤4.5 h) and late (>4.5 h) arrivers. Multivariate analyses were performed to assess the effect of early arrival on clinical outcomes and predictors of late arrival. Results: Among the 539 patients, 28.4% arrived early and 71.6% arrived late. Early hospital arrival was significantly associated with favorable outcomes (three-month modified Rankin Scale [mRS]: 0−2, adjusted odds ratio [aOR]: 2.03, 95% confidence interval: [CI] 1.04–3.96) regardless of various confounders, including receiving reperfusion therapy and type of stroke onset time. Furthermore, a lower initial National Institute of Health Stroke Scale (NIHSS) score (aOR: 0.94, 95% CI: 0.90–0.97), greater pre-stroke mRS score (aOR: 1.58, 95% CI: 1.18–2.13), female sex (aOR: 1.71, 95% CI: 1.14–2.58), unclear onset time, and ≤6 years of schooling (aOR: 1.76, 95% CI: 1.03–3.00 compared to >12 years of schooling) were independent predictors of late arrival. Conclusions: Thus, the onset-to-door time of≤4.5 h is crucial for better clinical outcome, and lower NIHSS score, greater pre-stroke mRS score, female sex, unclear onset times, and ≤6 years of schooling were independent predictors of late arrival. Therefore, educating about the importance of early hospital arrival after acute ischemic stroke should be emphasized. More strategic efforts are needed to reduce the prehospital delay by understanding the predictors of late arrival.

Marked protein catabolism is common in critically ill patients. We hypothesized that optimal protein supplementation using nitrogen balance might be associated with better outcomes in the neurointensive care unit (NICU) patients. A total of 175 patients admitted to the NICU between July 2017 and December 2018 were included. Nitrogen balance was measured after NICU admission and measurements were repeated in 77 patients. The outcomes were compared according to initial nitrogen balance results and improvement of nitrogen balance on follow-up measurements. A total of 140 (80.0%) patients had a negative nitrogen balance on initial assessments. The negative balance group had more events of in-hospital mortality and poor functional outcome at three months. In follow-up measurement patients, 39 (50.6%) showed an improvement in nitrogen balance. The improvement group had fewer events of in-hospital mortality (p = 0.047) and poor functional outcomes (p = 0.046). Moreover, improvement of nitrogen balance was associated with a lower risk of poor functional outcomes (Odds ratio, 0.247; 95% confidence interval, 0.066–0.925, p = 0.038). This study demonstrated that a significant proportion of patients in the NICU were under protein hypercatabolism. Moreover, an improvement in protein balance was related to improved outcomes in neurocritically ill patients. Further studies are needed to confirm the relationship between protein balance and outcomes.

BACKGROUND: Early neurological deterioration (END) is a frequent complication of acute ischemic stroke. Although END worsens clinical outcomes, standardized treatment strategies remain undefined, resulting in variability in clinical practice. This study examines real-world treatment patterns for END and compares the effects of different strategies on neurological and functional outcomes. METHODS: This study analyzed data from a nationwide, prospective, multicenter stroke registry in South Korea, including patients with noncardioembolic stroke who developed END due to stroke progression between January 2019 and August 2024. END was defined as new or worsening neurological symptoms meeting National Institutes of Health Stroke Scale criteria (≥2-point total or ≥1 point in consciousness or motor subscores) with radiological confirmation. Patients were classified into conservative management, antithrombotics change, and induced hypertension (iHTN). The primary outcomes were neurological improvement, defined as a ≥2-point reduction in the National Institutes of Health Stroke Scale score, and 3-month functional outcome measured by modified Rankin Scale ordinal shift. Secondary outcomes included good functional recovery (modified Rankin Scale score, 0–2) and composite vascular events (death, stroke, and myocardial infarction). Multivariable analyses adjusted for age, sex, prestroke modified Rankin Scale, initial National Institutes of Health Stroke Scale score, vascular risk factors, the TOAST (Trial of ORG 10172 in Acute Stroke Treatment) classification, acute thrombolysis, and laboratory covariates. RESULTS: Among 3067 patients with END due to stroke progression, 1840 (60.0%) received conservative management, 747 (24.4%) underwent antithrombotic changes, and 480 (15.7%) were treated with iHTN. Neurological improvement occurred in 34.2% of patients, with the highest in the iHTN group (41.5%) compared with the conservative (32.2%) and antithrombotics change groups (34.4%; P <0.001). In adjusted analyses, iHTN increased the odds of neurological improvement (adjusted odds ratio, 1.55 [95% CI, 1.25–1.92]) and a favorable 3-month modified Rankin Scale shift (adjusted odds ratio, 1.24 95% CI, 1.03–1.48]) compared with conservative management, particularly in patients with large artery atherosclerosis. Antithrombotics change showed no significant association with neurological or functional recovery. CONCLUSIONS: In patients with noncardioembolic ischemic stroke who developed END due to stroke progression, iHTN was associated with favorable clinical outcomes.

Kim DY, et al. J Korean Med Sci. 2024 Aug;39(34):e278. https://doi.org/10.3346/jkms.2024.39.e278

Cerebral paragonimiasis (CP), caused by aberrant migration of Paragonimus worms, frequently invokes serious illness. The causal relationship between the lesion characteristics and patients’ symptoms has poorly been understood. CP serodiagnosis has not been properly evaluated to date. A total of 111 CP cases were diagnosed in our laboratory between 1982 and 2003. This study retrospectively assessed the clinical and imaging characteristics of the 105 patients along with the evaluation of diagnostic potentials of recombinant P. westermani yolk ferritin (rPwYF) by enzyme-linked immunosorbent assay (ELISA) employing patients’ sera and cerebrospinal fluids (CSFs). We analyzed 60 male and 45 female patients; 50 early-stage patients with non-calcified enhancing nodule(s) (median age, 38 years; interquartile range [IQR], 24.75–52; median symptom duration, 0.75 years; IQR, 0.2–2) and 54 chronic cases having calcified lesion(s) (median age, 33 years; IQR, 25–41; median symptom duration, 10 years; IQR, 5–20). One patient showed a normal neuroimage. The patients were largely diagnosed in their 30s. The parietal lobe was most commonly affected, followed by occipital, frontal, and temporal lobes. Twenty-six patients had lesions encompassing ≥ two lobes. The patients complained mainly of seizures, headaches, hemiparesis, and focal neurologic deficits (P < 0.001). Seizures and visual defects were predominant in patients with calcified lesion(s) (P < 0.001). The diagnostic sensitivity and specificity of rPwYF against serum/CSF were 100%/97% and 97.2%/92.5%, respectively. The specific IgG antibody levels against rPwYF in sera and CSFs showed a positive correlation (r = 0.59). The clinical manifestations of the early-stage patients might be associated with cortical lesions or meningeal irritation, while those in the chronic stage were caused by conglomerated space-occupying lesions. rPwYF would be useful for the serodiagnosis of both early and chronic CP cases.

Background: Elevated metabolic activity of amygdala is known to be related to atherosclerotic cardiovascular event by increasing inflammatory cell production from bone marrow. We tried to identify the factors of metabolic activity in the amygdala, vertebrae, liver, spleen, and internal carotid artery related to the future vascular events after stroke. Methods: A total of 110 patients with acute stroke were included (72±10 years of age, 39% women) and underwent whole-body ¹⁸ F-fluorodeoxyglucose (FDG) positron emission tomography between August 1, 2015 and February 28, 2020. We compared the FDG uptake in the amygdala, vertebrae, liver, spleen, and internal carotid artery between patients with and without recurrent vascular event. Cox proportional hazards model was used to identify factors related to recurrent stroke and vascular event. Results: During the median follow-up period of 18 months, 22 patients experienced vascular events, including 15 stroke recurrence. Patients with recurred vascular event had a significantly higher FDG uptake in the amygdala and vertebrae than those without. The Cox proportional hazard model including diabetes, renal function, and carotid stenosis showed that a higher FDG uptake in the amygdala was independently associated with total vascular events (hazard ratio, 3.11 [95% CI, 1.11–8.70]) and higher FDG uptake in the vertebrae with stroke recurrence (hazard ratio, 4.94 [95% CI, 1.29–18.9]). Conclusions: The increased metabolic activities of the vertebrae and amygdala are related to future vascular event among stroke survivors.