Stroke Risk After Coronary Artery Bypass Graft Surgery and Extent of Cerebral Artery Atherosclerosis

Lee, E.J.,Choi, K.H.,Ryu, J.S.,Jeon, S.B.,Lee, S.W.,Park, S.W.,Park, S.J.,Lee, J.W.,Choo, S.J.,Chung, C.H.,Jung, S.H.,Kang, D.W.,Kim, J.S.,Kwon, S.U. Elsevier Biomedical 2011 JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY - Vol.57 No.18

Objectives: We aimed to define the relationship between cerebral atherosclerosis and stroke after coronary artery bypass grafting (CABG). Background: Although cerebral atherosclerosis may play a crucial role in the advent of post-CABG stroke, only extracranial carotid artery disease has been extensively studied, and the effects of atherosclerosis on the mechanisms underlying post-CABG stroke remain unclear. Methods: Pre-operative magnetic resonance angiography was performed on 1,367 consecutive CABG patients to assess intracranial and extracranial cerebral atherosclerosis. Disease severity was evaluated by atherosclerosis score, as determined by the number of steno-occlusions of cerebral arteries and the degree thereof. Post-CABG strokes (within 14 days) were classified as atherosclerotic (strokes attributable to pre-defined atherosclerosis) or other (strokes caused by other mechanisms). Associations between post-CABG stroke and each type of atherosclerotic disease (extracranial carotid artery disease, intracranial, extracranial, or extracranial and/or intracranial cerebral atherosclerosis), differentiated according to the involved arteries, were analyzed. Results: Stroke occurred in 33 patients, and the atherosclerosis score was independently associated with stroke development (odds ratio: 1.35; 95% confidence interval: 1.16 to 1.56). Atherosclerotic stroke was defined in 15 (45%), and constituted >40% of both immediate (within 24 h) and delayed strokes. Intracranial, extracranial, and extracranial and/or intracranial cerebral atherosclerosis were significantly associated with stroke. Conclusions: Cerebral atherosclerosis was closely related to the occurrence of post-CABG stroke, being both an independent risk factor for and the cause of a significant proportion of strokes. Pre-operative evaluation of intracranial and extracranial cerebral arteries, apart from the extracranial carotid artery, may be useful to predict the likelihood of post-CABG stroke.

대장암 환자에서 발생한 뇌졸중

김충린,김용미,전재용,김진천,권순억,김희철,최경효 대한재활의학회 2009 Annals of Rehabilitation Medicine Vol.33 No.2

Objective: To find the characteristics of stroke in colorectal cancer patients. Method: We retrospectively analyzed 32 patients of stroke in colorectal cancer who were operated from January 2001 to December 2002 by reviewing their charts and brain CTs or MRIs. The type, risk factor, localization and origin of stroke and the stage of colorectal cancer were analyzed. Results: The mean age was 69.2 years. TNM stage II (41%) was the most common. Twenty-three cases were ischemic stroke, four were hemorrhagic stroke and the others were unidentified. Diabetes (63%), hypertension (53%), cardiac disease (19%), and family history of stroke (9%) were observed in patients. The main cause of ischemic stroke was arterial thrombosis, and lacunar and middle cerebral infarction were more common in ischemic stroke. Conclusion: Several common risk factors between colorectal cancer and stroke were observed, and these risk factors are associated with the atherosclerosis of cerebral vascular system. To reduce the incidence of cerebrovascular disease and colorectal cancer, we may need to control those risk factors. Objective: To find the characteristics of stroke in colorectal cancer patients. Method: We retrospectively analyzed 32 patients of stroke in colorectal cancer who were operated from January 2001 to December 2002 by reviewing their charts and brain CTs or MRIs. The type, risk factor, localization and origin of stroke and the stage of colorectal cancer were analyzed. Results: The mean age was 69.2 years. TNM stage II (41%) was the most common. Twenty-three cases were ischemic stroke, four were hemorrhagic stroke and the others were unidentified. Diabetes (63%), hypertension (53%), cardiac disease (19%), and family history of stroke (9%) were observed in patients. The main cause of ischemic stroke was arterial thrombosis, and lacunar and middle cerebral infarction were more common in ischemic stroke. Conclusion: Several common risk factors between colorectal cancer and stroke were observed, and these risk factors are associated with the atherosclerosis of cerebral vascular system. To reduce the incidence of cerebrovascular disease and colorectal cancer, we may need to control those risk factors.

닫힌 사슬운동과 슬링운동프로그램 병행이 뇌졸중 편마비환자의 균형과 보행 및 등속성근기능에 미치는 영향

조완주(Cho, Wan-Ju) 한국체육과학회 2015 한국체육과학회지 Vol.24 No.2

This study conducted closed kinetic chain and sling exercise with 16 patients with hemiplegia after stroke for 12 weeks to examine the effects of closed kinetic chain and sling exercise on balance, walking, and isokinetic muscle function. The subjects were male patients who were diagnosed as hemiplegia caused by stroke in J University Hospital of G Metropolitan City and had chronic hemiplegia over 12 months after a stroke attack. They should participate in exercise based on physiatrist’s opinion, walk independently using walking assistance devices, and not have subcutaneous atrophy and orthopedic-diseases of lower extremity. Their consents to the whole process of experiment were obtained and they were willing to participate in the study. The subjects were randomly assigned to the exercise group(n=10) and the control group(n=8). 2 participants of the exercise group dropped out. The purpose of this study was to examine how closed kinetic chain and sling exercise for 12 weeks made a difference to balance, walking, and isokinetic muscle function in patients with hemiplegia after stroke. The results of analysis and comparison were as follows. First, for the change of balance ability, patients with hemiplegia after stroke who participated in closed kinetic chain and sling exercise showed improved balance. It suggests that closed kinetic chain and sling exercise had a positive effect in patients with hemiplegia after stroke. Second, for the change of walking ability, patients with hemiplegia after stroke who participated in closed kinetic chain and sling exercise showed improved walking in both TUG and 10MWT. It suggests that closed kinetic chain and sling exercise had a positive effect in patients with hemiplegia after stroke. Third, for the change of isokinetic muscle function, patients with hemiplegia after stroke who participated in closed kinetic chain and sling exercise showed the improvement of affected extension, unaffected extension, affected flexion, and unaffected flexion. It suggests that closed kinetic chain and sling exercise had a positive effect in patients with hemiplegia after stroke. Based on the findings, closed kinetic chain and sling exercise had a positive effect on the improvement of balance, walking, and isokinetic muscle function in patients with hemiplegia after stroke. However, it is difficult to generalize the findings for all patients with hemiplegia after stroke because the number of the subjects of this study was small. It is considered that more various exercise programs should be applied to patients with hemiplegia after stroke who are usually limited in exercise.

Stroke-Specific Predictors of Major Bleeding in Anticoagulated Patients With Stroke and Atrial Fibrillation: A Nationwide Multicenter Registry-Based Study

정다다,송태진,김범준,허성혁,정진만,오경미,김치경,Sungwook Yu,박광열,김정민,박종호,박만석,김준태,황양하,김용재,정종원,방오영,김경문,서우근,최재철 대한신경과학회 2023 Journal of Clinical Neurology Vol.19 No.5

Background and Purpose The congestive heart failure, hypertension, age, diabetes, previous stroke/transient ischemic attack (CHA2DS2-VASc) and hypertension, abnormal renal/liver function, stroke, bleeding history or predisposition, labile international normalized ratio, elderly, drugs/alcohol (HAS-BLED) scores have been validated in estimating the risks of ischemic stroke and major bleeding, respectively, in patients with atrial fibrillation (AF). This study investigated stroke-specific predictors of major bleeding in patients with stroke and AF who were taking oral anticoagulants (OACs). Methods Subjects were selected from patients enrolled in the Korean ATrial fibrillaTion EvaluatioN regisTry in Ischemic strOke patieNts (K-ATTENTION) nationwide multicenter registry between 2013 and 2015. Patients were excluded if they were not taking OACs, had no brain imaging data, or had intracranial bleeding directly related to the index stroke. Major bleeding was defined according to International Society of Thrombosis and Haemostasis criteria. Cox regression analyses were performed to assess the associations between clinical variables and major bleeding and Kaplan-Meier estimates were performed to analyze event-free survival. Results Of a total of 3,213 patients, 1,414 subjects (mean age of 72.6 years, 52.5% males) were enrolled in this study. Major bleeding was reported in 34 patients during the median follow-up period of 1.73 years. Multivariable analysis demonstrated that initial National Institutes of Health Stroke Scale scores (hazard ratio [HR] 1.07, p=0.006), hypertension (HR 3.18, p=0.030), persistent AF type (HR 2.51, p=0.016), and initial hemoglobin level (HR 0.74, p=0.001) were independently associated with major bleeding risk. Except for hypertension, these associations remained significant after adjusting for the HAS-BLED score. Intracranial atherosclerosis presented a trend of association without statistical significance (HR 2.21, p=0.050). Conclusions This study found that major bleeding risk was independently associated with stroke-specific factors in anticoagulated patients with stroke and AF. This has the clinical implication that baseline characteristics of patients with stroke and AF should be considered in secondary prevention, which would bring the net clinical benefit of balancing recurrent stroke prevention with minimal bleeding complications.

The Comparison of Risk Factors for Ischemic Stroke or Intracranial Hemorrhage in Korean Stroke Patients

Sun-Young Choi,Ji-In Kim,Shin-Woo Hwang 대한의생명과학회 2018 Biomedical Science Letters Vol.24 No.4

Stroke is a leading cause of death in the Korean population and remains a major health burden worldwide. The two main pathologic types of stroke are ischemic stroke and intracranial hemorrhage (ICH), but comparisons of risk factors for these have been limited. We under took a nationwide population-based study to analyze the relationship between these risk factor sand ischemic stroke and ICH. From January 2003 to December 2013, a total of 37,561 patients with newly diagnosed ischemic stroke or ICH were identified using the National Health Insurance Service data base as the study population. Multivariable logistic regression analysis was used to determine the association between baseline risk factors and presentation with ICH versus ischemic stroke. The incidence of ischemic stroke showed an increasing rend every year, while there was no significant change in the incidence of ICH. Of the several risk factors associated with stroke, old age (OR 2.35, 95% CI 2.12~2.49, P < 0.001) was more closely associated with ischemic stroke than ICH, whereas renal disease (OR 0.74, 95% CI 0.55~0.99, P = 0.04) and carotid disease (OR 0.25, 95% CI 0.17~0.35, P < 0.001) were more strongly associated with ICH. In addition, diabetes mellitus, dyslipidemia, hypertension, ischemic heart disease and male sex was associated with an increased risk of ischemic stroke. Old age was more strongly associated with ischemic stroke than ICH, while carotid stenosis and renal impairment were more closely associated with ICH risk. Classic risk factors for stroke have considerably different associations with the two main pathologic types of stroke.

Diabetes and Stroke: What Are the Connections?

Ofri Mosenzon,Alice Y.Y. Cheng,Alejandro A. Rabinstein,Simona Sacco 대한뇌졸중학회 2023 Journal of stroke Vol.25 No.1

Stroke is a major cause of death and long-term disability worldwide. Diabetes is associated with an increased risk of cardiovascular complications, including stroke. People with diabetes have a 1.5–2 times higher risk of stroke compared with people without diabetes, with risk increasing with diabetes duration. These risks may also differ according to sex, with a greater risk observed among women versus men. Several mechanisms associated with diabetes lead to stroke, including large artery atherosclerosis, cerebral small vessel disease, and cardiac embolism. Hyperglycemia confers increased risk for worse outcomes in people presenting with acute ischemic stroke, compared with people with normal glycemia. Moreover, people with diabetes may have poorer post-stroke outcomes and higher risk of stroke recurrence than those without diabetes. Appropriate management of diabetes and other vascular risk factors may improve stroke outcomes and reduce the risk for recurrent stroke. Secondary stroke prevention guidelines recommend screening for diabetes following a stroke. The diabetes medications pioglitazone and glucagon-like peptide-1 receptor agonists have demonstrated protection against stroke in randomized controlled trials; this protective effect is believed to be independent of glycemic control. Neurologists are often involved in the management of modifiable risk factors for stroke (including hypertension, hyperlipidemia, and atrial fibrillation), but less often in the direct management of diabetes. This review provides an overview of the relationships between diabetes and stroke, including epidemiology, pathophysiology, post-stroke outcomes, and treatments for people with stroke and diabetes. This should aid neurologists in diabetes-related decision-making when treating people with acute or recurrent stroke.

Stroke outcomes are worse with larger leukoaraiosis volumes

Ryu, Wi-Sun,Woo, Sung-Ho,Schellingerhout, Dawid,Jang, Min Uk,Park, Kyoung-Jong,Hong, Keun-Sik,Jeong, Sang-Wuk,Na, Jeong-Yong,Cho, Ki-Hyun,Kim, Joon-Tae,Kim, Beom Joon,Han, Moon-Ku,Lee, Jun,Cha, Jae-Kw Oxford University Press 2017 Brain Vol.140 No.1

<P>Leukoaraiosis or white matter hyperintensities are frequently observed on magnetic resonance imaging of stroke patients. We investigated how white matter hyperintensity volumes affect stroke outcomes, generally and by subtype. In total, 5035 acute ischaemic stroke patients were enrolled. Strokes were classified as large artery atherosclerosis, small vessel occlusion, or cardioembolism. White matter hyperintensity volumes were stratified into quintiles. Mean age (+/- standard deviation) was 66.3 +/- 12.8, 59.6% male. Median (interquartile range) modified Rankin Scale score was 2 (1-3) at discharge and 1 (0-3) at 3 months; 16.5% experienced early neurological deterioration, and 3.3% recurrent stroke. The Cochran-Mantel-Haenszel test with adjustment for age, stroke severity, sex, and thrombolysis status showed that the distributions of 3-month modified Rankin Scale scores differed across white matter hyperintensity quintiles (P < 0.001). Multiple ordinal logistic regression analysis showed that higher white matter hyperintensity quintiles were independently associated with worse 3-month modified Rankin Scale scores; adjusted odds ratios (95% confidence interval) for the second to fifth quintiles versus the first quintile were 1.29 (1.10-1.52), 1.40 (1.18-1.66), 1.69 (1.42-2.02) and 2.03 (1.69-2.43), respectively. For large artery atherosclerosis (39.0%), outcomes varied by white matter hyperintensity volume (P = 0.01, Cochran-Mantel-Haenszel test), and the upper three white matter hyperintensity quintiles (versus the first quintile) had worse 3-month modified Rankin Scale scores; adjusted odds ratios were 1.45 (1.10-1.90), 1.86 (1.41-2.47), and 1.89 (1.41-2.54), respectively. Patients with large artery atherosclerosis were vulnerable to early neurological deterioration (19.4%), and the top two white matter hyperintensity quintiles were more vulnerable still: 23.5% and 22.3%. Moreover, higher white matter hyperintensities were associated with poor modified Rankin Scale improvement: adjusted odds ratios for the upper two quintiles versus the first quintile were 0.66 (0.47-0.94) and 0.62 (0.43-0.89), respectively. For small vessel occlusion (17.8%), outcomes tended to vary by white matter hyperintensitiy volume (P = 0.10, Cochran-Mantel-Haenszel test), and the highest quintile was associated with worse 3-month modified Rankin Scale scores: adjusted odds ratio for the fifth quintile versus first quintile, 1.98 (1.23-3.18). In this subtype, worse white matter hyperintensities were associated with worse National Institute of Health Stroke Scale scores at presentation. For cardioembolism (20.6%), outcomes did not vary significantly by white matter hyperintensity volume (P = 0.19, Cochran-Mantel-Haenszel test); however, the adjusted odds ratio for the highest versus lowest quintiles was 1.62 (1.09-2.40). Regardless of stroke subtype, white matter hyperintensities were not associated with stroke recurrence within 3 months of follow-up. In conclusion, white matter hyperintensity volume independently correlates with stroke outcomes in acute ischaemic stroke. There are some suggestions that stroke outcomes may be affected by leukoaraiosis differentially depending on stroke subtypes, to be confirmed in future investigations.</P>

도시 중년 성인이 인지하는 뇌졸중 생활습관 위험요인과 뇌졸중 인식

송희영,허혜경,박소미 대한임상건강증진학회 2012 Korean Journal of Health Promotion Vol.12 No.1

Background: Modifying risk factors and improving stroke awareness in the general community have been emphasized for preventing stroke. This study aimed to explore modifiable lifestyle risk factors and the awareness of stroke and to compare scores for stroke knowledge according to lifestyle risk factors and recognition of important indicators among adults in urban areas. Methods: A cross-sectional study was conducted with a total of 196 participants aged 40 to 65 selected by a convenient sampling of community cultural centers, churches, and recreational groups. Participants completed a structured questionnaire including general characteristics, risk factors of stroke, and awareness of stroke including general knowledge, risk factors, reactions to warning symptoms, and knowledge on personal risk factors of stroke such as body weight, blood pressure, blood sugar, and cholesterol level. Results: Less than 30% of the participants engaged in regular physical activity and low fat diet and 33% of the participants were classified as having 'higher' level of knowledge on stroke. Knowledge on their personal risk factors of stroke were generally poor. Scores for knowledge on stroke were not different for lifestyle risk factors and knowing whether their body weight and blood pressure level were within normal limits. Meanwhile, scores for knowledge on stroke were significantly higher among those knowing whether their blood sugar and cholesterol level were within normal limits. Conclusions: There is a need to improve stroke awareness among community adults by providing more targeted information on warning symptoms, risk factors of stroke, and important indicators of major conditions related to stroke and their contribution to stroke prevention. 연구배경: 본 연구는 지역사회 성인에서 뇌졸중의 생활습관 위험요인 분포와 뇌졸중의 경고증상, 위험요인 및 뇌졸중 발생 시 대처 그리고 뇌졸중 위험질환 관련 주요 지표인 혈압, 체중, 혈당 및 혈중 콜레스테롤에 대한 개인의인지를 포함한 뇌졸중에 대한 인식을 확인하고자 시도되었다. 방법: 본 연구는 횡단적 서술조사 연구로 연구대상자는선정기준에 따라 두 개의 중소도시 지역에서 연구의 목적을 이해하고 참여에 동의한 196명(평균 연령 44.81세)을 편의표집 하였다. 연구자 소속 대학의 연구윤리위원회의 승인을 거친 후 대상자에게 참여자 권리 보호에 대해 설명후 동의서에 서명하도록 하였다. 일반적 특성과 뇌졸중의위험요인, 뇌졸중의 정의와 경고증상, 위험요인 및 발생 시대처, 그리고 뇌졸중 위험질환 관련 지표인 혈압, 체중, 혈당 및 혈중 콜레스테롤에 대한 인지를 묻는 구조화된 설문지를 배부하고 자가보고 하도록 하였다. 결과: 대상자 중 30% 이하에서 현재 규칙적인 신체활동과 저지방 식이를 하고 있었고 뇌졸중 지식은 평균 16.42점으로 대상자 중 33%가 뇌졸중의 정의, 경고증상 및 위험요인을 잘 알고 있는 ‘높은’ 지식 집단이었다. 체중, 혈당및 혈중 콜레스테롤의 정상 범주 여부에 대해서 대부분의대상자들이 모른다고 응답하였고 일반적 특성, 뇌졸중 위험요인, 혈압과 체중 인지 여부에 따른 지식의 차이는 유의하지 않았다. 자신의 혈당과 혈중 콜레스테롤이 정상 범주에 속하는지를 알고 있는 대상자에서 뇌졸중 지식이 유의하게 높았다. 결론: 본 연구는 지역사회 성인에서 규칙적 신체활동과저지방 식이조절을 증진하고 뇌졸중 경고증상, 위험요인및 뇌졸중 위험요인 관련 주요 지표에 대한 인지를 보완하여 뇌졸중 인식의 증진이 필요함을 제시하고 있다. 이를위해 지역사회 중년 성인 대상으로 개인의 혈당과 혈중 콜레스테롤과 같은 주요 지표와 뇌졸중 위험과의 관련성을포함한 뇌졸중 인식과 다양한 생활습관 위험요인 조절을 증진할 수 있는 중재의 개발 및 효과검증 연구가 필요하다.

단일 병원에서의 소아뇌졸중의 원인, 임상적 양상 및 기능회복에 대한 연구

류주석,박진홍,박은하,차은혜,성인영 대한재활의학회 2009 Annals of Rehabilitation Medicine Vol.33 No.3

Objective: To investigate the changes of causes, clinical features, and functional outcomes in childhood strokes. Method: This study included 152 patients, aged from 1 to 18 years, who were diagnosed with stroke and admitted to a tertiary hospital between January 2000 and April 2004. All medical records and neurologic images of the patients were reviewed. A parental questionnaire was used to investigate patients' functional outcomes. These results were compared with those of the previous study performed in the same hospital in 2001. Results: The number of hemorrhagic stroke was 78 (51.3%) and that of ischemic stroke was 74 (48.7%). When compared to the previous study, the incidence of hemorrhagic stroke especially above the age of 10 years decreased and that of ischemic stroke below the age of 10 years increased. The causes of stroke were arteriovenous malformation (AVM, 42.8%), Moyamoya disease (37.5%), vasculitis (5.3%), cardiac disease (3.9%), hematologic disease (2.0%), and undetermined (8.5%). Common clinical features were headache (53.8%), vomiting (43.6%) and loss of consciousness (28.2%) in the hemorrhagic stroke, and hemiparesis (94.6%), headache (35.1%) and speech disorder (31.1%) in the ischemic stroke. 86.0% of the hemorrhagic and 64.8% of the ischemic stroke patients were categorized in the ‘good' outcome group. Conclusion: The incidence of ischemic stroke increased to the similar level of hemorrhagic stroke. The most common causes were AVM in the hemorrhagic and Moyamoya disease in the ischemic stroke. Most of these patients showed good functional outcome, regardless of the causes of stroke. Objective: To investigate the changes of causes, clinical features, and functional outcomes in childhood strokes. Method: This study included 152 patients, aged from 1 to 18 years, who were diagnosed with stroke and admitted to a tertiary hospital between January 2000 and April 2004. All medical records and neurologic images of the patients were reviewed. A parental questionnaire was used to investigate patients' functional outcomes. These results were compared with those of the previous study performed in the same hospital in 2001. Results: The number of hemorrhagic stroke was 78 (51.3%) and that of ischemic stroke was 74 (48.7%). When compared to the previous study, the incidence of hemorrhagic stroke especially above the age of 10 years decreased and that of ischemic stroke below the age of 10 years increased. The causes of stroke were arteriovenous malformation (AVM, 42.8%), Moyamoya disease (37.5%), vasculitis (5.3%), cardiac disease (3.9%), hematologic disease (2.0%), and undetermined (8.5%). Common clinical features were headache (53.8%), vomiting (43.6%) and loss of consciousness (28.2%) in the hemorrhagic stroke, and hemiparesis (94.6%), headache (35.1%) and speech disorder (31.1%) in the ischemic stroke. 86.0% of the hemorrhagic and 64.8% of the ischemic stroke patients were categorized in the ‘good' outcome group. Conclusion: The incidence of ischemic stroke increased to the similar level of hemorrhagic stroke. The most common causes were AVM in the hemorrhagic and Moyamoya disease in the ischemic stroke. Most of these patients showed good functional outcome, regardless of the causes of stroke.

The Incidence of Stroke by Socioeconomic Status, Age, Sex, and Stroke Subtype: A Nationwide Study in Korea

서수라,김철웅,김수영,이상이,윤태호,박형근,이승은 대한예방의학회 2014 Journal of Preventive Medicine and Public Health Vol.47 No.2

Objectives: To date, studies have not comprehensively demonstrated the relationship between stroke incidence and socioeconomic status. This study investigated stroke incidence by household income level in conjunction with age, sex, and stroke subtype in Korea. Methods: Contributions by the head of household were used as the basis for income levels. Household income levels for 21 766 036 people were classified into 6 groups. The stroke incidences were calculated by household income level, both overall within income categories and further by age group, sex, and stroke subtype. To present the inequalities among the six ranked groups in a single value, the slope index of inequality and relative index of inequality were calculated. Results: In 2005, 57 690 people were first-time stroke patients. The incidences of total stroke for males and females increased as the income level decreased. The incidences of stroke increased as the income level decreased in those 74 years old and under, whereas there was no difference by income levels in those 75 and over. Intracerebral hemorrhage for the males represented the highest inequality among stroke subtypes. Incidences of subarachnoid hemorrhage did not differ by income levels. Conclusions: The incidence of stroke increases as the income level decreases, but it differs according to sex, age, and stroke subtype. The difference in the relative incidence is large for male intracerebral hemorrhage, whereas the difference in the absolute incidence is large for male ischemic stroke.