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박종호,Bruce Ovbiagele,홍근식,권순억 대한뇌졸중학회 2017 Journal of stroke Vol.19 No.3
Background and Purpose Elevated blood pressure (BP) is associated with greater severity of intracranial atherosclerotic stenosis (ICAS) and increased risk of ischemic stroke. Because little is known about the relationship of maintained BP level with progression of symptomatic ICAS (sICAS), we evaluated the independent association of maintained systolic BP (SBP) with risk of sICAS progression. Methods We analyzed the Trial of cilOstazol in Symptomatic intracranial Stenosis 2, which evaluated 402 stroke patients with sICAS (mean age, 64.5±11.3 years; male, 52.2%). Study participants were categorized into four groups according to mean SBP level: low-normal (<120 mm Hg), normal to high-normal (120 to 139 mmHg), high (140 to 159 mm Hg), and very-high (≥160 mm Hg). Progression of sICAS was defined as worsening in the degree of stenosis by ≥1 grade on the 7-month magnetic resonance angiography follow-up. Results sICAS progression was observed in 52 (12.9%) subjects. Percentages of sICAS progression by mean SBP category showed a J-shape pattern: low-normal (21.4%), normal to high-normal (10.7%), high (11.4%), and very-high (38.9%). In multivariable analysis, compared to the normal to high-normal SBP group, odds ratios (95% confidence intervals) were low-normal, 1.88 (0.62–5.67); high, 1.06 (0.47–2.37); and very-high, 8.75 (2.57–29.86). Rate of sICAS progression by 10-mm Hg strata showed a similar pattern to findings from mean SBP category (9.47; 2.58–34.73 for SBP ≥160 mm Hg). Conclusions Among individuals with a recent ICAS stroke, very-high SBP level during the short-term period after the index stroke was associated with significantly greater odds of sICAS progression.
박종호,이준영,Bruce Ovbiagele 대한뇌졸중학회 2017 Journal of stroke Vol.19 No.2
Background and Purpose One explanation for the ‘obesity paradox’, where obese patients seem tohave better cardiovascular outcomes than lean patients, is that obese patients display anidentifiable high cardiovascular risk phenotype that may lead to receiving or seeking earlier/moreaggressive treatment. Methods We analyzed a clinical trial dataset comprising 3643 recent (<120 days) ischemic strokepatients followed up for 2 years. Subjects were categorized as lean (body mass index [BMI], <25kg/m2, n=1,006), overweight (25-29.9 kg/m2, n=1,493), or obese (≥30 kg/m2, n=1,144). Subjectswere classified as level 0 to III depending on the number of secondary prevention prescriptionsdivided by the number of potentially indicated drugs (0=none of the indicated medications andIII=all indicated medications as optimal combination drug treatment [OCT]). Independentassociations between each BMI category and stroke/myocardial infarction/vascular death (majorvascular events [MVEs]) and all-cause death were assessed. Results MVEs occurred in 17.4% of lean, 16.1% of overweight, and 17.1% of obese patients; deathoccurred in 7.3%, 5.5%, and 5.1%, respectively. Individuals with a higher BMI status received moreOCT (45.8%, 51.7%, and 55.3%, respectively; P<0.001). In the lean patient group, multivariableadjusted Cox analyses, showed that compared with levels 0-I, level II and level III were linked tolower risk of MVEs (hazard ratio [HR] 0.55; 95% confidence interval [CI]: 0.32–0.95 and HR 0.48;95% CI: 0.28−0.83, respectively) and death (0.44; 0.21–0.96 and 0.23; 0.10−0.54, respectively). Conclusions OCT for secondary prevention after an ischemic stroke is less frequent in lean (vs. obese) subjects, but when implemented is related to significantly better clinical outcomes.
Trends in Incident and Recurrent Rates of First-Ever Ischemic Stroke in Taiwan between 2000 and 2011
Meng Lee,Yi-Ling Wu,Bruce Ovbiagele 대한뇌졸중학회 2016 Journal of stroke Vol.18 No.1
Background and Purpose The burden of stroke is comparatively greater in Asian countries than in the Western world. While there has been a documented recent decline in the incidence of stroke in several Western nations due to better risk factor management, much less is known about the nature and trajectory of stroke in Asia over the last decade. The objective of this study was to explore risk factors, medication use, incidence, and one-year recurrence of stroke in Taiwan. Methods We conducted a nationwide cohort study by reviewing all hospitalized patients (≥ 18 years) with a primary diagnosis of ischemic stroke between 2001 and 2011 from Taiwan National Health Insurance Research Database. Results A total of 291,381 first-ever ischemic stroke patients were enrolled between 2000 and 2011. The average age was about 70 years and approximately 58.6% of them were men. While prevalence of diabetes mellitus and hyperlipidemia, as well as use of statins, antiplatelet agents, and oral anticoagulant agents for atrial fibrillation significantly increased; incidence (142.3 vs. 129.5 per 100,000 in 2000 and 2011, respectively) and one-year recurrence (9.6% vs. 7.8% in 2000 and 2011, respectively) of stroke declined during this period of time. Conclusions Over the last decade in Taiwan, rates of primary ischemic stroke and one-year recurrent stroke decreased by 9% and 18% respectively.
Impact of Reperfusion after 3 Hours of Symptom Onset on Tissue Fate in Acute Cerebral Ischemia
Bang, Oh Young,Liebeskind, David S.,Buck, Brian H.,Yoon, Sa Rah,Alger, Jeffry R.,Ovbiagele, Bruce,Saver, Jeffrey L. Wiley (Blackwell Publishing) 2009 Journal of neuroimaging Vol.19 No.4
<P>BACKGROUND: Reperfusion of penumbral tissue is a promising strategy for treatment of acute cerebral ischemia more than 3 hours from symptom onset. However, there has been only sparse direct evidence that reperfusion after 3 hours prevents infarct growth. METHODS: We analyzed clinical and serial magnetic resonance imaging (MRI) data on patients who received endovascular recanalization therapy 3-12 hours after last known well time. Multimodal MRIs were acquired pretreatment, early (1-20 hours), and late (2-7 days) after treatment. Degree of recanalization was assessed on end of procedure catheter angiogram, degree of reperfusion on early posttreatment perfusion MRI, and infarct growth by analysis of diffusion lesion volumes on pretreatment and late MRIs. RESULTS: Twenty-seven (12 men, 15 women) underwent endovascular recanalization procedures at 6.0 +/- 2.1 hours (range, 3.0-11.5 hours) after last known well time. Immediate posttreatment perfusion lesion (Tmax > or =4 seconds) volume correlated strongly with infarct growth (r= .951, P < .001), exceeding the correlations of vessel recanalization score (r=-.198, P= .446) and pretreatment diffusion-perfusion mismatch volume (r= .518, P= .033). Without reperfusion, enlargement of DWI lesion volume was observed in all patients, and extent of enlargement depended on volume of immediate posttreatment perfusion defects. CONCLUSION: Our data indicate that posttreatment reperfusion is the major determinant of threatened tissue outcome, and suggest reperfusion even after 3 hours of symptom onset can alter tissue fate over a wide range of mismatch volumes.</P>
Patterns and Predictors of Blood-Brain Barrier Permeability Derangements in Acute Ischemic Stroke
Bang, Oh Young,Saver, Jeffrey L.,Alger, Jeffry R.,Shah, Samir H.,Buck, Brian H.,Starkman, Sidney,Ovbiagele, Bruce,Liebeskind, David S. Ovid Technologies Wolters Kluwer -American Heart A 2009 Stroke Vol.40 No.2
<P>BACKGROUND AND PURPOSE: MRI permeability imaging is a promising approach to identify patients with acute ischemic stroke with an increased propensity for hemorrhagic transformation (HT). Permeability imaging provides direct visualization of blood-brain barrier derangements in ischemic fields. METHODS: We retrospectively analyzed clinical and MRI data on patients with acute cerebral ischemia within the middle cerebral artery territory to identify the frequency, patterns, and predictors of permeability derangements and their association with HT types. RESULTS: A total of 179 permeability scans was obtained in 127 patients (59 men; mean age, 66.8 years). Among 179 image sets (82 pre-/no treatment and 97 posttreatment), permeability derangements were present in 29 images, frequently at the basal ganglia (n=23) and rarely at the juxta-cortical area (n=6). After adjusting for covariates, diastolic pressure (OR, 1.12, per 1-mm Hg increase; 95% CI, 1.02 to 1.22) and s-glucose (OR, 1.04, per 1-mg/dL increase; 95% CI, 1.01 to 1.07) were independently associated with pretreatment permeability derangements, whereas low-density lipoprotein cholesterol (OR, 0.97, per 1-mg/dL increase; 95% CI, 0.94 to 0.99), malignant MRI profile (OR, 24.84; 95% CI, 1.50 to 412.93), and time from onset to recanalization therapy (OR, 1.47, per 1-hour increase; 95% CI, 1.10 to 1.96) were independently associated with permeability derangements after recanalization therapy. Types of HT varied among the patients with permeability derangements (no HT, 4; hemorrhagic infarct type, 12; and parenchymal hematoma, 13) and transient derangements (without subsequent HT) and normalization of derangements (in the presence of HT) on permeability images was observed in several cases. CONCLUSIONS: Permeability derangements, a dynamic process associated with ischemic stroke pathophysiology and recanalization therapy, vary in pattern and evolution toward HT. Several prognostic and therapeutic predictors for HT are independently associated with pre- and posttreatment permeability derangements.</P>
Bang, Oh Young,Saver, Jeffrey L.,Kim, Suk Jae,Kim, Gyeong-Moon,Chung, Chin-Sang,Ovbiagele, Bruce,Lee, Kwang Ho,Liebeskind, David S. Ovid Technologies Wolters Kluwer -American Heart A 2011 Stroke Vol.42 No.8
<P>Collaterals sustain the ischemic penumbra to limit growth of the infarct core before revascularization, yet the impact of baseline collateral flow on hemorrhagic transformation (HT) after endovascular therapy remains unknown.</P>