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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.
Determinants of the distribution and severity of hypoperfusion in patients with ischemic stroke
Bang, O. Y.,Saver, J. L.,Alger, J. R.,Starkman, S.,Ovbiagele, B.,Liebeskind, D. S. Ovid Technologies (Wolters Kluwer) - American Acad 2008 Clinical Neurophysiology Vol.71 No.22
<P>BACKGROUND: In acute cerebral ischemia, two variables characterize the extent of hypoperfusion: the volume of hypoperfused tissue and the intensity of hypoperfusion within these regions. We evaluated the determinants of the intensity of hypoperfusion within oligemic regions among patients who were eligible for recanalization therapy for acute ischemic stroke. METHODS: We analyzed data, including pretreatment diffusion-weighted imaging (DWI) and perfusion-weighted imaging, on 119 patients with acute middle cerebral artery infarctions. The intensity of hypoperfusion within oligemic regions was characterized by the hypoperfusion intensity ratio (HIR), defined as the volume of tissue with severe hypoperfusion (Tmax > or = 8 seconds) divided by the volume of tissue with any hypoperfusion (Tmax > or = 2 seconds). Based on the DWI data, we divided the patients into four stroke phenotypes: large cortical, small (< 1 cm diameter) cortical, border-zone, and deep pattern. RESULTS: The mean (SD) volume of severe hypoperfusion was 54.6 (52.5) mL, and that of any hypoperfusion was 140.8 (81.3) mL. The HIR ranged widely, from 0.002 to 0.974, with a median of 0.35 (interquartile range 0.13-0.60). The volume of any hypoperfusion did not predict the intensity of hypoperfusion within the affected region (r = 0.10, p = 0.284). Angiographic collateral flow grade was associated with HIRs (p value for trend = 0.019) and differed among DWI lesion patterns. In multivariate analysis, diastolic pressure on admission (odds ratio 0.959, 95% CI 0.922-0.998) and DWI pattern of deep infarcts (odds ratio 18.004 compared with large cortical pattern, 95% CI 1.855-173.807) were independently associated with a low HIR. CONCLUSIONS: The intensity of hypoperfusion within an oligemic field is largely independent of the size of the oligemia region. Predictors of lesser intensity of hypoperfusion are lower diastolic blood pressure and presence of a deep diffusion-weighted imaging lesion pattern.</P>
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>