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

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

Update of the Korean Clinical Practice Guidelines for Endovascular Recanalization Therapy in Patients with Acute Ischemic Stroke

Patients with severe stroke due to acute large cerebral artery occlusion are likely to be severely disabled or die if reperfusion is not achieved in a timely manner. Intravenous tissue plasminogen activator (IV-TPA) administered within 4.5 hours after stroke onset was previously the only proven therapy, but IV-TPA alone does not sufficiently improve the outcome of patients with acute large artery occlusion. With the introduction of the advanced endovascular therapy that enables faster and more successful recanalization, recent randomized trials consecutively and consistently demonstrated the benefit of adding endovascular recanalization therapy (ERT) to IV-TPA. Accordingly, to update the recommendations, we assembled members of a writing committee appointed by the Korean Stroke Society, the Korean Society of Interventional Neuroradiology, and the Society of Korean Endovascular Neurosurgeons. The writing committee revised recommendations based on a review of the accumulated evidence, and a formal consensus was achieved by convening a panel of 34 experts from the participating academic societies. The current guideline provides evidence-based recommendations for ERT in patients with acute large cerebral artery occlusion regarding patient selection, treatment modalities, neuroimaging evaluation, and system organization.N

2019 Update of the Korean Clinical Practice Guidelines of Stroke for Endovascular Recanalization Therapy in Patients with Acute Ischemic Stroke

Endovascular recanalization therapy (ERT) has been a standard of care for patients with acute ischemic stroke due to large artery occlusion (LAO) within 6 hours after onset since the five landmark ERT trials up to 2015 demonstrated its clinical benefit. Recently, two randomized clinical trials demonstrated that ERT, even in the late time window up to 16 hours or 24 hours after last known normal time, improved the outcome of patients who had a target mismatch defined as either clinical-core mismatch or perfusion-core mismatch, which prompted the update of national guidelines in several countries. Accordingly, to provide evidence-based and up-to-date recommendations for ERT in patients with acute LAO in Korea, the Clinical Practice Guidelines Committee of the Korean Stroke Society decided to revise the previous Korean Clinical Practice Guidelines of Stroke for ERT. For this update, the members of the writing group were appointed by the Korean Stroke Society and the Korean Society of Interventional Neuroradiology. After thorough reviewing the updated evidence from two recent trials and relevant literature, the writing members revised recommendations, for which formal consensus was achieved by convening an expert panel composed of 45 experts from the participating academic societies. The current guidelines are intended to help healthcare providers, patients, and their caregivers make their well-informed decisions and to improve the quality of care regarding ERT. The ultimate decision for ERT in a particular patient must be made in light of circumstances specific to that patient. J Korean Neurol Assoc 38(2N