Korean Journal of Stroke

KOREAN JOURNAL OF STROKE

Volume 10 Supplement 1 June 2008

Program and Abstracts of 3rd International Conference on Intracranial Atherosclerosis and Annual Spring Meeting of the Korean Stroke Society

대한뇌졸중학회지 제10권 부록1 2008년

Copyright ⓒ 2008 Korean Stroke Society Printed : June 10, 2008 Issued : June 18, 2008 http://www.stroke.or.kr ISSN 1229-4101 3rd International Conference on ICAS Intracranial Atherosclerosis 2008 and Annual Spring Meeting of the Korean Stroke Society

Contents

002 _ Welcome Message 003 _ Organizing Committee 004 _ Program at a Glance 005 _ Floor Plan 006 _ Conference Information 008 _ Scientific Program - Keynote and Invited Lectures - Oral Presentations - Poster Presentations 015 _ Luncheon Symposia 016 _ Accommodation and Transportation 018 _ General Information 019 _ Sponsors 020 _ Exhibition

Abstracts 003 _ Invited Sessions 031 _ Oral Sessions 053 _ Poster Sessions 115 _ Interesting Case Discussion Author Index Welcome Message

Dear Colleagues,

I am pleased to welcome you to the 3rd International Conference on Intracranial Atherosclerosis to be held in Seoul, Korea from June 18 to 20, 2008. This year’s meeting is held in conjunction with the Annual Meeting of the Korean Stroke Society which will make the meeting more meaningful.

During the last year, our Organizing Committee has worked hard on making a timely scientific program, and you will find that the Scientific Program is designed to provide you sessions discussing the latest basic and clinical research results in the field of intracranial atherosclerosis. There are also sessions which discuss other aspects of the disease for the interest of our participants.

June is a beautiful month in Korea, and with its mild weather you can enjoy our beautiful city of Seoul with modern innovations integrated with traditional Asian culture. Seoul has been the capital of Korea for over 600 years, making it truly resourceful for enjoying Korean culture. We have Social Programs and tours to let you discover the charms behind Seoul and I also hope these programs will provide you with opportunities to make new friends and renew old friendships.

I thank you for being a part of this wonderful conference, and I hope you leave with wonderful memories of your stay in Seoul.

Jong S. Kim, MD, PhD Chairman, Organizing Committee 3rd International Conference on Intracranial Atherosclerosis President Korean Stroke Society

3rd International Conference on 2 ICAS Intracranial Atherosclerosis 2008 and Annual Spring Meeting of the Korean Stroke Society Organizing Committee

Chairman Jong Sung Kim Secretary Sun Uck Kwon Members Hee-Joon Bae Ki Hyun Cho Chin-Sang Chung Ji Hoe Heo Gyeong-Moon Kim Byung-Chul Lee Yong-Seok Lee Jong-Moo Park Byung-Woo Yoon Kyung-Ho Yu Honorary Members Jae Kyu Roh Kwang Ho Lee International Program Committee Members Juan F Arenillas David C Bonovich Louis R Caplan KS Lawrence Wong

June 18-20, 2008, Grand InterContinental Seoul, Seoul, Korea 3 www.icas2008.or.kr Program at a Glance

Date Time Grand Ballroom 1&2 Chrysanthemum June 18 (Wednesday) 18:30-20:00 Welcome Reception

09:00-09:05 Welcoming Address 09:05-09:30 Keynote Speech 09:30-10:45 Invited Session 1 Epidemiology and Risk Factor

10:45-11:00 Coffee Break

11:00-12:00 Oral Session 1 Oral Session 2 Epidemiology & Risk Factors Neuroimaging & Pathophysiology

June 19 12:00-14:00 Luncheon Symposium (Thursday) Supported by Bristol-Myers Squibb & sanofi-aventis Korea Co.,Ltd.

14:00-15:35 Invited Session 2 Stroke Mechanism and Clinical Syndromes

15:35-15:50 Coffee Break

15:50-17:25 Invited Session 3 Imaging Diagnosis

17:25-19:00 Poster Session (1F, Lobby)

19:00-21:00 Gala Dinner

08:00-09:00 Oral Session 3 Oral Session 4 Treatment On-going Trials/Others

09:00-10:35 Invited Session 4 Medical Treatment vs. Intervention

10:35-10:50 Coffee Break

10:50-12:00 Interesting Case Discussion June 20 (Friday) 12:00-14:00 Luncheon Symposium Supported by Korea Otsuka Pharm. Co.,Ltd. Supported by Myung In Pharm. Co.,Ltd.

14:00-15:00 Oral Session 5 Oral Session 6 Clinical Aspects and Metabolic Syndrome Natural Course & Prognosis

15:00-15:20 Coffee Break

15:20-16:55 Invited Session 5 Other Therapies and Clinical Outcome

17:00-17:10 Closing Remarks

June 18 17:30-18:30 June 19 09:00-18:00 Registration June 19 08:00-19:00 Exhibition June 20 08:00-17:00 June 20 07:30-17:00

3rd International Conference on 4 ICAS Intracranial Atherosclerosis 2008 and Annual Spring Meeting of the Korean Stroke Society Floor Plan

Session Room (Chrysanthemum)

Session Room Exhibition (Grand Ballroom 1&2) (Grand Ballroom 3)

Registration and Exhibition (Lobby, 2F)

VIP Room (Lotus) Poster Session (Lobby, 1F)

Preview & Secretariat (Wisteria) Main Entrance

June 18-20, 2008, Grand InterContinental Seoul, Seoul, Korea 5 www.icas2008.or.kr Conference Information

Registration

Registration Desk Place : June 18 Chrysanthemum, Foyer June 19~20 Lobby of 2nd Floor Operation Hours : June 18 17:30-18:30 June 19 08:00-19:00 June 20 07:30-17:00

Name Badge Name badge will be used as a pass. Delegates are required to wear the name badge throughout the entire conference. Please note that admission to the scientific session room is restricted to the registered delegates wearing their name badges.

Registration Fee Includes Admission to all Scientific Sessions. Luncheon Symposia Access to Exhibition Area Conference Kit Final Program & Abstract Book Welcome Reception (June 18, 2008 / 18:30-20:00) Gala Dinner (June 19, 2008 / 19:00-21:00 ) Due to the limited seating, reservations must be made.

Speakers & Chairs

Preview Room Place : Wisteria Room (2F) Operation Hours : June 18 17:30-18:30 June 19 08:00-18:00 June 20 07:30-16:00 All speakers must visit the preview room and check their presentation files at least 3 hours before the presentation.

Session Room Speakers need to present themselves to the chairs at the session room 5 minutes before the session begin. Speakers should announce their arrival to the staff and be at the designated seat, which will be located at the first row of the session room.

6 ICAS 3rd International Conference on Intracranial Atherosclerosis 2008 and Annual Spring Meeting of the Korean Stroke Society Conference Information

Poster Presentation Place: Lobby of the 1st Floor Presenting author should be in front of his/her poster during the designated presentation time. Mounting & demounting should be made according to the schedule below and the posters left behind the demounting time will be removed without notice. Mounting June 19, 08:00-09:00 Presentation June 19, 17:25-19:00 Demounting June 20, 17:00-18:00

A Q&A Session will take place during the Poster Presentation. We invite all those interested to come to the Ground Floor Lobby at that time.

Social Programs

Welcome Reception All registered participants and accompanying persons are cordially invited to the Welcome Reception. It will give you an opportunity to share a warm welcome and to mingle with colleagues in pleasant surroundings. Place : Chrysanthemum Room (2F), Grand InterContinental Hotel Seoul Date & Time : June 18 (Wednesday), 18:30-20:00

Gala Dinner We invite you to join your peers and colleagues for a chance to relax and enjoy a delightful evening of Korean and Western food & entertainment. Gala Dinner will be a great opportunity for the participants to enjoy a colorful evening full of folklore and excellent food, and have the chance to become acquainted with each other. Place : Grand Ballroom 1&2 (2F), Grand InterContinental Hotel Seoul Date & Time : June 19 (Thursday), 19:00-21:00

Conference Secretariat Office

During the Conference Place : Wisteria Room (2F) Operation Hours : June 18 15:30-18:30 June 19-20 07:30-18:00

After the Conference InSession International Convention Services, Inc. 4F Yoongjeon Bldg, 829-6 Yeoksam-dong, Gangnam-gu, Seoul 135-915 Korea Phone: +82-2-3452-7132 (Dir) / +82-2-3471-8555, Fax: +82-2-521-8683 E-mail: [email protected] Website: www.icas2008.or.kr

June 18-20, 2008, Grand InterContinental Seoul, Seoul, Korea 7 www.icas2008.or.kr Scientific Program

Keynote and Invited Lectures

June 19, 2008 (Thursday) Invited Session 3 : Imaging Diagnosis 15:50-17:25 Grand Ballroom 1 & 2 Keynote Speech : Global Importance of ICAS Chairs Jose C Navarro (Manila), Deok Hee Lee (Seoul) 09:05-09:30 Grand Ballroom 1 & 2 Invited Session 3-1 The Application of MRI Chair Kwang Ho Lee (Seoul) Dong-Wha Kang (Seoul) Keynote Speech Global Importance of ICAS Invited Session 3-2 Assessment of Intracranial Atherosclerosis by David C Bonovich (San Francisco, CA) CT & MR Angiography Seung-Koo Lee (Seoul) Invited Session 1 : Epidemiology and Risk Factor Invited Session 3-3 TCD in Intracranial Stenosis 09:30-10:45 Grand Ballroom 1 & 2 Jose C Navarro (Manila) Chairs KS Lawrence Wong (Hong Kong), Invited Session 3-4 Assessment of Ischemic Stroke by Byung Chul Lee (Anyang) Perfusion Imaging Modalities Invited Session 1-1 Epidemiology of Intracranial Atherosclerosis Jun Hatazawa (Osaka) KS Lawrence Wong (Hong Kong) Panel Discussion What Is the Standard Method to Assess ICAS? Invited Session 1-2 Pathologic Characteristics Dong-Wha Kang (Seoul), Seung-Koo Lee (Seoul), Xiang Yan Chen (Hong Kong) Jose C Navarro (Manila), Jun Hatazawa (Osaka), Invited Session 1-3 Risk Factors for Intracranial Atherosclerosis Deok Hee Lee (Seoul) Oh Young Bang (Seoul) Panel Discussion Why ICAS Is More Common in Asians than in Caucasians? June 20, 2008 (Friday) KS Lawrence Wong (Hong Kong), Xiang Yan Chen (Hong Kong), Oh Young Bang (Seoul), Invited Session 4 : Medical Treatment vs. Intervention Byung Chul Lee (Anyang) 09:00-10:30 Grand Ballroom 1 & 2 Chairs Marc Chimowitz (Charleston, SC), Dae Chul Suh (Seoul) Invited Session 2 : Stroke Mechanism and Clinical Syndromes Invited Session 4-1 Statin and Other Miscellaneous Therapy 14:00-15:35 Grand Ballroom 1 & 2 Christopher Chen (Singapore) Chairs Louis R Caplan (Boston, MA), Jong S Kim (Seoul) Invited Session 4-2 Elective Stenting: an Effective Treatment for Invited Session 2-1 Stroke Mechanisms in Patients with Selected Patients with Symptomatic Intracranial Vascular Occlusive Disease Atherosclerotic Intracranial Stenosis of 70% Louis R Caplan (Boston, MA) to 99% at Experienced Centers Invited Session 2-2 Intracranial Atherosclerosis : Impact on Clinical Wei-Jian Jiang (Beijing) Syndrome Invited Session 4-3 Stenting vs. Medical Therapy for Symptomatic Jong S Kim (Seoul) Intracranial Arterial Stenosis Invited Session 2-3 Intracranial Arterial Dissection Marc Chimowitz (Charleston, SC) Sung-Chun Tang (Yun-Lin) Invited Session 4-4 Self-Expanding Stenting for Acute Ischemic Invited Session 2-4 Intracranial Atherosclerosis and Dementia Stroke Alex E Roher (Sun City, AZ) Henry Woo (Stony Brook, NY) Panel Discussion Stroke Mechanism and Clinical Consequence Panel Discussion Do We Have Enough Evidence for Louis R Caplan (Boston, MA), Jong S Kim (Seoul), Stent/Angioplasty? Alex E Roher (Sun City, AZ), Sung-Chun Tang (Yun-Lin) Christopher Chen (Singapore), Wei-Jian Jiang (Beijing), Marc Chimowitz (Charleston, SC), Henry Woo (Stony Brook, NY), Dae Chul Suh (Seoul)

8 ICAS 3rd International Conference on Intracranial Atherosclerosis 2008 and Annual Spring Meeting of the Korean Stroke Society Scientific Program

Invited Session 5 : Other Therapies and Clinical Outcome Invited Session 5-3 Surgical Treatment of Moyamoya Disease 15:20-16:55 Grand Ballroom 1 & 2 Gary K Steinberg (Stanford, CA) Chairs Didier D Leys (Lille), Chang Wan Oh (Seongnam) Invited Session 5-4 Rehabilitation Following Ischemic Stroke Invited Session 5-1 Intracranial Atherosclerosis: Natural Course Caused by Intracranial Atherosclerosis and Prognosis Nam-Jong Paik (Seongnam) Juan F Arenillas (Valladolid) Panel Discussion Therapies That Can Affect the Outcome of ICAS Invited Session 5-2 Antithrombotic Therapy in Symptomatic Juan F Arenillas (Valladolid), Yong-Seok Lee (Seoul), Intracranial Stenosis Gary K Steinberg (Stanford, CA), Yong-Seok Lee (Seoul) Nam-Jong Paik (Seongnam), Didier D Leys (Lille), Chang Wan Oh (Seoul)

Interesting Case Discussion

June 20, 2008 (Friday)

Interesting Case Discussion 10:50-12:00 Grand Ballroom 1 & 2 Chairs Louis R Caplan (Boston, MA), Byung-Woo Yoon (Seoul)

Oral Presentations O04 Middle Cerebral Artery Stenosis of Asymptomatic June 19, 2008 (Thursday) Residents is Not Associated with Angiotensin-Converting Enzyme Gene Insertion/Deletion Polymorphism: Oral Session 1 : Epidemiology & Risk Factors a Community-Based Study in Foshan Area of China 11:00-12:00 Grand Ballroom 1 & 2 Hai-Wei Huang (Guangzhou) Chairs Yukito Shinohara (Tokyo), Chin-Sang Chung (Seoul) O05 Which Lipid Profiles Is Associated with Large Artery O01 Results from the Boston Medical Center Stroke Atherosclerotic Stroke? Database: Implications for an International Intracranial Mi Sun Oh (Anyang) Atherosclerotic Disease (ICAD) Registry Jason Viereck (Boston, MA) Oral Session 2 : Neuroimaging & Pathophysiology O02 Protocol of a Prospective Hospital-Based Cohort Study 11:00-12:00 Chrysanthemum of Symptomatic Intracranial Atherosclerosis in China Chairs Jun Hatazawa (Osaka), Ki Hyun Cho (Gwangju) (ICAS-CHINA) O06 Distribution and Severity of Perfusion Defects in Yongjun Wang (Beijing) Patients with Intracranial Atherosclerotic Stroke O03 Lipoprotein(a) and Burden of Cerebrovascular Suk Jae Kim (Seoul) Atherosclerosis in Patients with Ischemic Stroke O07 Detection of the Siphon Internal Carotid Artery Stenosis: Byung-Su Kim (Seoul) Transcranial Doppler Sonography versus Angiography Yong You (Hong Kong)

June 18-20, 2008, Grand InterContinental Seoul, Seoul, Korea 9 www.icas2008.or.kr Scientific Program

O08 Comparison between European Countries for the O18 Early Effect of Fluvastatin on Inflammatory Markers in Availability of Facilities Necessary to Detect Intracranial Acute Ischemic Stroke (FIMA): Preliminary Ongoing Study Atherosclerosis. Eung Gyu Kim (Busan) Didier Leys (Lille) O19 Circulating Pericyte Progenitor Cells as a Candidate Stem O09 Does Middle Cerebral Artery Stenosis Affect Cell Population in Acute Stroke Neurovascular Coupling of Posterior Cerebral Artery? Kon Chu (Seoul) Tai Hwan Park (Seoul) O20 Effects of Uric Acid on Silent Brain Infarction in Healthy O10 Pathology of Atherosclerotic Intracranial Stenosis Elderly Adults Angelito Jonas L Kalaw (Manila) Sung Hyuk Heo (Seoul)

June 20, 2008 (Friday) Oral Session 5 : Clinical Aspects & Metabolic Syndrome 14:00-15:00 Grand Ballroom 1 & 2 Oral Session 3 : Treatment Chairs Jason Viereck (Boston, MA), Eung Gyu Kim (Busan) 08:00-09:00 Grand Ballroom 1 & 2 O21 Mirror Pattern of the Cerebral Artery Atherosclerosis in Chairs Henry Woo (Stony Brook, NY), Kyung Cheon Chung (Seoul) Patients with Acute Ischemic Stroke O11 Trial of Efficacy and Safety of Cilostzol on the Progression Young Dae Kim (Seoul) of Symptomatic Intracranial Stenosis Comparing Clopidogrel: O22 Intracranial Atherosclerosis in Anterior Cerebral Artery Trial of Cilostazol in Symptomatic Intracranial Stenosis-2 Territory Infarction: Its Significance and Stroke Mechanism (TOSS-2) Baseline Characteristics and Current Status Jong S Kim (Seoul) Sun U Kwon (Seoul) O23 Intracranial Atherosclerosis in Patients with CADASIL O12 Clinical and Angiographic Outcome of Self-Expandable Jay Chol Choi (Jeju) Stenting in Symptomatic Intracranial Arterial Stenosis O24 Endothelial Apoptosis Associated with Intracranial Thomas Leung (Hong Kong) Atherosclerosis in Metabolic Syndrome O13 Measurement of Clopidogrel-Induced Platelet Inhibition Soon-Tae Lee (Seoul) May Predict Early Complications Following Stent-Assisted O25 Significant Associations of Metabolic Syndrome and Its Angioplasty for Symptomatic Intracranial Atherosclerotic Components with Silent Brain Infarction in Elderly People Disease Hyung-Min Kwon (Seoul) Soo Joo Lee (Daejeon) O14 Intracranial Stenting in Patients with Intracranial Stenosis Oral Session 6 : Natural Course & Prognosis Associated with Adjacent Aneurysm 14:00-15:00 Chrysanthemum Hyun Sin In (Seoul) Chairs Juan F Arenillas (Valladolid), Joung-Ho Rha (Incheon) O15 Dynamic Cerebral Autoregulation in Patients with Recent O26 Acute Symptomatic Intracranial Artery occlusion (ASIA) Atherosclerotic Stroke during External Counterpulsation Study I: Natural History Li Xiong (Hong Kong) Woong-Woo Lee (Seongnam) O27 The abstract has been moved to the Poster Session, P 117. Oral Session 4 : On-going Trials / Others O28 Long-term Prognosis of Middle Cerebral Artery Stenosis 8:00-09:00 Chrysanthemum under Medical Treatment Chairs Christopher Chen (Singapore), Ji Hoe Heo (Seoul) Byung-Chul Lee (Anyang) O16 Cilnidipine effect on High blood pressure and cERebral O29 Platelet Aggregation Might be an Important Factor for the perfusion in Ischemic Stroke patients with Hypertension Progression on Symptomatic Middle Cerebral Artery Keun-Sik Hong (Goyang) Stenosis? O17 Aggressive Glucose Control in Acute Ischemic Stroke by Jae-Kwan Cha (Busan) Insulin Infusion (AGAIN) - pilot study O30 Intracranial Angioplasty for Symptomatic Middle Cerebral Nayoung Kim (Seoul) Artery Stenosis: Long-Term Follow-Up Joon-Tae Kim (Gwangju)

10 ICAS 3rd International Conference on Intracranial Atherosclerosis 2008 and Annual Spring Meeting of the Korean Stroke Society Scientific Program

Poster Presentations

June 19, 2008 (Thursday) Prognosis & Prevention 17:25-19:00 Lobby (1F) Chair Dookyo Jung (Daegu) Epidemiology & Risk Factor P013 State of Current Lipid and Hypertension Treatment of Chair Hee-Joon Bae (Seongnam) Stroke Patients in Korea: the STROKE Study P001 PON Gene Polymorphism and Atherosclerosis of Internal Hee-Joon Bae (Seongnam) Carotid Artery P014 Effects of a Lifestyle Promotion Program for Stroke Byoung-Soo Shin (Jeonju) Prevention Tailored to the Stage of Physical Activity and P002 Race-Ethnic Differences in Impact of Metabolic Syndrome Diet Modification among Adults on Distribution of Cervicocephalic Atherosclerosis Hee-Young Song (Wonju) Oh Young Bang (Seoul) P015 The Leukoaraiosis Is More Prevalent in the Large Artery P003 A Case-Control Study of Sasang Constitution and the Risk Disease Subtype among Korean Patients with Ischemic of Stroke Stroke Chang-ho Han (Goyang) Seung-Jae Lee (Seoul) P004 Stroke Risk Prediction by Blood Endothelial Microparticles P016 Combinatorial Effects of Endothelial Nitric Oxide Synthase Keun-Hwa Jung (Seoul) (eNOS) Gene Polymorphisms in Silent Brain Infarction P005 The Association of Intracranial Large Artery Disease and Jeong Kwon Choi (Seongnam) Metabolic Syndrome Is Ethnicity-Dependent P017 Ischemic Stroke Caused by Internal Carotid Artery Deidre De Silva (Singapore) Atherosclerosis: Intracranial vs. Extracranial P006 The Ankle Brachial Index and Atherosclerosis Burden in Sea Mi Park (Seoul) Patients with First-ever Recent Ischemic Stroke P018 The Pre-hospital Delay and Medical Knowledge of the Ji-Hee Lee (Daejeon) Patient or Bystander about Acute Stroke P007 Vascular Risk Factors and Prevalence of Cerebral Artery Seong Hwan Ahn (Gwangju) Calcification in Patients with Acute Ischemic Stroke P019 Prevalence of Aspirin Resistance in Stroke Patients Kwang-Yeol Park (Seoul) Samart Nidhinandana (Bangkok) P008 Distribution and Risk Factors of Extracranial or Intracranial P020 Progression of the Intracranial Arterial Stenosis in a Artery Stenosis in Ischemic Stroke Patients: Results from Korean Population Taiwan Stroke Registry Kyusik Kang (Jinju) Jiann-Shing Jeng (Taipei) P021 Serum VEGF Level in Acute Ischemic Stroke Patients P009 Classic Risk Factors for Stroke Are Not Major Correlates with the Prognosis of Stroke Determinants for Location of Cerebral Atherosclerosis Seung-Chul Lee (Seoul) Young Dae Kim (Seoul) P022 Decreased Number of Endothelial Progenitor Cells in P010 Is Metabolic Syndrome Associated with Stroke in Patients with Recurrent Stroke Normotensive and Prehypertensive Individuals? Hee-Kwon Park (Seoul) Yong Jae Kim (Seoul) P023 D-dimer in Intracranial Artery Stenosis with Acute P011 Prevalence of Intracranial Stenosis among Adult Filipino Ischemic Stroke Patients: a Five Year Review Ji-Yong Lee (Wonju) Carter Rabo (Manila) P024 Factors Associated with Neurological Progression in P012 Polymorphism of Vascular Endothelial Growth Factor Patients with Acute Ischemic Stroke Subtype as Large (VEGF) Gene as an Independent Risk Factor for Patients Artery Atherosclerosis with Silent Brain Infarction Yong-Jin Cho (Goyang) Jae ho Lee (Seongnam)

June 18-20, 2008, Grand InterContinental Seoul, Seoul, Korea 11 www.icas2008.or.kr Scientific Program

Imaging & Diagnosis P038 Measurement of Carotid Plaque for Assessment of Chair Gyeong-Moon Kim (Seoul) Atherosclerosis in Patients with Stroke P025 Are Facilities Necessary to Detect Intracranial Hyo Suk Nam (Seoul) Atherosclerosis Available in European Hospitals? P039 Intravascular Ultra Sonography Finding of a Case of Clotilde Balucani (Lille) Radiation Induced Carotid Artery Stenosis P026 Benign Oligemia Despite of a Malignant MRI Profile in Young Eun Kim (Anyang) Acute Ischemic Stroke P040 A One-Year Review of the Carotid and Transcranial Oh Young Bang (Seoul) Doppler Findings of Patients of the Philippine General P027 Infarct Pattern on Diffusion Weighted Image in Cardioembolic Hospital for the Year 2007 Stroke: Atrial Fibrillation vs. Patent Foramen Ovale Agnes Cariaga (Manila) Jeong Lee (Incheon) P041 Preliminary Study: Fluid-Structure Interaction Analysis of P028 Diagnosis of the Intracranial Artery Dissection by Carotid Artery Bifurcation and Its Application to the Multiplanar CT Angiography Evaluation of Atherosclerosis Tai Hwan Park (Seoul) Sang Ok Park (Seoul) P029 Clinical Significance of Coexisting Carotid Atherosclerosis P042 Correlation of Cerebral Artery Calcification and Brachial- in Patients with Intracranial Small- or Large-Vessel Disease Ankle Pulse Wave Velocity in Patients with Acute A-Hyun Cho (Seoul) Ischemic Stroke P030 A Case of Small Arteriovenous Malformation in Right Pil-Wook Chung (Seoul) Posterior Fossa, with Draining Venous Aneurysm P043 Comparison in Two Serial TCD Findings of Symptomatic Geum Jin Yoon (Gwangju) Middle Cerebral Artery (MCA) between MCA Disease and P031 Two Cases of Early Wallerian Degeneration Detected Only Tandem Arterial Pathology by Diffusion Tensor Image in Stroke Patient Kyung Bok Lee (Seoul) Sun A Lee (Seoul) P044 Intracranial Pulsatility Index and Homocysteine P032 Magnetic Resonance Spectroscopic Finding of Acute Seul-Ki Jeong (Jeonju) Ischemic Infarction Due to Autologous Fat Injection P045 Cerebral Infarction Caused by a Mobile Thrombus Attached Sang Hun Yi (Seoul) to Atherosclerotic Plaques in the Aortic Arch P033 Screening Strategies for a Diagnosis of Coronary Artery Jun Young Lee (Daejeon) Stenosis in Patients with Cerebral Infarction Using Dual P046 The Relationship between Carotid Plaques and Stenosis of Source CT Intracranial Arteries Seul-Ki Jeong (Jeonju) Yo Han Jung (Seoul) P034 ASPECT Score on Contrast Enhancement CT to Estimate P047 The Relation between Extracranial Carotid Plaque and Pial-Collateral Circulation Status Intracranial Arterial Stenosis Jun Young Choi (Suwon) Seo Hyun Kim (Wonju) P035 Absence of the Common Carotid Artery: a Rare Vascular Anomaly Stroke Mechanism & Topography Seong Jin Yim (Seoul) Chair Sun U Kwon (Seoul) P048 Extracranal and Intracranial Artery Disease in Relation to Neurovascular Imaging the Neurological Deficit Chair Yong-Seok Lee (Seoul) Anita Arsovska (Skopje) P036 Distribution of Artificial Cerebral Microemboli Is Not P049 Posterior Communicating Artery Hyperplasia: a Potent Related to Lesion Location in Stroke Patients Prognostic Predictor in Acute Brainstem Infarction Caused Jun Lee (Daegu) by Basilar Artery Occlusion or Severe Stenosis P037 Clinical Profiles and Sonographic Findings of Patients Ji Man Hong (Suwon) Seen at the Diosdado Macapagal Stroke Center, P050 Basilar Artery Atherosclerotic Disease Is Related to Philippine General Hospital Subacute Lesion Volume Increase in Pontine Base Infarction Jessie Colacion (Manila) Kyung-Hee Cho (Seoul)

12 ICAS 3rd International Conference on Intracranial Atherosclerosis 2008 and Annual Spring Meeting of the Korean Stroke Society Scientific Program

P051 Etiology and Stroke Pattern of Posterior Cerebral Artery P065 Hypoglossal Nerve Palsy Associated with Relevant Territory Infarcts: Analysis of 205 Patients with Diffusion Internal Carotid Artery Stenosis Mimicking Internal Carotid Weighted MRI Artery Dissection Eugene Lee (Seoul) Ilhong Son (Gunpo) P052 Lenticulostriate Artery Territory Infarcts: Correlation of P066 Posterior Reversible Encephalopathy Syndrome Axial Location with Large Artery Disease and White Matter Associated with Acute Pancreatitis Hyperintensities Sejin Lee (Daegu) Hahn Young Kim (Seoul) P067 Unusual Case of Hypertensive Encephalopathy Involving P053 Topographic Pattern and Stroke Mechanism Associated the Whole Brainstem and Subcortical Deep Structures with Progressive Motor Deficits in Acute Motor Stroke Jong-Ho Park (Goyang) Pil-Wook Chung (Seoul) P068 Chronic Isolated Vertigo Followed by Progressive Posterior P054 Different Prevalence of Systemic Atherosclerosis between Circulation Stroke Patients with Perforating Artery Territorial Infarction Sucjoo Kim (Seoul) Presumably due to Small Artery Disease and Those due to P069 Hemangioblastoma Presenting with Wallenberg’s Arterial Embolus Syndrome Hye-yeon Choi (Seoul) Seunghwan Yoon (Seoul) P055 Recurrent Isolated Vertigo from Hypoplastic Vertebral Artery P070 Isolated Ptosis as Presenting Symptom of a Basal Sung-Ho Ahn (Busan) Ganglionic Infarction P056 Golfer’s Stroke from Internal Carotid Artery Dissection Hak Seung Lee (Iksan) Kwang-Dong Choi (Busan) P071 Vascular Ehlers-Danlos Syndrome Presenting with P057 Simultaneous Posterior Ischemic Optic Neuropathy, Bilateral Internal Carotid Artery Dissection Cerebral Border Zone Infarction, and Spinal Cord Infarction Sang-Bae Ko (Seoul) after Correction of Malignant Hypertension Jae-Hwan Choi (Busan) Neuropsychological Aspects & Others P058 Lateral Medullary Infarction Subsequent to Medial Medullary Chair Soo Joo Lee (Daejeon) Infarction in a Patient with Vertebral Artery Occlusion P072 Effect of Leukoaraiosis on the Conscious Condition in Jee-Hyun Kwon (Ulsan) Patients with Ischemic Stroke P059 Five Cases of Cerebral Infarction Associated with Multiple Xiaojuan Wang (Guangzhou) Myeloma P073 Acute Memory Disturbance after Cerebellar Infarction: a Sang-Won Park (Daegu) Case Report Hyun Cho (Ulsan) Stroke Syndrome & Clinical Aspects P074 Neuropsychological Profile of Thalamic Infarction: a Chair Jae-Kwan Cha (Busan) Comparison between Left and Right Thalamic Lesions P060 Comparison of the Characteristics for In-Hospital and Out- Jaeseol Park (Anyang) Of-Hospital Ischemic Strokes P075 Cognitive Profiles and Behavioral Psychological Hyun-Ji Cho (Seoul) Assessment Pattern in the Patient with Strategic Infarction P061 Low-Flow Type Boderzone Infarction Induced by Heavy Soo Yoon Lee (Busan) Smoking P076 A Case of Thalamic Infarction Presenting with Neglect Il Mi Jang (Seoul) Syndrome as a Predominant Symptom P062 Boderzone Infarction as a Complication of Bacterial Hyun Woo Yang (Busan) Meningitis P077 Hypokinetic Dysarthria in Midbrain Infarction and Ji Sun Kim (Seoul) Somatotopic Organization of Subtantia Nigra P063 Cerebrovascular Complications Associated with Scrub Miseon Kwon (Seoul) Typhus P078 A Case of Dissociated Crossed Aphasia and Anarthria in Young-Mok Song (Cheonan) Right Hemispheric Lesion P064 Moyamoya Disease with Subclavian Artery Involvement Kee Ook Lee (Daejeon) Seunghwan Yoon (Seoul)

June 18-20, 2008, Grand InterContinental Seoul, Seoul, Korea 13 www.icas2008.or.kr Scientific Program

P079 Misownership and Somatoparaphrenia in the Patient with P093 Effect of Intravenous He-Ne Laser Irradiation on Pulse Right PCA Infarction: Disconnection Syndrome Wave Velocity Seung Don Yoo (Seoul) Ju-ah Lee (Jecheon) P080 Hemimedullary Syndrome due to Separate Medial and P094 Large Territorial Infarction without Massive Edema: Lateral Medullary Infarctions in Acute Stage: Case Report Frequency and Association with Vascular Risk Factors of 2 Patients Dong Ick Shin (Cheongju) Sam Yeol Ha (Seoul) P081 A Case of Tremor as Initial Manifestation by Acute Angioplasty & Stenting Cerebellar Infarction Chair Woo Suk Choi (Seoul) Jong Hwan Choi (Daegu) P095 Angioplasty and Stenting for Total Occlusion of Intracranial P082 Squamous Cell Carcinoma of the Lung Presenting with Segment of Internal Carotid Artery: Case Report Hydrocephalus and Multiple Intracranial Stenoses Jie Shuai (Chongqing) Sung Ik Lee (Gunpo) P096 Outcome of Lenticulostrate Artery after Self-Expandable P083 Hemiplegic Migraine Caused by Brain Perivascular Spaces Stenting for High-Grade Middle Cerebral Artery Stenosis Young Ha Lee (Seoul) Thomas Leung (Hong Kong) P097 Initial Experience of Intracranial Stenting with Drug- Thrombolysis & Challenging Therapy Eluting Stent (ICS-cyper) for the Symptomatic Severe Chair Keun-Sik Hong (Goyang) Intracranial Stenosis P084 Organized Protocol and Computerized Electronic Activation Won Jung Chung (Seoul) System Reduce In-Hospital Delay for Intravenous t-PA P098 Angioplasty and Stenting of Symptomatic Atherosclerotic Treatment in Acute Ischemic Stroke Stenosis of Middle Cerebral Artery with Wingspan System: Keun-Sik Hong (Goyang) Evaluation of Procedural Safety and Technical P085 Additional Therapy after Intravenous t-PA Thrombolysis in Considerations in Relation to Vascular Morphology Acute Major Infarction Patients Simon Yu (Hong Kong) Do-Sung Yoo (Uijeongbu) P099 Drug-Eluting Stenting of Symptomatic Ostial Vertebral P086 Diffusion/Perfusion Mismatching as an Indication for the Artery Stenosis: Clinical and Angiographic Results at 1 Thrombolytic Therapy in Major Stroke Patients Year Follow Up Do-Sung Yoo (Uijeongbu) Simon Yu (Hong Kong) P087 MRI-Based Thrombolysis Reduced Symptomatic P100 Delayed Intracerebral Hemorrhage after Carotid Artery Hemorrhage in Hyperacute Ischemic Stroke Stenting Hyung-Won Jeon (Busan) Kwang Deog Jo (Gangneung) P088 Delayed Neurological Deteriorations and Subcortical P101 Emergent Middle Cerebral Artery Stenting as Failure of White Matter Changes Following Reperfusion of Acute Recanalization after Intra-arterial Thrombolysis Middle Cerebral Artery Occlusion Sung-Il Sohn (Daegu) Yangha Hwang (Daegu) P102 Stent-Assisted Thrombolysis in Four Cases of Acute Basilar P089 Trehalose Induces Ischemic Tolerance via Activation of Occlusion Autophagy In Vitro and In Vivo Soo yoon Lee (Busan) Kon Chu (Seoul) P103 Bilateral Spontaneous Carotid Cavernous Fistula Treated P090 Autologous Adipose-Derived Stem Cell Transplantation Using Transvenous Embolization in Focal Cerebral Ischemia Hyun-jung Jung (Gwangju) Soon-Tae Lee (Seoul) P104 Aneurysmal Rupture of Internal Carotid Artery Aneurysm P091 Delayed and Repeated Injections of Recombinant Human Mimicking Pituitary Apoplexy Presented as Intra-Sellar Erythropoietin Have No Beneficial Effect in Rats with Hemorrhage Ischemic Stroke Jun Bum Park (Ulsan) Seong-Ho Koh (Seoul) P105 Natural History of Incidental Intracranial Aneurysm in P092 Successful Treatment with Intra-Arterial Thrombolysis in Patients with Ischemic Stroke Ischemic Stroke Caused by Infective Endocarditis Yoon-Sang Oh (Seoul) Ki-Joo Kim (Jeonju)

14 ICAS 3rd International Conference on Intracranial Atherosclerosis 2008 and Annual Spring Meeting of the Korean Stroke Society Scientific Program

Functional Recovery P112 Clinical Outcome Prediction by Motor Evoked Potentials Chair Min Ho Jeon (Seoul) of the Upper and Lower Extremity after Acute Ischemic P106 Long-Term Effect of rTMS on Motor Recovery of Stroke Stroke Patients Yeong Bae Lee (Incheon) Bohyun Joen (Seoul) P113 Longitudinal Changes of Structural and Functional Brain P107 Standardization and Reliability of Korean Version of Connectivity in Subcortical Stroke Patients Frenchay Aphasia Screening Test (K-FAST) Chang-hyun Park (Seoul) Sung-Bom Pyun (Seoul) P114 Improvement of Cognitive Function after Carotid Stent P108 The Change of Neuroplasticity of Brain after Extracranial Ji Hee Lee (Daejeon) Intracranial Bypass Surgery in the Patients of Cerebral P115 Change of Respiratory Function in Acute Hemiplegic Infarction Stroke Patients Seung Don Yoo (Seoul) Bo ryun Kim (Seoul) P109 Effect of Robot-Assisted Gait Therapy on Cardiopulmonary P116 Cognitive Dysfunction in Patient with Posterior Inferior Fitness in Subacute Stroke Patients Cerebellar Artery Territory Infarction Min Su Kim (Seoul) Boram Lee (Daejeon) P110 The Effect of Neuromuscular Electrical Stimulation on P117 Intracranial Large Artery Disease Is an Independent Risk the Trunk Control in Hemiplegic Stroke Patients Factor for 6-Month Vascular Outcomes among Ethnic Yong mi Kim (Seoul) South Asian Ischemic Stroke Patients P111 The Effect of Functional Electrical Stimulation on the Deidre De Silva (Singapore) Recovery of Lower Motor Function in Hemiplegic Patients with Stroke Yong-Il Shin (Iksan)

Luncheon Symposia

June 19, 2008 (Thursday) Luncheon Symposium (Supported by Myung In Pharmaceutical Co.,Ltd.) Luncheon Symposium 12:30-13:00 Grand Ballroom 1 & 2 (Supported by Bristol-Myers Squibb & sanofi-aventis Korea Co.,Ltd.) Chair Beum Saeng Kim (Seoul) 12:10-13:00 Grand Ballroom 1 & 2 LS3 Inflammation in Acute Stroke & Intracranial Chair David C Bonovich (San Francisco, CA) Atherosclerosis: Potential Role of Triflusal LS1 Prevention of Cerebral Small Vessel Disease Juan F Arenillas (Valladolid) Oscar Benavente (San Antonio, TX)

June 20, 2008 (Friday) Luncheon Symposium (Supported by Korea Otsuka Pharmaceutical Co.,Ltd.) 12:00-12:30 Grand Ballroom 1 & 2 Chair Niphon Poungvarin (Bangkok) LS2 Prevention of Stroke 2008 Louis R Caplan (Boston, MA)

June 18-20, 2008, Grand InterContinental Seoul, Seoul, Korea 15 www.icas2008.or.kr Accommodation and Transportation

Hotel Information

Grand InterContinental Seoul Address : 159-8 Samseong-Dong, Gangnam-gu, Seoul Tel : +82-2-555-5656 Website : http://seoul.intercontinental.com

COEX InterContinental Seoul Address : 159 Samseong-Dong, Gangnam-gu, Seoul Tel : +82-2-3452-2500 Website : http://seoul.intercontinental.com

Hotel Riviera Seoul Address : 53-7 Cheongdam-dong Gangnam-gu, Seoul Tel : +82-2-541-3111 Website : http://www.hotelriviera.co.kr/eng/index.asp

Ellui Hotel Address : 129 Chungdam-Dong, Gangnam-Gu, Seoul 135-100 Tel : +82-2-514-3535 Website : http://www.ellui.com/english/main/main.asp

IBIS Seoul Address : 893-1 Daechi-Dong, Gangnam-Gu, Seoul 135-840 Tel : +82-2-3011-8888 Website : http://www.ambatel.com/ibis/english/indexmsie.php

Samgsung Casaville Seoul Address : 945-29 Daechi3-dong, Gangnam-gu, Seoul Tel : +82-2-539-9080 Website : http://www.casaville.co.kr

16 ICAS 3rd International Conference on Intracranial Atherosclerosis 2008 and Annual Spring Meeting of the Korean Stroke Society Transportation

Limousine Bus (Incheon International Airport ↔ Grand InterContinental Seoul) Limousine Bus (Incheon International Airport Grand InterContinental Seoul) Limousine buses for hotels are available at the Incheon International Airport. To purchase a bus ticket, you are advised to go to the Transportation Information Counter (near exits 2, 4, 9, 13) on the arrival floor (1st floor) of the passenger. Fare is KRW 14,000, and buses are available every 30 minutes.

Taxi Taxi fare is approximately KRW 95,000 for a deluxe taxi and KRW 70,000 for a regular taxi including the expressway toll fee from Incheon International Airport to the venue. It usually takes about 60~70 minutes, but it may vary depending on traffic conditions. From midnight to 4:00 am, a 20% extra charge is added to the fare for regular taxis, but not for deluxe taxis. Translation services are available upon request and a receipt can be issued.

June 18-20, 2008, Grand InterContinental Seoul, Seoul, Korea 17 www.icas2008.or.kr General Information

Conference Venue Grand InterContinental Seoul 159-8 Samseong-Dong, Gangnam-gu, Seoul, Korea (Tel: +82-2-555-5656)

Climate Korea's climate is regarded as a continental climate from a temperate standpoint and a monsoonal climate from a precipitation standpoint. The climate of Korea is characterized by four distinct seasons: spring, summer, fall, and winter. During the conference, the weather should be mild, making it the best season for visiting Korea. The average temperature is 21℃ (69.8。F).

Time Difference Korean time is 9 hours ahead of Greenwich Mean Time (GMT+9).

Passport and Visa Any foreign visitor wishing to enter the Republic of Korea must have a valid passport and obtain a Korean visa before arriving. Visitors with roundtrip tickets from countries that have a special agreement with Korea may be exempted from the visa requirement, and can stay in Korea visa-free for periods up to 30 days, or 90 days, depending on the type of agreement between the two countries. When uncertain as to the requirement for and entry visa to Korea, please contact the Korean Embassy or a consulate as soon as possible. For ore information, please visit the official website of the Korean Ministry of Foreign Affaris and Trade at www.mofat.go.kr/me/index.jsp.

Insurance It is advised that participants arrange their own personal health, accident and travel insurance.

Business Hours Government offices are open from 9:00 a.m. to 6:00 p.m. on weekdays. They are closed on weekends. Banks, meanwhile, are open from 9:00 a.m. to 4:30 p.m. on weekdays. Like government offices, the are closed on weekends. Department stores usually operate from 10:30 a.m. to 8:00 p.m. seven days a week, although they usually close one day a month (usually a Monday). Smaller shops, however, tend to stay open from early morning until late evening.

Useful Websites Information about Seoul: http://english.seoul.go.kr Information about Korea: http://www.tour2korea.com Incheon International Airport: http://www.airport.or.kr/eng/airport/ Korean Ministry of Foreign Affairs and Trade: http://www.mofat.go.kr/me/index.jsp

18 ICAS 3rd International Conference on Intracranial Atherosclerosis 2008 and Annual Spring Meeting of the Korean Stroke Society Sponsors

The Organizing Committee of ICAS 2008 gratefully acknowledges the support by the following companies.

Supporting Organizations

June 18-20, 2008, Grand InterContinental Seoul, Seoul, Korea 19 www.icas2008.or.kr Exhibition

Exhibition Hours June 19 (Thu) 09:00 - 18:00 June 20 (Fri) 08:00 - 17:00

Exhibition Layout

8 21 7 20 16 13

12 Session Room 19 15 6 11

10 18 14 5 9

17 4

Registration Desk 1 3

1 2

Grand Inter-Continental Hotel Seoul (2F)

1 Bristol Myers Squibb Korea/sanofi-aventis Korea Co., Ltd. 12 Soelim International Inc. 2 Korea Otsuka Pharm. Co., Ltd. 13 Green Cross Corp. 3 Myung In Pharm. Co., Ltd. 14 Boryung Pharm. Co., Ltd. 4 Bukwang Pharm. Co., Ltd. 15 Pfizer Pharm. Korea Ltd 5 ChongKunDang Pharm. 16 Novartis Korea/Pfizer Korea 6 Bayer Korea 17 Hyundai Pharm. 7 MSD Korea Ltd. 18 Dong-A Pharm. 8 Daewoong Pharm. Co., Ltd. 19 JIN YANG Pharm. Co., Ltd 9 Kelimmedical 20 Korea Medical Foods Co., Ltd 10 SK Chemicals Life Science 21 Internet Lounge 11 GlaxoSmithKline

20 ICAS 3rd International Conference on Intracranial Atherosclerosis 2008 and Annual Spring Meeting of the Korean Stroke Society Abstracts of 3rd International Conference on Intracranial Atherosclerosis and Annual Spring Meeting of the Korean Stroke Society Invited Sessions 3rd International Conference on ICAS Intracranial Atherosclerosis 2008 and Annual Spring Meeting of the Korean Stroke Society

Keynote and Invited Sessions

Keynote Speech Chairs｜Kwang Ho Lee Global Importance of ICAS David C Bonovich (San Francisco,CA)｜05

Invited Session 1 Chairs｜KS Lawrence Wong, Byung Chul Lee Invited Session 1-1 Epidemiology of Intracranial Atherosclerosis KS Lawrence Wong (Hong Kong)｜06 Invited Session 1-2 Pathologic Characteristics Xiang Yan Chen (Hong Kong)｜07 Invited Session 1-3 Risk Factors for Intracranial Atherosclerosis Oh Young Bang (Seoul)｜10

Invited Session 2 Chairs｜Louis R Caplan, Jong S Kim Invited Session 2-1 Stroke Mechanisms in Pateints with Intracranial Vascular Occlusive Disease Louis R Caplan (Boston, MA)｜11 Invited Session 2-2 Intracranial Atheroclerosis : Impact on Clinical Syndromes Jong S Kim (Seoul)｜12 Invited Session 2-3 Intracranial Arterial Dissection Sung-Chun Tang (Yun-Lin)｜13 Invited Session 2-4 Intracranial Atherosclerosis and Dementia Alex E Roher (Sun City, AZ)｜14

Invited Session 3 Chairs｜Jose C Navarro, Deok Hee Lee Invited Session 3-1 The Application of MRI Dong-Wha Kang (Seoul)｜15 Invited Session 3-2 Assessment of Intracranial Atherosclerosis by CT & MR Angiography Seung-Koo Lee (Seoul)｜16 Invited Session 3-3 TCD in Intracranial Stenosis Jose C Navarro (Manila)｜17 Invited Session 3-4 Assessment of Ischemic Stroke by Perfusion Imaging Modalities Jun Hatazawa (Osaka)｜18

Invited Session 4 Chairs｜Marc Chimowitz, Dae Chul Suh Invited Session 4-1 Statin and Other Miscellaneous Therapy Christopher Chen (Singapore)｜19 Invited Session 4-2 Elective Stenting: an Effective Treatment for Selected Patients with Symptomatic Atherosclerotic Intracranial Stenosis of 70% to 99% at Experienced Centers Wei-Jian Jiang (Beijing)｜20 Invited Session 4-3 Stenting vs. Medical Therapy for Symptomatic Intracranial Arterial Stenosis Marc Chimowitz (Charleston, SC)｜24 Invited Session 4-4 Self-Expanding Stenting for Acute Ischemic Stroke Henry Woo (Stony Brook, NY)｜25

Invited Session 5 Chairs｜Didier D Leys, Chang Wan Oh Invited Session 5-1 Intracranial Atherosclerosis: Natural Course and Prognosis Juan F Arenillas (Valladolid) ｜26 Invited Session 5-2 Antithrombotic Therapy in Symptomatic Intracranial Stenosis Yong-Seok Lee (Seoul)｜27 Invited Session 5-3 Surgical Treatment of Moyamoya Disease Gary K Steinberg (Stanford, CA)｜28 Invited Session 5-4 Rehabilitation Following Ischemic Stroke Caused by Intracranial Atherosclerosis Nam-Jong Paik (Seongnam)｜29

3rd International Conference on Intracranial Atherosclerosis and Annual Spring Meeting of the Korean Stroke Society KEYNOTE SESSION

Keynote Speech

Keynote Session Global Importance of ICAS David C Bonovich Department of Neurology, University of California San Francisco, San Francisco, CA, USA

Large vessel intracranial atherosclerosis (ICAS) is a significant problem worldwide. It accounts for 10-15% of all stroke in Europe and North America, and up to a third of strokes in Asia. Studies suggest that the risk of recurrent stroke is as high as 10% per year and as high as 20% in the initial two weeks after initial event. In patients with stenoses grater than 80% the yearly risk of recurrent stroke is even higher. Stroke manifests in several different ways in patients with ICAS including distal embolization, hyperperfusion syndromes, and parent vessel occlusion. Current studies indicate that antiplatelet agents and risk factor modification offer the best means of prevention. In the acute phase after stroke related to ICAS, short tem use of anticoagulants and possibly even hypertensive therapy might offer benefit in preventing extension of the initial stroke and recurrence in the short term. There is growing interest in the role of interventional management of in the acute phase to minimize severity of stroke related to ICAS. Such interventions include the use of thrombolytic agents and devices to remove clot from arteries either alone or in combination. Finally with the introduction of intracranial stents, the role of intracranial stenting to prevent recurrent stroke needs to be investigated.

Presenting authors are indicated in bold. S5

3rd International Conference on Intracranial Atherosclerosis and Annual Spring Meeting of the Korean Stroke Society INVITED SESSIONS

Invited Session 1 Epidemiology and Risk Factor

Invited Session 1-1 Epidemiology of Intracranial Atherosclerosis KS Lawrence Wong Department of Medicine & Therapeutics, The Chinese University of Hong Kong, Hong Kong SAR, China

Intracranial atherosclerosis is the most common vascular lesion found in stroke patient, except among European and North American. In normal Chinese population aged more than 50, 7-8% have asymptomatic intracranial atherosclerosis as studied by TCD. The prevalence increases to up to 30% if there are multiple risk factors such as diabetes and hypertension. Among patients with TIA and minor stroke, the frequency of intracranial atherosclerosis can be up to 70%. Among stroke patients, intracranial atherosclerosis is present in around 30-50%. The frequency is similar among Chinese, Korean, Thai and Sin- gaporeans. In Europe and North American, intracranial atherosclerosis is relatively uncommon, accounting for about 8-10% only. However, recent pathologic study in France suggests that intracranial atherosclerosis may be more common than expected.

S6 Presenting authors are indicated in bold. Korean J Stroke(Supplement 1) 2008;10

3rd International Conference on Intracranial Atherosclerosis and Annual Spring Meeting of the Korean Stroke Society INVITED SESSIONS

Invited Session 1 Epidemiology and Risk Factor Invited Sessions Sessions Invited

Invited Session 1-2 Pathological Characteristics Xiang-Yan CHEN1, Mark Fisher2 1Division of Neurology and Medicine and Therapeutics, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong SAR, China 2Department of Neurology, University of California, Irvine, CA, USA

Atherosclerosis is a lifetime illness evolving slowly over many years, which involves multiple arteries throughout the body, including intracranial and extracranial arteries. In intracranial vessels, atherosclerosis usually occurs in the setting of widespread vascular disease. In the recent years, however, it has been found that intracranial atherosclerosis (ICAS) is more prevalent than in extracranial atherosclerosis in many Asian countries. Thus, the ICAS seems to occur in two separate patterns: 1) in patients with severe extracranial and systemic atherosclerosis, and 2) in some racial, ethnic groups who often have isolated intracranial arterial disease with little evidence of extracranial, coronary or systemic disease.

General Features of Atherosclerosis Atherosclerotic lesions begin with inflammatory reactions followed by smooth muscle proliferation and thickening of the arterial wall. Histologically, atherosclerotic plaques have three principal components: 1) cells, including smooth muscle cells, macrophages and other leukocytes; 2) connective tissue extracellular matrix, including collagen, elastin fibers, and prote- oglycans; and 3) intracellular and extracellular lipid deposits. Fatty streaks, fibrous plaques, and complicated plaques are the pathologic hallmarks of atherosclerosis. The firstly observed pathologic change in the artery is a so-called fatty streak. It is characterized by the adhesion of monocytes to the endothelium and their migration to the subendothelial potions of the arterial wall. In this location, they form a foamy appearance microscopically. With increasing age, the fatty streak is transformed into a fibrous plaque. It consists of a core of cellular debris, free extracellular lipid, and cholesterol crystals under a “cap” consisting of foam cells, transformed smooth muscle cells, lymphocytes, and connective tissue. The most advanced stage of atherosclerosis is the complicated lesion, which contains calcification, hemosiderin deposition, and luminal surface disruption. The evolution of atherosclerosis is a complex interaction of cellular events, intercellular messengers, hemodynamic factors, and vascular risk factors. The cellular contributors to plaque development are monocytes/macrophages, endothelial cells, smooth muscle cells, and, to a lesser degree, lymphocytes and platelets.

Pathological Characteristics of Atherosclerosis in Different Arteries The pathological characteristics of atherosclerosis are different according to the location of the lesion (coronaries, carotids, or aorta). Rupture-prone plaques in the coronary arteries, the so-called “vulnerable plaques”, have a thin fibrous cap and a large lipid core. In contrast to the coronary artery, high-risk plaques in carotid arteries are usually severely stenotic. Thus, the term “high-risk” has been used rather than “vulnerable”, which only implies the presence of a lipid-rich core. However, based on study results in which a large number of carotid endarterectomy specimen were carefully examined, it was found that carotid plaque morphology such as intraplaque hemorrhage or reparative neovascularization importantly influences plaque instability. It has been presumed that ICAS may be similarly affected by the hemodynamic factors as in arteries elsewhere. However, this assumption should be made cautiously considering the epidemiologic differences between intra- and extracranial atherosclerotic disease.

Animal Models for Intracranial Atherosclerosis To evaluate atherosclerosis in intracranial arteries, animal models have been developed in various species, including swine, chickens, dogs, rabbits, rats, and monkeys. The models are useful for studying morphological characteristics, the pathogenesis of cerebral atherosclerosis, and may be applied in the examination of the strategies to prevent or treat human diseases.

Presenting authors are indicated in bold. S7

3rd International Conference on Intracranial Atherosclerosis and Annual Spring Meeting of the Korean Stroke Society INVITED SESSIONS

It is difficult to induce atherosclerosis in the cerebral arteries, especially in intracranial arteries, although atherosclerosis can be produced in rabbits by feeding them with atherogenic diet, or can occurs spontaneously in Watanabe heritable hyperli- pidemic (WHHL) rabbits. To produce cerebral atherosclerosis in nonhuman species, additional application of hypertension is more effective than inducing hyperlipidemia alone. In a cynomolgus monkey, for example, hypertension accelerated the formation of cerebral atherosclerosis. But Ito et al demonstrated spontaneously developed cerebral atherosclerosis in selecti- vely bred homozygous WHHL rabbits which are known to show hypercholesterolemia and severe coronary atherosclerosis. These intracranial lesions occurred in the absence of hypertension in 24 of 25 animals at various sites, mainly in the arteries at the base of the brain. Thus, the coronary atherosclerosis-prone homozygous WHHL rabbit may be used as an animal model for spontaneous cerebral atherosclerosis. In addition, there are other methods to produce cerebral atherosclerosis in animals. Yamori et al successfully developed fat deposition in the posterior communicating arteries in normotensive rats by bilateral or unilateral carotid artery ligation or basilar artery ligation and following high-fat choleteral feeding. These results suggest that aside from high blood pressure, hemodynamic derangement is also an important factor for the development of atherosclerosis in cerebral arteries. The animal models have demonstrated morphological characteristics of ICAS atherosclerosis. The model of hypertensive WHHL rabbits showed that atherosclerotic lesions in cerebral arteries remained less severe than in the aorta and coronary arteries, and exhibited qualitative morphologic differences. Kato et al studied the development of cerebral atherosclerosis in rabbits by light microscopy and found that intimal lesions were mainly composed of accumulations of foam cells and smooth muscle cells. Another study of experimental rabbits demonstrated early lesions of ICAS by microscopy and found widespread thickening and contraction seen in almost all intracranial small arteries. Hyaline degeneration could be seen in some of the arteries. Most of the cerebral parenchymal capillary endothelia were swollen and some of these cells contained lipid. Imai et al investigated cerebral atherosclerosis in swine and found necrosis in progression of diet-induced lesions from proliferative to atheromatous stage.

Human Autopsy Studies Investigating pathological characteristics of ICAS has been particularly difficult due to the limitations of autopsied patients, time-consuming dissections of the arteries, and numerous technical problems associated with specimen preparation, shipment, and storage. Grading systems that need validation are also elements adding to the complexity of these studies. Nevertheless, autopsy study is still an important and valuable method to investigate ICAS. It is recommended that all basic studies of human atherosclerosis should include both macroscopic and microscopic description of the same arterial segments with the use of adequate terminology.

Risk Factors In cerebral atherosclerosis, quantitative differences in severity exist according to age, gender, races, hypertension, diabetes mellitus and lipid disorders. Autopsy studies in stroke patients have shown that African-American and Japanese frequently have intracranial vascular occlusion, whereas Caucasians more often have extracranial lesions[1]. The pathological data from an autopsy study of Hong Kong, China showed that the extent of ICAS was much more severe than what was shown in white and Japanese populations, and that atherosclerotic narrowing of the extracranial carotid artery was less severe in Hong Kong Chinese than in Caucasians. Moosy investigated development of cerebral atherosclerosis in various age groups and found that the earliest sites of deposition were the internal carotid and vertebral arteries, followed by the basilar artery and middle cerebral artery[2]. Similar study of atherosclerosis in infants, children and young adults in Japan found that atherosclerosis of aortas, coronary arteries and cerebral arteries increased with age; the most severe lesions were seen in the aorta, and with decreasing severity, in the coronary and cerebral arteries. Atherosclerosis occurred later and was less extensive in intracranial arteries than in extracranial arteries. In a New Orleans study, 1093 extracranial carotid and intracranial arteries were evaluated for black- white and male-female differences during ten year period. Raised lesions (fibrous plaques and complicated fibrous plaques) in the carotid arteries increased with age in both races but the rate of increase was greater in black women. Both fatty streaks and fibrous plaques began at the end of the second decades to the beginning of the third decades in the intracranial arteries.

S8 Presenting authors are indicated in bold. Korean J Stroke(Supplement 1) 2008;10

3rd International Conference on Intracranial Atherosclerosis and Annual Spring Meeting of the Korean Stroke Society INVITED SESSIONS

The possible mechanism may be greater activity of antioxidant enzymes in intracranial arteries contributing to their greater resistance to atherosclerosis and that with increasing age, accelerated atherosclerosis occurs in intracranial arteries secondary

to decreased antioxidant protection. Sessions Invited Hyperlipidemia is another risk factor of cerebral arterial atherosclerosis, as verified by a high correlation between increased cholesterol and Baker’s score and more frequency of severe cerebral atherosclerosis with some features of advanced atherosclerosis in subjects with elevated blood cholesterol levels than those with normal blood cholesterol level. But blood pressure was reported to be the most important risk factor for cerebral atherosclerosis. Intracranial advanced atherosclerotic lesions were more common in blacks of both sexes at all ages. Regarding risk factors, blacks consistently have higher rates of hypertension than whites, suggesting that hypertension or other unidentified factors may have an impact on the racial difference of ICAS. According to a clinical study smoking may be the most significant independent predictor of the presence of atherosclerosis of the intracranial internal carotid artery.

Distribution of Intracranial Atherosclerosis Common locations for symptomatic atherosclerosis are the origin of the internal carotid artery, the intracavernous portion of the internal carotid artery, the first segment of the middle cerebral artery, the origin and the distal portion of the vertebral artery, and mid-portion of the basilar artery. The origin of the internal carotid artery is the most frequent site for severe atherosclerosis in persons of European ancestry, whereas intracranial arteries, especially the middle cerebral artery, are most commonly affected among persons of African or Asian heritage. According to a study comparing Japanese people living in Hiroshima with Japanese living Honolulu, Hawaii, atherosclerosis of the major branches of the circle of Willis was more severe in the Honolulu group whereas arteriosclerosis of penetrating arteries was more common in the Hiroshima group, with histologic features of intimal hyperplasia, subintima foam cells and cholesterol cleft deposition. The latter group also showed a higher incidence of cerebral infarcts. Another clinical study, carried out among male participants in the Honolulu Heart Program, also showed an association of the severity of cerebral atherosclerosis with autopsy-verified cerebral infarcts and hemorrhage. Atherosclerosis of MCA most commonly affects its first portion (M-1 segment), which extends from the origin of the artery to its bifurcation in the Sylvian fissure. The lenticulostriate vessels arise from this section, and the origins of these vessels can be affected by the development of an atherosclerotic plaque. Less commonly, the distal M-1 segment or the proximal portions of the first major branches of the middle cerebral artery (M-2 segment) can be involved. The majority of stenoses are less than 7mm in length. Hemorrhage, ulceration, and calcification were found in intracranial plaques, but were much less frequent as compared to extracranial atherosclerotic diseases. An autopsy study carried out in Hong Kong, China reported that the luminal stenosis caused by atherosclerotic plaque, the percentage of lipid in the atherosclerotic lesion, and the presence of intraplaque neovasculature in the MCA may play a key role in leading to clinical, ischemic events.

Presenting authors are indicated in bold. S9

3rd International Conference on Intracranial Atherosclerosis and Annual Spring Meeting of the Korean Stroke Society INVITED SESSIONS

Invited Session 1 Epidemiology and Risk Factor

Invited Session 1-3 Risk Factors for Intracranial Atherosclerosis Oh Young Bang Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea

Intracranial atherosclerotic stroke differs from extracranial atherosclerotic stroke in many aspects, including the patterns of index and recurrent stroke. However, the apparent differences in risk factors for intra- and extracranial atherosclerosis are unclear and the mechanisms that underlie strokes in patients with intracranial atherosclerosis are not well known. Consequently, patients with intracranial stenosis receive the same treatment as those with carotid atherosclerosis. Several novel substances have emerged recently as risk factors for atherosclerosis. The recent advances in risk factors for intracranial atherosclerosis will be summarized, together with the results of recent clinical trials of patients with intracranial atherosclerotic stroke. In addition, vascular localization of symptomatic large artery atherosclerosis differs for unknown reasons by race-ethnicity; higher prevalence of intracranial atherosclerosis in Asians and African-Americans. Despite of current globalization of West- ernized lifestyle, the raceethnic groups showed differences in the prevalence of conventional and novel risk factors; including visceral adiposity/ insulin resistance, smoking habits, and plasma levels of several biomarkers. It is also possible some risk factors promote distinct sites of symptomatic cervicocephalic atherosclerosis by race-ethnicity. Both may in part explain the well-known differences in race-ethnic prediction to intracranial or extracranial atherosclerosis, and will be discussed.

S10 Presenting authors are indicated in bold. Korean J Stroke(Supplement 1) 2008;10

3rd International Conference on Intracranial Atherosclerosis and Annual Spring Meeting of the Korean Stroke Society INVITED SESSIONS

Invited Session 2 Stroke Mechanism and Clinical Syndromes Invited Sessions Sessions Invited

Invited Session 2-1 Stroke Mechanisms in Patients with Intracranial Vascular Occlusive Disease Louis R Caplan Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA

Mechanisms for brain infarction arising from intracranial atherosclerosis include: in situ atherosclerosis of large arteries with superimposed thrombotic occlusion, artery-to-artery embolism, and local branch occlusion of the orifice of deep perforating branches. Reduced perfusion often coexists with artery-to-artery embolism and these two mechanisms are closely inter-related.

Acute Thrombosis Acute thrombosis begins with fissuring of the fibrous cap of atherosclerotic plaques, which disrupts the endothelial surface of the artery. Release of tissue factors promotes the development of a clot on the surface of the plaque. Local occlusion and secondary artery-to-artery embolism can result.

Artery-to-artery Embolism White and red thrombi often form on the surface of plaques and break loose to embolize to more distal portions and branches of the artery. TCD monitoring of patients with intracranial artery stenosis may show microembolic particle HITS.

Branch Occlusive Disease Flow through the penetrating arteries that branch from the major intracranial basal arteries can be compromised by 3 different pathogenetic mechanisms: lipohyalinosis within the penetrating artery; atheromatous branch disease in which a plaque within the parent artery or near its orifice obstructs flow; or occlusion of the parent artery at the sites of penetrating artery origin. All lead to hypoperfusion of brain tissue fed by the compromised penetrators.

Presenting authors are indicated in bold. S11

3rd International Conference on Intracranial Atherosclerosis and Annual Spring Meeting of the Korean Stroke Society INVITED SESSIONS

Invited Session 2 Stroke Mechanism and Clinical Syndromes

Invited Session 2-2 Intracranial Atherosclerosis: Impact on Clinical Syndrome Jong S Kim Department of Neurology, Asan Medical Center, Seoul, Korea

Literatures often read ‘Intracranial atherosclerosis accounts for 8-10% of stroke, but is more often seen in certain ethnic groups such as Asians, Blacks and Hispanics.’ However, considering enormous population living in Asia (over 60% of world population), and Africa (12%) and the relatively small number of people living in Europe (11%) or North America (8%), the above sentence may have to be revised as follows; ‘Intracranial atherosclerosis is the major cause of stroke worldwide. However, extracranial atherosclerosis is more often seen in certain ethnic groups such as Caucasians.’ With advances of imaging technologies such as MR angiography, CT angiography and transcranial Doppler, intracranial atherosclerosis is now being more easily recognized. Recent studies using these technologies as well as diffusion weighted MRI identified mechanisms for brain infarction or TIA arising from intracranial atherosclerosis, which include thrombosis leading to complete occlusion, artery-to-artery embolism, hemodynamic compromise (hypoperfusion), local branch occlusion of the orifice of a deep perforator, or the combination of these mechanisms. According to recent MRI studies, occlusion of perforator orifice at the area of local thrombosis (atheromatous branch occlusion) leading to ‘lacune’ like infarcts is the most frequent pattern of stroke due to intracranial atherosclerosis, which usually is associated with mild arterial stenosis. The intracranial atherosclerosis producing branch occlusion is one of the main mechanisms of subcortical as well as pure brainstem infarcts. On the other hand, artery to artery embolism is usually associated with more severe degree of vascular stenosis. The embolism is often associated with concomitant perfusion deficits in the territory of the stenosed vessel. Perhaps, underlying perfusion deficits may contribute to the development of embolic infarction through impaired clearance of emboli. In-situ thrombotic occlusion is less common and usually produces infarcts that are larger than those caused by other mechanisms. However, unlike patients with cardiogenic embolism, the in situ thrombotic occlusion rarely produces whole territory infarction because of the relatively well developed collateral circulation in patients with chronic atherosclerotic disease. In patients with middle cerebral artery steno-occlusion, the initial lesions are usually restricted to the striatocapsular area, borderzone area or the combination of both, which may enlarge progressively along with progressive neurological worsening. The least common stroke mechanism seems to be purely hemodynamic stroke or TIA, which is seen in patients with severe stenosis or occlusion with insufficient collaterals. Thus, the stroke pattern and resultant clinical syndromes may vary according to the mechanism of stroke and development of collateral circulation. With sufficient collaterals, total thrombotic intracranial occlusion may remain asymptomatic, or produce only minor brain infarcts or TIAs. As discussed above, intrinsic atherothrombotic occlusion rarely produces malignant, whole territory infarction and, in this sense, the prognosis is benign as compared to cardiogenic embolism. However, intracranial atherosclerosis may be associated with unstable clinical course or recurrence in patients with subcortical infarction. The intracranial atherosclerotic stenosis, especially symptomatic one, is not a static condition and may progress or regress in a relatively short period of time. Pro- gressive stenosis of intracranial arteries is closely related to the development of ischemic events. The annual risk of stroke relevant to the stenosed intracranial vessel is approximately 8%. Stenosis with following characteristics is particularly risky, and should be carefully managed: severe degree, symptomatic, associated with hemodynamic instability, progressive narrowing, and unresponsiveness to medication.

S12 Presenting authors are indicated in bold. Korean J Stroke(Supplement 1) 2008;10

3rd International Conference on Intracranial Atherosclerosis and Annual Spring Meeting of the Korean Stroke Society INVITED SESSIONS

Invited Session 2 Stroke Mechanism and Clinical Syndromes Invited Sessions Sessions Invited

Invited Session 2-3 Intracranial Arterial Dissections Sung-Chun Tang1, Jiann-Shing Jeng2 1Department of Neurology, National Taiwan University Hospital, Yun-Lin Branch, Yun-Lin, Taiwan 2Stroke Center & Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan

Cervicocerebral artery dissections occur in 1-2% of all ischemic strokes, but they are one of the major causes of stroke in the young and middle-aged patients. The incidence of spontaneous arterial dissections was 1.7-3.0/100,000 in the carotid arteries and 1.0-1.5 /100,000 in the vertebral arteries. Intracranial arterial dissection (IAD) is infrequent as compared to extracranial arterial dissections. But the frequency of IAD may be underestimated because the diagnosis of IAD is more difficult. It is also likely that many IAD leading to occlusion of the intracranial arteries are not recognized as dissections. Patients with IAD are generally younger than those with extracranial dissections, having symptoms usually in their second to fourth decades. Subarachnoid hemorrhage (SAH) is more common in patients with IAD than in those with extracranial dissections. Besides, patients with IAD in the carotid artery territory are relatively younger than those having vertebrobasilar artery territory dissection. Cervicocerebral artery dissections can result from either a primary intimal tear with secondary dissection into the media layer, or a primary intramedial hemorrhage. In contrast to the extracranial cervical arteries, the intracranial arteries lack external elastic lamina and have only a thin adventitial layer. Therefore, IAD more easily lead to development of subadventitial dissections or dissecting aneurysm formation and subsequent SAH. Pathological studies of middle cerebral artery dissections showed mainly subintimal dissection, as opposed intracranial vertebral artery dissections in which half of cases showed subadventitial dissections. There are traumatic and spontaneous dissections of the cervicocerebral arteries. In patients with spontaneous dissections, minor trauma may still be important. Conditions predisposing spontaneous arterial dissections include fibromuscular dyspla- sia, cystic medial necrosis, α1 antitrypsin deficiency, Ehlers-Danlos syndrome type IV, Marfan’s syndrome, autosomal dominant polycystic kidney disease, tuberous sclerosis, migraine, recent infection and hyperhomocysteinemia. Medical treatment of IAD is not well established. Anticoagulants are not routinely used because of the risk of SAH. Recently, a non-randomized study showed that anticoagulant therapy appeared to be safe for treatment of IAD with no evidence of SAH and 79% had a good outcome at 3 months. But there has been no randomized trial that compares anticoagulants, antiplatelets and conservative management without using antithrombotics. telets and conservative management without using antithrombotics. Surgical or endovascular treatment of IAD is considered for patients with symptomatic dissecting aneurysms, especially those with hemorrhagic manifestation, or with recurrent ischemic symptoms despite adequate antithrombotics. The prognosis of IAD was poorer than extracranial dissections. Intracranial VA dissections with SAH have poorer outcome. With the advancement of diagnostic tools, particularly noninvasive neuroimaging, more mild cases with intracranial dissections were found out.

Presenting authors are indicated in bold. S13

3rd International Conference on Intracranial Atherosclerosis and Annual Spring Meeting of the Korean Stroke Society INVITED SESSIONS

Invited Session 2 Stroke Mechanism and Clinical Syndromes

Invited Session 2-4 Intracranial Atherosclerosis and Dementia Alex Roher1, Chera Esh1, Zsolt Garami2, Malek Belohlavek3, Marwan Sabbagh1, Thomas Beach1 1Sun Health Research Institute, Sun City, AZ, 2DeBakey Heart Center, Methodist Hospital, Houston, TX, and 3Mayo Clinic, Scottsdale, AZ, USA

Background: Clinical and experimental data suggest that cerebral blood flow decreases with age and is significantly lower in Alzheimer’s disease (AD). Epidemiological studies indicate that the risk factors for atherosclerotic vascular disease (AV D) are also risk factors for AD. Objectives: To determine whether or not atherosclerotic stenoses of the circle of Willis, carotid and coronary arteries correlate with dementia and with the neuropathological markers of AD. Methods: Transcranial Doppler ultrasound, carotid duplex ultrasound and echocardiography were carried out on 40 patients with the clinical diagnosis of AD and 40 non-demented (ND) control individuals. In addition, circle of Willis, carotid arteries and coronary arteries were removed from 40 consecutive autopsies, fixed and cross-sectioned every 3-5 mm. All arteries were electronically measured to obtain an index of stenosis. The neuropathological lesions of AD (amyloid plaques, neurofibrillary tangles) and white matter rarefaction were also quantified. Results: The arteries of the circle of Willis had lower mean flow velocities and higher pulsatility index values in AD individuals. There was a positive correlation between the degree of arterial stenosis and the neuropathological lesions of AD. The Mini Mental State Examination (MMSE) scores decrease as the degree of stenosis increases. Conclusion: Our data suggests that arterial stenosis of the circle of Willis plays an important role in brain hypoperfusion in individuals with AD, thus participating in the development of the AD neuropathological lesions and neuronal damage and consequently in the dementing process.

S14 Presenting authors are indicated in bold. Korean J Stroke(Supplement 1) 2008;10

3rd International Conference on Intracranial Atherosclerosis and Annual Spring Meeting of the Korean Stroke Society INVITED SESSIONS

Invited Session 3 Imaging Diagnosis Invited Sessions Sessions Invited

Invited Session 3-1 The Application of MRI Dong-Wha Kang Department of Neurology, Asan Medical Center, Seoul, Korea

The essential diagnostic step for intracranial atherosclerosis (ICAS) is vascular imaging such as catheter angiography, computed tomography angiography, magnetic resonance angiography or transcranial Doppler. Magnetic resonance imaging (MRI) is primarily a tool for the detection of acute or chronic cerebral infarcts resulting from intracranial atherosclerosis. However, recent studies have shown that advanced MRI techniques provide clinicians a variety of valuable information that vascular imaging cannot. This additional information includes the characterization of vessel walls or clot, the pathogenic mechanism of initial or recurrent strokes, and perfusion status, which can be obtained from various imaging techniques such as high-resolution MRI, gradient echo T2*-weighted image, and diffusion- and perfusion-weighted images. This topic will discuss the available data on the application of these MRI techniques in the assessment of ICAS.

Presenting authors are indicated in bold. S15

3rd International Conference on Intracranial Atherosclerosis and Annual Spring Meeting of the Korean Stroke Society INVITED SESSIONS

Invited Session 3 Imaging Diagnosis

Invited Session 3-2 Assessment of Intracranial Atherosclerosis by CT & MR Angiography Seung-Koo Lee Department of Radiology, Yonsei University College of Medicine, Seoul, Korea

Imaging diagnosis of intracranial arterial stenosis is critical in the judgments of therapeutic strategy and prediction of prognosis. Transfemoral catheter angiography (TFCA) is the gold standard for the evaluation of vessel pathology and widely used in clinical practice. Contemporary neuroimaging issues are development of non-invasive techniques and their clinical applications. CT and MR angiography is promising with its powerful ability to describe atherosclerotic disease in vivo and state- of-the-art techniques are rapidly introduced in current neuroradiology field. Spotlight is focused on CT angiography (CTA) after introduction of multi-detector CT (MDCT) with increased z-axis and temporal resolution. Full coverage of entire intracranial arteries as well as neck vessels is possible within very short time. CT is also very useful in the evaluation of calcified plaques and superior to MR angiography with relatively higher spatial resolution (in comparison to routine clinical 1.5T scanner) and advantages of less motion and turbulent artifacts. CT perfusion (CTP) is simultaneously performed with CTA. Absolute quantification of cerebral blood flow is possible with CTP and it is very helpful in the assessment of overall hemodynamics in brain with intracranial atherosclerotic stenosis. MRI is the main diagnostic procedure for CNS disease. MRI is radiation free and has higher soft tissue & gray-white matter contrast than CT. Time of flight (TOF) technique does not need contrast agent, and development of high field system and new pulse sequences, MRA is getting closer to conventional angiography with high quality. MRA can also be performed with MR perfusion imaging. Recently, quantitative MRA techniques were introduced. QMRA can depict flow velocity in each intracranial artery as similar as Doppler ultrasound study. Further clinical evaluation is expected although QMRA needs more verification for feasibility. Contrast enhanced MRA (CEMRA) is very promising with its rapid acquisition and higher resolution. Improved data acquisition by key-hole CENTRA technique and application of high molar contrast agent such as gado- butrol enabled CEMRA as a routine clinical sequence. 4-D track MRA, so called MR-DSA, is recently developed sequence with increased temporal resolution and serial dynamic imaging. Although spatial resolution of 4-D track MRA is still not enough for proper evaluation of intracranial stenosis, future application is expected because high field system and optimized pulse design will solve the problems. CTA and MRA is the first line evaluation method of intracranial atherosclerosis and they have complementary roles each other. Appropriate application of these non-invasive angiographic techniques will provide better outcome in diagnosis and treatment of intracranial stenosis.

S16 Presenting authors are indicated in bold. Korean J Stroke(Supplement 1) 2008;10

3rd International Conference on Intracranial Atherosclerosis and Annual Spring Meeting of the Korean Stroke Society INVITED SESSIONS

Invited Session 3 Imaging Diagnosis Invited Sessions Sessions Invited

Invited Session 3-3 TCD in Intracranial Stenosis Jose C Navarro Department of Neurology, University of Santo Tomas Hospital, Manila, Philippines

Transcranial Doppler (TCD) has been established diagnostic test for the diagnosis and screening of intracranial stenosis. Compared to other ancillary tests, TCD is non-invasive, can be performed repeatedly, and cheap. The accuracy (sensitivity, specificity, positive and negative predictive values) of this test has been well studied utilizing DSA or MRA as the “gold standard”. Review of some papers utilizing different cut-off levels will be presented. Much of the studies have utilized absolute mean flow velocity such 80 cm/sec, 90 cm/sec and 100 cm/sec as abnormal cut-off levels. Other parameters will also be discussed to increase the accuracy of this test. Furthermore the accuracy of TCD will be analyzed following published articles and some recommendations will be given in establishing the diagnosis of intracranial stenosis.

Presenting authors are indicated in bold. S17

3rd International Conference on Intracranial Atherosclerosis and Annual Spring Meeting of the Korean Stroke Society INVITED SESSIONS

Invited Session 3 Imaging Diagnosis

Invited Session 3-4 Assessment of Ischemic Stroke by Perfusion Imaging Modalities Jun Hatazawa Department of Nuclear Medicine and Tracer Kinetics, Osaka University Graduate School of Medicine, Osaka, Japan

Ischemic stroke, which is the most common acute neurologic disease, is a leading cause of death and disability in Japan and most other industrial societies. The assessment of patients with atherosclerosis is needed for the management and prevention of complication and stroke. Perfusion study with acetazolamide challenge is widely used to monitor the impaired cerebrovascular reactivity (CVR) in addition to baseline cerebral blood flow (CBF). 15O gas PET parameters, such as cerebral blood volume (CBV) and oxygen extraction fraction (OEF), are also keys for the assessment of cerebral circulation. Autoregu- lation of CBF is generally refers to the capacity of CBF to remain relatively constant despite variation in perfusion pressure, which is experimentally well-known as a predictor of stroke. Although some previous reports suggested the impairment of this autoreulatory system in atherosclerotic patients, the role of perfusion imaging studies still remain unknown. In chronic stroke patients with intracranial artery occlusive disease, we measured CBF, CMRO2, CBV, OEF, and CVR using PET/ SPECT. The angiographical findings and clinical characteristics were also investigated to explore the clinical significance of their imaging findings. Our observations show 1. Monitoring systematic blood pressure control is important to evaluate CVR in chronic major artery occlusive disease, 2. Development of collateral vasculature is associated with the OEF elevation, and 3. Extensive of Moyamoya vessels is a sign of severe homodynamic impairment with the high CBV and OEF. These results suggest the importance of imaging studies in chronic stroke patients.

S18 Presenting authors are indicated in bold. Korean J Stroke(Supplement 1) 2008;10

3rd International Conference on Intracranial Atherosclerosis and Annual Spring Meeting of the Korean Stroke Society INVITED SESSIONS

Invited Session 4 Medical Treatment vs. Intervention Invited Sessions Sessions Invited

Invited Session 4-1 Statin and Other Miscellaneous Therapy Christopher Chen1, Jinghao Han2, KS Lawrence Wong2 1Department of Pharmacology, National University of Singapore, Singapore 2Department of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, China

Treatments for intracranial atherosclerosis (ICAS) can be considered under the broad categories suggested by Virchow’s triad: blood flow, endothelial damage and hypercoagulability. This triad of factors remains a useful concept for understanding the pathogenesis of venous and arterial, thrombosis. Anticoagulant therapy, antithrombotic therapy, antiplatelet therapy and revascularization procedures are presented elsewhere in this meeting. The evidence for the effectiveness and safety of other treatments remains limited and will be reviewed. Statins may be of particular benefit in ICAS but the evidence remains scanty. Statins may act directly on the vascular endothelium and have anti-inflammatory and plaque-stabilizing effect in addition to their ability to lower LDL cholesterol levels. Further trials of statins in patients with ICAS are warranted. Other potential anti-atherogenic therapeutic strategies targeting the vessel wall include lowering homocysteine, modulation of the inflammatory response and improving endothelial function. Strategies to improve cerebral blood flow (CBF) can play an important role in stroke management. Improvement of CBF can be accomplished in two broad ways: directly opening arteries or augmenting cerebral blood flow. Possible treatments which require further research include agents which raise blood pressure/blood volume, diastolic counterpulsation and spheno-palatine ganglion stimulation. Better understanding of the pathology of ICAS will lead to selection of the right therapeutic targets. It is also essential to ensure adequate trial designs with appropriate inclusion criteria, sensitive and clinically relevant outcome measures, adequate length and global enrollment.

Presenting authors are indicated in bold. S19

3rd International Conference on Intracranial Atherosclerosis and Annual Spring Meeting of the Korean Stroke Society INVITED SESSIONS

Invited Session 4 Medical Treatment vs. Intervention

Invited Session 4-2 Elective Stenting: an Effective Treatment for Selected Patients with Symptomatic Atherosclerotic Intracranial Stenosis of 70% to 99% at Experienced Centers Wei-Jian Jiang Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China

Introduction Elective angioplasty assisted with self-expanding (Wingspan) or balloon-expandable stent is increasingly being used to treat patients with symptomatic atherosclerotic intracranial stenosis (SAIS) of 70% to 99%.1-4) However, the stenting itself is a “double-edged sword”, which may prevent subsequent stroke; on the other hand, it may also cause procedure-related stroke or death. Some evidence suggested that patients with SAIS of 70% to 99% may benefit from stenting if the risk of procedure- related stroke or death within 30 days is under an acceptable level (such as <6%).3-5) Like any neurosurgical intervention, the procedure-related stroke or death risk is largely determined by patient’s selection, operator’s experience and periprocedural managements by neurologist with special experience. Our viewpoint, derived from our experience and similar studies in the literature, is that elective angioplasty with stent (possibly self-expanding stent is better than balloon-expandable stent) may be an effective treatment for selected patients with SAIS of 70% to 99% at experienced centers. This viewpoint still needs to be proven by randomized controlled trials (RCT) comparing stenting plus medical therapy with medical therapy alone.

Patient Selection Current Inclusion and Exclusion Criteria for Lesions at Our Center: 1) stenosis degree: only 70% to 99%; 2) qualifying event: TIA or minor stroke, excluding large infarction (>1/3 area of the stenotic artery); 3) time from qualifying event to stenting: within 3 months; 4) stenosis etiology: atherosclerosis, other than non-atherosclerosis; 5) stenosis length: segmental (≤15 mm), but not diffused lesion; 6) parent artery diameter: 2 mm to 4.5 mm. Other Exclusion Criteria for Patients: 1) known contraindication to heparin, aspirin, clopidogrel, anesthesia and contrast media; 2) concurrent intracranial tumor, aneurysm and cerebral arteriovenous malformation; 3) hemoglobin <10 g/dl, platelet count <100,000; international normalized ratio >1.5 (irreversible) and uncorrectable bleeding diathesis. Explanation: Stenosis degree: Between 2001 and 2006, stenting indication at our center was refractory SAIS of ≥50%. Since 2007, it has been revised to SAIS of 70% to 99%. The reason is 1) the Warfarin-Aspirin Symptomatic Intracranial Disease (WASID) trial demonstrated that patients with SAIS of 70% to 99% are at particularly high risk of ischemic stroke in the territory of the stenotic artery on medical therapy, because the cumulative probability of this type of stroke in patients with 70% to 99% stenosis (n=206) was 18% (95% CI 13% to 24%) at 1 year, significantly higher than that in patients with 50% to 69% stenosis (n=355) (7% at 1 year, 95% CI 5% to 10%; hazard ratio [HR] 2.03, 95% CI 1.29 to 3.22)5); 2) one of our studies showed that patients with SAIS of 70% to 99% (n=121) after elective angioplasty with balloon-expandable stent did not present a higher ipsilateral stroke risk (including any stroke and death within 30 days) than patients with 50% to 69% stenosis (n=92) (7.2% at 1 year, 95% CI 2.6% to 11.8% vs 5.3% at 1 year, 95% CI 0.7% to 9.9%; HR 1.09, 95% CI 0.42 to 2.87), suggesting that patients with 70% to 99% stenosis seems to benefit from stenting by indirect comparison with those of WASID, while patients with 50% to 69% stenosis does not.4) Time from qualifying event to stenting: At our center, between 2001 and 2006, symptomatic stenosis was arbitrarily defined as any lesion causing qualifying event within 6 months, similar to the definition of symptomatic carotid stenosis in North American Symptomatic Carotid Endarterectomy Trial (NASCET) and European Carotid Surgery Trial (ECST).6,7)

S20 Presenting authors are indicated in bold. Korean J Stroke(Supplement 1) 2008;10

3rd International Conference on Intracranial Atherosclerosis and Annual Spring Meeting of the Korean Stroke Society INVITED SESSIONS

Since 2007, it has been revised to any lesion leading qualifying event within 3 months, after the publication of the WASID trial, which showed that a recent event in the stenotic arterial area within median 21 days is another independent predictor of 5)

subsequent stroke. This suggests that recurrent stroke probability in patients with SAIS is higher in the earlier time after Sessions Invited qualifying event. Thus, the earlier the patients with SAIS receive stenting therapy after qualifying event, the more benefit they may obtain. Intracranial atherosclerosis: Since the end of 2007, in vivo high-resolution MR imaging (HRMRI) of intracranial arterial wall has been applied in some of our patients. In vivo HRMRI of intracranial arterial wall is an evolving technique.8,9) Finding of eccentric wall thickness and inhomogenous enhancement on HRMRI could support the diagnosis of atherosclerotic disease; otherwise non-atherosclerosis cause may be possible. In general clinical practice, intracranial atherosclerosis is diagnosed by the present of atherosclerotic risk factors as well as findings on DSA, MRA or CTA. However, either DSA or MRA or CTA reflects the features of arterial luminal surface and blood flow. Some findings (such as concentric stenosis and irregular luminal surface) can also be seen in non-atherosclerotic disease (such as vasculitis of medium artery of the CNS). Athero- sclerotic risk factors may also coexist in these patients. Thus, misdiagnosis of atherosclerotic disease may be made despite patient actually suffers from a non-atherosclerotic disease (such as benign angiitis of the CNS). The exact proportion of non- atherosclerotic stenosis of intracranial medium artery is not clear now (may be very low), but interventional neuroradiologists should keep in mind of it, and avoid stenting in patients with this condition, even in low suspicious patients, because stenting for them may carry a higher risk of stroke or death risk.

Operator’s Experience Two studies of case series with larger number of patients reached different conclusions about outcomes of stenting for patients with SAIS of 70% to 99% compared with those of the WASID trial, and showed that long-term outcomes of elective stenting appear largely to be determined by any stroke and death risk within 30 days. The NIH Wingspan registry study showed that angioplasty with Wingspan stent for these patients has no advantage compared with medical therapy.3) The cumulative probability of primary endpoint event (any stroke and death within 30 days plus ipsilateral stroke beyond 30 days) was 14.0% at 6 months (95% CI 8.7% to 22.1%). Another study from our center showed that long-term outcomes of these patients after elective angioplasty with balloon-expandable stent compare favorably with those of the WASID trial.4) The cumulative probability of the same primary endpoint event as the NIH Wingspan registry was 7.2% at 1 year (95% CI 2.6% to 11.8%). The disparate outcomes could partially be explained by difference in operator’s experience reflected by 30-day outcomes and annual case volume between the 2 studies. In the NIH Wingspan registry, 16 US medical centers contributed to the study. A total of 129 patients with 70% to 99% SAIS were enrolled between November 2005 and October 2006. The average annual volume of stenting for these patients was 8.6 cases per center. In another study, a total of 121 patients with 70% to 99% SAIS were enrolled in one center between Septem- ber 2001 and June 2005. The average annual volume was 32.3 cases per center. Ipsilateral stroke frequency beyond 30 days between the 2 studies was almost the same: 3.42% (4/117; 95% CI 1.34% to 8.46%) between 30 days and 6 months in the NIH Wingspan registry vs 3.45% (4/116; 95% CI 1.35% to 8.53%) between 30 days and a mean follow-up duration of 26 months in our center, but any stroke and death rate within 30 days was higher in the NIH registry than in our study (9.30%, 12/129 vs 4.96%, 6/121) (95%CI 5.40% to 15.56% vs 2.29% to 10.40%), although not statistically different. Furthermore, subgroup analysis of the NIH Wingspan registry showed that primary endpoint risk is associated with operator’s experience. The primary endpoint event occurred in 8 (23%) of 35 patients enrolled by 10 low enrolling sites (1 to 8 patients per center) and only 8 (9%) of 94 patients enrolled by 6 high enrolling sites (14 to 19 patients per center). The primary endpoint rate was 14.3% (95% CI 6.2% to 31.0%) at 24 hours, 17.2% (95% CI 8.1% to 34.4%) at 30 days, and 26.9% (95% CI 13.8% to 48.5%) at 6 months for low enrolling sites; and 3.2% (95% CI 1.0% to 9.6%) at 24 hours, 6.8% (95% CI 3.1% to 14.5%) at 30 days, and 9.5% (95% CI 4.9% to 18.3%) at 6 months for high enrolling sites. The Kaplan-Meier curves for the 2 groups were significantly different (HR 2.9, 95% CI 1.1 to 7.8; P=0.022). Explanation: Procedure-related stroke or death rate and annual volume of stenting should be the most objective indexes to reflect experience level of an interventional operator. This is the principle behind AHA recommendation for carotid endarterectomy

Presenting authors are indicated in bold. S21

3rd International Conference on Intracranial Atherosclerosis and Annual Spring Meeting of the Korean Stroke Society INVITED SESSIONS

(CEA) in symptomatic patients with carotid stenosis 50% to 99%, requiring the risk of perioperative stroke or death to be less than 6%.10) Of notice, stents used in above 2 studies were of completely different type. Theoretically, self-expanding stent (Wingspan stent) following submaximal angioplasty and slow balloon inflation should be more suitable for intracranial circulation than balloon-expandable stent.1,2) However, the Wingspan stent in the NIH registry seems to have no advantage in 30-day outcomes compared with the balloon-expandable stent in our study. In order to compare procedural safety of Wingspan stent with balloon-expandable stent for 70% to 99% SAIS, we analyzed 30-day outcomes of the 2 types of stents in patients with 70% to 99% SAIS at our center. We have treated 306 patients with ≥50% SAIS (316 lesions), including 207 patients with 70% to 99% SAIS (214 lesions) with elective balloon-expandable stent since September 2001; and 56 patients with SAIS of 70% to 99% (60 lesions) by elective angioplasty with Wingspan stent between January 2007 and April 2008. Balloon-expandable stent was successfully placed in 195 (91.1%; 95% CI 86.6% to 94.2%) of 214 stenoses of 70% to 99%. Within 30 days, ischemic stroke occurred in 7 patients, hemorrhagic stroke in 6 patients (2 deaths), stent thrombosis in 5 patients who were successfully treated by IA thrombolysis with urokinase, and TIA in 7 patients. Thus, within 30 days following balloon-expandable stent, any stroke or death rate was 6.28% (13/207; 95% CI 3.71% to 10.45%), and neurologic complication rate was 12.08% (25/207; 95% CI 8.32% to 17.22%). Wingspan stent was successfully placed in 59 (98.3%; 95% CI 91.1% to 99.7%) of 60 stenoses of 70% to 99%. Within 30 days, no death occurred, one patient had embolic stroke, one experienced TIA, and one had acute stent thrombosis that was successfully treated by IA thrombolysis with urokinase. Thus, any stroke or death rate within 30 days of Wingspan stenting was 1.79% (1/56; 95% CI 0.32% to 9.45%), lower than balloon-expandable stenting and the NIH Wingspan registry (9.30%; 95% CI 5.40% to 15.56%), although not statistically different. Neurologic complication rate was 5.36% (3/56; 95% CI 1.84% to 14.61%), also lower than that of balloon-expandable stenting (12.08%; 95% CI 8.32% to 17.22%) and the NIH registry (16.28%, 21/129; 95% CI 10.90% to 23.61%), again not statistically different. In the NIH registry, neurologic complications consisted of 12 events of stroke or death, 2 TIAs, 2 cerebral infarcts with neurologic signs lasting less than 24 hours, 1 somnolence for 3 days, and 4 stent thromboses that were successfully treated with IIb/IIIa agents in three cases and not specified in the other case. Our experience showed that the safety of self-expanding stent seems better than balloon-expandable stent’s. The lack of statistical difference in 30-day stroke and death risk or neurologic complication rate between the 2 types of stents at our center, or between the NIH Wingspan registry and our Wingspan study could be a type II error.

Periprocedural Managements by Neurologists with Special Experience The utmost important periprocedural managements are: prevention of procedure-related complications, timely identification and prompt treatment of them. One of our studies showed that aggressive endovascular and medical therapy for cerebrovascular complications (11.8%, 20 of 169) can reduce the stroke risk (5.9%, 10 of 169) and fatal or irreversible stroke rate (4.7%, eight of 169).11) Explanation: Periprocedural managements include prevention, identification and treatment of thrombosis, embolism, perforator stroke, cerebrovascular spasm and hyper-perfusion syndrome, etc. The managements are rather complex and beyond the scope of this article. Therefore, a good team-approach including neurologists with special experience is needed.

Reference 1) Bose A, Hartmann M, Henkes H, et al. A novel, self-expanding, nitinol stent in medically refractory intracranial atherosclerotic stenoses: the Wings- pan study. Stroke 2007;38:1531-1537. 2) Fiorella D, Levy EI, Turk AS, et al. US multicenter experience with the wingspan stent system for the treatment of intracranial atheromatous disease: periprocedural results. Stroke 2007;38:881-887. 3) Zaidat OO, Klucznik R., Alexander MJ, et al. The NIH registry on use of the Wingspan stent for symptomatic 70-99% intracranial arterial stenosis. Neurology 2008;70:1518-1525. 4) Jiang WJ, Xu XT, Du B, et al. Comparison of elective stenting of severe vs moderate intracranial atherosclerotic stenosis. Neurology 2007;68:420-426. 5) Kasner SE, Chimowitz MI, Lynn MJ, et al. Predictors of ischemic stroke in the territory of a symptomatic intracranial arterial stenosis. Circulation 2006;113:555-563.

S22 Presenting authors are indicated in bold. Korean J Stroke(Supplement 1) 2008;10

3rd International Conference on Intracranial Atherosclerosis and Annual Spring Meeting of the Korean Stroke Society INVITED SESSIONS

6) European Carotid Surgery Trialists’ Collaborative Group: Randomised trial of endarterectomy for recently symptomatic carotis stenosis: final results of the MRC European Carotid Surgery Trial (ECST). Lancet 1998;351:1379-1387. 7) North American Symptomatic Carotid Endarterectomy Trial Collaborators. Beneficial effect of carotid endarterectomy in symptomatic patients with

high-grade carotid stenosis. N Engl J Med 1991;325:445-453. Sessions Invited 8) Klein IF, Lavallee PC, Touboul PJ, et al. High-resolution MRI identifies basilar artery plaques in paramedian pontine infarct. Neurology 2005; 64:551-552. 9) Klein IF, Lavallee PC, Schouman-Claeys E, et al. In vivo middle cerebral artery plaque imaging by high-resolution MRI. Neurology 2006;67:327-329. 10) Sacco RL, Adams R, Albers G, et al. Guidelines for prevention of stroke in patients with ischemic stroke or transient ischemic attack: a statement for healthcare professionals from the American Heart Association/American Stroke Association Council on Stroke: cosponsored by the Council on Cardiovascular Radiology and Intervention: the American Academy of Neurology affirms the value of this guideline. Stroke 2006;37:577-617. 11) Jiang WJ, Du B, Leung TW, Xu XT, Jin M, Dong KH. Symptomatic intracranial stenosis: cerebrovascular complications from elective stent placement. Radiology 2007;243:188-197.

Presenting authors are indicated in bold. S23

3rd International Conference on Intracranial Atherosclerosis and Annual Spring Meeting of the Korean Stroke Society INVITED SESSIONS

Invited Session 4 Medical Treatment vs. Intervention

Invited Session 4-3 Stenting vs. Medical Therapy for Symptomatic Intracranial Arterial Stenosis Marc Chimowitz Department of Neurosciences, Medical University of South Carolina, SC, USA

Intracranial arterial stenosis causes approximately 50,000 strokes per year in the United States and may be the most common cause of stroke worldwide. The optimal approach to the diagnosis and treatment of this disease remains understudied and poorly defined, in this lecture, a patient presenting with severe symptomatic intracranial arterial stenosis will be discussed to point out the challenges involved in the diagnosis and treatment of this disease. Using data from recently completed clinical trials (WASID, Sonia) and multicenter registries, the roles of antithrornbotic therapy, risk factor management, and angioplasty/stenting will be presented. The design of a recently funded NIH trial that will compare intensive medical therapy alone versus intensive medical therapy plus angioplasty and stenting in patients with severe symptomatic intracranial arterial stenosis will also be discussed.

S24 Presenting authors are indicated in bold. Korean J Stroke(Supplement 1) 2008;10

3rd International Conference on Intracranial Atherosclerosis and Annual Spring Meeting of the Korean Stroke Society INVITED SESSIONS

Invited Session 4 Medical Treatment vs. Intervention Invited Sessions Sessions Invited

Invited Session 4-4 Self-Expanding Stenting for Acute Ischemic Stroke Henry Woo1, David Fiorella2 1Departments of Neurosurgery and Radiology, Cerebrovascular Center, University at Stony Brook, State University of New York, Stony Brook, NY, USA 2Departments of Radiology and Neurosurgery, Cleveland Clinic Foundation, Cleveland, OH, USA

Numerous advances have occurred in the endovascular treament of acute stroke. Recently, revascularization with newly available self expanding stents have been reported. These devices are designed for deployment in the intracranial circulation as they are more flexible and may potentially provide better recanalization rates than the prior generation of mechanical throm- bectomy devices. This presentation will review the early reports and preliminary experience of the effectiveness of self- expanding stents for acute cerebrovascular occlusions. We will present individual cases that will highlight the main advantages of this techique, in particular the immediate restoration of flow after stent deployment and the recanalization rates than can be achieved. In addition, the potential pitfalls will be described including: 1) the hemorrhagic risk secondary to the requirements for platelet inhibition and thrombogenicity of a newly implanted stent, 2) the risk of in stent stenosis, and 3) the medico-legal concerns in the United States with the off label use of HDE devices. Finally, we will also introduce the concept of temporary endovascular bypass and its potential advantages over permanent self-expanding implants.

Presenting authors are indicated in bold. S25

3rd International Conference on Intracranial Atherosclerosis and Annual Spring Meeting of the Korean Stroke Society INVITED SESSIONS

Invited Session 5 Other Therapies and Clinical Outcome

Invited Session 5-1 Intracranial Atherosclerosis: Natural Course and Prognosis Juan F Arenillas Stroke Unit, Department of Neurology, Hospital Clinico Universitario, University of Valladolid, Valladolid, Spain

Natural Course: Intracranial large-artery atherosclerosis (ICAS) is a major cause of ischemic stroke worldwide. Symp- tomatic ICAS is burdened with a high risk of clinical recurrence. In the WASID trial, the annual recurrence rates for any ischemic stroke were as high as 15% and 14% in the aspirin and warfarin arms, respectively. Moreover, symptomatic ICAS patients are also exposed to an elevated risk of having coronary ischemic events and vascular death. As another main feature of this disease, intracranial stenoses may progress over time. Finally, ICAS is a multifocal disease, with a substantial proportion of patients showing coexistent asymptomatic intracranial stenoses besides the culprit lesion. Prognostic Factors: The factors that characterize those ICAS patients who are at highest risk for progression and recurrence may be divided in two categories. 1) Local factors (vulnerable intracranial stenosis): These include the severity of the culprit lesion, the location of the symptomatic stenosis, the number of diseased vessels, symptomatic vs. asymptomatic lesions, progression of intracranial stenoses, presence of hemodynamic compromise, presence of microembolic signals and plaque composition. 2) Systemic factors (vulnerable ICAS patients): They comprise classical risk factors (diabetes), the metabolic syndrome, female gender, failure of antithrombotic therapy, inflammation, impaired endogenous fibrinolysis, endogenous angiogenic balance, and genetic factors. Regarding genetic factors, a proposal will be made during this communication to under- take a worldwide genetic study as a project of the Intracranial Atherosclerotic Disease Study Group. The therapeutic implications of these prognostic factors will be discussed.

S26 Presenting authors are indicated in bold. Korean J Stroke(Supplement 1) 2008;10

3rd International Conference on Intracranial Atherosclerosis and Annual Spring Meeting of the Korean Stroke Society INVITED SESSIONS

Invited Session 5 Other Therapies and Clinical Outcome Invited Sessions Sessions Invited

Invited Session 5-2 Antithrombotic Therapy in Symptomatic Intracranial Stenosis Yong-Seok Lee Department of Neurology, Seoul National University Boramae Hospital, Seoul, Korea

Intracranial arterial stenosis (IAS) is an important cause for ischemic stroke, especially in non-Caucasians. Annual risk of recurrent stroke has been known 12-15%, with most strokes occurring in the first year. Among therapeutic options including antithrombotic medications, risk factor modification, and endovascular treatment, antiplatelet agents are still the mainstay of the therapy. WASID trial was to compare the safety and efficacy of warfarin (INR 2-3) with aspirin (1,300 mg/day) in patients with symptomatic intracranial stenosis (50-99% by DSA). The primary endpoint (ischemic stroke in any vascular territory, intracranial hemorrhage, or vascular death not caused by ischemic stroke) was reached in 22% of the patients in both groups (HR of 1.04; 95% CI, 0.73-1.48; p=0.83). In the warfarin group, a post hoc analysis revealed that an INR less than 2.0 was associated with a significantly higher rate of ischemic stroke (p>0.00001) whereas an INR greater than 3.0 was associated with a significantly higher rate of major hemorrhage (p>0.00001). No subgroup was clearly identified that had a better outcome on warfarin versus aspirin. Death was significantly more frequent in warfarin group (9.7% vs. 4.3%; p=0.02). In conclusion, warfarin has been shown to be no better than aspirin in preventing recurrent strokes but poses a higher risk of serious bleeding and death. According to recent AHA/ASA guideline (2008), in addition to aspirin (50 to 325 mg daily), the combination of aspirin and extended-release dipyridamole, and clopidogrel monotherapy are all acceptable options for initial therapy of noncardio- embolic stroke. Although clopidogrel and aspirin/extended release dipyridamole has been shown to be superior to aspirin alone for prevention of recurrent stroke, none of these agents has been proved to be superior to aspirin in symptomatic IAS. In contrast, the combination of aspirin and clopidogrel provides no significant additional benefit compared with clopidogrel alone while significantly increasing the risk of hemorrhagic complications. Current evidences cannot recommend clopidogrel and aspirin combination therapy in patients with IAS unless there is a specific indication for this therapy (ie, coronary stent or acute coronary syndrome). Cilostazol is a phosphodiesterase-3 inhibitor that has been reported to reduce the rate of restenosis following coronary angioplasty and stenting. A multicenter, double blinded controlled trial investigated the potential effect of cilostazol on IAS. A total of 135 patients with a symptomatic IAS of the MCA M1 segment or basilar artery were randomized to cilostazol (200 mg/d) plus aspirin (100 mg/d) versus placebo and aspirin (100 mg/d). The IAS was quantified by MRA and TCD. Patients were followed for 6 months. The primary endpoint was progression of the IAS on MRA. No recurrent stroke occurred in either group. Progression of the IAS was less common in the cilostazol group (6.7% vs. 28.8%; p=0.008). However, this challenging trial has limitations by the inaccuracy of MRA for quantifying IAS, the small size of the study population, a high dropout rate (approximately 25%), a short follow-up period, and the absence of ischemic events during the trial. Subsequent international trial comparing cilostazol with clopidogrel combined with aspirin in symptomatic intracranial stenosis is cur- rently undergoing. Although there are growing evidences of the efficacy of endovascular treatment for symptomatic IAS, safety concern is still the matter of debate. Until the optimal therapeutic options for this potentially dangerous condition are clarified in the future, an evidence-based approach with single or combined antiplatelet therapy is the current treatment recommendation.

Presenting authors are indicated in bold. S27

3rd International Conference on Intracranial Atherosclerosis and Annual Spring Meeting of the Korean Stroke Society INVITED SESSIONS

Invited Session 5 Other Therapies and Clinical Outcome

Invited Session 5-3 Surgical Treatment of Moyamoya Disease Gary K Steinberg1,2, Raphael Guzman1,2, Marco Lee1,2, Teresa E Bell-Stephens1,2 1Department of Neurosurgery and 2Stanford Stroke Center, Stanford University School of Medicine, Stanford, CA, USA

Between 6/1991-3/2008, 297 patients with Moyamoya Disease (MMD) underwent 511 surgical revascularization procedures. Ages were 1-68 yo; 73% were female, 27% male; 70% were adults, 30%<18 yo. Fifty-nine percent were Caucasian, 30% Asian. Presenting symptoms in the adults were 86% TIAs/stroke, 14% hemorrhage; pediatric: 81% TIAs/stroke, 2% hemorrhage. Eighteen percent of the patients initially had unilateral MMD, however 32% progressed to bilateral MMD within 5-60 mos. Pre-operative testing included MR, digital subtraction angiography, CBF studies (Xenon CT and SPECT, ±Dia- mox), TCD and neuropsychological evaluation. In 36 patients with pre-operative neuropsychological testing, 31% had cognitive impairment, primarily in executive functioning. Direct Extracranial-Intracranial grafts were performed in 90% of patients (usually STA-MCA), while 10% of patients underwent indirect grafts. Intraoperative quantitative blood flow measurements (Transonics flowmeter) demonstrated increased flows in the MCA (M4) after bypass. Post-bypass intraoperative flows (STA and MCA) correlated with STA diameter. Follow-up was 1 mo- 17 yr. After the post-operative 30d period, two patients had a new ischemic stroke and one a recurrent bleed. Graft patency was 98%. Of 84 patients presenting with TIAs, 86% had resolution of their TIAs within 1 month of surgery; after 1 yr 93% no longer had TIAs. Nine patients (3.0%, 1.8% procedures) had perioperative strokes within 30d; 7/9 patients made a complete recovery. Eight patients had nine perioperative hemorrhages (2.7%, 1.8% procedures); 5/9 recovered completely, 2 made a partial recovery and 2 died. Fourteen patients developed a delayed transient neurologic event (TNE), usually mild-mod aphasia 1-3d post-op without MR infarct or edema (4.7%, 2.7% procedures). All TNEs resolved completely within days-weeks. Higher post-bypass intraoperative MCA blood flows predicted hemorrhage, suggesting hyperperfusion (p=.03). Interestingly, higher post-bypass intraoperative MCA and STA flows predicted perioperative ischemic strokes (p=.004 and .01). Patients presenting with stroke were at higher risk for developing delayed TNE (p=.04). In a subgroup of pediatric patients, post- operative Xenon CT flows were significantly improved in the hemisphere (p=.02), MCA territory (p=.02) and PCA territory (p=.04). Direct surgical revascularization (STA-MCA) is technically feasible, safe and provides immediate revascularization and increased cerebral flow in adult and pediatric MMD patients. Indirect surgical revascularization is preferred in children <5 yo and when donor or recipient arteries are <7 mm. Both direct and indirect bypass improve the natural history, angiographic appearance and CBF abnormalities in MMD patients.

S28 Presenting authors are indicated in bold. Korean J Stroke(Supplement 1) 2008;10

3rd International Conference on Intracranial Atherosclerosis and Annual Spring Meeting of the Korean Stroke Society INVITED SESSIONS

Invited Session 5 Other Therapies and Clinical Outcome Invited Sessions Sessions Invited

Invited Session 5-4 Rehabilitation Following Ischemic Stroke Caused by Intracranial Atherosclerosis Nam-Jong Paik Rehabilitation Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea

Recent researches on the neuroplasticity demonstrated that the mechanisms underlying the recovery following hemiparetic stroke are similar to that of skills training and motor learning. Based on these findings, task-oriented rehabilitative training such as constraint induced movement therapy, robot-assisted therapy, virtual reality training, neuromuscular electrical stimulation, body weight-supported treadmill training are being practiced for improvement of upper extremity function and walking. In addition, pharmacotherapy that could enhance rehabilitative training effect could be combined. In early stage of recovery when muscles are flaccid, mental imagery or action observation could be applied as a backdoor approach. Besides various cortical drivers such as repetitive transcranial magnetic stimulation, transcranial direct current stimulation, somatosensory stimulation that could potentially regulate the excitability of the brain, have been proposed and are under transfer from bench to bedside to enhance neural recovery in the stroke rehabilitation. Up to now, preliminary researches on task-oriented training and non-invasive cortical stimulation have shown promising results. This presentation is purposed to introduce the current state-of-the-art in novel rehabilitative strategies that are actively begin to be implemented in real rehabilitative clinical setting.

Presenting authors are indicated in bold. S29 Oral Sessions

3rd International Conference on Intracranial Atherosclerosis and Annual Spring Meeting of the Korean Stroke Society ORAL SESSIONS

Oral Session 1 Oral Session 1 Epidemiology & Risk Factors Epidemiology & Risk Factors

O01 O02 Results from the Boston Medical Center Stroke Protocol of a Prospective Hospital-Based Cohort Database: Implications for an International Study of Symptomatic Intracranial Intracranial Atherosclerotic Disease Atherosclerosis in China (ICAS-CHINA)

(ICAD) Registry ICAS-China Collaborative Group, Yongjun Wang1, Oral Sessions 2 Jason Viereck1, Helena Lau1, Juan F Arenillas2, Sun U Kwon3, KS Lawrence Wong KS Lawrence Wong4, Ling Feng5, Tanya Turan6, 1Department of Neurology, Beijing Tiantan Hospital, David C Bonovich7 Capital Medical University, Beijing, and 2 1 Department of Medicine, Chinese University of Hong Kong, Department of Neurology, Boston University Medical School, Boston, USA Prince of Wales Hospital, Hong Kong SAR, China 2Department of Neurology, University Hospital, Valladolid, Spain 3Department of Neurology, Asan Medical Center, Seoul, Korea 4 Department of Medicine and Therapeutics, The Chinese University : of Hong Kong, Prince of Wales Hospital, Hong Kong, China Background(s) Intracranial large-artery occlusive disease 5Department of Neurosurgery, Xuanwu Hospital, Beijing, China is the predominant vascular lesion found in Chinese stroke 6Department of Neurology, Emory School of Medicine, Atlanta, USA, and 7Department of Neurology, University of California, San Francisco, USA patients. Previous studies seldom use magnetic resonance ( ) angiography MRA or computer tomography angiography Background(s): Most published series of stroke from ICAD (CTA) as the screening tool for steno-occlusive cerebrovas- are from single sites or single geographic areas. To better cular diseases. study the epidemiology of this disease and test hypotheses, Objective(s): We aim to evaluate the natural history, iden- there is a need to study populations across geographical and tify the frequency and risk factors, assess current treatments ethnic boundaries, using uniform definitions and inclusion and find predictors of further vascular events or death for criteria. ICAS patients. Objective(s): To validate the associations of risk factors Method(s): ICAS-China is a hospital based, prospective, to ICAD in different ethnic groups. We present data from a multicenter, cohort study. We will enroll 4,000 consecutive single-site, multi-ethnic registry that can be broadened to a patients presented with cerebral ischemia within 7 days of multi-site project. symptom onset, including transient ischemic attack (TIA) : Method(s) During a two year period, 45 subjects with and cerebral infarction. All the inclusive patients will un- cerebral vascular disease due to ICAD were enrolled in the dergo 3D Time-of-Flight MRA (or CTA) and ultrasonogra- Boston Medical Center Database. They were compared to phic examinations to figure out whether they have intracra- subjects with other diagnoses, especially extracranial athero- nial or extracranial stenosis. The patients with intracranial sclerotic disease. Result(s): Subjects with ICAD were 67% African-Ameri- stenosis will be followed up for 3 months, and every 6 months, can (compared to 42% of all subjects and 28% among sub- until 24 months for the development of recurrent stroke (or jects with extracranial disease), and overwhelmingly hyper- TIA), cardiovascular event, or death. tensive (91%). The median age was 66. Four subjects (9%) Result(s): Ongoing trial were under age 45 (compared to none with extracranial dis- Conclusion(s): Up to now it is the largest prospective ease). The mean admission NIHSS was 4.6 (compared to 6.8 hospital-based cohort study of symptomatic ICAS in China. for extracranial disease), and the median Rankin score at We have recruited 31 hospitals and enrolled 550 patients up discharge from acute care was two. to 17th Mar, 2008. Since we use 3D-TOF MRA instead of Conclusion(s): The BMC experience confirms published transcranial Doppler (TCD) as the screening tool, our data is series from North America concerning race and hypertension, thought to be more reliable than that based on TCD. but was not designed to capture all information specific to ICAD. Expanding on its basic design, the ICAD registry will include additional parameters, including lipid profiles, diet and presence of metabolic syndrome. This database lays a foundation for a comprehensive study of ICAD at multiple sites worldwide.

Presenting authors are indicated in bold. S33

3rd International Conference on Intracranial Atherosclerosis and Annual Spring Meeting of the Korean Stroke Society ORAL SESSIONS

O03 O04 Lipoprotein(a) and Burden of Cerebrovascular Middle Cerebral Artery Stenosis of Asymptomatic Atherosclerosis in Patients with Ischemic Stroke Residents is Not Associated with Angiotensin- Byung-Su Kim1, Hyun-Suk Jung2, Oh Young Bang1, Converting Enzyme Gene Insertion/Deletion Chin-Sang Chung1, Kwang Ho Lee1, Gyeong-Moon Kim1 Polymorphism: a Community-Based Study Departments of 1Neurology and 2Family Medicine, Samsung Medical in Foshan Area of China Center, Sungkyunkwan University School of Medicine, Seoul, Korea Hai-Wei Huang1, Xian FU1, Dan xin Peng2, Shuang Quan Tan1, Mei Lic Huang3, Rui Jin Lin3, KS Lawrence Wong4 Background(s): Lipoprotein (a) [Lp(a)] has been report- 1Department of Neurology, The First Affiliated Hospital ed to be a risk factor for ischemic stroke. Although Lp(a) of Zhongshan University, Guangzhou 2Hospital Infection Administration, The First Affiliated Hospital, has potential atherothrombogenic properties, the role of Lp Sun Yat-Sen University, Guangzhou, The First Affiliated Hospital (a) in cerebrovascular atherosclerosis still remains unclear. of Zhongshan University, Guangzhou 3Department of Neurology, Rongqi Hospital of Shunde, Guangdong, and Objective(s): We investigated the relationship between 4Department of Medicine and Therapeutics, The Chinese University Lp(a) levels and the extent of intracranial and extracranial of Hong Kong, Hong Kong SAR, China large-artery occlusive disease in patients with ischemic stroke. Method(s): A total of 292 consecutive patients with acute Background and Purpose(s): The insertion/deletion (I/D) polymorphism of the angiotensin-converting enzyme (ACE) cerebral infarcts or TIAs were categorized into 4 cerebrovas- gene has been studied in relation to a variety of cardiovascu- cular atherosclerosis sutypes: no cerebrovascular atheroscle- lar disorders, including stroke. Numerous studies have been rosis (n=160), intracranial atherosclerosis, extracranial ath- conducted, with inconsistent results. However, the studies erosclerosis, and combined intracranial and extracranial ath- which concerned middle cerebral artery stenosis of asympto- erosclerosis. Levels of Lp(a), conventional risk factors for matic community residents were rare previously. ischemic stroke, clinical features and laboratory data were Objective(s): We investigated the association between compared between each groups. ACE genotype and the incidence of middle cerebral artery Result(s): The median Lp(a) level was highest in the large stenosis in a large, community-based study in Foshan area of artery disease group among other stroke subtypes according China. Method(s): In this study, 2500 people were recruited by to TOAST classification (31.7, 20.9-54.4 mg/dl, p=0.011). cluster sampling from RongShan community in Foshan area Patients with more severe intracranial or extracranial athero- and underwent physical examination, questionnaire survey, sclerosis were more likely to have higher Lp(a) levels (p< transcranial Doppler sonography (TCD) and the ACE geno- 0.001, p<0.001, respectively). In multivariate regression anal- type determination in 2006, and 780 (286 men and 494 wom- ysis adjusting on risk factors for ischemic stroke and lipid en; age: 58.53±11.61) of them that conformed with the profiles, Lp(a) level in the highest quartile compared with inclusion criteria were enrolled. Based on the results of TCD the lowest quartile was significantly associated with the the examination of middle cerebral artery (MCA), the subjects ( ) intracranial atherosclerosis (OR 7.32, 95% CI 2.71-19.80, were divided into two groups, the MCA stenosis MCAS group and the non-MCAS(control) group. p<0.001), extracranial atherosclerosis (OR 10.96, 95% CI Result(s): MCA stenosis was associated with significantly - = ) 0.97 124.27, p 0.053 , and combined intracranial and ex- increased percent of history of coronary heart disease and tracranial atherosclerosis (OR 53.41, 95% CI 6.04-472.28, diabetes mellitus, systolic and diastolic blood pressure, for p<0.001). men; but none were significant for women. Systolic and dia- Conclusion(s): Our data indicates that the elevated Lp(a) stolic blood pressure of the subjects with DD genotype was concentration is independently associated with the burden of highest among the ACE genotypes, for men; and diastolic cerebrovascular atherosclerosis in ischemic stroke patients, blood pressures were highest for women with II genotype. especially in the patients with advanced atherosclerosis. History of coronary heart disease (OR=3.0154; 95%CI: 1.2490-7.2385) and diabetes mellitus (OR=3.0068; 95%

CI: 1.2490-7.2386) were independent risk factors for the

MCA stenosis, but ACE gene polymorphism was not. Conclusion(s): In the asymptomatic community residents, traditional risk factors play an important role in the MCAS. ACE gene polymorphism was not an independent risk factor for the MCA stenosis, which may effect through the blood

pressure indices.

S34 Presenting authors are indicated in bold. Korean J Stroke(Supplement 1) 2008;10

3rd International Conference on Intracranial Atherosclerosis and Annual Spring Meeting of the Korean Stroke Society ORAL SESSIONS

Oral Session 2 Oral Session 2 Neuroimaging & Pathophysiology Neuroimaging & Pathophysiology

O05 O06 Which Lipid Profiles Is Associated with Large Distribution and Severity of Perfusion Defects in Artery Atherosclerotic Stroke? Patients with Intracranial Atherosclerotic Stroke Mi Sun Oh1, Kyung-Ho Yu1, Hee-Joon Bae2, Sun U Kwon2, Suk Jae Kim1, Jin Myoung Seok1, Gyeong Moon Kim1, 2 2 2 1 1 2 Keun-Sik Hong , Yong-Seok Lee , Joung-Ho Rha , Chin-Sang Chung , Kwang Ho Lee , Jeffry R Alger Oral Sessions Ja-Seong Koo2, Ki-Hyun Cho2, Eung-Gyu Kim2, David S Liebeskind2, Oh Young Bang1 2 2 1 Jae-Kwon Cha , Jae-Kyu Roh , Byung-Chul Lee 1Department of Neurology, Samsung Medical Center, 1Department of Neurology, Hallym University College of Medicine, Sungkyunkwan University, Seoul, Korea, and Anyang, Korea, and 2Korean Stroke Registry Study Group 2Department of Neurology, Stroke Center, University of California Los Angeles, Los Angeles, CA, USA

Background(s): Evidence of a causal relation between serum lipid profiles and stroke subtypes is inconsistent. Re- Background(s): Relatively little attention has been devoted cently, non-HDL cholesterol has been considered as a good to the difference in the pattern of hypoperfusion among stroke predictor of cardiovascular disease (CVD) and a secondary subtypes. target of therapy in patients with CVD. Objective(s): Our hypothesis was that intracranial large Objective(s): The aims of our study were to investigate artery atherosclerosis (IC-LAA) had a different degree of which lipid profiles are associated with large artery athero- diffusion-perfusion mismatch and severity of hypoperfusion sclerotic stroke and to determine whether non-HDL cholesterol is clinical relevance in patients with large atheroscle- and collateral flow compared with other stroke subtypes. rotic artery in Korea. Method(s): Consecutive patients underwent multiphasic Method(s): Among 29,108 with acute ischemic stroke or perfusion CT and diffusion- (DWI) and perfusion-weighted TIA, enrolled in Korean Stroke Registry, a nation-wide pro- (PWI) MRI for acute cerebral ischemia The stroke subtypes spective multicenter cooperative hospital-based stoke data- were determined according to the results of angiographic and bank in Korea, we analyzed 14,991 selected patients with cardiologic work ups. We assessed the difference in the mis- ischemic stroke arrived at the hospital within the 48-hours of match pattern and severity of hypoperfusion, DWI lesion pat- stroke onset and with measurement of fasting lipid profiles. The independent association between lipid profiles and large tern, and collateral grading among patients artery atherosclerotic stroke were evaluated by odds ratios Result(s): Among 88 patients, 25 (28.4%) was IC-LAA, (OR) and their 95% confidence interval (CI) using stepwise 41 (46.6%)-cardioembolism, 17 (19.3%)-extracranial la- logistic regression model, adjusting for major risk factors for rge artery atherosclerosis, and 5 (5.68%)-cryptogenic em- ischemic stroke. bolism. Although the volume of initial penumbra were not Result(s): The stroke subtypes were; 5981 large artery different among the groups, the degree of mismatch ([Tmax atherosclerotic (LAA) stroke, 4849 small vessel occlusive ≥ - ] ≥ ) ( = ) (SVO) diseases, and 4161 non-LAA, non-SVO disease (both 2 vol DWI vol /Tmax 2 vol was higher p 0.001 cardioembolic and cryptogenic stroke). Multivariable analy- and severity of hypoperfusion (Tmax≥8 vol/Tmax≥2 vol) sis indicated that each lipid variables had a positive (except was lower (p<0.001) in the IC-LAA group. Collateral grad- HDL) association with LAA compared to other stroke sub- ing was assessed in 54 patients, which was more likely to be types. Compared with the reference of lowest quartile, OR intermediate or excellent (p<0.001) in the IC-LAA group. for the highest quartile of non-HDL was the higher than Multiple logistic regression analysis revealed that the degree those for other lipid profiles and lipid ratios in LAA vs non- of mismatch and severity of hypoperfusion was independ- LAA and LAA vs non-LAA, non-SVO. In addition, the TC; HDL ratio (OR 2.14, 95% CI 1.88 to 2.45), TG; HDL ratio ently associated with stroke mechanisms (OR 2.11, 95% CI 1.83 to 2.43), and LDL; HDL ratio (OR Conclusion(s): Our data showed that patients with IC- 2.06, 95% CI 1.80 to 2.36) had also the higher ORs than LAA had a relatively large mismatch area of a less severe those of LDL and TC in LAA vs non-LAA, non-SVD. hypoperfusion, and good collateral flows compared with other Conclusion(s): Our study shows that non-HDL choleste- stroke subtypes. These results raise the possibility of extend- rol and the lipid ratios as well as the traditional lipid profiles ing time window for recanalization therapy in patients with are significantly associated with large artery atherosclerotic stroke in our population. IC-LAA.

Presenting authors are indicated in bold. S35

3rd International Conference on Intracranial Atherosclerosis and Annual Spring Meeting of the Korean Stroke Society ORAL SESSIONS

O07 O08 Detection of the Siphon Internal Carotid Artery Comparison between European Countries for Stenosis: Transcranial Doppler Sonography the Availability of Facilities Necessary to Detect versus Angiography Intracranial Atherosclerosis Yong You1, Qing Hao1, Thomas Leung1, Vincent Mok1, Didier Leys1, Clotilde Balucani1, Bernd Ringelstein2, Xiang-Yan CHEN1, Alex Lau2, Howan Leung1, Markku Kaste3, Werner Hacke4 1 KS Lawrence Wong 1Department of Neurology, Lille University Hospital, Lille, France 1Departments of Medicine & Therapeutics, and 2Department of Neurology, Munster University Hospital, Munster, 2Department of Diagnostic Radiology & Organ Imaging, Germany The Chinese University of Hong Kong, Hong Kong SAR, China 3Department of Neurology, Helsinki University Hospital, Helsinki, Finland, and 4Department of Neurology, Heidelberg University Hospital, Heidelberg, Background(s): Transcranial Doppler (TCD) is often used Germany to evaluate the intracranial large artery stenosis. The aim of this study was to evaluate the accuracy of TCD in detecting Background(s): Detection of intracranial atherosclerosis siphon internal carotid artery (SICA) stenosis against digital in practice depends partly on the facilities available for stroke subtraction angiography (DSA). care. Objective(s): We selected patients who underwent DSA Objective(s): To compare availability of facilities nec- and had preoperative TCD data available. essary to detect intracranial atherosclerosis between 25 Euro- Method(s): The SICA and the intracranial artery were eval- pean countries. uated through transorbital and transtemporal acoustic win- Method(s): We randomly selected 886 hospitals in 25 dow by TCD. We defined the best cutoff value for signifi- countries. We classified hospitals according to facilities ava- cant siphon ICA stenosis by receiver-operating characteristic ilable to detect intracranial atherosclerosis, in 3 categories: (ROC) curve analyses and assessed the accuracy by calcu- i) “all facilities” (availability of color-coded duplex imaging lating the sensitivity, specificity, positive and negative pre- of intracranial arteries [TCD], computed tomographic an- dictive values (PPV and NPV). giography [CTA], and magnetic resonance angiography Result(s): One hundred and forty-five patients with TCD [MRA]); ii) “some facilities” (availability of either TCD, or and angiography were recruited. Mean age was 65.7 years CTA, or MRA); and iii) “no facility” (neither TCD, nor CTA, (range from 28 to 88 yrs), and 75.1% (109/145) were men. nor MRA, or no brain imaging). We compared the proportion The peak systolic flow velocity (PSV)=120 cm/sec had the of hospitals meeting criteria for “all facilities” versus “none or highest area under the ROC curve (area under the ROC curve some” with the odds ratio method, and Germany as reference. =0.868) compared with the MFV=70 cm/s and MFV=80 Result(s): Of 886 hospitals, 272 (30.7%) met criteria for cm/s (area under the ROC curve=0.822 and 0.845). So the availability of “all facilities”. Hospitals were less likely to criteria for the siphon internal carotid artery stenosis was meet these criteria when located in Baltic countries (OR: defined by the PSV 120 cm/sec plus additional criteria (ab- 0.13; 95% CI.OR: 0.03-0.56), France (0.52; 0.31-0.89), normal spectrum, circumscribed velocity changes and side- Greece (0.11; 0.14-0.88), Poland (0.40; 0.21-0.77), and to-side difference). Twenty-nine patients were diagnosed with Iberic countries (0.11; 0.05-0.27). The other countries did SICA stenosis or occlusion on TCD. Fifteen patients had ab- not significantly differ from Germany. When comparing “all normal TCD findings that were not confirmed by DSA. One plus some facilities” versus “none” the results remain similar, patient with normal TCD but DSA showed mild (40%) ste- except for United Kingdom/Ireland which joined the less nosis. Accuracy parameters for TCD were as follows: sensi- equipped countries (0.43; 0.21-0.88). tivity=93.9%, specificity=96.7%, PPV=68.3%, NPV= Conclusion(s): There are important differences between 99.6%. Most of false-positive patients (11 of 15 patients) European countries for the facilities available to detect intra- had other significant intracranial large arteries lesions. cranial atheroma. Spain and France being in the less equip- Conclusion(s): TCD is both sensitive and specific in iden- ped countries, while a few former communist countries are tifying SICA stenosis. Abnormal findings of siphon carotid not, making likely that differences in economic levels are not on transcranial Doppler ultrasound require angiography to the only explanation. avoid omitting transcranial large arteries stenosis.

S36 Presenting authors are indicated in bold. Korean J Stroke(Supplement 1) 2008;10

3rd International Conference on Intracranial Atherosclerosis and Annual Spring Meeting of the Korean Stroke Society ORAL SESSIONS

O09 O10 Does Middle Cerebral Artery Stenosis Affect Pathology of Atherosclerotic Intracranial Stenosis Neurovascular Coupling of Posterior Angelito Jonas L Kalaw, Jose C Navarro, Carmelita V Navarro, Cerebral Artery? Alejandro II C Baroque, Johnny K Lokin Tai Hwan Park, Min Uk Jang, Sung Kyu Na, Jae-Hyeok Heo, Department of Neurology and Psychiatry, University of Santo Tomas Jin Young Ahn, Min Ky Kim Hospital, Manila, Philippines Department of Neurology, Seoul Medical Center, Seoul, Korea Background(s): Atherosclerotic stenosis of the major intracranial arteries causes 10% of ischemic stroke. The risk of Background(s): The change of blood flow velocity (FV) Oral Sessions in posterior cerebral artery (PCA) during visual stimulation recurrent stroke in patients with intracranial stenosis may be (VS) is commonly assessed for neurovascular coupling (NC). as high as 15% per year with increased mortality. Objective(s): We tried to assess the influence of middle Objective(s): It is purpose of this study to describe in- cerebral artery (MCA) stenosis on NC in PCA. tracranial arterial stenosis and its vascular risk factors in au- Method(s): In 9 patients with MCA stenosis (>70%) and topsied cases. 10 normal controls, P2 segment of PCA and contralateral Method(s): Eighty (80) consecutive autopsy cases were M1 of MCA were monitored simultaneously with TCD. The grossly and histologically examined from 2000 to 2006. Eigh- VS was performed using a checkerboard stimulus with flick- teen (18) autopsied cases satisfied the selection criteria ering at 1 Hz. The test consisted of 3 times of series with 1 and vascular risk factors were noted. Gross and histologic minute of resting and continuous VS period for 1 minute. In atherosclerotic changes of the stenotic middle cerebral and each series, time-averaged mean FV for last 30 s of resting basilar arteries were examined. Using a calibrated digital mi- (rFV) and 1 minute of VS period (vFV) were measured to crocaliper, intracranial atherosclerotic stenosis was categorized calculate the rate of change in FV (RCFV=vFV-rFV/rFV as either focal or diffuse and the degree of stenosis was ascer- ×100). RCFV was compared within individual well as be- tained following the calculation from the WASID trial. tween groups. Result(s): Of the 18 autopsy cases included, 9 cases (50%) Result(s): In control subjects, RCFV of right and left PCA had atherosclerotic segments. The mean age of the athero- was 16.9±2.8% and 16.5±2.4%, respectively. RCFV of sclerotic group was 65.3. Males in the atherosclerotic cases PCA ipsilateral to the stenotic MCA (n=12) was signifi- comprised 5 (55.6%). Eleven (68.7%) of the 16 abnormal cantly lower than that of contralateral PCA (n=6) (6.5±3.6 vessels examined were derived from the middle cerebral vs. 17.3±3.3%, p=.001) as well as that of PCA in control artery and five (31.3%) came from the basilar artery. Nine subject. Even though much lower than the RCFV of PCA, (56.2%) of the abnormal blood vessels showed focal athe- FV in MCA also increased during VS in both control sub- rosclerotic segment while 7 (43.8%) had diffuse atheroscle- jects (4.6±1.8%) and normal MCAs among patients (6.0 rotic segment. Of the abnormal blood vessels, 1 (6.3%) had ±1.1%, n=6). However, RCFV of stenotic MCAs (1.2± ≤30% arterial stenosis, 9 (56.2%) had 31-50%, 5 (31.2%) 0.6%, n=8) was significantly lower than that of normal MCA had 51-70%, and 1 (6.3%) had 71-total occlusion. (p=.002). Conclusion(s): Fifty percent (50%) of the autopsy series Conclusion(s): The change of FV in PCA during VS can revealed the presence of focal intracranial stenosis with 31- decrease in case of ipsilateral MCA stenosis. 50% severity.

Presenting authors are indicated in bold. S37

3rd International Conference on Intracranial Atherosclerosis and Annual Spring Meeting of the Korean Stroke Society ORAL SESSIONS

Oral Session 3 Oral Session 3 Treatment Treatment

O11 O12 Trial of Efficacy and Safety of Cilostzol on the Clinical and Angiographic Outcome Progression of Symptomatic Intracranial Stenosis of Self-Expandable Stenting in Symptomatic Comparing Clopidogrel: Trial of Cilostazol in Intracranial Arterial Stenosis Symptomatic Intracranial Stenosis-2 (TOSS-2) Thomas Leung1, Simon CH Yu2, Wynnie WM Lam2, Baseline Characteristics and Current Status Yannie OY Soo1, KS Lawrence Wong1 Sun U. Kwon1, Jong S Kim1, Dong-Wha Kang1, Joung-Ho Rha2, 1Division of Neurology, Department of Medicine and Therapeutics, and 2 Hee-Joon Bae3, MK Han3, JS Koo4, JM Park4, KM Kim5, Department of Radiology and Organ Imaging, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong SAR, China KS Hong6, YJ Cho6, Byung-Chul Lee7, Kyung-Ho Yu7, JH Lee8, YS Lee9, SH Lee10, HY Kim11, DE Kim12, SW Jeong12, KB Lee13, CT Mok14, TF Cheung15, Jose C Navarro16, C San Jose17, Background(s): The clinical and angiographic outcome 18 19 20 D Ratanakorn , N Poungvarin , NC Suwanwela of self-expandable stenting in symptomatic intracranial ste- 1Asan Medical Center, University of Ulsan, Seoul, Korea, 2Inha University Hospital, Incheon, Korea, 3Seoul National University Bundang Hospital, nosis remains unclear. Seongnam, Korea, 4Eulji University Hospital, Seoul, Korea, 5Samsung Objective(s): To report the short-term experience of self- Medical Center, Seoul, Korea, 6Ilsan Paik Hospital, Goyang, Korea, 7Hallym University Sacred Heart Hospital, Ahnyang, Korea, 8Hallym expandable stenting in symptomatic intracranial stenosis. University Kangdong Sacred Heart Hospital, Seoul, Korea, 9Boramae Method(s): Patients who had self-expandable stenting for Hospital, Seoul National University, Seoul, Korea, 10Seoul National University Hospital, Seoul, Korea, 11 Kunkuk University Hospital, Seoul, high-grade (>60%) symptomatic intracranial stenosis from Kotea, 12Dong-Guk University International Hospital, Goyang, Korea, Feb 2006- Feb 2008 were recruited for clinical follow-up and 13Soonchynghyang University Hospital, Seoul, Korea, 14Prince of Wales Hospital, Hong Kong SAR, China, 15Queen Mary Hospital, Hong Kong repeat digital subtraction angiography (DSA) 12 months after SAR, China, 16Santo Thomas University Hospital, Manila, Philippines, the procedure. 17Philippines General Hospital, Manila, Philippines, 18Ramathibodi Hospital, Bangkok, Thailand, 19Siriraj Hospital, Bangkok, Thailand, and Result(s): Of total 43 patients (47 stenoses), balloon pre- 20Chulalongkorn University, Bangkok, Thailand dilatation and stent implantation were technically successful (immediate residual stenosis <40%) in 40 patients (44 ste- Background(s): Cilostazol, a phosphodiesterase inhibitor, has been shown to reduce progression rate of symptomatic noses). In 22 patients who had DSA in 12 months, 5 patients intracranial stenosis (SIS). had >50% restenosis (22.7%). At a mean follow-up of 15.5 Objective(s): Trial of Cilostazol in Symptomatic Intracra- months, the frequency of any stroke, intracerebral hemorrhage, nial Arterial Stenosis-2 is to compare the efficacy and safety of cilostazol and clopidogrel on the prevention of the progre- or death was 6.9%. ssion of SIS Conclusion(s): Self-expandable stenting in high grade Method(s): TOSS-2, an investigator initiated multicenter international double blind randomized trial attempts to re- symptomatic intracranial stenosis is relatively safe and with cruit 480 acute ischemic stroke patients with SIS in the M1 a high rate of technical success. The restenosis rate appears segment of MCA or BA. The participants are randomly allo- to be higher than that in the pre-marketing studies. cated into cilostazol or clopidogrel group. They are also sup- posed to take 75-125 mg aspirin per day additionally. SIS will be assessed by MRA at the time of recruitment and at the final visit. The primary outcome is the progression of SIS on MRA. Occurrence of new ischemic lesions on MRI, clinical stroke events and major bleeding complications will be analyzed as secondary outcome measures. Result(s): For this trial, 27 investigators of 20 centers from 4 countries participiated. So far, 483 patients have been screened and 436 enrolled. 47 patients (9.7%) were excluded because the poor quality of MRI and MRA. The locations of the SIS were the left MCA (92 of 210, 43.8%), the right MCA (81, 35.6%) and the BA (37, 17.6%). Drop-out rates were 12.1% (26 of 215) and clinical events developed in 10 patients. There were no major bleeding complications. Conclusion(s): The process of TOSS-2 is on-going as planned, and patient enrollment will be completed in April 2008. It is expected that TOSS-2 results will give provide a better strategy in the management of SIS.

S38 Presenting authors are indicated in bold. Korean J Stroke(Supplement 1) 2008;10

3rd International Conference on Intracranial Atherosclerosis and Annual Spring Meeting of the Korean Stroke Society ORAL SESSIONS

O13 O14 Measurement of Clopidogrel-Induced Platelet Intracranial Stenting in Patients with Intracranial Inhibition May Predict Early Complications Stenosis Associated with Adjacent Aneurysm Following Stent-Assisted Angioplasty for Hyun Sin In1, Jin Woo Choi1, Byung Se Choi1, Deok Hee Lee1, Symptomatic Intracranial Atherosclerotic Disease Sang Joon Kim1, Dong Wha Kang2, Sun U Kwon2, Jae Young Koh2, Jong S Kim2, Dae Chul Suh1 Soo Joo Lee1, Jae Guk Kim1, Byung Hee Lee2, Boram Lee1, Soo-Jin Yoon1, Jong-Un Chun1, Gun-Sei Oh1, In-Kyu Yu2 1Department of Radiology and Research Institute of Radiology and 2Department of Neurology, Asan Medical Center, Seoul, Korea 1Departments of Neurology, and 2Radiology, Eulji University Hospital, Daejeon, Korea Oral Sessions Background(s): Symptomatic intracranial stenosis asso- Background(s): Platelet reactivity studies have demon- ciated with adjacent aneurysm or vascular ectasia has not been strated a wide inter-individual variability in the inhibitory described in detail. response to clopidogrel. Objective(s): The purpose of this study was to analyze Objective(s): To determine the relationship between the morphologic type of intracranial stenosis associated with ad- poor response to clopidogrel and peri-procedural complica- jacent aneurysm or vascular ectasia and to report stenting re- tions such as in-stent thrombosis and cerebral embolism fo- sult and clinical outcome. llowing stent-assisted angioplasty for symptomatic intracra- Method(s): Among 150 patients who underwent intra- nial atherosclerotic disease. cranial stenting over 6-year period (August 2003-January Method(s): Twenty-eight patients, who have received st- 2008), 10 patients (8 : 2=M : F, mean, 62.5years) had in- ent-assisted angioplasty procedures in intracranial arteries, tracranial stenosis associated with adjacent aneurysm or were enrolled. Before the intervention, all patients were on vascular ectasia. The location, type, procedure-related consi- aspirin and received a loading dose of 300 mg clopidogrel. deration, complications, and clinical or radiological follow- The platelet function was determined with the VerifyNow-P2 up results were assessed. We defined as fusiform vs saccular Y12 assay. This assay reports the results as P2Y12 Reaction and aneurysm vs ectasia (luminal change ≥1.5 times). The Units (PRU), Inhibition (%) and BASE in less than 5 mi- clinical status including event, final patient status and res- nutes. Inhibition (%) is calculated as (1-PRU/BASE)×100. tenosis were determined based on clinical follow-up. Diffusion-weighted image (DWI) was performed the day be- Result(s): Among 10 patients with 11 lesions, locations fore and repeated within 48 hours after the procedure to scre- were 3 in the internal carotid arteries (ICA) (27%, 2 caver- ening for procedure-related ischemic lesions including si- nous, 1 petrous), 2 M1 (18%) and 6 vertebrobasilar arteries lent embolism. (55%, 3 vertebrobasilar junctions, 3 basilar arteries). The Result(s): Ineffective aggregation-inhibition (percentage type of aneurysm or ectasia included fusiform ectasia (n=6), of Inhibition <20), defined as suboptimal responders to clo- fusiform aneurysm (n=1), saccular aneurysm (n=3) with pidogrel, on the platelet function test was observed in 12/28 (n=2) or without (n=1) ulceration. The lesions were distal (42.9%) patients. DWI detected procedure-related embolic (n=7) or proximal (n=3) to the stenosis. Three patients lesions in 16 (64%). In-stent thrombosis on angiography dur- have one more aneurysm in the contralateral ICA. Proce- ing procedure was found in 8 (32%). Patients with positive dural success was achieved in all patients (10/10). There were DWI lesion had more often suboptimal response to clopi- no lesion-related strokes and deaths during 3-26 months dogrel than one without DWI lesion (10/16 vs. 2/12, p= follow-up (median 14.5 years). Final modified Rankin scale 0.02). The number of DWI lesions inversely correlated with was good (≤2) in all patients and there were no significant the value of Inhibition percentage (r=-0.78; p<0.001). The restenosis in 5 patients with angiographic follow-up. suboptimal responder to clopidogrel was more often found Conclusion(s): Intracranial stenosis can be rarely asso- in patients showing in-stent thrombosis than in ones without ciated with aneurysm. Stenting could be done without further (6/8 vs. 2/16, p=0.04). risk of stroke. The target of the treatment needs to be con- Conclusion(s): The level of platelet aggregation before sidered aneurysm as well as stenosis. angioplasty and stenting may correlate with early thrombo- embolic complications following the intervention.

Presenting authors are indicated in bold. S39

3rd International Conference on Intracranial Atherosclerosis and Annual Spring Meeting of the Korean Stroke Society ORAL SESSIONS

Oral Session 4 Oral Session 4 On-going Trials/ Others On-going Trials/ Others

O15 O16 Dynamic Cerebral Autoregulation in Patients with Cilnidipine effect on High blood pressure and Recent Atherosclerotic Stroke during External cERebral Perfusion in Ischemic Stroke patients Counterpulsation with Hypertension Li Xiong, Jing Hao Han, Wai hong Leung, Howan Leung, Keun-Sik Hong1, Jong-Moo Park2, Dong-Wha Kang3, KS Lawrence Wong Yong-Seok Lee4, Ja-Seong Koo2, Yong-Jin Cho1, Joung-Ho Rha5, 6 7 7 Department of Medicine and Therapeutics, The Chinese University of Yu-Kyeong Kim , Moon-Ku Han , Seong-Ho Park Hong Kong, Hong Kong SAR, China 1Department of Neurology, Ilsan Paik Hospital, Inje University, Goyang, 2 Department of Neurology, Eulji General Hospital, Eulji University School of Medicine, Seoul, Background(s): Serial transcranial doppler ultrasonogra- 3Department of Neurology, Asan Medical Center, Ulsan University, Seoul, 4 ( ) Department of Neurology, Seoul Munincipal Boramae Hospital, Seoul, phy TCD monitoring cerebral blood flow during external 5Department of Neurology, Inha University Hospital, Incheon, counterpulsation (ECP) may provide more information on the 6Department of Nuclear Medicine, Seoul National University, Seoul, and 7 ( ) Department of Neurology, Seoul National University Bundang Hospital, status of dynamic cerebral autoregulation dCA after acute Seongnam, Korea atherosclerotic stroke. Objective(s): This study investigates whether dCA asse- Background(s): For ischemic stroke patients, ideal anti- ssed from mean blood pressure (MBP) and mean cerebral hypertensive agent should reduce blood pressure (BP) with- blood flow velocity (CBFV) change from baseline during out reduction of cerebral blood flow (CBF). : ECP is impaired after acute atherosclerotic ischemic stroke Objective(s) To compare the effect of calcium channel blocker cilnidipine and anigotensin receptor blocker losartan onset and the effect of time course in the dCA impairment on CBF in hypertensive ischemic stroke patients. after acute stroke. Method(s): This is a multicenter, randomized, double-bl- Method(s): Eleven patients with large artery occlusive ind, active control, non-inferiority trial. We randomized 196 disease in unilateral middle cerebral artery stroke (MCAS) hypertensive patients with ischemic stroke (≥2 weeks) to cilnidipine 10-20 mg/day or losartan 50-100 mg/day for 4 and ten healthy controls were enrolled. A course of 35 daily weeks with a target BP of 140/90 mmHg. We evaluated CBF one-hour sessions of ECP were applied to each patient wi- by 99mTc-HMPAO SPECT and BP before and after treat- thin 7 days of symptom onset and controls. During ECP ment. Primary outcome was the change in global CBF on treatment, Bilateral MCAs were monitored by TCD to eva- SPECT. The non-inferiority margin was defined as less than -8.6% with one-sided p value of 0.025. Secondary outcomes luate cerebral blood flow on day 3, 5, 7, 10, 14, 18, 21, 24, included lesional CBF (ipsilesional hemisphere or cerebel- 28, 35 after stroke onset in MCAS and on the first ECP se- lum) changes, proportion of patients without global CBF re- ssion in controls. duction, and BP. Result(s): In MCAS, the greatest increase of mean CBFV Result(s): Global CBF significantly increased in both gr- in the relevant MCA and irrelevant MCA was respectively oups (clinidipine, 8.97±29.60%, p=0.0071; losartan, 11.34 ±31.41%, p=0.0012) The absolute difference of global CBF noted at day 14 and day 18 which was 3.56% (median) and changes between two groups is -2.37% (97.5% CI -13.2% 7.01% from baseline and then gradually decreased. MBP to 8.38%). Lesional CBF changes were -0.06%±1.42% increased at every measurement points during ECP. The di- for cilnidipine and -0.36%±2.12% for losartan (p=0.29). fferences in the magnitude of change from baseline in both Proportions of patients without global CBF reduction were 78.3% for cilnidipine and 74.4% for losartan (p=0.57). Sys- mean CBFV and MBP were significant between MCAS and tolic and diastolic BP decreased by 13.7±12.7/7.0±7.6 controls (p<0.05). mmHg for cilnidipine and 13.1±14.2/6.2±8.3 mmHg for Conclusion(s): DCA was globally impaired during the lorsatan (p=0.78 for SBP, p=0.53 for DBP). The rates of acute and subacute stage of atherosclerotic ischemic stroke. treatment related adverse events were 8.4% for cilnidipine ( = ) The impairment of dCA would last 14 to 18 days after acute and 11.6% for losartan p 0.47 . Conclusion(s): We failed to prove non-inferiority of cil- MCA ischemic stroke onset. nidipine compared with losartan for the global CBF change. However, both the cilnidipine and losartan treatment increased the global CBF despite BP reduction (Clinicaltrials.gov registration identification number is NCT00325637).

S40 Presenting authors are indicated in bold. Korean J Stroke(Supplement 1) 2008;10

3rd International Conference on Intracranial Atherosclerosis and Annual Spring Meeting of the Korean Stroke Society ORAL SESSIONS

O17 O18 Aggressive Glucose Control in Acute Ischemic Early Effect of Fluvastatin on Inflammatory Stroke by Insulin Infusion (AGAIN)-pilot study Markers in Acute Ischemic Stroke (FIMA): Nayoung Kim, Jong-Moo Park, Byung-Kun Kim, Ohyun Kwon, Preliminary Ongoing Study JungJu Lee, Ja-Seong Koo Eung Gyu Kim1, Man S Park2, Bong G Yoo3, Yong J Kim4, Department of Neruology, Eulji General Hospital, Eulji University Yo S Kim5, Nak C Choi6, Jun Lee7, Jae K Cha8, Ki H Cho2 College of Medicine, Seoul, Korea 1Departments of Neurology, Paik Hospital, Busan, 2Chonnam National University Hospital, Gwangju, 3Gosin Gospel Hospital, Busan, Background(s): Hyperglycemia in acute ischemic stroke 4 Ewha Womans University Hospital, Seoul, Oral Sessions is associated with poor neurological recovery and mortality. 5Wonkwang University Hospital, Iksan, 6Gyungsang National University Hospital, Jinju, Objective(s): We designed insulin infusion protocol for 7Yeungnam University Hospital, Daegu, and aggressive blood glucose control and investigated its feasi- 8Dong-A University Hospital, Busan, Korea bility and safety. Method(s): We included ischemic stroke patients presen- Background(s): Laboratory evidence and findings from ting within 48 hours after onset, whose initial blood glucose clinical and population studies suggest that inflammation is levels were between 100-300 mg/dL. The insulin fluid made important in atherosclerosis and ensuing clinical complica- of 50 U regular insulin in 500 mL normal saline or 5% dex- tions. High levels of hs-CRP in the blood seem to predict trose water was infused for 24 hours. Infusion rate was ad- prognosis and recurrent events in patients with stroke. In the justed according to the capillary glucose level every 2 hours. Myocardial Ischemia Reduction with Aggressive Cholesterol Target glucose levels were 80-130 mg/dL. During interven- Lowering (MAIRACL) study, statin reduced early recurrence tion period all patients fasted and were monitored in intensive of cardiovascular events and stroke. This supports the value care unit. of early statin therapy in acute vascular event. Result(s): Total 45 patients were enrolled (7 saline; 38 Objective(s): 1) Investigate whether fluvastin affect the dextrose water). Saline-based protocol was discarded due to circulating concentration of soluble inflammatory markers frequent hypoglycemia. In dextrose water group, initial glu- (hs-CRP, CD40L) in acute ischemic stroke patients. 2) Ex- cose level was 151±44 mg/dL which was lowered to 94±26 plore the effect of fluvastatin on reducing concentration and mg/dL by insulin infusion and 67% of the measured glucose relative distribution of lipids those patients. levels were within target range. Mean glucose level of 16 Method(s): Prospective randomized open label trial (8 (42%) patients with diabetes was higher than that of 22 pa- University Hospitals are participated) we are enrolling acute tients without diabetes (99±33 vs. 81.6 mg/dL, p=0.001). ischemic stroke patients for whom blood sampling is possible Three (8%) patients required intravenous glucose for sym- within 72 hours symptom onset and total cholesterol is below ptomatic hypoglycemia and two of whom discontinued the 240 mg/dL. we are excluded cardiogenic embolism, chronic protocol due to recurrent hypoglycemia and symptoms mi- liver disease, chronic use of NSAID, cancer, patients with micking stroke aggravation, respectively. thrombolysis, previous history of ischmeic and hemorrhagic Conclusion(s): This pilot study revealed our insulin in- stroke, previous use of statin. We are using 300 mg of aspirin fusion protocol was effective to control hyperglycemia in ac- with or without Fluvastain 80 mg based on randomization ute ischemic stroke patients. Further study is on going with a for 4 weeks. we are checking baseline blood tests (lipid pro- revised protocol for reducing hypoglycemia and assessing file and hs CRP) at admission, 1 week, and 4 weeks with CD clinical outcomes. 40L at admission and 4 weeks. We are also checking other variables accoriding to the Korean Stroke Registry. Result(s): ongoing Conclusion(s) : ongoing

Presenting authors are indicated in bold. S41

3rd International Conference on Intracranial Atherosclerosis and Annual Spring Meeting of the Korean Stroke Society ORAL SESSIONS

O19 O20 Circulating Pericyte Progenitor Cells as Effects of Uric Acid on Silent Brain Infarction a Candidate Stem Cell Population in Acute Stroke in Healthy Elderly Adults Kon Chu1, Keun-Hwa Jung1, Soon-Tae Lee1, Hee-Kwon Park1, Sung Hyuk Heo1,2,3, Seung-Hoon Lee1,2, Hyung-Min Kwon2,4, Jae-Jun Bahn1, Dong-Hyun Kim1, Jin-Hee Kim1, Seung Ho Choi5, Byung-Woo Yoon1,2 2 1 1 1 Eun-Cheol Song , Manho Kim , Sang Kun Lee , Jae-Kyu Roh 1Department of Neurology, Seoul National University Hospital, 1Stroke & Neural Stem Cell Laboratory, Stem Cell Research Center, 2Clinical Research Center for Stroke, Seoul National University Hospital, 3 Clinical Research Institute, Department of Neurology, Seoul National Department of Neurology, Kyung Hee University College of Medicine, University Hospital, Seoul, and 4Department of Neurology, Seoul Municipal Boramae Hospital, and 5 2Department of Neurology, Inha University Hospital, Incheon, Korea Healthcare Research Institute, Seoul National University Hospital Healthcare System Gangnam Center, Seoul, Korea

Background(s): Activated endothelial cells secrete plate- Background(s): Uric acid has been known to have neu- let-derived growth factor (PDGF)-β, which signals through roprotective property via antioxidant effect, but several cli- its receptor PDGFR-β, expressed by pericytes, resulting in nical data have indicated an association with increased risk proliferation and recruitment of pericytes to the newly for- of vascular events. med vessels. The concept that circulating pericytes partici- Objective(s): In this study, we sought to examine effects pate in regeneration after injury remains highly controversial. of uric acid level on the presence of silent brain infarctions A recent study has identified a subset of highly proliferative (SBIs) seen on brain magnetic resonance imaging (MRI) cell population in peripheral blood mononuclear cells (PB- among healthy elderly population. MNCs) of acute stroke patients. Method(s): A consecutive series of 1,577 neurologically Objective(s): In this study, we undertook to identify the healthy elderly adults were included for this analysis. They pericyte progenitors in the peripheral blood culture from st- underwent brain MRI including fluid-attenuated inversion roke patients. recovery (FLAIR) sequence, and we examined associations Method(s): PBMNCs were isolated from the peripheral between uric acid level and presence of SBI. SBI was deter- blood of 16 acute stroke patients, and 31 risk factor-only gr- mined as a small focal lesion with signal intensity corres- oup. The fraction of pericyte progenitor cells (PPCs) in PB- ponding to liquor surrounded by a hyperintense gliotic rim MNCs was measured using flow cytometry with anti-NG2 on the FLAIR sequence. and anti-PDGFR-β antibodies. The outgrowth cells were Result(s): Eighty-eight subjects (5.6%) were found to characterized by immunostaining and flow cytometry with have ≥1 SBIs. Age, hypertension, and diabetes were found pericyte markers. to be significantly related to the presence of SBI. Subjects Result(s): The fraction of pericyte progenitors in PBMNCs with highest quartile of uric acid level (≥7.1 mg/dL for men was higher in acute stroke patients (median: 2.37, 0.01- and ≥5.3 mg/dL for women) were more likely to have SBIs. 35.82) than risk factor-only group (median: 0.02, 0-1.28, After controlling for possible confounders including vascular p=0.000). Outgrowth cells could be more efficiently isolat- risk factors, the highest quartile of uric acid level remained ed from stroke patients (80%) than risk factor-only (30%) significant [adjusted odds ratio (OR), 1.84; 95% confidence group. They exhibited pericyte characteristics, according to interval (CI), 1.14-2.96]. However, the association was their morphology and protein expression profiles. Outgrowth significant in women (OR 2.64; 95% CI, 1.27-5.46), but cell generation was also closely associated with higher NG2+ not in men (OR 1.27; 95% CI, 0.65-2.49). cell numbers in peripheral blood. Conclusion(s): Our results indicate that serum uric acid is Conclusion(s): The feasibility of extracting and culturing an independent risk factor for the presence of SBI, although pericytes in large numbers suggests that such autologous the effects might be different between genders. cells will be useful for applications ranging from basic research to cell-based therapy. Further understanding of mobi- lizing mechanism may aid the development toward the treatment and prevention of stroke.

S42 Presenting authors are indicated in bold. Korean J Stroke(Supplement 1) 2008;10

3rd International Conference on Intracranial Atherosclerosis and Annual Spring Meeting of the Korean Stroke Society ORAL SESSIONS

Oral Session 5 Oral Session 1 Clinical Aspects & Metabolic Syndrome Epidemiology & Risk Factors

O21 O22 Mirror Pattern of the Cerebral Artery Intracranial Atherosclerosis in Anterior Cerebral Atherosclerosis in Patients with Acute Artery Territory Infarction: Its Significance Ischemic Stroke and Stroke Mechanism Young Dae Kim, Hye Yeon Choi, Yo Han Jung, Jong S Kim, Suk Y Kang Oral Sessions Hyo Suk Nam, Ji Hoe Heo Department of Neurology, Asan Medical Center, Seoul, Korea Department of Neurology, Yonsei University College of Medicine, Seoul, Korea Background(s): Anterior cerebral artery (ACA) territory

infarction is uncommon and its etiology and stroke mechani- Background(s): Cerebral atherosclerosis may be influ- sms have rarely been investigated. The aim of the present enced by local factors as well as systemic factors. If this is study was to verify its stroke mechanisms and to make cli- true, it is assumable that atherosclerosis in certain artery or nical-imaging correlations. Especially, we are interested in segment of one side may be accompanied by that in the elucidating the significance of, and the stroke mechanism of corresponding portion of the other side in individual patient intracranial ACA atherosclerotic disease in patients with ACA (‘Mirror pattern’). territory infarction. Objective(s): We determined whether the mirror pattern Objective(s): To verify the stroke mechanisms of ACA of cerebral artery atherosclerosis presents. atherosclerosis. Method(s): The angiographic findings of 2,172 consecu- Method(s): Clinical, MRI and angiographic (mostly MR tive patients with ischemic stroke were reviewed retrospec- angiography) findings of 100 consecutive patients with ACA tively. The presence (location) and severity (the degree of infarction were studied. Stroke mechanisms were identified stenosis) of atherosclerosis were compared between the right by correlating the MRI-identified lesion patterns and the un- and left sides at predetermined seven arteries/segments. derlying vascular lesions. Result(s): There were 2,619 stenotic arteries/segments in Result(s): Motor dysfunction (n=91), hypobulia/apathy the left side from 1,343 patients and 2,596 stenotic arteries/ (n=43), urinary incontinence (n=30), and grasp reflex (n= segments in the right side from 1,355 patients. Among 1,232 25) were common clinical manifestations. Angiographic patients with atherosclerotic lesions at 2 or more arteries/ (mostly MR angiography) results showed that 68 patients segments, the mirror pattern was observed in 827 patients had local ACA atherosclerosis, most often at A2 segment. (67.1%). The mirror pattern was most frequently found in The stroke mechanisms included cardiogenic embolism in the extracranial internal carotid artery (E-ICA, 339/1,232, 10, internal carotid artery (ICA)-ACA embolism in six, and 27.5%), followed by the middle cerebral artery (330/1,232, ACA atherosclerosis in 61 patients. In the latter group, de- 26.8%). The correlation of stenosis severity between left and tailed stroke mechanisms included local branch occlusion right sides was modest and of those, highest in the E-ICA (n=20), in-situ thrombotic occlusion (n=20), artery to ar- (r=0.43, p<0.001). Multiple logistic regression analyses tery embolism (n=12), and the combination the two (n=9). revealed that the mirror patterns of atherosclerosis were asso- Patients with intrinsic ACA disease more often had hypo- ciated with past history of ischemic stroke and number of bulia (p=0.077) and corpus callosal involvement (p=0.016) stenotic lesions. than those with embolism either from the ICA or the heart. Conclusion(s): Atherosclerosis in the cerebral arteries may Conclusion(s): Local intracranial atherosclerosis is the develop and progress in a mirror pattern. These findings sug- most important etiology of ACA territory infarction in our gest that occurrence and progression of cerebral atherosc- population, producing infarction with a variety of mecha- lerosis are influenced by local and/or endogenous factors nisms. Topographic lesion patterns and consequent clinical such as hemodynamic and developmental cause. features are determined by diverse pathogenic mechanisms

and the status of collateral circulation.

Presenting authors are indicated in bold. S43

3rd International Conference on Intracranial Atherosclerosis and Annual Spring Meeting of the Korean Stroke Society ORAL SESSIONS

O23 O24 Intracranial Atherosclerosis in Patients Endothelial Apoptosis Associated with with CADASIL Intracranial Atherosclerosis Jay Chol Choi, Jung Seok Lee, Sa-Yoon Kang, Ji-Hoon Kang in Metabolic Syndrome Department of Neurology, Cheju National University Hospital, Soon-Tae Lee, Kon Chu, Keun-Hwa Jung, Hee-Kwon Park, Jeju, Korea Jae-Sung Lim, Dong-Hyun Kim, Woo-Seok Im, Jeong-Eun Park, Jin-Hee Kim, Jae-Jun Ban, Jun-Young Chang, Eun-Cheol Song, Sang Kun Lee, Manho Kim, Jae-Kyu Roh Background(s): Cerebral autosomal dominant arteriopa- Department of Neurology, Seoul National University Hospital, Seoul, Korea thy with subcortical infarcts and leukoencephalopathy (CA-

DASIL) is a prototype of single gene disorder causing recu- Background(s): Apoptotic vascular endothelial cells shed rrent stroke and cognitive deficits. Although the involvement plasma membrane submicron vesicles, known as micropar- of cerebral small vessels is characteristic of this disorder, pre- ticles, into the blood. The level of circulating endothelial mi- vious studies have described occasional involvement of large croparticles (EMPs) is a surrogate marker of ongoing endo- arteries. thelial damage. Objective(s): To further address this issue in patients with Objective(s):We investigated the significance of EMPs in CADASIL, we evaluated the frequency and characteristics intracranial atherosclerosis (IAS) in patients with metabolic of intracranial atherosclerosis (ICAS) in CADASIL with ma- syndrome (MetS). gnetic resonance angiography (MRA). Method(s): We enrolled consecutive MetS patients from Method(s): Between May 2004 and December 2007, there our stroke prevention clinic. EMP-rich plasma was prepared were 52 consecutive patients with CADASIL confirmed by from citrated venous blood samples using serial ultracentri- genetic test or skin biopsy. Among them, 36 patients had un- fugation and then used to count EMPs (≤1 μm) by flow derwent MRA. We retrospectively reviewed vascular risk cytometry with anti-CD31, anti-CD42, Annexin-V, and anti- factors including hypertension, diabetes mellitus, blood cho- CD62E antibodies. lesterol, smoking status using medical record. In this study, Result(s): A total of 112 patients were enrolled, and 39 intracranial atherosclerosis was defined as more than 50% patients had IAS (IAS patients). There was no difference in stenosis compared with normal proximal artery on MRA. patient risk factor profiles between the IAS patients and the Result(s): The mean age of the patients were 62.8±12.5 non-IAS patients. However, the mean levels of EMPs (CD years (range from 40 to 86) and 51.4% were men. The most 31+/CD42-, CD31+/Annexin-V+) were significantly higher common initial manifestation was ischemic stroke including in the IAS patients than the non-IAS patients. Multiple linear TIA (47.2%) followed by headache, cognitive deficits, and regression analysis identified the CD31+/Annexin-V+ level vascular parkinsonism. Among them, 13 patients (35.1%) as the independent predictor of IAS in MetS. Extracranial had ICAS on 19 intracranial arteries. The mean age of the atherosclerosis in the carotid or vertebral arteries was not patients with ICAS was non-significantly higher than the associated with EMP level. In IAS patients, the level of apo- patients without ICAS (67.8±11.9 years vs 60.0±12.2 ptotic EMP (CD31+/Annexin-V+) was correlated with waist years). Sex, hypertension, diabetes mellitus, smoking status circumference and diastolic blood pressure, and the level of were not different between the patients with ICAS and wi- EMPs for activated endothelial cells (CD62E+) was cor- thout ICAS. Total cholesterol was significantly higher in related with the volume of subcortical white matter change. patients with ICAS (219.0±41.7 mg/dL vs 184.1±31.7 mg/ Multiple linear regression analysis identified the waist cir- dL, p<0.01). Three patients had corresponding infarction on cumference as the independent predictor of endothelial apo- the involved large cerebral arteries. ptosis (CD31+/Annexin-V+ level) in IAS patients with MetS. Conclusion(s): This study reaffirms that the patients with Conclusion(s): Active endothelial apoptosis involves in CADASIL frequently have intracranial arterial stenoses. In IAS with MetS, with which some components of MetS, such this study, an elevated level of cholesterol was associated as high waist circumference, are associated. with the presence of ICAS.

S44 Presenting authors are indicated in bold. Korean J Stroke(Supplement 1) 2008;10

3rd International Conference on Intracranial Atherosclerosis and Annual Spring Meeting of the Korean Stroke Society ORAL SESSIONS

Oral Session 6 Oral Session 6 Natural Course & Prognosis Natural Course & Prognosis

O25 O26 Significant Associations of Metabolic Syndrome Acute Symptomatic Intracranial Artery occlusion and Its Components with Silent Brain Infarction (ASIA) Study I: Natural History in Elderly People Woong-Woo Lee, Mi Hwa Yang, Chae-won Shin, Youngchai Ko,

Hyung-Min Kwon1, Wi-Sun Ryu2, Chi-Kyung Kim2, Jin-Ho Park3, Jung-Hyun Park, Moon-Ku Han, Hee-Joon Bae Oral Sessions Seung-Hoon Lee2, Yong-Seok Lee1, Byung-Woo Yoon2 Department of Neurology, Stroke Center, Seoul National University Bundang Hospital, Seongnam, Korea 1Department of Neurology, Seoul National University Boramae Hospital, Seoul, 2Department of Neurology, Seoul National University Hospital, Seoul, and 3Healthcare Research Institute, Seoul National University Hospital Background(s): Most of our knowledge about the natural Healthcare System Gangnam Center, Seoul, Korea history of acute intracranial large artery occlusion (AILAO) came from old studies based on brain autopsy or clinical Background(s): A silent brain infarction (SBI) can pre- symptoms, which seems to be inadequate especially in terms dict clinical overt stroke or dementia. Studies focusing on an of timing of diagnosing cerebral occlusion after symptom onset. elderly population most common for SBI are sparse. Meta- Objective(s): To elucidate clinical profiles and outcomes bolic syndrome (MetS) is associated with an increased risk of AILAO. of the subsequent development of cardiovascular disease or Method(s): A consecutive series of patients hospitalized stroke. from 2004/1 to 2007/10 due to AILAO within 24 hours from Objective(s): We examined the associations between SBI onset were collected. AILAO was defined as intracranial ICA, and MetS in healthy elderly individuals. MCA, or BA occlusion confirmed by angiography with rele- Method(s): We studied 1,270 healthy consecutive sub- vant lesions on diffusion weighted image. Patients with con- jects who visited Seoul National University Hospital Health- current steno-occlusion of proximal ICA were excluded. care System Gangnam Center and who underwent MRI of Result(s): Among 1058 patients with acute ischemic st- the brain. Subjects’ ages ranged from 65 to 96 years and their roke or TIA, 189 (17.9%) had AILAO (male 53.4%, age 68.6 mean age was 70 years (732 men and 538 women). MetS ±13.0 years, median NIHSS=11). Locations of occlusion was defined using the criteria of the National Cholesterol consisted of MCA M1 in 99 (52.4%), MCA M2 in 50 Education Program Adult Treatment Panel III. We examined (26.5%), distal ICA in 20 (10.6%), and BA in 20 (10.6%). associations between full syndrome (at least 3 of the 5 con- Embolic source was detected in 103 (54.5%). Favorable out- ditions) as well as its components and SBI by controlling come (MRS 0-2 at 3 months) was observed in 78 (42.4%) possible confounders. of 184 in whom MRS at 3 months was available. Follow-up Result(s): One hundred forty-seven subjects (12%) were angiography was performed in 122 (64.6%) and recanaliz- found to have one or more SBI on MRI. Age was found to ation was observed in 88 (72.1%). Thrombolysis and pre- be significantly related to SBI prevalence (OR, 1.14; 95% sence of embolic source were strong predictors of early re- CI, 1.03-1.25). A history of coronary artery disease was canalization (p<0.001). In addition to recanalization status, associated with and elevated odds ratio of SBI (OR, 5.69; age, initial NIH stroke scale, heparin use, location of occlu- 95% CI, 1.96-16.6), and MetS was significantly associated sion, and history of stroke might be correlated with clinical with SBI (OR, 2.68; 95% CI, 1.14-6.26). The components outcome (p<0.1). model of MetS showed a strong significance between hyper- Conclusion(s): We reported the clinical profiles and out- triglyceridemia (OR, 5.48; 95% CI, 2.00-15.00) and SBI. comes in patients with acute intracranial large artery occlu- Conclusion(s): MetS was found to be significantly associ- sion presented within 24 hours from symptom onset. Benefit ated with SBI. This finding has clinical utility in terms of of active intervention was suggested. identifying healthy elderly people at increased risk of developing SBI.

Presenting authors are indicated in bold. S45

3rd International Conference on Intracranial Atherosclerosis and Annual Spring Meeting of the Korean Stroke Society ORAL SESSIONS

O28 O29 Long-term Prognosis of Middle Cerebral Artery Platelet Aggregation Might be an Important Stenosis under Medical Treatment Factor for the Progression on Symptomatic Byung-Chul Lee, Mi Sun Oh, Kyung-Ho Yu, Soo-Jin Jo, Middle Cerebral Artery Stenosis? Ju Hun Lee, San Jung, Jun-Hyun Shin Jae-Kwan Cha1, Hyung-Won Jeon1, Hyun-Sook Kim1, Department of Neurology, Hallym Univeristy College of Medicine, Myung-Jin Kang2, Yu-Sil Lee1 Anyang, Korea 1Departments of Neurology and 2Radiology, Dong-A University, Busan, Korea Background(s): In Asian, intracranial artery disease is more common than extracranial artery disease. However, only Background(s): Symptomatic intracranial stenosis is an limited data are available on the long term prognosis and risk important cause for ischemic stroke, especially in Asian. How- for stroke recurrence of patients with intracranial artery dis- ever, there was no any data about the relationship between ease, yet. its progressions and the extent of platelet aggregation. Objective(s): The aims of this study were to determine Objective(s): In this study, we investigated the relation- long-term stroke recurrence rate and mortality and to investi- ship between the progression of symptomatic MCA stenosis gate predictor of stroke recurrence in patients with MCA on MRA and extent of platelet aggregation by using optical stenosis. platelet aggregpmeter. Method(s): Out of 2,254 ischemic stroke or transient Method(s): We recruited forty-three patients (M : F=29 : ischemic attack (TIA) patients admitted to Hallym Stroke 14, mean age 60.9±10.1 years) with stenosis of middle Center within 7 days after onset between March 1999 and cerebral artery (M1 portion) having previous history of December 2007, we identified 218 patients (mean age, 64.4 ischemic stroke on its territory. All patients were taken the ±12.3 years, male, 53.9%) with MCA stenosis (more than follow-up MRA and we analyzed the changes of stenosis 50% based on MRA). Among them, we excluded patients degree on MCA. Also, we evaluated the extent of platelet with other potential causes of stroke, such as cardiac embolic aggregation by using platelet aggregometer for arachidonic source. We reviewed the medical records (119) and per- acid or adenosine diphosphate (ADP). formed the telephone interview (99) if not being followed in Result(s): Of the total 43 patients with symptomatic MCA our hospital. We defined “symptomatic” (171) as an index stenosis, 16 patients (37.2%) showed worsening, while 19 stroke occurred in the vascular territory of the identified MCA (44.2%) were showed stationary and 8 (18.6%) improved disease and “asymptomatic”(47) when the patient has MCA the degree of stenosis of MCA on MRA for the observation stenosis but index stroke occurred in other vascular territory. periods (mean 14.3±7.6 months). Compared to the statio- Result(s): With a median follow-up of 33 months, the nary or improved group, the extent of ADP induced platelet composite outcome event were 52 (recurrent stroke in 34 aggregation (56.6±18.0% vs. 38.9±23.3%, p=0.012) was and death in 18). The cumulative rate of stroke recurrence significantly higher in the aggravated group. during 1 and 5 years were 9.2% and 21%. The cumulative Conclusion(s): In this study, the symptomatic MCA ste- rate of mortality during 1 and 5 years were 4.1% and 11.1% nosis is a dynamic process showing aggravated or improved (Kaplan-Meier survival analysis). Univariate analysis showed course. During this processes, the extent of ADP-induced that symptomatic MCA stenosis were significantly related to platelet aggregation might be involved. Further studies will stroke recurrence compared to asymptomatic MCA stenosis be needed to clarify this notion. (long rank, 4.60; p=0.03). After adjustment for age, sex, hypertension, diabetes, hyperlipidemia, and smoking, symptomatic MCA stenosis were remained an independent predictor for recurrent stroke in Cox proportional-hazard regression model (Hazard ratio, 4.23, 95% CI, 1.01 to 17.9, p=0.049). Conclusion(s): In this study, long term prognosis of MCA stenosis was similar to the previous studies in other country. Patients with MCA stenosis, especially symptomatic stenosis, are at higher risk of recurrence.

S46 Presenting authors are indicated in bold. Korean J Stroke(Supplement 1) 2008;10

3rd International Conference on Intracranial Atherosclerosis and Annual Spring Meeting of the Korean Stroke Society ORAL SESSIONS

O30

Intracranial Angioplasty for Symptomatic Middle

Cerebral Artery Stenosis: Long-Term Follow-Up

Joon-Tae Kim1, Seong-Min Choi1, Seung-Han Lee1,

Man-Seok Park1, Woong Yoon2, Byeong-Chae Kim1, Myeong-Kyu Kim1, Jae-Kyu Kim2, Ki-Hyun Cho1 Departments of 1Neurology and 2Radiology, Chonnam National University Hospital, Gwangju, Korea

Oral Sessions Background(s): Patients with symptomatic middle cerebral artery (MCA) stenosis are a high recurrence rate of ischemic events. Endovascular therapy for patients with symptomatic MCA stenosis is becoming more widespread. Recently, primary intracranial stent placement has been suggested as an alternative to medical therapy. However, the complication rate of stent assisted angioplasty is higher than the known annual risk of stroke. Objective(s): This study was undertaken to evaluate the long-term outcome of angioplasty alone in the treatment of symptomatic MCA stenoses. Method(s): We retrospectively evaluated 40 consecutive patients with symptomatic MCA stenosis (greater than 60%) who underwent primary balloon angioplasty at our institution between 1994 and 2005. All patients had symptomatic despite proper medical therapy. We reviewed patients’ records for angiographic findings, periprocedural complications, and follow-up outcomes. We assessed the angiographic findings, the incidence of ischemic stroke in the territory of treatment as well as the incidence of all strokes and death. Result(s): Angioplasty successfully dilated the stenotic arteries in 38 of 40 patients. The rate of periprocedural complications was 25% (10 of 40 patients), but the rate of symptomatic complications was 10%. Continuous follow-up were successfully performed in 30 of 40 patients. During follow- up period, which ranged from 40 to 114 month (median, 56 months), ischemic stroke occurred in three patients and restenosis (greater than 60%) developed in 2 patients. The remaining patients did not develop further ischemic events. Conclusion(s): MCA angioplasty seems to be a safe and effective procedure for the prevention of secondary ischemic stroke.

Presenting authors are indicated in bold. S47 Poster Sessions

3rd International Conference on Intracranial Atherosclerosis and Annual Spring Meeting of the Korean Stroke Society POSTER SESSIONS

Epidemiology & Risk Factor Epidemiology & Risk Factor June 19, 17:25-19:00

P001 P002 PON Gene Polymorphism and Atherosclerosis Race-Ethnic Differences in Impact of Metabolic of Internal Carotid Artery Syndrome on Distribution of Cervicocephalic Byoung-Soo Shin1,2, Jin Kim3, Youn-Sil Kim2, Kee-Won Kim4 Atherosclerosis 1Department of Neurology, Chonbuk National University Hospital Oh Young Bang1, Jeffrey L Saver2, David S Liebeskind2, and Medical School, Bruce Ovbiagele2 2 Chonbuk National University Hospital Research Institute 1 of Clinical Medicine, Departments of Neurology, Samsung Medical Center, 3 Sungkyunkwan University, Seoul, Korea, and Department of Neurology, Chonbuk National University 2 Graduate School, and UCLA Medical Center, Los Angeles, CA, USA 4Department of Pharmacology, Chonbuk National University Medical School, Jeonju, Korea Background(s): Vascular localization of symptomatic large

artery atherosclerotic (LAA) stroke differs for unknown rea- Background(s): Atherosclerotic lesions in the extracranial

sons by race-ethnicity. The metabolic syndrome (MetSD) is Poster Sessions internal carotid artery and intracranial carotid arteries ac- associated with higher atherosclerotic stroke risk and com- count for a substantial proportion of the cerebrovascular prises abnormal risk factors that can vary by race. events. The paraoxonase (PON) gene can reduce the risk of Objective(s): Thus, we investigated whether MetSD may developing atherosclerosis. contribute to race-ethnic differences in LAA stroke by exam- Objective(s): The purpose of this study was to determine ining the association of MetSD with symptomatic intra- and correlation of the carotid artery stenosis and PON gene poly- extracranial atherosclerosis among a diverse race-ethnic group. morphism. And we also evaluate the association between Method(s): We analyzed data prospectively collected over carotid artery stenosis and presence of cerebrovascular risk a 4-year period on subjects with ischemic stroke or TIA. In- factors. dependent vascular risk factor associations with intracranial Method(s): This study included 656 individuals (male and extracranial LAA vs. non-LAA mechanism were eval- 355, female 301) were genotyped the PON1M55L, PON1 uated in two groups stratified by self-reported race-ethnicity. Q192R, PON2A148G and PON2S311C polymorphisms us- Result(s): 1,167 patients met study criteria. Intracranial ing melting point analysis with LightCycler real-time poly- LAA was more prevalent in Hispanics and non-whites vs. merase chain reaction (PCR) technology. Atherosclerotic le- non-Hispanic whites (20.4% vs. 9.6%, p<0.001), while ex- sion of Internal carotid artery was assessed by means of MRA tracranial LAA had a more frequent point value in non-His- and classified extracranial internal carotid arterial athero- panic whites compared to Hispanics and non-whites (10.7% sclerosis and/or intracranial carotid arterial atherosclerosis vs. 7.5%, p=0.267). No significant differences were observed and normal. in the prevalence of MetSD between intra vs. extracranial Result(s): There are no significant difference in PON LAA or whites vs. non-whites. After adjusting for covariates, gene polymorphism and allele frequencies between two MetSD was associated with intracranial LAA in Hispanics groups (p>0.05). In simple regression analysis atheroscle- and non-whites (OR, 1.80; 95% CI, 0.97-3.32), and was as- rosis of internal carotid artery was associated with age (p= sociated with extracranial LAA in non-Hispanic whites (OR, 0.000), HDL (p=0.013), Apoa1 (p=0.034), Apob (p= 1.98; 95% CI, 1.13-3.45). Among MetSD components, in- 0.005), HbA1c (p=0.012) Homocystein (p=0.026), hy- creasing degree of obesity independently predicted extra- pertension (p=0.000) Diabetes (p=0.02). In multiple re- cranial LAA, whereas a high triglyceride level predicted in- gression analysis carotid stenosis s associated with age (p= tracranial LAA (p<0.05). 0.000), diabetes (p=0.002) Apob (p=0.005) and HDL (p= Conclusion(s): The MetSD promotes distinct sites of symp- 0.010). tomatic cervicocephalic atherosclerosis by race-ethnicity. Conclusion(s): This study did not provide association This finding may in part explain the well-known differences between PON gene polymorphism and carotid stenosis but in race-ethnic predilection to intracranial or extracranial ath- we confirmed atherosclerotic lesion of carotid arteres has erosclerosis. correlation with age, diabetes, Apob, and HDL.

Presenting authors are indicated in bold. S55

3rd International Conference on Intracranial Atherosclerosis and Annual Spring Meeting of the Korean Stroke Society POSTER SESSIONS

P003 P004 A Case-Control Study of Sasang Constitution and Stroke Risk Prediction by Blood Endothelial the Risk of Stroke Microparticles Chang-ho Han1, Daeryoung Kang2, Heechoul Ohrr3 Keun-Hwa Jung1, Kon Chu1, Soon-Tae Lee1, 1 1 1 1Department of Internal Medicine (KM), Dongngguk University Hee-Kwon Park , Dong-Hyun Kim , Jae-Jun Bahn , International Hospital, Goyang, Jin-Hee Kim1, Eun-Cheol Song2, Manho Kim1, Sang Kun Lee1, 2Department of Epidemiology & Biostatistics, Graduate School of Jae-Kyu Roh1 Public Health, Yonsei University, Seoul, and 1Departments of Neurology, Seoul National University Hospital, Seoul, and 3Department of Preventive Medicine, College of Medicine, 2Inha University Hospital, Incheon, Korea Yonsei University, Seoul, Korea

Background(s): Aging population is a global trend, and Background(s): The levels of circulating endothelial mi- increasing cases of stroke is becoming an important public croparticles (EMPs) have been reported to represent a vas- health issue. Sasang constitution was first originated from the cular damage. Detailed profiling of these blood endothelial literature written by Jema Lee (1837-1900) and according to markers may provide insights for stroke pathogenesis and Korean medicine and Sasang constitutional medicine sought risk prediction. for the cause of stroke from the imbalance of constitution. Objective(s): In this study, we undertook to characterize Objective(s): The objectives of this case-control study were the EMP levels in the stroke patients. to investigate whether the relative risk of stroke is different Method(s): We enrolled the 71 acute stroke patients and depending on Sasang constitution, to grasp interaction effects 261 patients with only vascular risk factors (RF controls). between Sasang constitution and other risk factors, and to MP-rich plasma was prepared from citrated venous blood build the best decision model which can detect risky group samples using serial ultracentrifugation, and was used for of stroke at early stage. counting EMPs (≤1 μm) using flow cytometry. This meth- Method(s): From October 2005 through March 2007, 331 od allowed the fractionation of apoptotic EMPs (CD31+ case subjects from 3 university hospitals were met the inclu- /CD42-, CD31+/Annexin V+) and activated EMPs (CD sion criteria. And the same of healthy control group extracted 62E+). Clinical, laboratory, and radiological factors asso- by a simple random selection using PROC SURVEYSELECT ciated with EMP levels were assessed. with consideration of age and gender. Moreover, the interac- Result(s): The EMP levels were significantly elevated in tion effects between Sasang constitution and stroke risk acute stroke patients, compared to RF controls. In total study factor was accomplished by logistic regression analysis. And population, multivariate analysis identified the presence of using the CART algorithm, the best decision tree model of acute event as a significant independent predictor of a high stroke events was established. CD62E+ EMP number. In the acute stroke group, higher Result(s): In a condition that age and gender were con- NIHSS scores were associated with higher CD62E+ EMP trolled by logistic regression, the relative risk of stroke attack numbers. In the RF group, the increases of CD31+Annexin by Sasang constitution classification was obtained; Soyangin’s V+ EMPs and CD62E+ EMP were associated with the pre- risk ratio was 1.75 times higher than Taeumin’s, and it was sence of intracranial stenosis and extracranial stenosis, res- statistically significant (OR=1.75, 95% CI 1.23-2.49). Ac- pectively. In addition, the levels of CD31+CD42- EMPs cording to decision tree analysis of CART algolithm, the most and CD62E+ EMPs were positively correlated with intra- overriding variable was the presence of risk factor of cardio- cranial (r=0.133, p=0.032) and extracranial stenosis se- vascular disease. And, among the groups without past history, verity, respectively. The model with CD62E+ EMP and CD they were divided the most if they were Soyangin or not. The 62E+ to CD31+AV+ EMP ratio could predict the extracra- misclassification rate of CART algolithm was 0.274 though. nial stenosis with high sensitivity and specificity. Conclusion(s): This study suggests that the risk of stroke Conclusion(s): EMP levels may be a new marker for vas- is different significantly according to Sasang constitution. cular pathology with increased risk of ischemic stroke. And the risk of stroke increases with the interaction effects between the Sasang constitution and the other risk factors. Moreover this study supports that it is possible to make an accurate estimate model of a stroke attack with Sasang constitution in the near future.

S56 Presenting authors are indicated in bold. Korean J Stroke(Supplement 1) 2008;10

3rd International Conference on Intracranial Atherosclerosis and Annual Spring Meeting of the Korean Stroke Society POSTER SESSIONS

P005 P006 The Association of Intracranial Large Artery The Ankle Brachial Index and Atherosclerosis Disease and Metabolic Syndrome Burden in Patients with First-ever is Ethnicity-Dependent Recent Ischemic Stroke Deidre De Silva1, Fung-Peng Woon2, Hui-Yi Gan3, Ji-Hee Lee, Dae-Hyun Kim, Eung-Seok Oh, Jun-Young Lee, Christopher Chen1, Hui-Meng Chang1, Meng-Cheong Wong4 Young-Hoon Lee, Jei Kim 1Department of Neurology, Singapore General Hospital Campus, Department of Neurology, Chungnam National University Hospital, National Neuroscience Institute, Daejeon, Korea 2Department of Research, National Heart Centre, 3Neurovascular Laboratory, Singapore General Hospital, and 4National Medical Research Council, Singapore Background(s): Cerebral infarction, coronary artery disease and peripheral artery disease (PAD) are the main clin- Background(s): Metabolic syndrome, a known risk factor ical manifestation of atherosclerosis. PAD is associated with of ischemic stroke, has been shown to be associated with in- an excessive risk for cardiovascular events and mortality. tracranial large artery disease (ICLAD) among ethnic Kore- However, the prevalence and risk factors of PAD in cerebral ans. Serum triglyceride/ high density lipoprotein (TG/HDL) infarction patients have not been rarely studied. ratio has been proposed as a surrogate for metabolic syn- Objective(s): The objective of this study was to inves- Poster Sessions drome.

tigate the prevalence of the subclinical or clinical PAD, and Objective(s): We aimed to investigate if ICLAD was as- other locations of atherosclerotic lesion in first-ever ischemic sociated with metabolic syndrome and serum TG/HDL ratio stroke patients. among ethnic Chinese and ethnic South Asian ischemic stroke Method(s): Ankle brachial index (ABI) was measured in patients. 324 consecutive patients (55% men; mean age 66.6 years) Method(s): We prospectively recruited ethnic Chinese who had suffered first-ever recent cerebral infarction. Pa- and ethnic South Asian ischemic stroke patients admitted to tients with ABI <0.9 were considered positive for PAD. Cor- a tertiary public hospital in Singapore. Metabolic syndrome onary artery disease was defined as a history of acute coro- was defined by standard criteria, using the Asian Pacific mod- nary syndrome or angina, or the confirmation by EKG or ification. ICLAD was diagnosed on transcranial color-coded echocardiography. Doppler or magnetic resonance angiography. Result(s): The prevalence for any atherosclerotic loca- Result(s): Among the 135 eligible ethnic Chinese patients, tions was 25.3% for any location, 16.4% for coronary artery ICLAD was present among 57%, was associated with met- disease, and 11.4% for PAD. With regard to vascular risk abolic syndrome (p=0.003) and was more likely with in- factors, PAD was associated with older age (p<0.001), high creased number of metabolic syndrome components (p= fibrinogen (p<0.001), high Lp(a) (p=0.017), carotid artery 0.021). Serum TG/HDL ratio was associated with ICLAD stenosis (p=0.004), and diabetes mellitus (p=0.03). In the (p=0.048) but was not independent of metabolic syndrome logistic regression analysis, independent indicators of PAD in multivariate analysis (p=0.817). Among the 182 eligible risk were older age, high fibrinogen and carotid artery ste- ethnic South Asian patients, ICLAD was present among 48% nosis. but was not associated with metabolic syndrome (p=0.105). Conclusion(s): Twenty-five percent of the patients with Conclusion(s): Metabolic syndrome was associated with first-ever ischemic stroke had other locations of athero- ICLAD among ethnic Chinese, but not among ethnic South sclerotic lesion and the prevalence of PAD was 11.4%. Our Asians. Hence, we conclude that the metabolic-ICLAD as- results report that the prevalence of PAD in patients with sociation may be ethnicity-dependent. The association of first-ever cerebral infarction was quite different from that in serum TG/HDL with ICLAD found among ethnic Chinese westerners and that PAD was related with older age, carotid was not independent of metabolic syndrome. artery stenosis, and high fibrinogen.

Presenting authors are indicated in bold. S57

3rd International Conference on Intracranial Atherosclerosis and Annual Spring Meeting of the Korean Stroke Society POSTER SESSIONS

P007 P008 Vascular Risk Factors and Prevalence of Cerebral Distribution and Risk Factors of Extracranial Artery Calcification in Patients with Acute or Intracranial Artery Stenosis in Ischemic Stroke Ischemic Stroke Patients: Results from Taiwan Stroke Registry Kwang-Yeol Park1, Young Chul Youn1, Ju-Hong Min1, Jiann-Shing Jeng1,3, Li-Ming Lien2, Lung Chan3, Sam-Yeol Ha1, Oh-Sang Kwon1, Pil-Wook Chung2, Shin-Joe Yeh1, Hou-Chang Chiu2, Sien-Tsong Chen4, Yong-Bum Kim2, Heui-Soo Moon2, Bum Chun Suh2 Hong-Yi Chiou5, Chung-Y Hsu6 1Departments of Neurology, Chung-Ang University Hospital, 1Stroke Center and Department of Neurology, National Taiwan Chung-Ang University School of Medicine, and University Hospital, Taipei, 2Kangbuk Samsung Hospital, Sungkyunkwan University 2Department of Neurology, Shin Kong WHS Memorial Hospital, Taipei, School of Medicine, Seoul, Korea 3Section of Neurology, Department of Internal Medicine, Far Eastern Memorial Hospital, Taipei, 4Department of Neurology, Chang Gung Memorial Hospital, Lin-Kou, Background(s): Vascular calcification is known to be as- 5Department of Public Health, Taipei Medical University, Taipei, and 6Department of Medicine, Taipei Medical University, Taipei, Taiwan sociated with cardiovascular mortality.

Objective(s): Our aim was to investigate distribution pat- Background(s): Asians have higher frequency of intra- tern and risk factors of cerebral artery calcification in pa- cranial stenosis than extracranial cervical stenosis in patients tients with acute ischemic stroke. with ischemic stroke. Method(s): We identified 159 consecutive patients with Objective(s): To investigate the distribution and risk fac- acute ischemic stroke who underwent 16-slice CT angiog- tors of extracranial and intracranial stenosis in patients with raphy within seven days of symptom onset. We retrospec- acute ischemic stroke. tively reviewed stroke database to assess the risk factors and Method(s): Patients were recruited from Taiwan Stroke demographics. Calcifications of the intracranial and extra- Registry, a multi-center prospective stroke registry since May, cranial arteries above the carotid bifurcation level were scored 2006 in Taiwan. Patients were included if qualified criteria: (0: no calcification; 1: tiny; 2: mild; 3: moderate; 4: severe). acute ischemic stroke or TIA receiving both extracranial and Result(s): The ages of the stroke patients ranged from 29 intracranial vascular studies, and a follow-up of at least 3 to 90 years (66±12 years). Cerebral artery calcification months. Patients were categorized into 4 groups: I) both ex- was found in 137 patients (86.2%). Intracranial internal ca- tracranial internal carotid artery (ICA) and intracranial mid- rotid artery (ICA) was the most frequently affected arteries dle cerebral artery (MCA) stenosis >50%; II) only ICA ste- (77%), followed by extracranial ICA (43%), intracranial nosis >50%; III) only MCA stenosis >50%; and IV) both vertebral artery (VA, 17%), extracranial VA (4%), and an- ICA and MCA stenosis <50%. ICA or MCA stenosis was terior cerebral artery (1%). Moderate-to-severe calcifica- diagnosed by ultrasonography or angiography. Risk factors, tions (score 3 and 4) were distributed in intracranial ICA topography of cerebral infarct, and outcome were compared (38%), extracranial ICA (12%), and intracranial VA (5%). among 4 groups. An older age, diabetes mellitus, and hypertension were sig- Result(s): There were 6,441 patients (male, 65.7%; mean nificantly associated with artery calcification on univariate age, 67.0+12.9 years), including 5.6% in group I, 5.4% in analysis (p<0.05). Independent risk factors for cerebral ar- group II, 24.2% in group III, and 64.8% in group IV. There tery calcification on multiple logistic regression were older were 11.0% with extracranial ICA stenosis and 29.8% with age (odds ratio, OR=1.17; 95% confidence interval, CI= intracranial MCA stenosis. Patients with ICA stenosis were [1.08-1.26]) and hypertension (OR=6.28; 95% CI=[1.53 older and had more heart disease. Patients with MCA ste- -25.7]). nosis had more diabetes mellitus. Case-fatality 3 months Conclusion(s): Cerebral artery calcifications are common after stroke onset was 4.1% in all patients, and highest in in patients with ischemic stroke and intracranial ICA is the group 1 (7.5%). most frequently and severely affected artery. An older age Conclusion(s): Intracranial MCA stenosis was three times and hypertension are the independent risk factors for cere- higher than extracranial ICA stenosis in Chinese ischemic bral artery calcification. stroke patients. Patients with both ICA and MCA stenosis

had more severe neurological presentation and higher case-

fatality.

S58 Presenting authors are indicated in bold. Korean J Stroke(Supplement 1) 2008;10

3rd International Conference on Intracranial Atherosclerosis and Annual Spring Meeting of the Korean Stroke Society POSTER SESSIONS

P009 P010 Classic Risk Factors for Stroke Are Not Major Is Metabolic Syndrome Associated with Stroke Determinants for Location of Cerebral in Normotensive and Prehypertensive Atherosclerosis Individuals? Young Dae Kim, Hye Yeon Choi, Yo Han Jung, Yong Jae Kim Hyo Suk Nam, Ji Hoe Heo Department of Neurology, Ewha Womans University Mokdong Hospital, Department of Neurology, Yonsei University College of Medicine, Seoul, Korea Seoul, Korea Background(s): Patients with Metabolic Syndrome (MS) Background(s): Intracranial artery (IC) atherosclerosis are at increased risk for cardiovascular disease and stroke. has been often suggested to have different risk factor profiles On the other hand, clinicians may have to evaluate and treat from extracranial artery (EC) atherosclerosis. all of the atherogenic risk factors regardless of whether a Objective(s): We determined whether there are differ- patient meets the diagnosis criteria for MS. It has been ac- ences in stroke risk factors between IC and EC atheroscle- knowledged that hypertension is the most common com- rosis in stroke patients with the same ethnicity. ponent of MS and the greatest contributor to ischemic stroke. Method(s): Data were obtained from the Yonsei Stroke It should be tested whether the concept of MS can be used to Poster Sessions

Registry between January 1999 and June 2007. Among 3,057 identify individuals at higher risk for stroke when the extent consecutive Korean patients who had angiographic studies of their hemodynamic and metabolic abnormalities is only performed, patients with cardiac sources of embolism and mild, if present at all. those with other causes of stroke were excluded. Then, pa- Objective(s): We investigated whether MS is associated tients with atherosclerosis both in the IC and EC arteries with stroke in normotensive or prehypertensive individuals. (856 patients) were excluded. Finally, we could identify Method(s): We analyzed the data from 2005 Korea NHA- 1,313 patients who had no lesion (n=488), isolated IC ath- NES. We analyzed data from individuals aged >30 years who erosclerosis (I-IC) (n=566) or isolated EC atherosclerosis had a blood pressure of less than 140/90 mmHg and were (I-EC) (n=256). We have investigated the association be- not taking antihypertensive medications. MS was defined tween the location of atherosclerosis and vascular risk factors. according to modified NCEP-ATP III criteria Result(s): When compared with patients with normal an- Result(s): After adjustment for gender and age, the as- giographic findings, those with I-IC were associated with sociation between MS and stroke did not reach stastistical older age and hypertension, and those with I-EC were as- significance in normotensive or prehypertensive individuals. sociated with older age, initial blood sugar levels, and LDL. Conclusion(s): Thus, presence of MS may not increase In direct comparison between I-IC and I-EC, classic risk the prevalence of stroke in Korean individuals without hy- factors (hypertension, diabetes, hypercholesterolemia, smok- pertension. ing, previous stroke, and coronary artery disease) and laboratory tests (blood pressures, blood sugar, triglyceride, C- reactive protein, white blood cell counts, and erythrocyte sediment rate) were not different between them. On multivariate analysis, only significant variables were male and total cholesterol levels, which were higher in I-EC. Conclusion(s): Classic risk factors for stroke may not be major determinants for location of cerebral artery atherosclerosis.

Presenting authors are indicated in bold. S59

3rd International Conference on Intracranial Atherosclerosis and Annual Spring Meeting of the Korean Stroke Society POSTER SESSIONS

P011 P012 Prevalence of Intracranial Stenosis among Adult Polymorphism of Vascular Endothelial Growth Filipino Patients: a Five Year Review Factor (VEGF) Gene as an Independent Risk Carter Rabo, Jose C Navarro, Johnny K Lokin, Factor for Patients with Silent Brain Infarction Alejandro Baroque Jae ho Lee1, Jeong Kwon Choi1, Seung Ho Hong3, Department of Neurology and Psychiatry, UST Hospital, Ok Joon Kim2, Su Jin Bae1, Doyeun Oh1, Nam Keun Kim1 Manila, Philippines 1Institute for Clinical Research, 2Department of Neurology, College of Medicine, Pochon CHA University, Seongnam, and 3Department of Science Education, Cheju National University Background(s): Intracranial stenosis is one of the risk of Education, Jeju, Korea factors for stroke. Transcranial Doppler is said to be a suitable tool for screening intracranial stenosis. This study aims Background(s): Vascular endothelial growth factor (VE- to determine the prevalence of intracranial stenosis among GF) is a candidate in atherosclerosis-related diseases, such patients who underwent transcranial doppler ultrasonography. as cerebrovascular or cardiovascular diseases, as well as in Objective(s): Transcranial doppler studies done from June various cancers. However, the role of VEGF polymorphisms 2002-May 2007 a tertiary hospital were reviewed. Diag- in silent brain infarction (SBI) susceptibility has not been nosis of intracranial stenosis was based on the results of the reported. mean flow velocities obtained. Objective(s): Thus, this study was performed to analyze Method(s): This study aims to determine the prevalence associations between the VEGF -2578C>A, -634G>C, and of intracranial stenosis among patients who underwent trans- 936C>T polymorphisms and SBI. cranial doppler ultrasonography. Method(s): Using polymerase chain reaction (PCR)-am- Result(s): Intracranial stenosis were found in 298 out of plified DNAs, the VEGF -2578C>A, -634G>C, and 936C the 795 patients who underwent transcranial doppler. 62% of >T polymorphisms were analyzed in 264 patients with SBI them were male with the area of the middle cerebral artery and in 224 control subjects. The VEGF -2578C>A poly- being the most common site of stenosis. morphism was detected by direct electrophoresis of PCR Conclusion(s): Thirty-seven percent of the patients had fragments on agarose gels. The VEGF -634G>C and 936C intracranial stenosis and 59% of them are in the distribution >T polymorphisms were analyzed by PCR-RFLP. of the middle cerebral artery. Result(s): Although the VEGF -2578C>A, -634G>C, and 936C>T polymorphisms did not influence SBI susceptibility significantly, when the data were stratified by age, the VEGF 936CT and overall 936 (CT+TT) genotypes were associated with higher risk in SBI subjects younger than 55 years old. The VEGF -2578CA and overall –2578 (CA+ AA) genotypes were also marginally associated with higher risk in SBI subjects younger than 55 years old. Conclusion(s): In subjects younger than 55 years old, some genotypes of the VEGF 936C>T and -2578C>A polymorphisms showed a significant difference between the case and control groups. This is the first report on the significant association of VEGF polymorphisms in SBI subjects. To confirm the effects of the VEGF polymorphisms on SBI, further functional and population studies are required.

S60 Presenting authors are indicated in bold. Korean J Stroke(Supplement 1) 2008;10

3rd International Conference on Intracranial Atherosclerosis and Annual Spring Meeting of the Korean Stroke Society POSTER SESSIONS

Prognosis & Prevention Prognosis & Prevention

P013 P014 State of Current Lipid and Hypertension Effects of a Lifestyle Promotion Program Treatment of Stroke Patients in Korea: for Stroke Prevention Tailored to the Stage the STROKE Study of Physical Activity and Diet Modification Kwang Ho Lee1, Jong S Kim2, Yong Jae Kim3, among Adults 4 5 6 7 Eung Gyu Kim , Je Kim , Yong-Seok Lee , Hee-Joon Bae , Hee-Young Song Seung-Han Suk8, Jun Lee9, Ki Hyun Cho10, Jae-Kwan Cha11, Jaseong Koo12, Juneyong Lee13 Department of Nursing, Yonsei University Wonju College of Medicine, Wonju, Korea 1Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, 2Asan Medical Center, Seoul, Background(s): Reduction in the risk of stroke depends 3Ewha Womans University Mokdong Hospital, Seoul, 4Inje University Pusan Paik Hospital, Busan, on changing modifiable unhealthy lifestyles such as lack of 5Chungnam National University Hospital, Daejeon, 6 physical activity and high fat diet in the general population,

Seoul National University Boramae Hospital, Seoul, Poster Sessions 7Seoul National University Bundang Hospital, Seongnam, which will contribute to the prevention of stroke. Lifestyle

8 Wonkwang University College of Medicine, Gunpo, change is a complex, dynamic and sequential process that is 9Yeungnam University Hospital, Daegu, 10Chonnam National University Hospital, Gwangju, to be initiated and maintained by individuals’ readiness for 11 Dong-A University Medical Center, Busan, 12Eulji University Eulji General Hospital, Seoul, and change. Therefore, interventions to promote lifestyle changes 13Department of Biostatistics, Korea University College of Medicine, for stroke prevention should be designed and tailored accord- Seoul, Korea ing to the stage of physical activity and diet modification in

Background(s) and Objective(s): We tried to investigate adults. the prevalence of hypertension and dyslipidemia and the pro- Objective(s): This study assessed the effectiveness of a portion to reach BP/lipid goals in Korean stroke patients. brief, tailored lifestyle promotion program for adults residing Method(s): This is a nationwide, multi-center, retrospec- in urban areas, in particular to help participants to increase tive observational study, planning to recruit patients from lifestyle physical activity levels and to encourage reducing 12 hospitals scattered over the nation. Eligibility criteria were amount of fat intake. as follows; 1) hospitalized within 7 days from the onset of acute cerebral infarction or transient cerebral ischemia, 2) av- Method(s): A randomized controlled design was used. ailable medical records, 3) discharged within 3 months, and Twenty participants in each of two groups completed as- 4) followed up at out-patient-clinic after 3 months but not sessments at two time points-baseline and post intervention. later than 9 months. Participants were allocated for either an experiment group Result(s): During 2005, 5,523 patients were hospitalized, receiving the lifestyle promotion program or for a control 1,808 were randomly selected, and 1,050 met all the criteria. group receiving a usual stroke education. Among 1,672 who met the eligibility criteria 1) & 2), 61.8% had a history of hypertension, 38.2% took antihypertensive Result(s): After the intervention, increases in progression during hospitalization, and 47.7% had BP>140/90 mmHg at of reducing fat intake, self-efficacy for low fat diet, knowl- discharge. If we define hypertension as having any of these, edge on stroke and perceived benefit of low fat diet in the 81.5% were hypertensive. For dyslipidemia, only 5.4% had a experimental group were significantly greater than in control history, 34.4% took medications during hospitalization, and group. 28.5% had LDL cholesterol 130 mg/dL or more. If we define Conclusion(s): Results provide evidence of the effec- dyslipidemia as a history or high LDL cholesterol, 32.7% were dyslipidemic. Among 1,050 who met all the criteria, tiveness of a lifestyle promotion program in helping partic- 17.3% had no BP data, and 75.5% had no lipid measurement ipants to reduce the risk of stroke by modifing lifestyle and after discharge. During follow-up period, BP was controlled enhance the readiness for change. Suggestions in relation to in 52.6% of hypertensives, and LDL cholesterol was con- the rest of results will be discussed. trolled in 24.5% of dyslipidemics. : Conclusion(s) This study showed that in Korean stroke patients, the prevalence of hypertension and dyslipidemia are relatively high, and about a half of hypertensives and one fourth of dyslipidemics are under-treated.

Presenting authors are indicated in bold. S61

3rd International Conference on Intracranial Atherosclerosis and Annual Spring Meeting of the Korean Stroke Society POSTER SESSIONS

P015 P016 The Leukoaraiosis Is More Prevalent in the Large Combinatorial Effects of Endothelial Nitric Oxide Artery Disease Subtype among Korean Patients Synthase (eNOS) Gene Polymorphisms in Silent with Ischemic Stroke Brain Infarction Seung-Jae Lee1, A-Hyun Cho1, Kwang-Soo Lee1, Jae Ho Lee1, Jeong Kwon Choi1, Ok Joon Kim2, Su Jin Bae1, Yeong-In Kim1, Joong-Seok Kim1, Bum-Soo Kim2, Doyeun Oh1, Nam Keun Kim1 2 1 So-Ryoung Chung , Sang-Bong Lee 1Institute for Clinical Research and 2Department of Neurology, Departments of 1Neurology and 2Radiology, Bundang CHA General Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea Pochon CHA University, Seongnam, Korea

Background(s): Several studies have suggested that the Background(s): Silent brain infarction (SBI), a unique specific stroke subtype may influence the presence of leuko- form of cerebrovascular disorder, is frequently detected on araiosis in patients with ischemic stroke. magnetic resonance imaging (MRI) of apparently healthy Objective(s): We investigated the association between elderly persons, and it is known to increase the risk of de- stroke subtype and leukoaraiosis in Korean patients with is- veloping into stroke and other related diseases. Although chemic stroke by MRI. detailed mechanisms of pathogenesis have yet to be deter- Method(s): There were 594 patients included in this study mined, recent studies suggest that SBI can be significantly that were classified as large artery disease, lacune and cardio- influenced by genetic factors. embolic stroke. For large-artery disease, the analysis focused Objective(s): In this study, we investigated the role of on the intracranial or extracranial location of the stenosis, polymorphisms in endothelial nitric oxide synthase (eNOS) and the multiplicity of the stenotic lesions. Leukoaraiosis gene (i.e., -786T>C, 4a4b and 894G>T) as a risk factor for grading was performed according to the Atherosclerosis Risk SBI. in Communities Study. Method(s) and Result(s): The prevalence of SBI was Result(s): There was a significant association between shown to be significantly higher in patients with the eNOS leukoaraiosis and the stroke subtypes; the large-artery-dis- 894GT genotype (OR, 2.0; 95% CI, 1.30-3.08) and 894 ease group had higher prevalence of leukoaraiosis than did GT+TT genotype (OR, 2.05; 95% CI, 1.34-3.16), com- the other groups. In the subanalysis of the large-artery-dis- pared with the 894GG genotype. However, in the case of - ease group, the leukoaraiosis was more prevalent in the 786T>C and 4a4b polymorphisms, no significant difference mixed and intracranial stenosis group than did the extra- was observed between SBI patients and the normal subjects. cranial stenosis group. Strikingly, we found that the prevalence of SBI can increase Conclusion(s): The association of leukoaraiosis with as twice as high when either -786T>C or 4a4b polymor- large-artery disease in this study might be due to the rela- phism was combined with 894G>T polymorphism: -786 tively high prevalence of intracranial occlusive lesions in TC+CC/894GT+TT (OR, 3.83; 95% CI, 1.24-11.8) and Korean stroke patients compared to other ethnic groups. 4a4b+4a4a/894GT+TT (OR, 4.08; 95% CI, 1.34-12.4), respectively. Conclusion(s): According to the haplotype analysis, we found that three haplotypes (-786T-4b-894G, -786T-4b- 894T and -786C-4a-894T) were shown to be significantly different between SBI patients and the control subjects. Taken together, we found that three different polymorphic loci in the eNOS gene can play interactively, thereby leading to synergistic effects for the generation of SBI.

S62 Presenting authors are indicated in bold. Korean J Stroke(Supplement 1) 2008;10

3rd International Conference on Intracranial Atherosclerosis and Annual Spring Meeting of the Korean Stroke Society POSTER SESSIONS

P017 P018 Ischemic Stroke Caused by Internal Carotid The Pre-hospital Delay and Medical Knowledge Artery Atherosclerosis: of the Patient or Bystander about Acute Stroke Intracranial vs. Extracranial Seong Hwan Ahn, In Seong Choo, Hoo Won Kim, Sea Mi Park, Dong-Wha Kang, Sun U Kwon, Jong S Kim Jin Ho Kim Stroke Center and Department of Neurology, Asan Medical Center, Department of Neurology, Chosun University Hospital, Gwangju, Korea Seoul, Korea Background(s): Majority of stroke patients are still un- Background(s): In contrast to extracranial internal carotid able to receive thrombolysis because they do not reach within artery atherosclerotic disease (EC-ICAD), intracranial ath- 3 hours. erosclerotic disease (IC-ICAD) is considered an uncommon Objective(s): The aim of this study is to know which com- cause of stroke, and has rarely been appropriately inves- mon knowledge about stroke gave an effect on pre-hospital tigated. Moreover, because intracracranial atherosclerosis is delay. relatively frequent in Asians, the importance of IC-ICAD Method(s): From May 2007 to December 2007, consec- may be greater in Asians than in Caucasians. utive stroke patients and bystanders were interviewed pro-

Objective(s): The purpose of this study was to elucidate spectively with a neurology doctor at admission. Knowledge Poster Sessions the prevalence of IC-ICAD and to examine the difference of stroke related with hyper-acute stage (stroke warning sign, between IC-ICAD and EC-ICAD regarding risk factors, thrombolysis, and three hours limitation), educational back- DWI lesion pattern and clinical outcome. ground and first action at onset time were questioned. Also, Method(s): We retrospectively studied patients with is- we investigated interval from onset to hospital, demographic chemic stroke or TIA related with ICA atherosclerosis (> factors, previous stroke history, and neurological examina- 50%) by MR angiography. Risk factors, clinical outcome, tions. and DWI lesion pattern were compared between the two Result(s): One hundred fifty nine patients were included. groups. Thirty five patients (28.2%) were reached within 3 hours. In Result(s): Out of 215 patients, the IC-ICAD was about these group, patients of families who knew ‘3hours limita- one-fourth as common as EC- ICAD (49 vs. 166 patients). tion’ were more frequent (p=0.003). There is no significant The mean age of patients with IC-ICAD was lower (60.2+ difference between pre-hospital time and educational back- 12.8 vs. 67.8+10.3) and the prevalence of hypertension was grounds or to know ‘stroke warning sign’ or ‘thrombolytic lower (61.2% vs. 81.9%) than in those with EC-ICAD (p< therapy’. In the logistic regression analysis, younger age 0.001 and p=0.003, respectively). The patients with IC- (OR 0.95, 95% confidence interval [CI] 0.90-0.99, p= ICAD showed a high prevalence of single DWI lesion 0.014), use of emergency medical service (OR 5.70 CI pattern while EC-ICAD was more closely associated with 1.62-20.03, p=0.007), more severe neurological state (OR multiple lesion pattern (p=0.002). There were no differ- 1.27, CI 1.12-1.44, p<0.001) and to know ‘3 hours limita- ences in clinical outcome (3 month Responder analysis with tion’ (OR 9.75, CI 2.60-36.50, p=0.001) independently logistic regression; p=0.614). related with the arrival within 3 hours from onset. Conclusion(s): IC-ICAD is a relatively frequent cause of Conclusion(s): The knowledge of patient or bystander stroke in our population as compared to the western society. about stroke is an important factor related with prehospital Patients with IC-ICAD may be younger and have hyperten- interval. In the public educational information about stroke, sion less often than those with EC-ICAD. The difference in emphasis of ‘3 hours limitation’ and ‘Use of emergency med- DWI pattern might reflect different hemodynamic features ical service’ may give more chances of thrombolysis to stroke between the two groups. patients.

Presenting authors are indicated in bold. S63

3rd International Conference on Intracranial Atherosclerosis and Annual Spring Meeting of the Korean Stroke Society POSTER SESSIONS

P019 P020 Prevalence of Aspirin Resistance in Stroke Progression of the Intracranial Arterial Stenosis Patients in a Korean Population Samart Nidhinandana1, Siriprang Changchit2 Kyusik Kang1, Su-Ho Lee2, Seung-Hoon Lee2, 2 1Department of Neurology and Psychiatry, and Byung-Woo Yoon 2 Neurologic Division Department of Medicine, Phramongkutklao Hospital, 1Department of Neurology, Gyeongsang National University Hospital, Bangkok, Thailand Jinju, and 2 Department of Neurology and Clinical Research Center for Stroke, Seoul National University Hospital, Seoul, Korea Background(s): The aim of the present study was to study the prevalence of aspirin resistance in cerebrovascular disease Background(s): The natural history of intracranial artery patients in Phramongkutklao hospital. stenosis (ICAS) in a Korean population is unclear. Objective(s): To study the prevalence of aspirin resistance Objective(s): To compare the progression rate of ICAS in in cerebrovascular disease patients in Phramongkutklao hos- patients with stroke or transient ischemic attack (TIA) and pital. the rate in patients without these conditions. Method(s): The ischemic stroke survivors in neurologic Method(s): We retrospectively reviewed records to iden- department in Phramongkutklao hospital were enrolled, both tify patients who had ICAS and undergone baseline magnetic of acute stroke and stable stroke, who received aspirin at resonance angiography (MRA) during the period of January least 60 mg, at least 7 days and the last dose of aspirin at 2002 to May 2003. We enrolled the patients who: (1) under- least 24 hours before blood test for platelet aggregation. went the baseline MRA within 3 months from onset of ische- ADP and Collagen are used as platelet aggregator. In this mic stroke or TIA (group A) or had no history of cerebro- study “Aspirin resistant” is the mean aggregation more than vascular disease (group B); and (2) had stenosis in the M1 60% both ADP and Collagen. “Aspirin semiresponder” is the segment of middle cerebral artery or basilar artery when they mean aggregation less than 60% for ADP or Collagen. underwent the baseline MRA. The enrolled patients under- Result(s): Prevalence of Aspirin resistance in Phramong- went repeat MRA. The extent of stenosis of three intracranial kutklao hospital is 56%. arteries in each patient was classified into 5 grades. Progres- Conclusion(s): Prevalence of Aspirin resistance in Phra- sion was defined as worsening of stenosis by one or more mongkutklao hospital is 56% (79/141), and there are rela- grades on the repeat MRA as compared with the baseline tionship between Aspirin resistance and timing in the first MRA. episode of stroke. Result(s): Twenty-three patients underwent the repeat

MRA between August 2007 and February 2008. Progression

was detected in 1 of 21 ICAS in group A (4.76%) and in 2 of

19 ICAS in group B (10.5%). The progression rate was not

significantly different between the two groups (p=0.596).

Conclusion(s): Our pilot study shows that the progression

rate of ICAS is not different between the patients with a

previous history of stroke or TIA and those without a history

of cerebrovascular disease. We are continuously enrolling

new patients in this study.

S64 Presenting authors are indicated in bold. Korean J Stroke(Supplement 1) 2008;10

3rd International Conference on Intracranial Atherosclerosis and Annual Spring Meeting of the Korean Stroke Society POSTER SESSIONS

P021 P022 Serum VEGF Level in Acute Ischemic Stroke Decreased Number of Endothelial Progenitor Patients Correlates with the Prognosis of Stroke Cells in Patients with Recurrent Stroke Seung-Chul Lee, Seong-Ho Koh, Kyu-Yong Lee, Hee-Kwon Park, Kon Chu, Keun-Hwa Jung, Soon-Tae Lee, Young-Joo Lee Jae-Sung Lim, Jun-Young Chang, Manho Kim, Sang Kun Lee, Department of Neurology, College of Medicine, Hanyang University, Jae-Kyu Roh Seoul, Korea Stroke & Neural Stem Cell Laboratory, Stem Cell Research Center, Clinical Research Institute, Department of Neurology, Seoul National University Hospital, Seoul, Korea Background(s): VEGF with neuroprotective and angiogenic effects is increased in the ischemic brain. Background(s): The number of circulating endothelial Objective(s): In the present study, we investigated wheth- progenitor cell (EPC) is a surrogate marker of the cardio- er serum VEGF level in acute and chronic stages of ischemic vascular status. However, it remains unclear whether the stroke patients correlated with several factors related with diminished number of EPC at the chronic phase of stroke is stroke including infarct volume, number of arterial stenosis, associated with the recurrent stroke. initial and follow-up NIHSS scores, and so on. Objective(s): We sought to find whether the circulating

Method(s): We evaluated patients with first-ever ischemic Poster Sessions EPCs at chronic phase were decreased in subjects with stroke ( stroke definitely defined as the small vessel disease SVD, recurrence. n=24) and the large vessel disease (LVD, n=27) by TOAST Method(s): Consecutive 48 patients, who had had acute classification from March 2007 to July 2007. Brain MR im- stroke, were enrolled and EPC colony-forming units (CFU) aging and MR angiography were performed in all the pain peripheral blood samples were evaluated during chronic tients. For evaluation of serum VEGF level, we sampled the stages (from 3 months after initial stroke). All the patients venous blood within 6 hours after stroke onset. Demographic took the second MRI scans separated more than one year features, lipid profiles, BP, Diabetic markers, Inflammatory after the stroke. We compared the EPC-CFU with the newly markers, NIHSS, Modified Rankin scale, infarct Volume, developed ischemic lesion on the second scans. number of arterial stenosis, and serum VEGF level (Mean Result(s): Mean duration between two scans was 1044± O.D.) were assessed. After 3-6 months, follow-up serum 411 days and the mean EPC-CFU was 45.0±28.9. Among VEGF level and NIHSS in 31 patients (SVD, n=17 and total of 48 patients, the newly-developed ischemic lesions LVD, n=14) were rechecked. were evident in 9 participants (18.8%). The participants with Result(s): Serum VEGF level in acute stage within 6hrs the new lesions (25.3±33.5), compared with those without after stroke onset was much more increased in LAD group (49.5±26.2), had smaller EPC-CFU (p=0.022, student’s t- than in SVD group. Serum VEGF level in acute stage strong- test). The patients with smaller EPC-CFU (<30) had more ly correlated with improvement of NIHSS score (p=0.039, recurrent stroke than those with more EPC (≥30) during R2=0.139) and with infarct volume (p=0.005, R2=0.156). the periods between two scans (p=0.004, OR=0.074, 95% In chronic stage, it was related with number of arterial steno- CI; 0.013-0.426). After adjusting age, hypertension, dia- sis (p=0.001, R2=0.582). betes, dyslipidemia and atrial fibrillation, the multivariate Conclusion(s): In conclusion, serum VEGF level in acute analysis revealed that the deceased EPC-CFU (<30) was the stage of ischemic stroke patients correlates with the prog- independent predictor of stroke recurrence (p=0.008; OR= nosis of stroke and infarct volume, and it in chronic stage 0.076; 95% CI, 0.011-0.518). with severity of arterial stenosis. Conclusion(s): The decreased number of circulating en-

dothelial progenitor cells is associated with the stroke recur-

rence.

Presenting authors are indicated in bold. S65

3rd International Conference on Intracranial Atherosclerosis and Annual Spring Meeting of the Korean Stroke Society POSTER SESSIONS

P023 P024 D-dimer in Intracranial Artery Stenosis with Acute Factors Associated with Neurological Ischemic Stroke Progression in Patients with Acute Ischemic Ji-Yong Lee, Hyun Chan Jang, Jeong Min Cha, Stroke Subtype as Large Artery Atherosclerosis Sang Hyun Park, Seo Hyun Kim, Sung Soo Lee Yong-Jin Cho1, Ja-Seong Koo2, Jong-Moo Park2, Department of Neurology, Yonsei University Wonju College of Medicine, Hee-Joon Bae3, Moon-Ku Han3, Min-Kyung Jung1, Wonju, Korea Dong-Wha Kang4, Kyung-Ho Yu5, Byung-Chul Lee5, 1 Keun-Sik Hong Background(s): The mechanisms that underlie strokes in 1Departments of Neurology, Inje University Ilsan Paik Hospital, Goyang, 2Eulji University Eulji General Hospital, Seoul, patients with intracranial artery stenosis (ICAS) are not well 3Seoul National University Bundang Hospital, Seongnam, 4 known. Asan Medical Center, University of Ulsan, Seoul, and 5Hallym University, Sacred Heart Hospital, Anyang, Korea Objective(s): We investigated the conventional vascular risk factor, inflammatory markers as well as D-dimer in stroke Background(s): Neurological progression in stroke sub- patients with intracranial artery stenosis (ICAS). type as large artery atherosclerosis (LAA) is a major prog- Method(s): We studied 83 consecutive patients with acute nostic components for functional outcome. ischemic stroke who performed MRA or conventional an- Objective(s): To investigate factors associated with neu- giography from July 2005 to December 2005. We had ex- rological progression in patients with LAA cluded patients with cardioembolic ischemic stroke. Patients Method(s): Among all consecutive patients with ischemic were divided into two groups: those with ICAS more than stroke within 7 days from onset who admitted 4 university 50% (n=23) and those without ICS (n=60). hospitals in Seoul metropolitan area, LAA identified by Result(s): There were no differences in conventional risk TOAST classification were included for this study. Baseline factors and inflmmatory markers, but D-dimer was signifi- demographics, past medical history, medical complications cantly higher in patients with ICAS than in those without after stroke, and modified Rankin Scale at 3 months were ICAS (p=0.034). The cutoff values for predicting ICAS assessed by predetermined protocol. Stroke severity was using receiver operating characteristic curves was 216 ng/ml. assessed by NIH Stroke Scale (NIHSS) at admission, on When D-Dimer at baseline was 126 ng/ml or more, its sen- hospitalization days 1, 2, 3, and week 1 and 2. Neurological sitivity was 60.9%, sensitivity 53.3% and positive predictive progression was defined as decrease of 2 points in total value 33.3%. NIHSS score or 1 point in motor scale score. Conclusion(s): Plasma D-dimer is significantly associated Result(s): Among 454 patients with LAA, 108 (23.8%) with ICAS in patients with acute ischemic stroke but its pos- showed neurological progression. Patients with progression itive predictive value for intracranial stenosis is not optimal. are more likely to have higher initial NIHSS (median=6 vs.

4, p<0.001), preceding pneumonia (17.6% vs. 7.8%, p=

0.003), early admission (onset to admission time within 24

hours=75.9% vs 50.0%, p<0.001), and worse functional

outcome at 3 months (mRS 3-6=70.2% vs. 31.4%, p<

0.001), and less likely to have prior stroke history (16.7%

vs. 26.9%, p=0.03) than those without progression. After

adjusting covariates, higher initial NIHSS (aOR=1.54, 1.13-

2.11), early admission within 24 hours from onset (aOR=

2.80, 1.68-4.67), and first-ever ischemic stroke (aOR=

2.31, 1.27-4.22) were significant factors associated with

stroke progression.

Conclusion(s): The neurological progression in acute

ischemic stroke of LAA was associated with higher initial

NIHSS, early admission within 24 hours from onset, and

first-ever ischemic stroke.

S66 Presenting authors are indicated in bold. Korean J Stroke(Supplement 1) 2008;10

3rd International Conference on Intracranial Atherosclerosis and Annual Spring Meeting of the Korean Stroke Society POSTER SESSIONS

Imaging & Diagnosis Imaging & Diagnosis

P025 P026 Are Facilities Necessary to Detect Intracranial Benign Oligemia Despite of a Malignant MRI Atherosclerosis Available in European Hospitals? Profile in Acute Ischemic Stroke Clotilde Balucani1, Didier Leys1, Bernd Ringelstein2, Oh Young Bang1, Kwang Ho Lee1, Suk Jae Kim1, Markku Kaste3, Werner Hacke4 Gyeong Moon Kim1, Chin-Sang Chung1, 2 2 1Departments of Neurology, Lille University Hospital, Lille, France, Jeffry R Alger , David S Liebeskind 2 Munster University Hospital, Munster, Germany, 1Department of Neurology, Stroke and Cerebrovascular Center, 3Helsinki University Hospital, Helsinki, Finland, and Samsung Medical Center, Sungkyunkwan University School of Medicine, 4 Heidelberg University Hospital, Heidelberg, Germany Seoul, Korea, and 2 Department of Neurology and UCLA Stroke Center, University of California, Los Angeles, CA, USA

Background(s): Intracranial atherosclerosis is a potential cause of cerebral ischemia which may remain under diag- Background & Significance: It has recently been sug- nosed in hospitals where some facilities for stroke care are gested that diffusion and perfusion MRI can identify sub- Poster Sessions lacking. groups likely to benefit or potentially harmed by reperfusion Objective(s): To evaluate the proportion of European hos- therapies. pitals where necessary facilities to detect intracranial athero- Case: We investigated serial MRI data of two patients sclerosis are available. with occlusion of the proximal MCA. In both cases, acute Method(s): We randomly selected 886 hospitals in 25 multiple cortical infarcts were observed on DWI and PWI countries. We classified hospitals according to facilities av- showed extensive areas of severe perfusion delays, indi- ailable to detect intracranial atherosclerosis, in 3 categories: cating a malignant MRI profile. Despite the malignant MRI i) “all facilities” (availability of color-coded duplex imag- profiles in these cases, now new ischemic lesions or hem- ing of intracranial arteries [TCD], computed tomographic orrhage evolved even in the face or persistent arterial oc- angiography [CTA], and magnetic resonance angiography clusion and the patients recovered without sequelae. [MRA]); ii) “some facilities” (availability of either TCD, Conclusion or Comment: Our exemplary cases suggest or CTA, or MRA); and iii) “no facility” (neither TCD, nor that time-domain PWI should be interpreted with caution in CTA, nor MRA, or no brain imaging). We determined the a certain scenarios of acute ischemic stroke. proportion of hospitals meeting criteria for the 3 categories and the number of patients they admitted in 2005.

Result(s): Of 886 hospitals, 272 (30.7 %) met criteria for availability of “all facilities”, 445 (50.2%) of “some facilities”, and 169 (19.1 %) of “no facility”. In 2005, they had admitted respectively 139,118 patients (42.0%), 160,393

(48.2 %) and 62,667 (9.8 %). Brain imaging (CT or MR) was available in 820 (92.6%) hospitals, MRA in 498

(56.2%), CTA in 619 (69.9%) and TCD in 352 (39.7%), with disparities between countries.

Conclusion(s): More than 40% of ischemic stroke patients are admitted in Europe in hospitals with all facilities to detect intracranial atheroma, and more than 90% in hospitals with at least one facility. The next step will be to evaluate if these facilities are really used.

Presenting authors are indicated in bold. S67

3rd International Conference on Intracranial Atherosclerosis and Annual Spring Meeting of the Korean Stroke Society POSTER SESSIONS

P027 P028 Infarct Pattern on Diffusion Weighted Image Diagnosis of the Intracranial Artery Dissection in Cardioembolic Stroke: Atrial by Multiplanar CT Angiography Fibrillation vs. Patent Foramen Ovale Tai Hwan Park, Myung Hoon Bae, Min Uk Jang, Joung-Ho Rha, Jeong Lee, Ki-Hwan Ji Jae-Hyeok Heo, Jin Young Ahn, Min Ky Kim Department of Neurology, Inha University Medical College, Department of Neurology, Seoul Medical Center, Seoul, Korea Incheon, Korea Background & Significance: Dissection of intracranial Background(s): Atrial fibrillation (AF) is an established artery (DIA) is a rare cause of stroke, while conventional source of cardioembolism, but the exact mechanism of ce- angiography remains the gold standard technique for di- rebral infarct in the patent foramen ovale (PFO) is still con- agnosis, which is not only invasive but no longer routine tool troversial. to examine elderly ischemic stroke patients. Objective(s): To find the differences between these two Case: We present two elderly patients of stroke attrib- cardiac conditions, we compared the acute infarct pattern. utable to the DIA. First case was a 65-year-old man admitted Method(s): Acute ischemic stroke patients were screened to our hospital because of left hemiparesis. Initial magnetic to have PFO by transcranial Doppler right to left shunt study. resonance image (MRI) and MR angiography (MRA) re- MRI including diffusion weighted image (DWI) were per- vealed scattered acute ischemic lesions at cortex of the MCA formed in all the patients. The infarct pattern was classified territory and focal stenosis of the ipsilesional right M1 as: TIA (no DWI lesion), Lacune (single, deep infarct < 2 segment of the MCA. He had no risk factors except 30-pack cm), SVTI (single vascular territory infarct, infarct can be years of smoking and minor head concussion of 12 hours either single or multiple within the territory), MVTI mul- before the onset of symptoms. Second case was a 62-year- tiple vascular territory infarct, not explained by single vessel old man with left hemiparesis and hemineglect. MRI on lesion). Symptomatic stenosis or occlusion of reevant artery admission disclosed multiple scattered cortical and subcor- was also investigated by MR angiography. Presence of tical acute ischemic lesions in right MCA territory. MRA atrial fibrillation (AF) was determined by electrocardiogra- showed moderate stenosis of the ipsilesional ICA petrous phy. Transthoracic echocardiography was also performed in portion. He had a well-controlled hypertension and diabetes. all the patients. CT angiography (CTA) was also performed at emergency Result(s): From June 2004 to July 2007, 1,559 acute room in both patients. We found pathognomonic double ischemic strokes were screened and 133 PFO and 156 AF lumen of arterial dissection on oblique plane perpendicular patients were identified. The infarct pattern of PFO was: TIA to the stenotic arterial segment by using AquariusNET (Te- 16%, Lacune 20%, SVTI 43%, MVTI 22% and that of AF raRecon) a software specifically designed to provide multi- was: TIA 2%, Lacune 2%, SVTI 57%, MVTI 39% respec- planar rendered images from Digital Imaging and Com- tively (p<0.01). SVTI with no relevant arterial stenosis/oc- munications in Medicine (DICOM) data sets of CTA source clusion and MVTI and were regarded as cardioembolic images (CTA-SI). Dissecting stenosis disappeared comple- pattern, and the proportion were 55/133 (41%) in PFO and tely on followed image in the first case. 101/156 (65%) in AF (p<0.01). Conclusion or Comment: A rare cause of ischemic st- Conclusion(s): In AF, cardioembolism is the major cause roke in the elderly, we could detect easily the DIA using user- of cerebral infarct, but in PFO, though substantial portion friendly imaging software from CTA-SI. shows cardioembolic pattern, mechanism other than the paradoxical embolism should be also considered.

S68 Presenting authors are indicated in bold. Korean J Stroke(Supplement 1) 2008;10

3rd International Conference on Intracranial Atherosclerosis and Annual Spring Meeting of the Korean Stroke Society POSTER SESSIONS

P029 P030 Clinical Significance of Coexisting Carotid A Case of Small Arteriovenous Malformation Atherosclerosis in Patients with Intracranial in Right Posterior Fossa, with Draining Venous Small- or Large-Vessel Disease Aneurysm A-Hyun Cho, Seung-Jae Lee, Hyun-Young Ji, Geum Jin Yoon, Yun Ju Choi, Joon Tae Kim, Young-Min Shon, Dong Won Yang, Beum Saeng Kim Seong Min Choi, Seung Han Lee, Man Seok Park, Department of Neurology, The Catholic University of Korea, Byeong Chae Kim, Myeong Kyu Kim, Ki Hyun Cho St. Mary’ Hospital, Seoul, Korea Department of Neurology, Chonnam National University Hospital, Gwangju, Korea Background(s): Although small vessel disease (SVD) and intracranial large vessel disease (ICLVD) have been Background & Significance: A mixed prospective and conidered as having somewhat distinct pathogenesis from restrospective studies estimated an arteriovenous malfor- typical extracranial atherosclerosis, carotid atherosclerosis mation detection rate of 1.24 per 100,000 person-years. And sometimes coexists with SVD and ICLVD. few cases were reported about aneurysms of intracranial Objective(s): We investigated the coexisting atheroscle- veins. osis in patients with SVD and ICLVD by carotid ultrasonog- Case: A 64-year-old man came to outpatient department Poster Sessions because of dull nature headache. There was no known his-

raphy and saw if its coexistence affected clinical prognosis. Method(s): We consecutively included ischemic stroke tory of head trauma, infection, or hypertension. No focal patients who were diagnosed as SVD (ischemic infarction neurologic sign was revealed by neurologic examination. T2 less than 20 mm within the territory of penetrating arteries and T1-weighted brain MRI showed a 6.5×6 mm size low without other pathology) or ICLVD (with responsible intra- signal intensity lesion in right dorsal pons. Signal of the ranial arterial stenosis without other causes). Neurological lesion were voided by gradient-echo method. A small arte- progression was defined by increase of NIHSS during the riovenous malformation in right posterior fossa, with draining first 7 days of admission or stroke recurrence within 1 month. venous aneurysm was reveal by digital subtraction angio- Duplex ultrasonography was performed to measure intima- graphy (DSA). media thickness (IMT) and carotid plaque. Conclusion or Comment: Vascular malformations are Result(s): Total 54 patients were included (SVD in 34, not common. Combination of different types of vascular mal- ICLVD in 20). Among them, 38 (70.4%) patients had ath- formations were rarely reported. We report a case of small erosclerotic plaque and 20 patients had increased IMT. The arteriovenous malformation in right posterior fossa, with increased IMT was observed more frequently in ICLVD than draining venous aneurysm. in SVD (60.0% vs. 32.4%, p=0.026). The presence of any of them was observed in 42 (77.8%) patients. Although CT or MR angiography showed normal extracranial internal carotid artery in 44 (63.6%) patients, atherosclerotic plaque was observed further on ultrasonography in 28 patients. All 9 patients who showed early neurological progression had increased IMT or carotid plaque. In addition, all 5 patients without any of them didn’ show neurological progression. Conclusion(s): About 78% of SVD and ICLVD had coexisting carotid atherosclerosis. Whether its coexistence affects the clinical prognosis is still unclear demanding further study.

Presenting authors are indicated in bold. S69

3rd International Conference on Intracranial Atherosclerosis and Annual Spring Meeting of the Korean Stroke Society POSTER SESSIONS

P031 P032 Two Cases of Early Wallerian Degeneration Magnetic Resonance Spectroscopic Finding Detected Only by Diffusion Tensor Image of Acute Ischemic Infarction Due to Autologous in Stroke Patient Fat Injection Sun A Lee, Sung Sang Yoon, Key Chung Park, Sang Hun Yi1, Dae-il Chang1, Sung Hyuk Heo1, Tae Beom Ahn, Dae-Il Chang, Kyung Cheon Chung, Key Chung Park1, Sung Sang Yoon1, Tae Beom Ahn1, Sung Hyuk Heo Kyung Cheon Chung1, Eui-Jong Kim2 Department of Neurology, Kyung Hee University College of Medicine, 1Departments of Neurology and 2Neuroradiology, Kyung Hee University Seoul, Korea College of Medicine, Seoul, Korea

Background & Significance: Wallerian degeneration (WD) Background & Significance: Autologous fat injection of the pyramidal tract after ischemic stroke is a wellkwon into the face is a frequently used technique in aesthetic sur- phenomenon. It is characterized by a highly stereotypical gery. There have been several case reports that patients had course, starting with disintegration of axonal structures wi- suffered from acute visual loss and cerebral infarction fol- thin days after injury, followed by degradation of myelin lowing fat injections into the face. We report a patient with along the affected tracts. It’s important to detect WD because acute fatal cerebral infarction after autologous fat injection the extent of WD correlates with the motor deficit. Conven- into the face with characteristic magnetic resonance spectros- tional magnetic resonance imaging (MRI) detects signal copy (MRS) findings. intensity changes that vary during the time course of WD, Case: Under local anesthesia, a 26-year-old right-handed but signal intensity changes are generally not detected until 4 woman had autologous abdominal fat injection to correct her weeks after stroke. We used diffusion tensor imaging (DTI) cosmetic problem. A few minute after injection, she com- to assess WD within early stage after ischemic stroke. We plained of headache and visual disturbance. Physical exami- describe here, two cases of ischemic stroke and compare with nation was stable. Neurologic examination showed a slightly their conventional MRI and DTI within early stage after drowsy mentality with dysarthria, left hemiparesis with pa- ischemic stroke onset. thologic reflexes, left central facial palsy, eyeball deviation Case: In case 1, the patient with left MCA infarction was to the right side, and sensory extinction. The right pupil was a 28-years-old female who presented with right side weak- dilated and unresponsive to direct light stimulation. Brain ness with Broca’s aphasia. In 3rd weeks after stroke onset, computed tomography (CT) was normal. Magnetic resonance MRI showed left MCA infarction without WD. But we image (MRI) with diffusion weighted imaging revealed mul- found WD using DTI. The same is true of the case 2. 67- tiple acute ischemic infarction in right MCA territory. Cere- years-old female had sudden onset right side central type bral magnetic resonance angiography (MRA) revealed that facial palsy with dysarthria. The ischemic lesions were visi- the right middle cerebral artery (MCA) was hypoplastic. ble in corona radiate and putamen in MRI. We couldn’t found Proton MRS was performed on the high signal intensities WD in MRI, but just only DTI showed that within 1 day in the right MCA territory. MRS from these lesions showed after ischemic stroke onset. markedly increased lactate and lipid peaks with normal N- Conclusion or Comment: As our two cases, we detect acetyl-aspartate/creatine (NAA/Cr). Carotid doppler (CD), WD of pyramidal tract within early stage after ischemic st- “air-bubble-test”, and screening tests for stroke revealed roke onset only in DTI. In previous studies, evidence of normal. severe pyramidal damage in the early phase after stroke Conclusion or Comment: To prove the cause of stroke in would be of great value to assess the prognosis and rehabil- this case, we used many tools such as CT, MRI, MRA, CD, itational potential of stroke patients Thus, DTI offers a way TCD, and MRS. Especially, MRS analysis was good for to detect severe degeneration of the pyramidal tract and may diagnosis of cerebral fat embolism following autologous fat be a helpful tool in forecasting and monitoring recovery in injection. patients with ischemic stroke.

S70 Presenting authors are indicated in bold. Korean J Stroke(Supplement 1) 2008;10

3rd International Conference on Intracranial Atherosclerosis and Annual Spring Meeting of the Korean Stroke Society POSTER SESSIONS

P033 P034 Screening Strategies for a Diagnosis of Coronary ASPECT Score on Contrast Enhancement CT Artery Stenosis in Patients with Cerebral to Estimate Pial-Collateral Circulation Status Infarction Using Dual Source CT Jun Young Choi1, Jae Hyuk Lee1, Ho Sung Kim2, 1 Seul-Ki Jeong1, Keun-Sang Kwon2, Sang-Rok Lee3, Ji Man Hong Gong-Yong Jin4 1Departments of Neurology and 2Diagnostic Radiology, Ajou University School of Medicine, Suwon, Korea 1Department of Neurology, 2Department of Preventive Medicine , 3Section of Cardiovascular Division, Department of Internal Medicine, and 4Department of Radiology, Chonbuk National University Hospital & Medical School, Jeonju, Korea Background(s): Collateral circulation system has a piv- otal role to maintain cerebral perfusion of ischemic pe- Background(s): It has been reported that stroke and is- numbra in acute ischemic stroke. Despite the introduction of chemic heart disease share some vascular risk factors and new imaging modalities (multimodal CT or MRI) for de- pathomechanisms. tecting collateral circulation, those can be less practical in Objective(s): To evaluate benefit from screening of coro- the setting of acute ischemic stroke due to the requirement of nary artery stenosis in patients with cerebral infarction using post-processing procedures. dual source CT (DSCT) Objective(s): To rapidly investigate pial-collateral circula- Poster Sessions

Method(s): From Nov 2007 to Feb 2008, forty eight tion status in acute anterior ischemic stroke patients, we patients (36 male, 12 female; mean age 62.6±9.4 years) measured ASPECT score on contrast enhancement CT. who had cerebral infarction without cardiac symptom un- Method(s): We retrospectively recruited 35 acute is- derwent cardiac CT angiography using DSCT as a screening chemic stroke patients who underwent intra-arterial throm- examination; gantry rotation time 0.33 seconds, tube voltage bolysis due to ICA or MCA occlusion in Ajou University 120 kV, tube current 560 mA with ECG-triggered tube Stroke Center over 2 years. Like original ASPECT score, we current modulation. All forty eight patients had either hy- evaluated 2 axial CT images with contrast enhancement by pertension or type 2 diabetes mellitus (DM) or dyslipidemia. visual inspection. Collateral circulation was angiographically All vessels ≥ 1.5 mm were considered for an assessment graded (Grade 1 to 5) and divided into good (<2 points) of significant coronary artery stenosis (diameter reduction and poor collateral groups (≥3 points). > 50%). We recommended invasive coronary angiography Result(s): Demographic data (age, sex, initial NIHSS, if significant coronary artery stenosis was detected at CT time to CT, stroke subtypes) and ASPECT score were not coronary angiography. Also, we evaluated usefulness of sc- significantly different between good and poor collateral reen examination of cardiac CT for age and vascular risk groups. Compared with poor collateral group, ASPECT factors in patients with cerebral infarction using Chi-square score on enhancement CT was significant higher in good test and logistic regression analysis. collateral group (9.2±1.6 vs. 6.4±2.8, p=0.004). The dif- Result(s): Cardiac CT images showed coronary artery ference of ASPECT score between contrast enhancement CT stenoses >50% in 24 patients (50.0%). Four of the 24 pa- and non-contrast CT was also greater in good collateral tients (16.7%) underwent percutaneous coronary interven- group (2.8±2.2 vs. 0.7±2.3, p=0.025). ASPECT score on tion (n=3) or operation (n=1). Among the patients with contrast enhancement had an inverse relationship with an- ischemic stroke, IFG, type 2 DM, and increased homocys- giographical collateralization grade (r=-0.531, p<0.001). teine showed indepdent association with coronary artery ste- Conclusion(s): ASPECT score on contrast enhancement nosis, adjusting for potential confounders. CT might be an easy and feasible way to find pial-collateral Conclusion(s): Cardiac CT angiography using DSCT ap- circulation status in the patients with acute anterior ischemic pears a promising screening technique for coronary artery stroke. stenosis in patients with ischemic stroke, especially with type 2 DM or increased homocysteine.

Presenting authors are indicated in bold. S71

3rd International Conference on Intracranial Atherosclerosis and Annual Spring Meeting of the Korean Stroke Society POSTER SESSIONS

Neurovascular Imaging Neurovascular Imaging

P035 P036 Absence of the Common Carotid Artery: Distribution of Artificial Cerebral Microemboli a Rare Vascular Anomaly Is Not Related to Lesion Location in Stroke Seong Jin Yim, Jung Hyeon Park, Sang Won Han, Patients Jong Sam Baik, Jeong Yeon Kim, Jae Hyeon Park Jun Lee, Sejin Lee, Jungsang Hah, Meeyoung Park Department of Neurology, Sanggye Paik Hospital, Inje University Department of Neurology, Yeungnam University Hospital, Daegu, Korea College of Medicine, Seoul, Korea

Background(s): Transcranial Dopper examination (TCD) Background & Significance: Absence of a common ca- has been proposed as an alternative method for the detection rotid artery (CCA) with separate origin of the respective of right-to-left shunt (RLS). However, significance of high external carotid artery (ECA) and internal carotid artery transient signals (HITS) with respect to the location of lesion (ICA) from the aortic arch is a rare anomaly. Only one case after recent stroke has not been proved. had ultrasonographic correlation. Objective(s): We attempt to indentify the relationship Case: A 52 year-old woman with a history of hyperten- between distributions of HITS and location of lesion. sion and hypercholesterolemia visited hospital due to vertigo Method(s): We studied 336 consecutive patients with car- and headache for three days. Physical and neurologic ex- dioembolic stroke or stroke of undetermined etiology or amination was unremarkable. Color-coded duplex sonography, transient cerebral ischemic attack for a year. Ischemic stroke performed for carotid and vertebral artery evaluation, reve- were classified according to lesion locations on the MRI: aled conventional anatomy on the left side. CCA, ECA, and 1)sleft anterior circulation, 2)right anterior circulation 3) ICA waveforms on the left side were normal. On the right, a bilateral anterior circulations, 4)posterior circulation, and CCA could not be demonstrated by color-coded duplex 5)mixed anterior and posterior circulation. A standard pro- sonography. Instead, there were two vessels of approxima- tocol for RLS diagnosis by TCD with simultaneously mon- tely equal size in close proximity to each other coursing ce- itoring of the bilateral middle cerebral arteries (MCA) and phalad from aortic arch. Cerebral angiography was consist- air mixed saline injection was conducted. We analyzed the ent with ultrasonographic findings. The ECA and ICA orig- distribution and number of HITS and MRI findings. inated directly from the brachiocephalic trunk and the ECA Result(s): Ninety-eight patients with adequate bilateral arose proximal to the ICA. temporal windows, index stroke on MRI, and HITS during Conclusion or Comment: We report the ultrasonographic TCD were included. HITS were found in the left MCA only findings of the agenesis of the CCA with separate aortic arch in 31 patients (31.6%), right MCA only in 15 (15.3%), and origins of the ECA and ICA. bilateral MCA in 52 (53.1%). There is no significant as-

sociation between the distribution of HITS and the lesion

locations(p=0.903). The mean numbers of HITS are 2 (±

0.2) in the left MCA, 2 (±0.3) in the right MCA, and 30

(±8.0) in the bilateral MCA (p<0.001).

Conclusion(s): The distributions of HITS do not reveal

significant associations with the lesion location, although the

increasing number of HITS shows possibilities of detection

of emboli in the bilateral MCA.

S72 Presenting authors are indicated in bold. Korean J Stroke(Supplement 1) 2008;10

3rd International Conference on Intracranial Atherosclerosis and Annual Spring Meeting of the Korean Stroke Society POSTER SESSIONS

P037 P038 Clinical Profiles and Sonographic Findings Measurement of Carotid Plaque for Assessment of Patients Seen at the Diosdado Macapagal of Atherosclerosis in Patients with Stroke Stroke Center, Philippine General Hospital Hyo Suk Nam, Yo Han Jung, Jae Jung Lee, Jessie Colacion, Ma Geraldine S Espiritu, Young Dae Kim, Hye Yeon Choi, Ji Hoe Heo Roland Dominic G Jamora Department of Neurology, Yonsei University College of Medicine, Seoul, Korea Department of Neurosciences, UP College of Medicine-Philippine General Hospital, University of the Philippines, Manila, Philippines Background(s): Using carotid Doppler (CD), carotid pla- Background(s): Transcranial Doppler (TCD) has been ques (CP) are frequently and easily found in stroke patients. used for various neurological indications at the Diosdado Ma- Objective(s): This study sought whether a CP could be capagal Stroke Center (DMSC), Philippine General Hospital. used as a parameter of systemic atherosclerosis in acute st- Objective(s): Describe the profiles and sonographic find- roke patients. ings of patients seen at the DMSC. Method(s): Consecutive patients who performed CD, Method(s): TCD records of patients seen from 2006- transcranial Doppler, and ankle brachial index (ABI) were

2007 were reviewed. Demographic, clinical and sonographic enrolled. A CP was defined as a focal structure encroaching Poster Sessions

data were gathered and summarized. into the arterial lumen of at least 0.5 mm or 50% of the sur- Result(s): Of the 357 patients, 344 (96.4%) were adults rounding intima-media thickness , or thickness ≥1.5 mm. and 190 (53.2%) of which were males. TCD were requested Result(s): Over 2 years, 492 patients were enrolled. Fify- to determine the stroke mechanism (90.5%), increased in- five patients were excluded due to poor temporal window tracranial pressure (4.8%), vasospasm (3.6%), and as an (n=49), and unavailable data (n=6). Of 437 patients, CP ancillary tool for migraine (1.4%) and epilepsy (0.6%). The were found in 330 (76%) patients. Median numbers of CP most common diagnoses of the patients were stroke (63%), were 2, quartiles of increase were 0, 1, 2-3, and 4-14. transient ischemic attack (8.1%), subarachnoid hemorrhage Patients with the highest quartile were older (p<0.001), and (3.6%), and vertebrobasilar insufficiency (3.6%). Abnor- of male predominance (p<0.001) compared with the first mal TCD were noted in 199 (55.7%) patients. TCD docu- three quartiles. Hypertension (p=0.001), diabetes (p<0.002), mented intracranial stenoses were found in 120 (33.6%) coronary artery disease (p<0.001), and previous stroke (p= patients, with 64 (53.3%) having a single-vessel involvement. 0.003) were common. Hemodyanamic parameters of the Stenoses were mostly in the anterior circulation (74.2%), highest quartile were higher mean velocity (80±30 vs. 72± mainly in the middle cerebral arteries (46%), the carotid 32, p=0.013), pulsatility index (0.83±0.23 vs. 0.77±0.19, siphons (18.6%), and anterior cerebral arteries (18.1%). p=0.012) in the middle cerebral arteries (MCA), and lower Thirty-six (16.7%) stenoses were located in the vertebro- ABI (1.14±0.13 vs. 1.17±0.08, p=0.01). Multivariate basilar circulation. Poor temporal window were found in 80 analysis revealed the independent predictors of the highest (22.4%) patients, most of which are bilateral (71%). Vaso- quartile were mean velocity of the MCA (OR 1.014, 95% CI spasm was documented in 9/13 of patients with subarachnoid 1.006-1.023), and ABI (OR 0.068, 95% CI 0.006-0.735), hemorrhage. along with other risk factors. Conclusion(s): TCD is utilized primarily to determine the Conclusion(s): Patients with carotid plaques had multiple presence of intracranial stenosis among stroke patients seen atherosclerotic risk factors. The carotid plaques were com- at the DMSC. A third of these had evidence of intracranial patible with other hemodynamic studies, which suggest gen- stenosis, affecting mainly the anterior cerebral circulation. eralized atherosclerotic process in these patients.

Presenting authors are indicated in bold. S73

3rd International Conference on Intracranial Atherosclerosis and Annual Spring Meeting of the Korean Stroke Society POSTER SESSIONS

P039 P040 Intravascular Ultra Sonography Finding of a Case A One-Year Review of the Carotid and of Radiation Induced Carotid Artery Stenosis Transcranial Doppler Findings of Patients of the Young Eun Kim, Mi Sun Oh, Kyung-Ho Yu, Byung-Chul Lee Philippine General Hospital for the Year 2007 Department of Neurology, Hallym University College of Medicine, Agnes Cariaga, Roland Dominic G Jamora, Anyang, Korea Ma Geraldine S Espiritu Department of Neurosciences, Philippine General Hospital, Background & Significance: Radiation-induced carotid Manila, Philippines stenosis may develop in patients who have had previous therapeutic cervical irradiation, although its occurrence is Background(s): Intracranial stenosis is a more common relatively rare. Intravascular ultra sonography (IVUS) is a cause of ischemic stroke among Asians than extracranial new technique in the assessment of plaque morphology. We carotid disease. report IVUS finding of a case of radiation-induced carotid Objective(s): In this paper, we describe the carotid Du- arterial stenosis performed while carotid angioplasty and plex scan (CDS) and transcranial Doppler (TCD) results of stenting. patients from the Philippine General Hospital who under- Case: A 38-year-old man was admitted to hospital with went both procedures in 2007 as part of the workup for their left hemiparesis. He had no conventional risk factors for stroke. ischemic stroke including hypertension, diabetes, hyper- Method(s): This is a retrospective review of the CDS and lipidemia. However, he had received the radiation therapy TCD records of the Philippine General Hospital for the year for cervical lymphoma 17 years ago. The radiation was di- 2007. rected at the cervical fields bilaterally. Brain MRI showed an Result(s): Only thirty-nine patients had available CDS acute infarction in the anterior division of the right MCA and TCD results from the Philippine General Hospital for territory and an old lesion in the left MCA territory. Cerebral the year 2007. Twenty-one (53.8%) presented with an ante- angiography revealed bilateral extracranial carotid artery rior circulation infarct, 9 (23.1%) presented with a posterior stenosis, 78.5% in the right side and 79.5% in left side by circulation infarct and 4 (10.3%) had strokes in unspecified NASCET measurement. IVUS was done just before angio- locations. CDS revealed 7 (17.9%) of these patients to have plasty and stenting in the right carotid artery. Distal IVUS greater than 50% stenosis of the internal carotid arteries. showed relatively homogenous luminal surface suggesting Tw ent y (51.3%) patients had intracranial stenosis docu- the fibrous lesion at the stenotic area. mented on TCD. Conclusion or Comment: The IVUS finding in this case Conclusion(s): The figures presented in this study cannot suggest the mechanism of radiation induced arterial stenosis be used to extrapolate for incidence data as this study is may be different to that of atherosclerotic lesion. limited by the small number of patients who only had available reports on TCD and CDS from the Philippine General Hospital. Some patients have undergone both or either procedures in outside institutions and we recognize the need for a more consolidated data. The study, however, still showed more patients to have intracranial stenosis than stenosis of the extracranial internal carotid arteries, which is consistent with published data on intracranial atherosclerosis being more common among Asians.

S74 Presenting authors are indicated in bold. Korean J Stroke(Supplement 1) 2008;10

3rd International Conference on Intracranial Atherosclerosis and Annual Spring Meeting of the Korean Stroke Society POSTER SESSIONS

P041 P042 Preliminary Study: Fluid-Structure Interaction Correlation of Cerebral Artery Calcification and Analysis of Carotid Artery Bifurcation and Its Brachial-Ankle Pulse Wave Velocity in Patients Application to the Evaluation of Atherosclerosis with Acute Ischemic Stroke Sang Ok Park1, Sung Tae Park2, Young Bae Ko3, Pil-Wook Chung1, Heui-Soo Moon1, Yong Bum Kim1, Kyung Hwan Yoon4, Dae Chul Suh1 Bum-Chun Suh1, Kwang-yeol Park2 1Department of Radiology, Asan Medical Center, Seoul, 1Departments of Neurology, Kangbuk Samsung Hospital, Sungkyunkwan 2Department of Radiology, Soonchunhyang University Hospital, Seoul, University School of Medicine, and 3Department of Mechanical Engineering, Korea Institute of Industrial 2Chung-Ang University Medical Center, Chung-Ang University School Technology, Bucheon, and of Medicine, Seoul, Korea 4Department of Mechanical Engineering, Dankook university, Yongin, Korea Background(s): Vascular calcification is known to be as- Background(s): There have been numerous studies to sociated with cardiovascular mortality and aortic stiffness as correlate fluid dynamic forces and atherosclerotic disease. In measured by pulse wave velocity is associated with major the early days, it was postulate that high wall shear stresses cardiovascular risk factors damage the arterial wall; endothelial disruption or denuda- Objective(s): Our aim was to investigate the correlation tion could lead to atherosclerosis. Since then, however, it has between aortic damage estimated by brachial-ankle pulse Poster Sessions become widely accepted that low or oscillatory shear stress wave velocity (baPWV) and cerebral artery calcification in contribute to atherogenesis. To simulate the flow dynamics patients with acute ischemic stroke. and wall mechanics of such arteries, finite element analyses Method(s): We identified patients with acute ischemic are used widely. stroke who visited our institution and underwent both 16- Objective(s): To evaluate the possibility of fluid-structure slice CT angiography and ba PWV. We retrospectively re- interaction analysis of the carotid artery bifurcation and to viewed the stroke database to assess the vascular risk factors apply the result in the evaluation of atherogenesis. and demographics. Calcifications of the intracranial and ex- Method(s): Initial images were obtained by using MR tracranial arteries above the carotid bifurcation level were angiography. The data were collected in DICOM format and scored by two board-certified neurologists (0: no calcifica- converted by a DICOM reader into a 3D image. The image tion; 1: tiny; 2: mild; 3: moderate; 4: severe). was then processed by using commercial visualization and Result(s): Sixty-six subjects free of end-stage renal dis- mesh generation software, which allowed extraction of the ease or peripheral arterial disease were included in the ana- luminal surface of the blood vessel. The subsequent final lysis. In univariate analysis, cerebral artery calcification was denudation output was used for simulations of blood flow correlated significantly with age (r=0.606, p<0.001) dis- and wall mechanics of carotid artery bifurcation. ease and baPWV (r=0.523, p<0.001). baPWV was signifi- Result(s): The extraction of vascular luminal surface from cantly higher in hypertensive than in normotensive (1995 vs the medical image data and reconstruction into 3D model for 1,703 cm/s, p<0.05). baPWV was significantly higher in mesh generation was performed easily. And in applying to diabetic patients than in nondiabetics (2,053 vs 1,768 cm/s, simulations of hemodynamics and wall mechanics for pa- p<0.05). Multiple regression analysis indicated that age and tients with atherosclerosis in carotid artery bifurcation, the cerebral artery calcification were independent determinants atherosclerotic areas were correlated well with areas of low of baPWV. shear stress. Conclusion(s): This study shows that pulse wave velocity Conclusion(s): We simulated flow dynamics and wall is correlated with the severity of cerebral artery calcification mechanics of carotid artery bifurcation using commercial in patients with ischemic stroke. softwares. And the atherosclerotic areas were correlated with areas of low shear stress.

Presenting authors are indicated in bold. S75

3rd International Conference on Intracranial Atherosclerosis and Annual Spring Meeting of the Korean Stroke Society POSTER SESSIONS

P043 P044 Comparison in Two Serial TCD Findings Intracranial Pulsatility Index and Homocysteine of Symptomatic Middle Cerebral Artery (MCA) Mi-Hye Lim, Tae-Ho Yang, Jin-Young Seo, Ki-Ju Kim, between MCA Disease and Tandem Arterial Sun-Young Oh, Byoung-Soo Shin, Man-Wook Seo, Pathology Young-Hyun Kim, Seul-Ki Jeong Department of Neurology, Chonbuk National University Hospital & Kyung Bok Lee, Il Mi Jang, Ji Sun Kim, Hakjae Roh, Medical School, Jeonju, Korea Moo Young Ahn

Department of Neurology, Soonchunhyang University Hospital, Seoul, Korea Background(s): An elevation of pulsatility index in the intracranial arteries represents vascular resistance distal to Background(s): Either middle cerebral artery (MCA) dis- the examined artery. Homocysteine was known to have di- ease or embolism from proximal atherosclerosis can manifest rect toxic effects on endothelium. MCA occlusion on angiography. Objective(s): To evaluate an association between the ho- Objective(s): The aims of our study were to elucidate the mocysteine and pulsatility index of the intracranial arteries differences in serial Transcranial Doppler (TCD) findings with a transcranial Doppler examination. between intracranial MCA disease and tandem arterial pa- Method(s): We evaluated consecutive patients with ische- thology. mic strokes referred to a neurovascular ultrasound laboratory Method(s): We have prospectively enrolled the patients from March 2007 to February 2008. Pulsatility index was with acute large infarcts located in the lenticulostriate artery defined as (peak systolic velocity-end-diastolic velocity)/ territory and MCA stenoocclusion on brain contrast-enhanced mean flow velocity as recommended by Gosling and King, magnetic resonance angiography (CE-MRA). We classified and ≥ .2 was considered abnormally high. According to stroke mechanisms into MCA disease (MCAD, n=25) and the pulsatility index criteria, homocysteine was evaluated, stroke of tandem arterial pathology (STAP, n=23) excluding adjusting for potential confounders. cardioembolic infarction. For all patients, TCD were per- Result(s): A total of 305 men and 246 women were en- formed 0 day and 7 days after CE-MRA. For the analysis of rolled for the present analysis (mean age, 63.9±11.6 vs. TCD diagnosis of MCA stenosis, we used a mean flow ve- 66.6±12. 3 yrs, p=0.008). Homocysteine was not so dif- locity (MFV) cutoff of ≥80 cm/s in the MCA as the cri- ferent according to the types of ischemic stroke, and was terion for stenosis. The MFVs of MCA were checked at depth elevated in the high PI group of many intracranial arteries of 60 and 66 mm on both sides. Complete or partial occlu- (both middle cerebral artery, basilar artery, and right verte- sions were diagnosed according to the TIMI flow grades and bral artery). Adjusting for age and sex, homocysteine was TCD wave forms. elevated in both middle cerebral artery and right vertebral Result(s): In the two serial TCD performed with a 1-week artery. interval in the STAP group, 9 patients (39.1%) showed a Conclusion(s): The vascular resistance in the intracranial reduced or normalized MCA flow velocity. These findings arteries was associated with homocysteine. A cause relation- were observed in only 3 patients in the MCA disease group ship between them should be sought in the clinical and epi- (12.0%, p=.046). demiologic settings. Conclusion(s): Significantly more patients with STAP showed reduced or normalized MCA flow velocity on follow-up TCD. This finding suggests that serial TCD as well as angiography can be used to discriminate intracranial MCA disease from stroke of proximal artery to artery embolization.

S76 Presenting authors are indicated in bold. Korean J Stroke(Supplement 1) 2008;10

3rd International Conference on Intracranial Atherosclerosis and Annual Spring Meeting of the Korean Stroke Society POSTER SESSIONS

P045 P046 Cerebral Infarction Caused by a Mobile The Relationship between Carotid Plaques and Thrombus Attached to Atherosclerotic Plaques Stenosis of Intracranial Arteries in the Aortic Arch Yo Han Jung, Yong Dae Kim, Hyo Suk Nam, Ji Hoe Heo Jun Young Lee, Young Hoon Lee, Eung Seok Oh, Department of Neurology, Yonsei University College of Medicine, Ji Hee Lee, Dae Hyeon Kim Seoul, Korea Department of Neurology, Chungnam National University Hospital, Daejeon, Korea Background(s): Atherosclerosis is a generalized disease process. Regardless of the anatomic location, the formation Background & Significance: Atherosclerotic lesions at of plaques may occur by the similar pathophysiologic mech- the aortic arch are recognized as potential sources of embolic anism. The presence of plaques in carotid arteries may be a stroke. Transesophageal echocardiography (TEE) is supe- marker of stenosis in intracranial arteries. There are limited rior to transthoracic echocardiography (TTE) in detecting informations about relationship between number of plaques cardiac source of embolism. There are some reports of em- in carotid arteries and stenosis of intracranial arteries. bolic stroke caused by a mobile thrombus located at the Objective(s): To determine whether there is a relationship aortic arch. However, the treatment to this lesion is still con- between the number of carotid plaques detected by carotid Poster Sessions troversial. Doppler and stenosis of intracranial arteries found by MRA Case: We recently encountered four patients with unex- or DSA. plained cerebral infarction, in whom TEE unexpectedly Method(s): Carotid Doppler and cerebral angiography showed evidence of freely mobile thrombi attached to athe- [(MR angiography (MRA) or digital subtraction angiogra- rosclerotic plaques in the aortic arch that was not detected by phy (DSA)] of 312 consecutive patients with ischemic the transthoracic approach. In follow-up TEE of all patients, stroke, after excluding those with cardioemloism and other mobile thrombus disappeared after anticoagulant treatment. causes of stroke were reviewed retrospectiely. However, cerebral infarction recurred despite anticoagulation Result(s): Among the 312 patients, carotid plaques were in one patient. detected in 254 patients (81.4%). Atherosclerosis of cere- Conclusion or Comment: More consideration should be bral arteries were detected in 271 patients (86.7%), and were given to the aortic arch as a source of embolism in patients classified into isolated intracranial atherosclerosis (N=89; with unexplained stroke. We suggest that more thorough an- 28.5%), isolated extracranial atherosclerosis (N=30; 9.6%), ticoagulation monitoring was needed in patients with mobile and combined intracranial and extracranial atherosclerosis thrombus in the aortic arch. (N=152; 48.7%). The presence of carotid plaques was significantly associated with presence of stenosis in isolated intracranial atherosclerosis (p<0.001) and combined stenosis of intracranial and extracranial arteries (p<0.001). Number of plaques in carotid arteries were correlated with number of segments or branch arteries with atherosclerosis stenosis in intracranial and extracranial arteries (correlation coefficient=0.402, p<0.001). Conclusion(s): The presence of plaques detected in carotid Duplex study in patients with ischemic stroke is predictive of the presence of stenosis in intracranial arteries, and number of carotid plaues is associated with the number of atherosclerotic cerebral arteries.

Presenting authors are indicated in bold. S77

3rd International Conference on Intracranial Atherosclerosis and Annual Spring Meeting of the Korean Stroke Society POSTER SESSIONS

Stroke Mechanism & Topography Stroke Mechanism & Topography

P047 P048 The Relation between Extracranial Carotid Plaque Extracranal and Intracranial Artery Disease and Intracranial Arterial Stenosis in Relation to the Neurological Deficit Seo Hyun Kim, Sang Hyun Park, Joung-Min Chon, Anita Arsovska, Ante Popovski Ji-Yong Lee, Sung-Soo Lee Clinic of Neurology, Skopje, Macedonia Department of Neurology, Yonsei University Wonju College of Medicine, Wonju, Korea Background(s): Evaluation of extra and intracranial ar-

tery disease in patients (pts) with stroke is very important for Background(s): Carotid plaque is a marker of cerebro- determination of its outcome. vascular disorder. Carotid plaque is easily evaluated by du- Objective(s): To correlate extracranial and intracranial ar- plex carotid ultrasonography. tery disease with the neurological deficit in pts with ischemic Objective(s): The present study was aimed at the inves- stroke. tigating the relation between carotid plaque measured by Method(s): We made prospective analysis of 50 pts with ultrasonography and intracranial arterial stenosis. ischemic stroke, aged 58-76 years. National Institute of Method(s): We retrospectively analyzed medical and Health Scale Score (NIHSS) was evaluated on admission sonographic records of acute stroke patients who admitted to and after 7 days. Extracranial and transcranial color duplex neurology department between July, 2004 and June, 2006. examination were carried out. Risk factors such as hyper- Plaque score, the sum of all plaque thicknesses, and maximal tension, hyperlipidemia, heart failure, smoking, alcohol and plaque thickness (MPT) of the carotid artery was compared diabetes were analyzed. between the patient with intracranial arterial stenosis and the Result(s): According to transcranial color duplex exam- others. ination (TCCD), pts were divided into 4 groups: I) normal Result(s): Among 848 patients with acute ischemic stroke, findings -16 pts; II) occlusion of middle cerebral artery 386 patients, who were evaluated by cerebral angiography (MCA) branches -8 pts; III) MCA trunk stenosis -15 pts and carotid sonography and did not have any significant and IV) occlusion of ACM trunk -11pts. In group I, most pts extracranial carotid stenosis or cardioembolism, were en- (62.5%) had normal carotid arteries. In group II, equal rolled. Plaque score and MPT of the carotid artery were sig- number of pts -3 (37, 5%) had significant stenosis and nificantly increased in the patients with intracranial arterial carotid occlusion, respectively. In group III most pts had non stenosis (plaque score, 4.7±3.9; MPT, 2.3±1.4) compared significant carotid stenosis (86, 67%). In the IV group; most with the others (plaque score, 3.2±3.3; MPT 1.6±1.4) pts had carotid occlusion (45, 45%). Statistical analysis (p<0.001). showed that for R=0.55 and p<0.05, there was a significant Conclusion(s): There were close relation between carotid correlation between carotid and intracranial artery disease. plaque and intracranial arterial stenosis in the acute stroke From the analyzed risk factors, in all four groups hyper- patients. tension dominated (75-80%). Patients with normal TCCD

findings had significantly better initial and control NIHSS.

In pts with pathologic TCCD findings, NIHSS on admission

was not significantly different (p>0.05), although higher

scores were registered in patients with MCA occlusion. Con-

trol NIHSS was significantly higher in pts with MCA occ-

lusion (p<0.05).

Conclusion(s): the level of neurological deficit correlated

with the level of extracranial and intracranial artery disease.

Patients with combined extracranial and intracranial occlu-

sive disease had the worst outcome.

S78 Presenting authors are indicated in bold. Korean J Stroke(Supplement 1) 2008;10

3rd International Conference on Intracranial Atherosclerosis and Annual Spring Meeting of the Korean Stroke Society POSTER SESSIONS

P049 P050 Posterior Communicating Artery Hyperplasia: Basilar Artery Atherosclerotic Disease is Related a Potent Prognostic Predictor in Acute Brainstem to Subacute Lesion Volume Increase in Pontine Infarction Caused by Basilar Artery Occlusion Base Infarction or Severe Stenosis Jong S Kim1, Kyung-Hee Cho1,2, Dong-Wha Kang1, 1 Ji Man Hong, Jun Young Choi, Sung Eun Yi, Jae-Hyuk Lee, Sun U Kwon Kyoung Hwa Shin 1Stroke Center and Department of Neurology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, and Department of Neurology, Ajou University Hospital, Suwon, Korea 2Department of Neurology, Keimyung University, Dongsan Medical Center, Daegu, Korea Background(s): Basilar artery (BA) occlusion or severe stenosis is a fatal cause of acute brainstem infarction, but it is Background(s): Main causes of pontine base infarction unclear what contribute to poor prognosis. are basilar artery atherosclerotic diseases (BAD) occluding Objective(s): To identify the predictor of prognosis in the orifice of perforating arteries and small vessel disease. patients with acute brainstem infarction caused by BA oc- Recent studies have reported that lesion volume frequently clusion or severe stenosis, we investigated the clinical char- increases, which is associated with poor outcome in patients acteristics, stroke mechanism, anatomical patterns of stroke with non-lacunar infarction. Poster Sessions involvement (lower level, higher level, multiple levels), wil- Objective(s): To investigate whether BAD is related to lisian collaterals via posterior communicating artery (PCoA). the lesion volume or clinical outcome in patients with pon- Method(s): We analyzed consecutive 28 patients with ac- tine base infarction ute brainstem infarction and BA occlusion or severe stenosis Method(s): We studied 56 patients who underwent 1) (>75% of diameter) who proven by 4-vessel cerebral an- diffusion weighted MRI within 48 hours after stroke onset, giography over a 4-year period. We divided into two groups: which revealed unilateral pontine base infarction, and 2) fol- good [<3 on the modified Rankin Score (mRS) at dis- low up MRI and MR angiography in the subacute stage. charge] and poor prognostic groups (≥3 on the mRS). We Neurologic progression was defined as increased NIHSS also evaluated multiple regression analysis for the poor score by ≥2 during admission. Clinical outcome was di- prognosis. chotomized as good and poor (≥3) according to the mo- Result(s): Among 28 patients, 15 patients (54%) had dified Rankin Scale at one month after the onset of stroke. good prognosis. The baseline demographics were not sig- Result(s): Twenty-two patients (39%) had BAD, and 15 nificantly differed between good and poor prognostic groups. (27%) had neurologic progression. Follow up MRI pe- Lower level involvement (p=0.017), atherosclerotic mech- rformed 3.5±1.1 days (range 2-7 days) after the initial anism (p=0.035), PCoA hyperplasia (p=0.02) were more MRI showed the lesion size significantly increased (p< significantly common in good prognostic group. Initial 0.001). Increased lesion volume was found in 35 patients NIHSS score (OR, 1.19; 95% CI, 1.01-1.39), existence of (63%) when defined by 20% increase, and in 28 (50%) PCoA hyperplasia (OR, 0.05; 95% CI, 0.01-0.85) were in- patients when defined by 50% increase The BAD was not dependently poor and good predicting factors for prognosis significantly related to demographic characteristics, risk fac- in multiple regression analysis, respectively. tors, initial and follow-up lesion volume, neurologic pro- Conclusion(s): In patients with acute brainstem infarction gression and clinical outcome, but was closely related to the caused by the BA occlusion or severe stenosis, 1) those who subacute increase in lesion volume (p=0.004 for 20% in- have good prognosis are considerable, 2) detailed observa- crease, p=0.029 for 50% increase). tion of initial clinical severity and PCoA hyperplasia might Conclusion(s): BAD it is related to subacute increase in be helpful to predict their prognosis. lesion volume, but not to ultimate poor clinical outcome in patients with pontine base infarction.

Presenting authors are indicated in bold. S79

3rd International Conference on Intracranial Atherosclerosis and Annual Spring Meeting of the Korean Stroke Society POSTER SESSIONS

P051 P052 Etiology and Stroke Pattern of Posterior Cerebral Lenticulostriate Artery Territory Infarcts: Artery Territory Infarcts: Analysis of 205 Patients Correlation of Axial Location with Large Artery with Diffusion Weighted MRI Disease and White Matter Hyperintensities Eugene Lee, Dong-Wha Kang, Sun U Kwon, Jong S Kim Hahn Young Kim, Hyun-Ji Cho, Jeeyoung Oh, Department of Neurology, Asan Medical Center, Seoul, Korea Seol-Heui Han Department of Neurology, Konkuk University Hospital, Seoul, Korea Background(s): Cardiogenic embolism has been shown to be the leading etiology of posterior cerebral artery (PCA) Background(s): MCA stenosis has been suggested as a territory infarcts. However, intrinsic PCA atherosclerotic dis- possible cause of the lenticulostriate artery territory infarcts ease may play a more important role in areas where intracra- (LSAI). However, which axial location of LSAI is more nial diseases are prevalent. correlated with MCA stenosis has not been determined. Objective(s): We aimed to assess the etiologies and stroke White matter hyperintensities (WMHs) possibly caused by pattern of PCA territory infarcts using diffusion-weighted chronic hypoperfusion might reflect underlying perfusion MRI (DWI) and magnetic resonance angiography (MRA). state of LSAI of different axial location. Method(s): we reviewed 229 consecutive acute PCA ter- Objective(s): To investigate MCA disease and WMHs in ritory infarct patients who underwent DWI and MRA within LSAI of different axial location. 7 days after onset. Method(s): A total of 120 consecutive cases of newly de- Result(s): 205 patients (male 56%, mean age 65.4±12.4) veloped LSAIs were classified into three groups: LAC group were recruited. “Superficial”, “deep” and “superficial plus (lacunar infarcts), VSCI group (ventral striatocapsular in- deep” infarcts accounted for 26.3% 47.8% and 25.9%, farcts), and DSCI group (dorsal striatocapsular infarcts). respectively. 126 patients had infarcts limited to the PCA MCAs were divided into three groups: normal group, MCS territory, whereas 79 patients had concomitant infarcts in group (MCA stenosis), and MCO group (abrupt MCA signal other territories. Large artery atherosclerosis (LAA, 42.4%) loss). The WMHs were graded according to Fazeka’s scale. was the most frequent etiology, followed by cardiogenic em- Result(s): The mean size of the infarcts was 1.22±0.54 bolism (20%), small-vessel occlusion (20%), undetermined cm in LAC (n=60), 3.18±0.73 cm in VSCI (n=40), and (18%) and other determined (3%) etiology. Among the 87 2.95±0.68 cm in DSCI (n=20). MCS was more frequently patients with LAA, 38 patients (male 46%, mean age 68.6± observed in DSCI (9/20, 45%) than in VSCI (11/40, 27.5%) 10.0) had intrinsic PCA disease, whereas 49 patients had or LAC (8/60, 13.3%), while MCO was more frequent in vertebrobasilar or aortic arch (extraPCA) disease with or VSCI (9/40, 22.5%) than in DSCI (2/20, 10%) or LAC without PCA disease. Among the 38 patients who had in- (0/60, 0%), p<0.001. The WMH score was higher in DSCI trinsic PCA disease only, atheromatous branch occlusion (19 than in VSCI (PVH: 1.30±0.73 vs. 0.62±0.74, p=0.001; patients) was most prevalent, followed by in situ throm- DWMH: 1.45±0.88 vs. 0.68±0.83, p=0.002). boocclusion (11 patients) and artery-to-artery embolism (8 Conclusion(s): MCA stenosis and WMHs correlate better patients). Lesions were located at the ventrolateral thalamic with DSCI than with VSCI or LAC. MCA stenosis might infarcts (57.9%), parieto-occipital area (44.7%), mid-tem- more frequently predispose to DSCI rather than to VSCI or poral lobe (26.3%) and anterolateral midbrain (21.1%). LAC. Chronic hypoperfusion of LSA might be underlying Conclusion(s): In our population, intrinsic PCA disease is condition of LSAI presenting with DSCI rather than VSCI or a relatively important cause of PCA territory infarct, produc- LAC. ing strokes in various mechanisms.

S80 Presenting authors are indicated in bold. Korean J Stroke(Supplement 1) 2008;10

3rd International Conference on Intracranial Atherosclerosis and Annual Spring Meeting of the Korean Stroke Society POSTER SESSIONS

P053 P054 Topographic Pattern and Stroke Mechanism Different Prevalence of Systemic Atherosclerosis Associated with Progressive Motor Deficits between Patients with Perforating Artery in Acute Motor Stroke Territorial Infarction Presumably due to Small Pil-Wook Chung1, Heui-Soo Moon1, Yong Bum Kim1, Artery Disease and Those due to Arterial Kwang-yeol Park2, Bum-Chun Suh1 Embolus 1Departments of Neurology, Kangbuk Samsung Hospital, Hye-yeon Choi, Young Dae Kim, Hyun Ji Cho, Hyo Suk Nam, Sungkyunkwan University School of Medicine, and Ji Hoe Heo 2Chung-Ang University Medical Center, Chung-Ang University School of Medicine, Seoul, Korea Department of Neurology, Yonsei University College of Medicine, Seoul, Korea

Background(s): Progressive hemiparesis occurs frequently Background(s): A small infarction in the perforating ar- during the acute stage of ischemic stroke. However, the to- terial territory (PAI) may be due to thromboemblism from pographic pattern of the lesions and stroke mechanism as-

the proximal artery atherosclerosis as well as small artery sociated with motor progression remain unclear. disease (SAD). Objective(s): We sought to identify the lesion patterns Objective(s): We tested the hypothesis that patients with and pathogeneses associated with motor progression. Poster Sessions PAI due to SAD may have distinct features of atherosclerosis Method(s): The study population included 135 consecu- in the other vascular beds from those with PAI due to arterial tive patients with acute motor stroke confirmed by diffusion- embolus. weighted imaging (DWI) within 24 hours of stroke onset. Method(s): Among patients with PAI identified from The topographic patterns, risk factors, and presumed stroke stroke registry, those with potential cardioembolic sources mechanism were compared between patients with and with- and other causes of stroke were excluded. Then, patients, out motor progression who had both angiographic and transesophageal echocar- Result(s): Of the 135 patients, 31.8% had motor progres- diographic studies undertaken, were finally included. The sion with a decrease of more than 1 point on the motor item patients were grouped into those who are likely to have SAD of the National Institute of Health Stroke Scale. Of the 110 and arterial embolus. Grouping was based on the presence or patients with subcortical infarcts, 35.5% had motor progres- absence of relevant artery atherosclerosis (RAA) and ath- sion, whereas 6.7% had motor progression in cortical in- erosclerosis of a parent artery (PAA ). Systemic evidence of farcts (p=0.036). Of the patients with subcortical infarcts, atherosclerosis included atherosclerosis in cerebral arteries patients with striatocapsular infarcts more frequently showed other than relevant arteries, atheroma in the descending aorta, motor progression than patients with pontine infarcts, in- coronary artery disease, and peripheral artery disease. Preva- ternal capsule infarcts and corona radiata infarcts (52.4% lence of systemic atherosclerosis, infarct site, and risk factor versus 40.9% versus 28.6% versus 8.3%, p=0.006). Deep were compared among three groups. perforating artery infarct showed frequent motor progression Result(s): Enrolled were 364 patients (men 218, mean age (39%) in comparison with large artery disease (25.6%) and 60.4 years). Classic risk factors of atherosclerosis and loca- cardioembolism (8%). tion of infarctions were not different among the groups. Conclusion(s): Deep perforating artery infarct is the ma- Evidence of systemic atherosclerosis was detected in 100 of jor cause of progressive motor deficits. The worsening of 107 patients with RAA (93.5 %), 72 of 81 with PAA (89%), focal neurological deficits might be caused by different me- and 90 of 183 without RAA (49.2 %), which was signifi- chanisms in cortical and deep subcortical infarcts. cantly lower in the patients without RAA.

Conclusion(s): PAI patients due to SAD may have lower

prevalence of atherosclerosis in other vascular beds than

those due to arterial embolus.

Presenting authors are indicated in bold. S81

3rd International Conference on Intracranial Atherosclerosis and Annual Spring Meeting of the Korean Stroke Society POSTER SESSIONS

P055 P056 Recurrent Isolated Vertigo from Hypoplastic Golfer’s Stroke from Internal Carotid Artery Vertebral Artery Dissection Sung-Ho Ahn1, Se-Jin Oh1, Ji-Won Yook1, Kwang-Dong Choi1, Se-Jin Oh1, Tae-il Yang1, Kwang-Dong Choi1, Tae-Hong Lee2, Ji Soo Kim3, Tae-Hong Lee2, Dae Soo Jung1 1 1 Kyu-Hyun Park , Dae Soo Jung 1Departments of Neurology and 2Radiology, Pusan National University Departments of 1Neurology and 2Radiology, Pusan National University Hospital, Busan, Korea Hospital, Busan, 3Department of Neurology, Seoul National University Bundang Hospital, Seongnam, Korea Background & Significance: Although earlier publica- tions have reported golf-induced stroke involving cerebellum Background & Significance: Recurrent vertigo lasting or brainstem due to vertebral artery dissection, golf-induced minutes without associated neurological or neuro-otological stroke from the internal carotid artery dissection has not been symptoms may be a sign suggesting vertebrobasilar insuf- previously described. ficiency (VBI). Although transient ischemia of the vestibular Case: A 47-year-old man presented with sudden onset of labyrinth, which is supplied by the internal auditory artery dysarthria and left-sided weakness during practicing golf on (IAA) originating from the anterior inferior cerebellar artery a driving range. His previous medical history was unre- (AICA), is a potential mechanism of isolated vertigo in VBI, markable. On examination he was drowsy and he had right reduced blood flow to the cerebellum or brainstem remains gaze preference, and visual and tactile extinction to the left another possibility. stimuli. He showed left central type facial palsy and left Case: A 55-year-old woman presented with acute onset of hemiparesis. Diffusion-weighted MRI of the brain showed vertigo and imbalance. The patient reported preceding recur- infarctions in the territory of right middle cerebral artery. rent vertigo with a frequency of once or twice a day for the Cerebral angiography revealed dissection of the right inter- preceding five days. Each episode of vertigo lasted approxi- nal carotid artery and occlusion of the right middle cerebral mately 30 minutes. Neurological examination revealed right artery. There was no underlying defect in the dissecting artery beating nystagmus in the primary position, which was aug- and the patency of other cerebral arteries was normal. He mented without fixation, during rightward gaze, and by underwent stent-assisted angioplasty of right internal carotid horizontal head-shaking and vibratory stimulation on the artery and subsequent intra-arterial urokinase injection in mastoids. Head impulse test, and saccadic and smooth pur- right middle cerebral artery. The patient remarkably recovered suit eye movements were normal. Bithermal caloric stimula- with only mild dysarthria within a week and was discharged tion and pure tone audiometry were unremarkable. Diffusion- home with aspirin (325 mg) and clopidogrel (75 mg). weighted MRI showed high signal intensities in the territory Conclusion or Comment: In the present case, a sudden, of left posterior inferior cerebellar artery. MR angiography severe stretch of the internal carotid artery over the upper exhibited only hypoplastic left vertebral artery with patent cervical spine by abrupt neck rotation while playing golf may vertebrobasilar arteries. force the internal carotid artery against the upper cervical ver- Conclusion or Comment: The present case suggests that tebrae, allowing it to become fixed in place and thus becom- isolated vertigo in VBI may develop due to transient ischemia ing susceptible to injury. in the cerebellar PICA territory from HVA. Clinicians should consider prescription of antiplatelet agents in patients with recurrent isolated vertigo lasting minutes and hypoplastic vertebral artery.

S82 Presenting authors are indicated in bold. Korean J Stroke(Supplement 1) 2008;10

3rd International Conference on Intracranial Atherosclerosis and Annual Spring Meeting of the Korean Stroke Society POSTER SESSIONS

P057 P058 Simultaneous Posterior Ischemic Optic Lateral Medullary Infarction Subsequent Neuropathy, Cerebral Border Zone Infarction, and to Medial Medullary Infarction in a Patient Spinal Cord Infarction after Correction with Vertebral Artery Occlusion of Malignant Hypertension Jee-Hyun Kwon, Hyun Cho, Hyun-Jin Seo Jae-Hwan Choi1, Kwang-Dong Choi1, Ji Soo Kim2, Department of Neurology, Ulsan University Hospital, Ulsan, Korea 3 1 Hak Jin Kim , Dae Soo Jung 1 Departments of Neurology, Pusan National University Hospital, Busan, and : 2Seoul National University Bundang Hospital, Seongnam, and Background & Significance Patients with isolated lat- 3Department of Radiology, Pusan National University Hospital, Busan, eral medullary infarction or medial medullary infarction usu- Korea ally have ipsilateral occlusion of the vertebral artery. Each infarction might develop simultaneously. However, it is rare. Background & Significance: Malignant hypertension We present a patient with vertebral artery occlusion who refers to severe hypertension and organ damage including developed lateral medullary infarction soon after medial progressive renal failure, heart failure, and encephalopathy. medullary infarction. Malignant hypertension requires urgent correction of blood Case: A 76-year-old woman with hypertension and dia- pressure. Paradoxically, a few reports have described patients betes mellitus suddenly developed dysphagia and dizziness. Poster Sessions with neurological abnormalities following treatment of ma- She presented left hemiparesis and numbness 13 days before lignant hypertension. Nevertheless, simultaneous optic ne- admission into our hospital. Diffusion weighted image at uropathy, cerebral border zone infarction, and spinal cord that time revealed right medial medullary infarction. Her infarction have not been previously fully described. neurologic deficits of the 1st attack had been markedly Case: A 31-year-old woman developed bilateral posterior improved for 10 days and she was discharged with aspirin. ischemic optic neuropathy and infarctions of the cerebral She complained of swallowing difficulty and dizziness 3 arterial border zones and spinal cord following correction of days after discharge from local clinic. Neurologic examina- malignant hypertension, which were documented by full tion at 2nd attack revealed right Horner syndrome, left clinical and neuroimaging studies. After maintenance of the hypoesthesia including the face and extremities and skew blood pressure within the normal range, leg weakness had deviation in the right eye corresponding with lateral med- resolved completely one day later. However, two months later, ullary syndrome. Magnetic resonance image taken at that visual acuities remained hand movements in both eyes and time showed acute infarction in the right lateral medulla and voiding difficulty had not improved. Bilateral optic disc subacute infarction in the medial medulla. Occlusion in the pallor was now evident and brain MRI showed persistent right distal vertebral artery was noted in the magnetic reson- high signal areas throughout the medulla and spinal cord ance angiography. We treated her with clopidogrel and aspirin without change. and her neurologic deficits did not progressed any more. Conclusion or Comment: This case suggests that the Conclusion or Comment: Lateral medullary infarction relative hypotension of autoregulatory failure induced by subsequent to medial medullary infarction may develop in treatment of malignant hypertension may give rise to these vertebral artery occlusion and physician should consider neurological complications. aggressive treatment such as combination therapy of antiplatelet agents in patient with parent artery occlusion.

Presenting authors are indicated in bold. S83

3rd International Conference on Intracranial Atherosclerosis and Annual Spring Meeting of the Korean Stroke Society POSTER SESSIONS

Stroke Syndrome & Clinical Aspects Stroke Syndrome & Clinical Aspects

P059 P060 Five Cases of Cerebral Infarction Associated with Comparison of the Characteristics for In-Hospital Multiple Myeloma and Out-of-Hospital Ischemic Strokes Sang-Won Park1, Tae-Wan Kim1, Won-Sik Lee3, Hyun-Ji Cho1, Hyung Jun Park2, Young-Dae Kim2, Sung-Il Sohn2 Dong Woo Lee2, Hye-Yeon Choi2, Seung Min Kim2, Ji Hoe Heo2 Departments of Neurology, 1Fatima Hospital, Departments of Neurology, 1Konkuk University School of Medicine, and 2Dongsan Medical Center, Keimyung University School of Medicine, and 2Yonsei University College of Medicine, Seoul, Korea 3Department of Hemato-oncology, Fatima Hospital, Daegu, Korea

Background(s): Patients who are being admitted to a hos- : Background & Significance Hematological diseases are pital due to diseases other than stroke may develop a stroke seldom found as the etiology of ischemic strokes. Especially, (in-hospital stroke; IHS). ( ) cerebral infraction associated with multiple myeloma MM Objective(s): However, the general characteristics of IHS is rare. We present four patients with cerebral infarction who have not been well known. have MM and suggest additional pathomechanism of ische- Method(s): We enrolled 111 consecutive patients who mic stroke in myeloma patients. developed IHS outside a neurology ward during a 5-year pe- : ( ) Case A 46-year-old woman patient 1 was admitted to riod at a single university hospital. The incidence, charac- our hospital because of right hemiparesis and dysarthria. She teristics and outcomes for IHS patients were retrospectively was suffered from MM for 5 years. Diffusion weighted MRI analyzed and compared with patients who develop ischemic showed abnormal high signal intensities on frontoparietal stroke outside of the hospital (out-of-hospital stroke; OHS). area. Conventional angiography showed focal stenosis of left Result(s): IHS comprised 0.04% of the total admissions ( ) distal ICA. 76-year-old man patient 2 was admitted due to during the study period. Forty-six percent of IHS occurred in sudden onset left hemiplegia. By bone marrow biopsy MM the department of cardiology or cardiovascular surgery and was diagnosed. MRI showed high signals on right internal 60% were associated with surgery or procedures. In compa- borderzone area and MRA showed occlusion of right prox- rison with the OHS patient group, the IHS patient group sh- ( ) imal MCA. A 59-year-old woman patient 3 developed right owed an increased frequency of cardiac disease, leukocytosis hemiplegia with dysarthria since 2 days ago. MRI showed and anemia. There were also differences in stroke subtypes high signals on left centrum semiovale and MRA showed between the OHS and IHS groups; cardioembolism, stroke ( ) occlusion of left ICA. A 64-year-old man patient 4 was of other determined etiologies and an incomplete evaluation admitted due to stuttering with dizziness. MRI showed high were more common in the IHS group, whereas large artery ( signals on left corpus callosum. A 81-year-old woman pa- atherosclerosis was more frequent in the OHS group. The ) tient 5 presented dyspnea. On laboratory test, increased Ig IHS group had up to a 10-fold higher mortality than the OHS ( ) G 9,005 mg/dL was checked. After bone marrow biopsy, group, with sepsis being the most common cause of death in she was diagnosed as MM. MRI showed leukoaraiosis and the IHS group. MRA showed stenosis of left distal ICA. Conclusion(s): IHS has distinct etiologies and stroke me- : Conclusion or Comment The present five cases provide chanisms from OHS. As a result, the implementation of the additional evidence to support atherothrombosis and hyper- activation system for brain attack code should be a focus on viscosity as pathogenesis of developing ischemic stroke in cardiology and cardiovascular surgery floors. Further, the pre- MM. Future studies collecting data from a large number of vention and management of infection could decrease mor- centers may possibly detect further significant mechanisms tality in IHS patients. of cerebral infarction in myeloma patients.

S84 Presenting authors are indicated in bold. Korean J Stroke(Supplement 1) 2008;10

3rd International Conference on Intracranial Atherosclerosis and Annual Spring Meeting of the Korean Stroke Society POSTER SESSIONS

P061 P062 Low-Flow Type Boderzone Infarction Induced Boderzone Infarction as a Complication of by Heavy Smoking Bacterial Meningitis Il Mi Jang, Doheui Kim, Ji Sun Kim, Young Soon Yang, Ji Sun Kim, Doheui Kim, Il Mi Jang, Young Soon Yang, Kyung Bok Lee, Hakjae Roh, Moo Young Ahn Kyung Bok Lee, Hakjae Roh, Moo Young Ahn Department of Neurology, Soonchunhyang University Hospital, Department of Neurology, Soonchunhyang University Hospital, Seoul, Korea Seoul, Korea

Background & Significance: Various causes of hemody- Background & Significance: Acute bacterial meningitis namic failure as well as thromboembolism can induce bor- can cause vascular complications which frequently mani- derzone infarction. Heavy smoking can acutely lead to hy- festes a large territorial or venous infarct. We report a 24-year- poxia by cerebral vasoconstriction. We report a patient who old woman with pneumococcal meningitis who had unusual had recurrent episodes of left sided numbness and dysarthria cerebral infarcts. in the middle of heavy smoking. Case: She was presented with headache and high fever Case: A 53-years-old man visited hospital for his right after resection of pontine schwannoma. Her CSF profiles in- ( ) ( sided numbness. For the last several months, he found that cluded pleocytosis WBC 1,440/ml , increased protein 384 Poster Sessions ) ( ) his right limb numbness and dysarthria aggravated insidi- mg/dl , and decreased glucose 2 mg/dl . In the course of an- ously during heavy smoking. He was a 30-pack-year current tibiotics treatment, she showed weakness in the right limbs. smoker, but did not have any vascular risk factor. On neu- Magnetic resonance image revealed multiple lesions in both rologic examination, he showed slight weakness and hype- hemisphere, mainly in the arterial borderzone areas. The la- sthesia in the right limbs. Brain magnetic resonance image boratory tests for blood clotting and coagulation were enti- revealed old ischemic change in the left internal borderzone rely normal. Anti-nuclear antibody, rheumatoid factor, and between anterior cerebral artery (ACA) and middle cerebral anti-neutrophil cytoplasmic antiboty were negative. There was artery (MCA). Decreased vascularity of the left ACA and neither arthersclerotic lesion in transfemoral cerebral angio- MCA with diffuse narrowing of the left distal ICA was de- grahy nor embolic source in the heart. tected in magnetic resonance angiography. Transcranial do- Conclusion or Comment: This is an unusual case of ce- ppler showed much decreased flow velocity of the left MCA rebral infarct with arterial borderzone involvement in patient compared with the right MCA. with bacterial meningitis. The cerebral infarct might be ex- Conclusion or Comment: The old infarct lesion was cau- plained by vasospasm or vasculitis of the small arteries in sed by chronic ischemic damage of ‘watershed’ area bet- which insufficient collaterals were supplied. ween ACA and MCA His fluctuating symptoms could result from transiently decreased cerebral flow due to vasocontric- tion and hypoxia evoked by heavy smoking.

Presenting authors are indicated in bold. S85

3rd International Conference on Intracranial Atherosclerosis and Annual Spring Meeting of the Korean Stroke Society POSTER SESSIONS

P063 P064 Cerebrovascular Complications Associated with Moyamoya Disease with Subclavian Artery Scrub Typhus Involvement Young-Mok Song, Jae Il Kim, Geun Ho Lee, Chang-Min Lee Seunghwan Yoon, Sunyoung Kim, Jongyun Lee, Department of Neurology, Dankook University Hospital, Cheonan, Korea Yeunkyung Jung, Imseok Koh, Philza Cho Department of Neurology, National Medical Center, Seoul, Korea Background & Significance: Scrub typhus is an infec- tious rickettsial disease caused by Orientia tsutsugamushi. Background & Significance: Moyamoya disease is cha- Cerebrovascular complications associated with scrub typhus racterized by progressive occlusion of the bilateral carotid have been rarely reported. forks associated with a fine vascular network at the base of Case: We report two patients with cerebrovascular events brain. Clinical manifestations include hemiplegia of sudden following scrub typhus, one with acute cerebral infarction onset, symptoms of intracranial bleeding and seizures. Extra- and the other with venous sinus thrombosis. The patients de- cranial involvement of moyamoya disease has been reported veloped fever, malaise, and eschars followed by neurological in several studies, but this was mostly in renal and major ab- deficits. The serum immunofluorescent antibody assay was dominal arteries. positive for Orientia tustusgamushi. Brain MRI showed an Case: A 45-year-old woman was admitted to our hospital acute infarct in the left parietooccipital cortex in one patient, for evaluation of mental change. She had mitral regurgitation and a hemorrhagic infarct in the left temporal lobe with and mitral valve replacement was performed at age 23. She thrombosis in the left transverse and sigmoid sinuses in the had 15 times stroke and was diagnosed with moyamoya dis- other patient. They had a good recovery after treatment with ease a year before. On neurological examination, she had a doxycycline. diplopia (left 3rd nerve palsy) and was drowsy mental status. Conclusion or Comment: Cerebrovascular system invol- Brain MR diffusion image revealed midbrain infarction. On vement should be considered in patients showing sudden admission his left hand was pallor and cyanotic change, and neurological deterioration after scrub typhus infection. her brachial blood pressure was 85/60 mmHg on left side (125/80 mmHg on right side). Bilateral subclavian CT angiography showed left subclavian artery occlusion and right subclavian artery stenosis. All serologic and immunologic tests, including anti-nuclear antibody, anti-phospholipid antibody, and anti-neutrophil cytoplasmic antibody were negative. Conclusion or Comment: The definitive cause, natural history, and pathogenesis of moyamoya disease remain unclear. Extracranial involvements of moyamoya disease have been most often reported in the renal artery. And renal artery stenosis may cause renovascular hypertension. Peripheral artery involvement in moyamoya disease is rare presentation. We reported the case of moyamoya disease with bilateral subclavian artery involvement.

S86 Presenting authors are indicated in bold. Korean J Stroke(Supplement 1) 2008;10

3rd International Conference on Intracranial Atherosclerosis and Annual Spring Meeting of the Korean Stroke Society POSTER SESSIONS

P065 P066 Hypoglossal Nerve Palsy Associated with Posterior Reversible Encephalopathy Syndrome Relevant Internal Carotid Artery Stenosis Associated with Acute Pancreatitis Mimicking Internal Carotid Artery Dissection Sejin Lee, Jun Lee, Minsu Park Ilhong Son1, Sunwon Kang1, Youngjin Kim1, Julee Jung1, Department of Neurology, College of Medicine, Yeungnam University, Sunjung Han1, Sungik Lee1, Hyunduk Yang1, Jaikyoo Lee2 Daegu, Korea 1Department of Neurology and Inam Neuroscience Research Center, and 2 Department of Emergency Medicine, Sanbon Medical Center, : Wonkwang University, Gunpo, Korea Background & Significance Reversible posterior leukoencephalopathy syndrome was first described as a distinct

Background & Significance: The peripheral hypoglossal clinico-radiological syndrome in 1996, and it is characterized by headache, vomiting, altered mentality, seizures and nerve palsy is caused by tumors, trauma, medullary infarctions, blurred vision. PRES is associated with a multitude of di- hysteria, multiple sclerosis, surgey, Guillain-Barre neuropa- verse clinical entities, such as hypertensive encephalopathy, thy, infection, and several vascular causes such as a carotid eclampsia, uremia, porphyria, connective tissue disease, im- artery aneurysm or dissection, dissection, thrombosis and munosuppressant toxicity, bilateral carotid artery dissection, kinking of the vertebral artery and an anomalous vertebral artery course. Also isolated hypoglossal nerve palsy is a rare sepsis, infection, and shock. We report a case of PRES asso- Poster Sessions

ciated with acute pancreatitis. manifestination of internal carotid artery (ICA) dissection Case: We describe a case of a 49-year-old man who pre- or thrombosis. sented with altered mental status. MRI showed the typical Case: A 77-year-old man admitted to our hospital due to features of PRES, including vasogenic edema at the parieto- suddenly developed dysarthria, dysphagia and tongue devia- occipital area and cerebellum, with minimal cytotoxic edema tion to the right side 3 days ago. 15 days previously, he re- presented pain in the right temporal and retroauricular area and microbleeds. Laboratory tests and abdominal computed tomography revealed acute pancreatitis. He recovered from but there was no tenderness on the area. Neurologic exami- PRES and acute pancreatitis within 8 days. nation at admission were unremarkable except for only right Conclusion or Comment: Since there has been no report hypoglossal nerve palsy associated dysarthria and dyspahgia. of an association between PRES and acute pancreatitis, it is Brain MRA performed at admission showed moderate nar- not conclusive whether acute pancreatitis can be a genuine rowing of ICA but no abnormal signal intensity on Diffusion Weighted Image (DWI). CT angiography showed moderate etiology of PRES. However, our patient had no known cause of PRES, except for acute pancreatitis. Based on the findings stenosis in the right proximal ICA. CSF study was normal. in our patient, we suggest that alcoholic pancreatitis might On 5th hospital day, susevere left hemiparesis (GI) and dy- complicate PRES. Our patient might be the first case report sarthria were developed suddenly, and we treated him with of PRES associated with acute pancreatitis, but more case intravenous heparin. And then after 1 hour, his symptoms reports are needed before any conclusions can be drawn. recovered to the previous condition. DWI showed acute infarction in the right frontal cortex, superficial perforator, border zone infarction.

Conclusion or Comment: We report a case of hypoglossal nerve palsy associated with relevant ICA stenosis.

Presenting authors are indicated in bold. S87

3rd International Conference on Intracranial Atherosclerosis and Annual Spring Meeting of the Korean Stroke Society POSTER SESSIONS

P067 P068 Unusual Case of Hypertensive Encephalopathy Chronic Isolated Vertigo Followed by Progressive Involving the Whole Brainstem and Subcortical Posterior Circulation Stroke Deep Structures Sucjoo Kim, Ji-Young Park, Jungmoo Nam, Curie Chung, Jong-Ho Park1, Hyeyun Kim1, Eun-Ja Lee2, Sung-Min Kim1, Byung-Kun Kim, Ohyun Kwon, Ja-Seong Koo, JungJu Lee, Hyun Jeong Han1 Jong-Moo Park Departments of 1Neurology and 2Diagnostic Radiology, Myongji Hospital, Department of Neurology, Eulji General Hospital, Eulji University Kwandong University College of Medicine, Goyang, Korea College of Medicine, Seoul, Korea

Background & Significance: In patients with hyperten- Background & Significance: Chronic isolated vertigo is sive encephalopathy, brain edema is frequently distributed in classically attributed to peripheral origin and rarely consi- the parieto-occipital white matter. We report a patient with dered to reflect vertebrobasilar ischemia. high arterial blood pressure, who had unusually extensive Case: We report two cases of progressive posterior circu- MRI-documented lesions. lation stroke presented with prolonged fluctuating dizziness Case: A 42-year-old woman had hypertension diagnosed as initial symptom. They came to outpatient clinic because 2 years earlier. One month before, she stopped antihyperten- of fluctuating dizziness for a few months, worsened by sud- sive medication. She was brought to the department of emer- den posture change. Both of them had diabetes mellitus. In- gency medicine because of dizziness, followed by drowsy itial neurologic examinations and routine brain MRI revealed and confused mentality. Initial blood pressure (BP) was no abnormalities. Several days later, they developed some 240/150 mmHg. Brain magnetic resonance (MR) imaging neurologic deficits; spontaneous nystagmus, eyeball move- depicted widespread vasogenic edema in the bilateral cere- ment impairment, bilateral motor weakness and altered alert- bellum, brainstem, basal ganglia, thalami, and subcortical ness. Brain MRI indicated multiple acute ischemic lesions white matters on apparent diffusion map, which was hype- on brainstem and cerebellum. In addition, MR angiography rintense on T2-weighted, and fluid-attenuated inversion re- denoted multifocal severe stenoses in vertebrobasilar arteries covery (FLAIR) images, while the same lesions showed in both patients. During admission, their neurologic symp- isointensity on T1- and diffusion-weighted images. Thoracic toms progressed for several days, accompanied by lesion echocardiography showed severe concentric left ventricular growth and additional lesions on subsequent neuroimagings. hypertrophy with diastolic dysfunction. After lowering ele- Conclusion or Comment: We suggest that chronic iso- vated BP for a week, she recovered her consciousness. The lated vertigo can be the only manifestation of vertebrobasilar score of the mini-mental status examination was 10/30 four ischemia. Cerebrovascular assessment may provide valuable days after symptom onset, which was later 23/30 seven days information for diagnosis and follow-up the patients with after initial study. Eight months after admission, her follow- chronic vertigo. up FLAIR image revealed reversible findings except leukoaraiosis. Conclusion or Comment: It is plausible that arterioles supplying the deep structures (e.g. thalamus, basal ganglia, and brainstem) are subjected to higher arterial pressure than the terminal branches supplying the cortex and subcortex. Thus, in our patient, paroxysmally accelerated hypertension may be necessary for the dysfunction of autoregulation and breakdown of the blood-brain barrier in cases of vasogenic edema of the whole brain.

S88 Presenting authors are indicated in bold. Korean J Stroke(Supplement 1) 2008;10

3rd International Conference on Intracranial Atherosclerosis and Annual Spring Meeting of the Korean Stroke Society POSTER SESSIONS

P069 P070 Hemangioblastoma Presenting with Isolated Ptosis as Presenting Symptom of Wallenberg’s Syndrome a Basal Ganglionic Infarction Seunghwan Yoon, Sunyoung Kim, Jongyun Lee, Hak Seung Lee, Hyun Young Park, Hyuk Chang, Yo Sik Kim, Yeonkyung Jung, Imseok Koh, Philza Cho Kwang Ho Cho Department of Neurology, National Medical Center, Seoul, Korea Department of Neurology, Wonkwang University Hospital, Iksan, Korea

Background & Significance: Wallenberg’s syndrome is Background & Significance: The ptosis secondary to ce- usually caused by infarction of the lateral portion of the me- rebral vascular event (cerebral ptosis) is unusual and has not dulla. But, it may be due to other than primary vascular dis- been well documented. Furthermore, this abnormality has orders. We report a patient with Wallenberg’s syndrome rarely been reported with deeper-seated vascular lesion. We caused by hemangioblastoma. present a patient with acute onset of cerebral infarction in Case: 61-year-man was admitted by suddenly developed right basal ganglia. The patient was right-handed and pre- vertigo and right side lateropulsion. Neurological examina- sented only unilateral ptosis (contralesional side). tion revealed right side Horner sign, right side limb ataxia, Case: A 58-year-old right-handed man without any history

left side hypalgesia and dysphasia. Temperature and pinprick of neurologic events was visited with acute onset of left pto- Poster Sessions

senses were decreased in the left arm, trunk and leg, to app- sis. He was alert and oriented with fluent speech. He had no roximately 60% of those on the right side. Vibration and sen- evidence of orofacial or limb apraxia. He had no facial weak- sation was spared. A diagnosis of lateral medullary syndrome, ness and no hemiparesis. There was no neglect or sensory known as Wallenberg syndrome, was made. MRI showed loss. Brain MRI done at time of admission showed a right hypersignal intensities in right lateral medullar. After onset, basal ganglia infarction. The ptosis was improved but still he felt slow developed intermittent right side hypalgesia and present when he was seen two weeks later. There was no evi- numbness. Follow up Brain MRI showed right medullary dence of extrapyramidal disease. mass. Surgical resection was done. Pathologic findings were Conclusion or Comment: The pathophysiologic substrate compatible with hemangioblastoma. for disorders of eyelid movements is not well known. Re- Conclusion or Comment: This patient presented a cli- cently, the basal ganglia have been shown to play an impor- nical picture consistent with Wallenberg’s syndrome. But, tant role in production of the blink reflex. This presentation final diagnosis is hemangioblastoma. Despite in most cases indicates that the control of eyelid movements is lateralized, Wallenberg’s syndrome is caused by an arteriosclerotic th- most likely to the non-dominant hemisphere, accounting for rombotic occlusion of the posterior inferior cerebellar artery, the development of these abnormalities with unilateral lesions. the vertebral artery or the basilar artery, it can be caused by syphilitic vascular disease, brain-stem tumor, metastatic carcinoma, metastatic brain-stem encephalitis caused by infect- ious foci in the lung, herpetic brain-stem encephalitis, de- myelinating disease, mechanical trauma to vertevral artery in the neck and so on. It should be kept in mind that it is but a clinical picture and there are several possible causes.

Presenting authors are indicated in bold. S89

3rd International Conference on Intracranial Atherosclerosis and Annual Spring Meeting of the Korean Stroke Society POSTER SESSIONS

Neuropsychological Aspects & Others Neuropsychological Aspects & Others

P071 P072 Vascular Ehlers-Danlos Syndrome Presenting Effect of Leukoaraiosis on the Conscious with Bilateral Internal Carotid Artery Dissection Condition in Patients with Ischemic Stroke Sang-Bae Ko, Seung-Hoon Lee, Byung-Woo Yoon Xiaojuan Wang1, Yannan Fang1, Hua Li2, Xianliang Li1, 1 1 Department of Neurology, Seoul National University Hospital, Li Ren , Aiwu Zhang Seoul, Korea Departments of Neurology, 1The First Affiliated Hospital, Sun Yat-sen University, and 2Guangdong 999 Brain Hospital, Guangzhou, China Background & Significance: Vascular Ehlers-Danlos

(VEDS) syndrome is a relatively rare connective tissue dis- Background(s): Nowadays leukoaraiosis (LA) has been order that causes arterial dissection, and is often difficult to believed as an important effective factor for stroke, cognitive diagnose due to the lack of typical joint laxity. We report a disturbance and dementia. The incidence of stroke in pati- case of VEDS which presented with multiple arterial dis- ents with LA was 50% higher than that in patients without sections at the internal carotid artery, and ascending aorta LA. However, little is known whether LA can affect the con- which posed him a great risk. scious condition of patients with ischemic stroke. Case: A 31-year-old man came to our clinic for further ev- Objective(s): To study the effect of LA on conscious con- aluation of bilateral neck pain. He was diagnosed as having a dition in patients with acute ischemic stroke. lower leg varicose vein with right tibial arteriovenous fistula Method(s): A follow-up study including 138 patients with at the age of 15. Two years later, he had an acute abdominal acute ischemic stroke was carried out. Patients were divided pain due to the spontaneous bilateral renal artery dissection. into LA group (n=78) and non-LA group (n=60) according Three years ago, he underwent laboratory work up due to to magnetic resonance imaging (MRI). Conscious condition easy bruisability, which did not reveal any abnormalities. was assessed by Glasgow Coma Scale (GCS) at the time of One month ago, he experienced severe neck pain and head- recruitment, 1, 3, 6, 9, and 12 months later. ache just after vigorous sneeze. Neck MRA identified bilate- Result(s): LA was found to be an independent affected ral internal carotid artery (ICA) dissection. Cerebral angio- factor on the conscious condition after ischemic stroke (OR graphy showed bilateral ICA dissection at the junction of =5.294, 95% CI=1.451-19.318). The GCS scores in LA cervical and petrous portion. Stent assisted coil embolization group was significant lower than that in non-LA group (p< was tried, however, patient collapsed during procedure. Em- 0.05) at the time of recruitment, 1 month and 3 months after ergency angiography identified dissection at the ascending stroke. aorta which progressed into the cardiac tamponade. Emergent Conclusion(s): LA may be an independent risk factor for pericardiocentesis with total aortic arch replacement was done conscious condition after ischemic stroke. LA may be a ne- without complication. Histologic examination of the aorta gative effect on the improvement of conscious disturbance in showed myxoid degeneration of vascular wall with irregular early stage after onset of stroke. shaped collagen fibrils, which was consistent with VEDS. Conclusion or Comment: Systemic searching for hidden arterial dissection should be made when VEDS is suspected. Special care with gentle manipulation is mandatory.

S90 Presenting authors are indicated in bold. Korean J Stroke(Supplement 1) 2008;10

3rd International Conference on Intracranial Atherosclerosis and Annual Spring Meeting of the Korean Stroke Society POSTER SESSIONS

P073 P074 Acute Memory Disturbance after Cerebellar Neuropsychological Profile of Thalamic Infarction: Infarction: a Case Report a Comparison between Left and Hyun Cho, Ji-Hyun Kwan, Hyun-Jin Seo Right Thalamic Lesions Department of Neurology, Ulsan University Hospitsl, Ulsan, Korea Jaeseol Park1, Yeonwook Kang1,2, Kyung-Ho Yu1, 1 Byung-Chul Lee 1 : Department of Neurology, Hallym University Sacred Heart Hospital, Background & Significance Studies employing func- Anyang, and tional magnetic resonance imaging (fMRI) and anatomical 2Department of Psychology, Hallym University, Chuncheon, Korea tracing provide evidence for a cortico-cerebellar circuitry. They postulate a disruption in widespread cortico-cerebellar Background(s): Thalamic lesion has consistently been circuitry as cause of impaired cognitive functions. But there found to induce neuropsychological impairments. There are were very few descriptions of clinically relevant cases that few studies in Korea that investigate the cognitive sequelae address this possibility. We describe the case with acute me- of the thalamic infarction and its laterality effect. mory disturbance after cerebellar infarction. Objective(s): This study was conducted to examine 1) the Case: A 55-year-old man was admitted with acute onset of characteristics of cognitive impairments at the early stage dizzy spells with intermittent vomiting. His brain MRI was after thalamic infarction and 2) the lateralized (left vs. right) Poster Sessions done on that day which revealed multiple lacunar infarctions effects of thalamic lesions. in bilateral occipital lobes, the right pons and the right ce- Method(s): A comprehensive neuropsychological exami- rebellum with hemorrhagic transformation in the left occi- nation, the Seoul Neuropsychological Screening Battery was pital lobes. Two days later, he suddenly developed amnesia. administered to 24 patients with an isolated thalamic infarct He had some degree of patched memory defect during the and 30 normal elderly. The patients were given the evaluation previous several days and could not remember his correct within a week after stroke onset. There were no significant address. Brain SPECT using Tc-99m-HMPAO showed de- differences between these two groups in age, education level, creased perfusion in the left temporal and prefrontal cortices or gender. and right cerebellum. Also additional MRI revealed increased Result(s): The patients showed lower performance than in the extent of the multiple lacunar infarctions in the right the normal elderly on K-MMSE, attention, language (con- cerebellum. Neuropsychological tests exhibited cognitive im- frontational naming), calculation, visuospatial perception and pairments in the domain of verbal and visual memory, verbal construction, verbal memory, motor programming & coordi- fluency and attention. nation, and frontal executive function tests. Further analysis Conclusion or Comment: We could suggest that the cere- was conducted to examine the laterality effect using Mann- bellum is a part of a widespread cortico-cerebellar network Whitney U test. It showed that delayed recall of verbal involving the frontal lobe, the parietal cortex and subcortical memory test was significantly lower in patients with the left brain areas. thalamic lesion than those with the right thalamic lesion. However, such a laterality effect was not found in any other tests except verbal memory test. Conclusion(s): The results showed that the thalamic patients got significant deficits in overall cognitive domains. Material-specific laterality effect was partially supported only in the left side. More data should be collected for further analyses based on the affected specific nucleus in the future.

Presenting authors are indicated in bold. S91

3rd International Conference on Intracranial Atherosclerosis and Annual Spring Meeting of the Korean Stroke Society POSTER SESSIONS

P075 P076 Cognitive Profiles and Behavioral Psychological A Case of Thalamic Infarction Presenting with Assessment Pattern in the Patient Neglect Syndrome as a Predominant Symptom with Strategic Infarction Hyun Woo Yang, Jung Chul Lim, Sung Hun Lee, Eung Gyu Kim Soo Yoon Lee, Sung Kwan Kim, Hyo-Jin Bae, Department of Neruology, Inje University College of Medicine, Jae-Kwan Cha, Kyung Won Park Busan Paik Hospital, Busan, Korea Department of Neurology, Dong-A University College of Medicine, Busan, Korea Background & Significance: Thalamic infarction can be presented with many clinical symptoms. But isolated neglect Background(s): Strategic infarct dementia (SID) is characterized by focal ischemic lesions involving specific sites syndrome was not reported at least our knowledge. that are critical for higher cortical functions. However, the Case: A 65-year-old man came to our department because mechanisms of SID, cognitive profiles and the pattern of of his abnormal behavior. He could not put on the shoes and behavioral psychological symptoms are not well defined. Objective(s): We evaluated lesion sites, neuropsychiatric he was continuously looking at his right side. Neurological symptoms, neuroimaging and characteristics of neuropsy- examination revealed hemispatial neglect and asomatognosia chological assessment profiles according to the location of to the left side. The other neurological examination was un- strategic infarct. Method(s): We recruited 61 vascular dementia patients remarkable. Magnetic resonance imaging (MRI) showed an caused by acute strategic infarction in the Dong-A Medical acute lesion on the right anterior thalamus. He was treated Center between September, 2001 and December, 2007. Am- with anti-platelet and his neglect was improved within four ong those patients, cases who had incomplete evaluations were excluded. Based on their clinical characteristics, brain days. imaging findings and comprehensive neuropsychological test Conclusion or Comment: Neglect syndrome can be a result, 46 patients with SID were included in this study. All predominant symptom of the thalamic infarction. patients were given a clinical history taking, a neurological examination and brain MRI with MRA. And then we evaluated neuropsychiatric symptoms and neuropsychological status using a Korean-version of the Neuropsychiatric Inven- tory (K-NPI) and Seoul Neuropsychological Screening Ba- ttery (SNSB) assessing attention, memory, language, visuospatial function and frontal executive functioning. We also analyzed the profiles of cognitive deficits according to the various lesion sites causing strategic infarcts. Result(s): Various sites were responsible for SID; thalamus (n=13), medial temporal lobe (n=11), ACA territorial lesion (n=9), genu of internal capsule (n=8), angular gyrus (n=3), occipital lobe with splenium (n=2). The thalamus, medial temporal lobe were the most common sites responsible for SID. The frequent neuropsychiatric symptoms were apathy (74%), indifference (17%) and depression (11%) according to the K-NPI. The patients showed neuropsychological deficits on various cognitive domains such as, attention, memory, language, visuospatial functions and frontal executive functioning in the detailed neuropsychological assessment. Followings are significant abnormal neuropsychological profiles on several cognitive domains according to the strategic lesion sites; the thalamic lesion group showed deficits on verbal memory and frontal executive function, the group of medial temporal lobe showed deficits on visuospatial function, verbal and visual memory and frontal executive function and the group of ACA territorial lesion and angular gyrus showed deficits on visuospatial function, visual memory and frontal executive function. Conclusion(s): Based on our results, we found that thalamus, medial temporal lobe and anterior cerebral arterial territorial lesion were the most common sites responsible for SID. The most frequent neuropsychiatric symptom and cognitive deficits in our patients are apathy and frontal executive dysfunctions with prominent memory impairment.

S92 Presenting authors are indicated in bold. Korean J Stroke(Supplement 1) 2008;10

3rd International Conference on Intracranial Atherosclerosis and Annual Spring Meeting of the Korean Stroke Society POSTER SESSIONS

P077 P078 Hypokinetic Dysarthria in Midbrain Infarction and A Case of Dissociated Crossed Aphasia and Somatotopic Organization of Subtantia Nigra Anarthria in Right Hemispheric Lesion Miseon Kwon1, Jae-Hong Lee1, Jaeseng Kim2, Jong S Kim1 Kee Ook Lee, Sang-Jun Na, Kyu Sun Yum, Young-Shin Kim, 1Departments of Neurology and 2Nuclear Medicine, Asan Medical Center, Jung Eun Kim, Yong-Duk Kim Seoul, Korea Department of Neurology, Konyang University College of Medicine, Daejeon, Korea Background & Significance: Hypokinetic dysarthria and palilalia are the acquired speech disorders frequently associ- Background & Significance: It is well known that apha- ated with the basal ganglia lesions. In this report, we present sia is major cortical symptom of left hemisphere. Crossed a patient who showed those speech problems after the left aphasia cases are uncommon events and rarely seen. Some midbrain infarction. previous literature reported that prevalence of crossed aphasia Case: A 55-year-old, right handed, diabetic woman was is approximately 0.38-3% in right-handed patients. We des- admitted to Asan Medical Center due to diplopia. She was a cribe a case of dissociated crossed aphasia and anarthria cau- right handed homemaker with 9 years of education. On neu- sed by right hemispheric lesion in right-handed patient. rological examination, she showed the left third nerve palsy, Case: A 82-year-old right-handed man presented with left Poster Sessions clumsiness in the right arm, and slight gait ataxia. Prominent side weakness, aphasia and mental change which was sud- dysarthria was also noted. The diffusion-weighted images of denly developed 3 hours ago. He had no medical history of the brain MRI revealed a small ischemic lesion restricted to diabetes mellitus, angina pectoris, hyperlipidemia. And, since the paramedian portion of the left midbrain. On speech eva- about ten years ago, he had suffered due to hypertension. On luation, she demonstrated severe hypokinetic dysarthria with neurological examination, he could not say any verbal sound palilalia, which is rarely observed in patients with the mid- and the motor power of patients was MRC grade 2. And, left brain lesion. There was no oral motor weakness or apraxia. side neglect and Positive Babinski sign was also detected. To elucidate the underlying mechanism of the speech symp- No other neurological signs were observed. The fluid-atten- toms of the patient, we employed 18F-FP-CIT PET imaging, uated inversion recovery (FLAIR) and T2-weighted images which revealed decreased 18F-FP-CIT uptake in the left ba- of magnetic resonance imaging (MRI) showed a high signal sal ganglia, particularly in the ventro-medial putamen. Four intensity and T1-weighted images showed hypo-intensity on months later, mild hypokenetic dysarthria still exist on her white matter in major right hemispheric lesion including mi- speech, whereas palilalia was not observed any longer. ddle and anterior cerebral artery area. The following aphasia Conclusion or Comment: We speculate that her speech study using Modified Western Aphasia Battery interpretated disorder may be related to a disruption of nigrostriatal dopa- motor-dominant aphasia. All laboratory studies were normal minergic pathway produced by the midbrain lesion involving or nonspecific. About 1 month after the onset, his left side the substantia nigra pars compacta. We also suggest a soma- neglect was completely improved, but, crossed aphasia and totopic organization of subtantia nigra based on the previous left side weakness were still remaining. reports, in addition to our patient. Conclusion or Comment: Crossed aphasia means that aphasia symptom caused by right hemispheric lesion in right-handed patient. The pathophysiologic mechanism of this phenomenon is not clearly elucidated. But, several pathophysiologic mechanism including mirror image hypothesis and anomalous dominance hypothesis are suggested in previous literature. We documented here an uncommon case of dissociated crossed aphasia and anarthria caused by right hemispheric lesion in right-handed patient. This case supported anomalous dominance hypothesis and demonstrated that variety of an aphasia type distribution in crossed aphasia.

Presenting authors are indicated in bold. S93

3rd International Conference on Intracranial Atherosclerosis and Annual Spring Meeting of the Korean Stroke Society POSTER SESSIONS

P079 P080 Misownership and Somatoparaphrenia Hemimedullary Syndrome due to Separate Medial in the Patient with Right PCA Infarction: and Lateral Medullary Infarctions in Acute Stage: Disconnection Syndrome Case Report of 2 Patients Seung Don Yoo1, Jin Mann Chon2 Sam Yeol Ha1, Gyeong-Moon Kim2, Chin-Sang Chung2, 2 Departments of Rehabilitation Medicine, 1East West Neo Medical Center, and Kwang Ho Lee 2 Kyung Hee Medical Center, Seoul, Korea Departments of Neurology, 1Chung-Ang University Yong-San Hospital, and 2 Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea Background & Significance: Hemiparetic stroke patients with disturbed perception for their motor weakness may ex- Background & Significance: Because of the separate ar- hibit abnormal body scheme toward the affected limbs (mi- terial topography supplying the medulla, the simultaneous sownership). The present case was hemineglect dyslexia and occurrence of ischemic lesions of its medial and lateral parts disturbed ownership (somatoparaphrenia) for her hemiple- are rare. gic limb in the involvement of right PCA. Case: Case 1) A 58-year-old hypertensive man noted ab- Case: Right handed, 70-year-old woman who had left he- rupt occiput headache, neck pain and dizziness. After twelve miplegia, different types of abnormal attitudes toward the hours, he developed left side weakness, right central type hemiplegic limb (delusional somatoparaphrenia: my daugh- facial palsy, dysarthria, dysphagia and left side hypsthesia. ter’s arm), hemineglect dyslexia, prosopagnosia, dyschro- First brain MRI revealed right lateral medullary infarction matopsia was admitted to our department. Usually, the patients and vertebral artery occlusion, but follow up brain MRI the with disturbed sensation of limb ownership for the paretic/ day after showed right medial medullary infarction and late- plegic limb had the involvement in the right parietal lobe and ral medullary lesion disappeared. Case 2) A 70-year-old man had the feeling that their contralesional limb(s) do not be- developed nausea and gait ataxia. He had hypertension and long to their body. Some authors suggested that the right diabetes. He also noted right side weakness after several hours posterior insula and right parietal lobe were a crucial struc- passing. Neurologic examination revealed right side weakness, ture involved in misownership. But, this case involved the decreased vibration sense in right side, upbeating nystagmus, right posterior corpus callosum, thalamus, inferior temporo- dysphagia and lateropulsion to left side. Brain MRI showed occipital lobe, fusiform gyrus and has not involved right only medial medullary infarction in diffusion image, but also posterior insula and parietal lobe. This symptom may be ca- lateral medulla was enhanced on T1 enhance image. used by the disconnection syndrome between those areas. Conclusion or Comment: We report two patients of he- Conclusion or Comment: Anatomically, somatoparaph- mimedullary syndrome due to an ipsilateral lateral medullary renia for hemiparetic limbs of this patient seems to be caused infarction followed by a separate medial medullary infarc- by the disconnection syndrome between the right posterior tion in acute stage. insula or parietal lobe and the lesion of PCA territory. We are going to investigate the crucial structures involved in the genesis of the sense of limb ownership.

S94 Presenting authors are indicated in bold. Korean J Stroke(Supplement 1) 2008;10

3rd International Conference on Intracranial Atherosclerosis and Annual Spring Meeting of the Korean Stroke Society POSTER SESSIONS

P081 P082 A Case of Tremor as Initial Manifestation by Squamous Cell Carcinoma of the Lung Acute Cerebellar Infarction Presenting with Hydrocephalus and Multiple Jong Hwan Choi, Tae Wan Kim Intracranial Stenoses Department of Neurology, Fatima Hospital, Daegu, Korea Sung Ik Lee1, Hyun Duk Yang1, Il Hong Son1, 2 Weon Cheol Han 1 : Department of Neurology and Inam Neuroscience Center, Background & Significance Cerebellar tremor is so irre- Sanbon Medical Center, and gular, its oscillations are of variable amplitude. The frequ- 2Department of Pathology, Sanbon Medical Center, College of Medicine, ency of cerebellar kinetic tremor is commonly described as Wonkwang University, Gunpo, Korea being 3-5 Hz. In early part of the cerebellar disease, severe tremor may not be seen. Background & Significance: Lung cancer is well known Case: A 46-year old man who had severe tremor of abrupt for metastatic cancer of brain. Patient with leptomeningeal onset. It was a rhythmical involuntary, 1-2 Hz, oscillatory metastasis usually present with multiple cranial neuropathies, movement of Lt.side and accentuated by action. His Diffu- patchy radiculopathies, or mental change. This is a rare case sion- MRI showed a high signal intensity lesion in Lt. Cere- with squamous cell carcinoma complicated by rapidly pro- bellar hemisphere and peduncle. His tremor had rapid remi- gressive hydrocephalus and multiple cerebral infarctions. Poster Sessions ssion by L-dopa. Case: A 72-year-old man with chronic obstructive pul- Conclusion or Comment: Here we report of a rare case monary disease and old pulmonary tuberculosis developed of isolated tremor manifestated by acute cerebellar infarction. headache for 2 weeks. His brain CT was unremarkable. Two weeks later, the patient complained of sustained headache. CSF study was revealed that intracranial pressure was 5 cm 3 ( ) CSF, WBC 19/mm lymphocyte 90% , protein 59.6 mg/dl ( ) and glucose 55 mg/dl serum 120 mg/dl . Although conservative treatment for 4 days, his headache did not subside. Follow-up CSF study after 4 days did not show significant differences except increased pressure 15 cmCSF as compared to previous study. His consciousness had deteriorated. Brain MRI showed hydrocephalus without meningeal enhancement. Chest CT revealed lung mass and squamous cell carcinoma confirmed by pathologic findings. After ventricu- loperitoneal shunting was performed, he improved and became nearly alert for several days. But stuporous mentality occurred without any lateralizing sign. MRI and MR angiography revealed acute multiple cerebral infarctions on diffusion weighted images and multiple stenoses of intracranial arteries which were normal in previous study. Conclusion or Comment: This case shows leptomeningeal metastasis of squamous cell carcinoma of the lung could be a possible source of rapidly progressive hydrocephalus and/or multiple ischemic strokes. Although it is not clear, impaired CSF absorption and vasculitis by metastasis of malignant cell in Virchow-Robin spaces may be the possible mechanism.

Presenting authors are indicated in bold. S95

3rd International Conference on Intracranial Atherosclerosis and Annual Spring Meeting of the Korean Stroke Society POSTER SESSIONS

Thrombolysis & Challenging Therapy Thrombolysis & Challenging Therapy

P083 P084 Hemiplegic Migraine Caused by Brain Organized Protocol and Computerized Electronic Perivascular Spaces Activation System Reduce In-Hospital Delay for Young Ha Lee, Sun A Lee, Sung Hyuk Heo, Sung Sang Yoon, Intravenous t-PA Treatment in Key Chung Park, Dae-il Chang, Kyung Cheon Chung Acute Ischemic Stroke Department of Neurology, Kyung Hee University College of Medicine, Keun-Sik Hong, Yong-Jin Cho Seoul, Korea Department of Neurology, Clinical Research Center, Ilsan Paik Hospital, Inje University, Goyang, Korea Background & Significance: Brain perivascular spaces (PVSs) are pial-lined, interstitial fluid-filled structures that Background(s): It is strongly recommended to reduce in- accompany penetrating arteries and arterioles of the variable hospital delay for intravenous (IV) tPA thrombolysis. Com- distance. puterized electronic activation system (CEAS) as well as or- Case: A 48-year-old woman with past medical history of ganized protocol can improve the process quality of IV tPA migraine per month visited our hospital because of right thrombolysis. sided tingling sensation since 3 months ago. She has taken Objective(s): To reduce in-hospital delay, we implemented medication for hypertension and diabetes during 5 months. organized protocol and CEAS for team approach and rapid She had a pulsating type headache with nausea and phono- activation of responsible medical personnels. sensitivity. Her tingling sensation was aggravated. Moreover Method(s): Primary endpoint was mean door-to-needle right arm weakness (grade IV+), central type facial palsy, time. Secondary endpoints were the proportion treated within and tongue deviation were developed on admission day. At 60 minutes after arrival, volume of IV tPA thrombolysis, admission day, her MMSE was 27 (calculation-2, memory- proportion of IV tPA treated ischemic stroke patients admin- 1). In the neuropsychological test, she performed well. In istered via emergency department (ER), and proportion of electroencephalogram, there were no epileptiform discharge mRS 0-1 at 3 months. and left-right discrepancy. Brain CT showed low attenuation Result(s): Door-to-needle time was reduced from 70.5± in left frontoparietotemporal cortex and subcortex. Brain 24.6 min to 59.4±24.7 min after organized protocol imple- MRI showed multiple dilated PVSs in left subcortex without mentation (p=0.062), and further to 48.3±20.2 min after enhancement or high signal in diffusion weighted imaging. CEAS implementation (p=0.006). Proportion treated within Brain SPECT showed decreased perfusion in left hemisphere. 60 min after arrival increased from 37.5% to 54.8% after Her symptom were recovered in 24 hrs, she discharged with- organized protocol implementaion (p=0.278), and to 82.4% out symptom. After discharge, she has been experienced head- after CEAS implementation (p=0.010). IV tPA treated pa- ache with hemiparesis. tients among the ischemic stroke patients administered via Conclusion or Comment: There was no report acute he- ER increased from 6.7% to 12.5% after organized protocol miparetic symptom that related with dilated PVSs. It is implementation, and to 12.5% after CEAS implementation. meaning that prominent dilated PVSs (without giant PVSs) At 3 months, mRS 0-1 was 37.5% before implementation, with gliosis can affect neuronal change. However, using ICHD 35.5% after organzied protocol implementation (p=0.733), IIR criteria, her symptom could be caused by sporadic hemi- and 50% after CEAS implementation (p=0.644). plegic migraine. We thought hemiplegic migraine may be Conclusion(s): Organized protocol and CEAS implemen- caused by dilated PVSs or gliosis. tation improve the quality of IV tPA thrombolysis process. We expect the improved outcome of IV tPA treated patients with this quality improvement.

S96 Presenting authors are indicated in bold. Korean J Stroke(Supplement 1) 2008;10

3rd International Conference on Intracranial Atherosclerosis and Annual Spring Meeting of the Korean Stroke Society POSTER SESSIONS

P085 P086 Additional Therapy after Intravenous t-PA Diffusion/Perfusion Mismatching as an Indication Thrombolysis in Acute Major Infarction Patients for the Thrombolytic Therapy in Major Do-Sung Yoo1, Jung-Wook Park2, Yoo-Dong Won3, Stroke Patients 1 1 3 1 Dong-Kyu Jang , Jin-Kyu Park , Ki-Tae Kim , Pil-Woo Huh , Do-Sung Yoo1, Jung-Wook Park2, Yoo-Dong Won3, 1 1 1 Dal-Soo Kim , Kyung-Suck Cho , Chun-Kun Park Dong-Kyu Jang1, Jin-Kyu Park1, Pil-Woo Huh1, Ki-Tae Kim3, Departments of 1Neurosurgery, 2Neurology, and 3Radiology, Kyung-Suck Cho1, Dal-Soo Kim1, Chun-Kun Park1 Uijeongbu St. Mary’s Hospital, The Catholic University of Korea, Departments of 1Neurosurgery, 2Neurology, and 3Radiology, College of Medicine, Uijeongbu, Korea Uijeongbu St. Mary’s Hospital, The Catholic University of Korea, College of Medicine, Uijeongbu, Korea Background(s): Intravenous tissue plasminogen activator (tPA) was accepted as a standard therapeutic modality. But Background(s): Therapeutic methods and indications for i.v. tPA therapy has critical problem, the actual recanalization thrombolytic therapy in acute infarction are unsettled problem. rate is not proved especially in case of major vessel occlusion. Recently, diffusion/perfusion mismatching on MR study is Objective(s): Authors analyzed the clinical and radiologic proposed as a good guideline for the thrombolytic therapy. results of our 1 year thrombolysis treatment result and pro- Objective(s): Authors tried thrombolytic therapy and an- pose our additional therapy. From Nov. 2006 to Oct. 2007, alyzed the clinical outcomes according to the diffusion/per- Poster Sessions

368 patients treated by the critical pathway for the acute stroke fusion mismatching. 45 patients who treated by I.A. throm- patient, were analysis. bolysis after intravenous tissue plasminogen activator (tPA) Method(s): The critical pathway include, early brain CT, were analyzed retrospectively. intravenous tPA and acute stroke MR imaging. And intra-ar- Method(s): After i.v. tPA, acute stroke MR was under- terial thrombolysis and/or intravenous urokinase, decom- taken. If major vessel occluded, I.A. thrombolysis was tried. pressive craniectomy followed as an additional therapy if it Group 1, 11 patients without mismatching and group 2, 34 needed. patients with mismatching were compared by recanalization Result(s): 70 patients (19%) were administered i.v. tPA rate and clinical outcomes. and 32 patients (46%) show non-recanlaization on MRA. 13 Result(s): Recanalization rate (include delayed recanali- patients of non-recanalization patients, followed additional zation) was 36.4% in group 1 and 75% in group 2. Mortality treatment. The mortality rate was 0% and favorable outcome was 36.4% in group 1 and 3% in group 2. Favorable out- (mRS <2) was 40%. come (mRS <2) was 9.1% in group 1 and 55.9% in group 2. Conclusion(s): Authors proposed that aggressive addi- Conclusion(s): Diffusion/perfusion mismatching group tional treatment should be followed after i.v. tPA therapy to shows higher recanalization rate, better clinical outcomes improve the clinical outcomes of the major vessel occlusion and less complication rate. And in mismatching group shows stroke patients. good collateral circulation on the pretreatment cerebral angiography.

Presenting authors are indicated in bold. S97

3rd International Conference on Intracranial Atherosclerosis and Annual Spring Meeting of the Korean Stroke Society POSTER SESSIONS

P087 P088 MRI-Based Thrombolysis Reduced Symptomatic Delayed Neurological Deteriorations and Hemorrhage in Hyperacute Ischemic Stroke Subcortical White Matter Changes Following Hyung-Won Jeon1, Jae-Kwan Cha1, MJ Kang2 Reperfusion of Acute Middle Cerebral Departments of 1Neurology and 2Radiology, Dong-A University Hospital, Artery Occlusion Busan, Korea Dain Lee1, Yangha Hwang1,2, Seung-Kuk Baik3, Yong-Sun Kim2,3, Sung-Pa Park1,2, Chung-Kyu Suh1,2 Background(s): Multi-modal MRI has been suggested as Department of 1Neurology, 2Brain Science and Engineering Institute, and 3Department of Radiology, Kyungpook National University Hospital, a very effective tool to select the suitable patients reducing Daegu, Korea hemorrhage for thrombolysis. Objective(s): In this study, we investigated the difference Background & Significance: To date, the long-term ef- of clinical outcomes and symptomatic hemorrhage rate be- fects of reperfusion on the salvaged brain tissues have not tween MRI based and CT based thrombolysis within 3 hr been addressed in the literatures. We report three cases pre- after ischemic stoke in retrospective. senting delayed neurological deteriorations combined with Method(s): We reviewed 73 patients with hyperacute subcortical white matter lesions following reperfusion thera- ischemic stroke who IV t-PA with between Jan. 2006 and pies of acute ischemic stroke. Dec. We chose the fastest possible image method without Case: Our three case series has some common features ( any time delay between CT or MRI and used IV t-PA 0.9 distinct from that of early reperfusion injury in that 1) the ) mg per kg followed intra-arterial thrombolysis. neurological symptoms appeared after one to two months of Result(s): Of total 73 patients with hyperacute ischemic reperfusion therapies, 2) these symptoms were accompanied stroke, 44 patients received IV t-PA based on CT and 29 on by the subcortical white matter changes on the brain MRI, and MRI. Although MRI based group showed delayed Door to 3) these findings were mostly reversible with time lapses. ( = Needle time 49.9±23.2 min. vs. 39.5±19.7 min., p Conclusion or Comment: To our knowledge, this is the ) 0.04 , there was no difference of the proportion of 90 days first case report addressing the chronic effects of reperfusion, ( ≤ = ) good clinical outcome mRS 2, 62.1 % vs. 52.3%, p 0.41 so-called ‘delayed white matter injury in reperfused brain’. between two groups. However, the rate of symptomatic hem- Our findings may suggest that the reperfused brain may be ( = ) orrhage was significantly lower 0% vs. 13.6%, p 0.038 susceptible after acute stages of ischemic stroke. So, long- in MRI group than in Angio. CT group. Regarding the 90-days term follow-up imaging might be needed to elucidate the real ( = ) ( < ) clinical out, age p 0.02 , initial NIHSS p 0.001 , and re- frequency and clinical features in the consecutive thrombo- ( < ) canalization p 0.001 was related in univariate analysis. Mul- lysis registry. ( tivariate analysis showed that recanalization OR-15.5, 95% < ) ( CI; 0.01 to 0.79, p 0.001 and age OR-6.9, 95% CI; 1.002 = ) to 1.282, p 0.048 was independently related with 90 days clinical outcome.Image method was not related with it. Conclusion(s): In this study, we demonstrated that MRI based t-PA could be used safely reducing the symptomatic hemorrhage with just about 10 min time delay compared to CT based thrombolysis.

S98 Presenting authors are indicated in bold. Korean J Stroke(Supplement 1) 2008;10

3rd International Conference on Intracranial Atherosclerosis and Annual Spring Meeting of the Korean Stroke Society POSTER SESSIONS

P089 P090 Trehalose Induces Ischemic Tolerance via Autologous Adipose-Derived Stem Cell Activation of Autophagy In Vitro and In Vivo Transplantation in Focal Cerebral Ischemia Kon Chu, Hee-Kwon Park, Jae-Joon Bahn, Keun-Hwa Jung, Soon-Tae Lee, Kon Chu, Keun-Hwa Jung, Jeong-Min Kim, Soon-Tae Lee, Kyung-Muk Kang, Manho Kim, Sang Kun Lee, Jae-Sung Lim, Eun-Cheol Song, Jin-Hee Kim, Jae-Kyu Roh Kyung-Mook Kang, Hee-Kwon Park, Sang Kun Lee, Stroke & Neural Stem Cell Laboratory, Stem Cell Research Center, Manho Kim, Jae-Kyu Roh Clinical Research Institute, Department of Neurology, Department of Neurology, Seoul National University Hospital, Seoul National University Hospital, Seoul, Korea Seoul, Korea

Background(s): Trehalose is a non-reducing disaccharide Background(s): Adipose-derived stem cells (ASCs) se- found in many organisms including the insects. It functions crete multiple angiogenic and antiapoptotic factors, along with to protect the integrity of cells against various environmental multipotent differentiation ability. Since adipose tissue is ab- stresses like heat, dehydration, and oxidation in yeast or bac- undant, reproducible, and easily accessed, ASCs are clinically teria and it also has beneficial effects in mammals where it is feasible stem cells. not endogenously synthesized. By inducing autophagy and Objective(s): We investigated whether autologous ASCs acting as a chemical chaperone, trehalose also protects mam- can be therapeutically applied to experimental focal cerebral Poster Sessions malian cells against neurodegenerative diseases via the mito- ischemia. chondrial pathway. Method(s): Focal cerebral ischemia was induced by in- Objective(s): We investigated whether the addition of traluminal thread occlusion of middle cerebral artery. One day trehalose enhance the ischemic tolerance. after surgery, ASCs were isolated from fresh subcutaneous Method(s): Using WST-1 assay, we measured the cell fat tissue of each animal, and incubated under endothelial viability of PC 12 cell line under oxygen-glucose deprivation, growth medium for seven days. The rats were randomly di- according to trehalose addition (1 mM). The LC3-I/II bands vided into two groups: ASCs vs. vehicle, and autologous were evaluated in PC 12 cell under trehalose treatment for ASCs (0.5-1 million cells in 0.5 cc PBS) or vehicle were the activity of the autophagy. We also added the trehalose intravenously administered at 7 days after the ischemnia. The (2%) to the drinking water of trehalose treatment group, animals were evaluated by modified limb placing test for 5 which the rats spontaneously drank. Cerebral ischemia-re- weeks, and by histologic analysis for capillary density and perfusion injury was induced by transient intraluminal thread hemispheric atrophy at 5 weeks. occlusion of middle cerebral artery (90 minutes) and the in- Result(s): In the autologous transplantation experiment, farct volume was measured by TTC stain at 24 hours. all the animals survived after harvesting subcutaneous fat Result(s): The results of WST-1 showed trehalose enhanc- without local complication, and 5×105-3×106 ASCs were ed the cell viability by 30.2% and this neuroprotective effect obtained from 1 g of fat tissue from each animal. ASCs- was ameliorated by autophagy inhibitor (3-MA). After the transplanted rats showed better functional outcome (mea- trehalose addition, the ratio of LC3-II versus LC3-I was in- sured by modified limb placing test) at 21 and 28 days after creased by two times, which indicated increased autophagy. the ischemia compared to the vehicle group (*p<0.05 vs is- Long-term oral trehalose treatment reduced the infarction chemia-vehicle). Autologous ASCs increased capillary density volume by 41.2% (p=0.024) and the wortmannin (PI3 ki- and attenuated the hemispheric atrophy after cerebral ischemia. nase inhibitor) eliminated the neuroprotective effect. Conclusion(s): Our results suggest that autologous ASCs Conclusion(s): Trehalose induced ischemic tolerance in are efficiently acquired, and effectively transplanted in cere- vitro and in vivo, via the enhancement of autophagy, which bral ischemia model. ASCs can be an autologous stem cell was dependent on PI3 kinase-Akt pathway. source that has therapeutic potentials in ischemic stroke.

Presenting authors are indicated in bold. S99

3rd International Conference on Intracranial Atherosclerosis and Annual Spring Meeting of the Korean Stroke Society POSTER SESSIONS

P091 P092 Delayed and Repeated Injections of Recombinant Successful Treatment with Intra-Arterial Human Erythropoietin Have No Beneficial Effect Thrombolysis in Ischemic Stroke Caused by in Rats with Ischemic Stroke Infective Endocarditis Seong-Ho Koh, A R Yoo, Yun J Kim, Sechul Oh, Hyun Y Kim, Ki-Joo Kim1, Jin-Young Seo1, Mi-Hye Lim1, Tae-Ho Yang1, Kyu-Yong Lee, Young J Lee, Seung H Kim Seok-Young Jeong1, Sun-Young Oh1, Seul-Ki Jeong1, 1 1 2 Department of Neurology, College of Medicine, Hanyang University, Man-Wook Seo , Young-Hyun Kim , Pyoung-Han Hwang , 2 1,3 Seoul, Korea Dae-Yeol Lee , Byoung-Soo Shin Departments of 1Neurology and 2Pediatrics, Chonbuk National University Hospital and Medical School, and Background(s): Erythropoietin is known to have neuro- 3Chonbuk National University Hospital Research Institute of Clinical protective effects. Medicine, Jeonju, Korea Objective(s): This study was undertaken to evaluate whether delayed and repeated treatments with recombinant hu- Background & Significance: The neurologic manifesta- man erythropoietin (rhEPO) could improve neurobehavioral tions such as ischemic or hemorrhagic stroke are common in deficits caused by ischemic stroke. septic emboli caused by infective endocarditis and showed Method(s): Twenty ischemic stroke model rats in E-E fatal outcome. Treatment with intra-arterial (IA) thromboly- group were injected via tail vein with 5 IU/g rhEPO once a sis within 6 hours of symptom onset has become a standard week after injection of the same dose of rhEPO at reperfu- treatment modality in acute ischemic stroke. However, the sion; 20 rats in E-S group with saline once a week after an value and safety of thrombolysis in acute stroke related with initial injection of 5 IU/g rhEPO; 20 rats in S-E group with 5 septic emboil is unknown. IU/g rhEPO once a week after an initial injection of saline; Case: We report a 26-year old woman present with hemi- and 20 rats in S-S group with saline once a week after an paresis of right side and global aphasia after suffering from initial injection of saline. Neurobehavioral functions were common cold during five days (NIHSS; 20). She was diag- assessed for 43 days. To investigate mechanisms of rhEPO nosed as embolic occlusion of left internal carotid artery sec- effects, the rats and 40 additional ischemic stroke model rats ondary to infective mitral endocarditis using with echocar- (20 rhEPO-treated vs. 20 saline-treated) were sacrificed at diography. After successful treatment with intra-arterial th- 43 days and 22 h, respectively, after the initial injection. rombolysis, her neurologic manifestations were improved Result(s): When compared with the S-S group, neurobe- (NIHSS; 7). havioral functions were improved in the E-E and E-S groups, Conclusion or Comment: In our patient, intra-arterial th- but not in the S-E group. At 22 h, survival signals increased rombolysis due to infective endocarditis had been a thera- and infarct volume and death signals decreased in the rh- peutic effect for recanalization of occluded vessel. The sa- EPO-treated rats, when compared with the saline-treated rats. fety of IA thrombolysis in cerebral infarction due to septic At 43 days, nestin increased in the E-E and S-E groups but emboli needs to be analyzed with more cases in further study. not in the E-S group, as compared with the S-S group. Conclusion(s): These findings suggest that delayed and repeated treatments with rhEPO have no beneficial effects in ischemic stroke, although acute treatment can improve neurobehavioral deficits.

S100 Presenting authors are indicated in bold. Korean J Stroke(Supplement 1) 2008;10

3rd International Conference on Intracranial Atherosclerosis and Annual Spring Meeting of the Korean Stroke Society POSTER SESSIONS

P093 P094 Effect of Intravenous He-Ne Laser Irradiation Large Territorial Infarction without Massive on Pulse Wave Velocity Edema: Frequency and Association Ju-ah Lee1, Huijeong Yu1, Gwangho Bae1, Younggi Yu2, with Vascular Risk Factors 1 1 Hoyeon Go , Kyunghwan Kong Dong Ick Shin1, Mi Sup Shim2, Hyung Suk Lee1, Department of 1Internal Medicine, and 2Obstretics and Gynecology, Jung Hoon Kim1, So Young Moon1, Ho Seong Han3 College of Oriental Medicine, Semyung University, Jecheon, Korea Departments of Neurology, 1Chungbuk National University Hospital, Cheongju, 2Maria Sungmo Hospital, Seoul, and Background(s): Atherosclesrosis is the risk factor of st- 3Sun General Hospital, Daejeon, Korea roke. PWV (pulse wave velocity) is the marker in atherosclerosis. As PWV is higher, the risk of stroke is higher be- Background(s): Within the first few days after the onset cause of atherosclerosis. of large territorial infarction, prognosis is mainly determined Objective(s): This study is aimed to investigate the effect by the presence of massive brain edema. of intravenous He-Ne laser irradiation therapy on arterial Objective(s): We designed this investigation to evaluate stiffness measured by brachial-ankle pulse wave velocity the frequency of large territorial infarction without massive ( ) baPWV . edema and to identify the potential vascular risk factors asso- Poster Sessions ( Method(s): We chose 19 patients 6 males and 13 fe- ciated with massive brain edema. males) with high baPWV values, and the difference of first Method(s): We retrospectively analyzed thirty-seven pati- BP and Last BP was 10 under out of 93 patients who re- ents with large territorial infarction admitted to Chungbuk ceived He-Ne laser irradiation therapy ten times. We checked National University hospital between March 2004 and June the baPWV values before and after the treatment. 2006. Patients were imaged with CT or MRI scan within 24 Result(s): The baPWV were significantly decreased by h from stroke onset and 5 days later in order to determine the intravenous He-Ne laser irradiation therapy for whole pa- presence of brain oedema. We subsequently analyzed vari- tients group (p=0.032)(Table 1). ous vascular risk factors to see if they are associated with the development of massive brain edema. Table 1. Comparison between Pre and Post He-Ne laser Treat- ment Result Result(s): Among 37 patients with a large territorial in- Pre-treatment Post-treatment Difference farction, 24 (64.9%) patients developed massive brain ede- p-value (Mean±SD) (Mean±SD) (Mean±SD) ma, whereas 13 (35.1%) patients did not, and the latter had † baPWV 692.05±70.43 11617.26±62.42 -74.79±32.75 0.025 better outcome. The frequency of massive brain edema cau- Systolic BP 135.05±03.33 00133.63±03.30 0-1.42±01.15 0.217 sed by large territorial infarction increased with the increas- Diastolic BP 084.26±01.62 00082.58±02.03 0-1.68±01.19 0.150 ing number of vascular risk factors (p=0.04) and the severity † baPWV: brachio-Ankle Pulse Wave Velocity ( : = : *Stasitical significance was evaluated by Wilcoxon matched- of the acute clinical features right MCA p 0.01, left MCA pairs signed-ranks test p=0.02). However, the role of each individual vascular risk factor was not found to be statistically significant. Conclusion(s): This study showed that arterial stiffness Conclusion(s): Our study suggests that massive brain ede- decreased by He-Ne laser irradiation therapy. ma caused by large territorial infarction is correlated to the number of vascular risk factors and the severity of acute clinical presentation.

Presenting authors are indicated in bold. S101

3rd International Conference on Intracranial Atherosclerosis and Annual Spring Meeting of the Korean Stroke Society POSTER SESSIONS

Angioplasty & Stenting Angioplasty & Stenting

P095 P096 Angioplasty and Stenting for Total Occlusion Outcome of Lenticulostrate Artery after of Intracranial Segment of Internal Carotid Artery: Self-Expandable Stenting for High-Grade Case Report Middle Cerebral Artery Stenosis Jie Shuai, Qianning Li, Hua Huang, Yuening Gu Thomas Leung1, Simon CH Yu2, Wynnie WM Lam2, 1 1 1 Department of Neurology, Xin Qiao Hospital of Third Military Medical Anne YY Chan , Alexander YL Lau , KS Lawrence Wong University, Chongqing, China 1Division of Neurology, Department of Medicine and Therapeutics, and 2 Department of Radiology and Organ Imaging, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong SAR, China Background & Significance: Intracranial atherosclerotic lesions account for about 8% to 10% of all ischemic strokes. Background(s): Self-expandable stenting is a therapeutic Unlike extracranial carotid artery stenosis, intracranial ath- option for refractory symptomatic intracranial stenosis. It is erosclerotic disease has been undetected in its diagnosis, un- unknown if the sustained radial force of self-expandable dervalued in its prognosis, and disregarded in its treatment stent or subsequent in-stent restenosis would cause late oc- modalities. clusion of perforators. Case: We report a patient with total occlusion of intra- Objective(s): We sought to prospectively investigate if cranial segment of left internal carotid artery (LICA C6) in sub-acute perforator territory infarction would develop after whom presented alert and well oriented, partial aphasia, right middle cerebral artery (MCA) angioplasty with self-expan- centrum face and lingua paralysis, right hemiplegia with 3 dable stent. degree power of upper and low right limb, hypoesthesia of Method(s): Twenty-two patients consecutively underwent right side of his body, sthenic right tendon reflex were ob- angioplasty with Wingspan system for symptomatic MCA served and NIHSS score and Barthel Index were 8 and 40 stenosis ≥60%. We compared the baseline and post-stent respectively. The brain CT scan showed left watershed (≥4 months) MRI and recorded any new infarct in the ip- infarction and CT perfusion showed a larger low perfusion silateral striato-capsular region. region (decreased CBF, increased CBV, deleyed MTT and Result(s): We found no new perforator territory infarct in TTP) in the left centrum semiovale. DSA showed total occlu- post-stent MRI of all patients. sion of intracranial segment of left internal carotid artery Conclusion(s): The use of a Wingspan stent in patients (LICA C6) and poor left posterior communicating artery with high-grade MCA stenosis is relatively safe for the len- (PComA). Under the general anesthesia, revascularization ticulostriate arteries. dealing with intracranial angioplasty and stenting was successfully done. At the third day after operation, CT perfusion showed an normal blood perfusion and Transcranial Doppler (TCD) showed symmetrical blood flow velocity at middle cerebral arteries (MCA). The patient was discharged at the eighth day with recovered right hemiplegia and partial aphasia. Conclusion or Comment: Angioplasty and stenting of intracranial artery stenosis may be safe, feasible and favorable for decreasing ischemic cerebrovascular events. For the revascularization of the intracranial artery occlusion, profes- sional preprocedural assessment, intraprocedural management and postprocedural medical treatment were very important.

S102 Presenting authors are indicated in bold. Korean J Stroke(Supplement 1) 2008;10

3rd International Conference on Intracranial Atherosclerosis and Annual Spring Meeting of the Korean Stroke Society POSTER SESSIONS

P097 P098 Initial Experience of Intracranial Stenting with Angioplasty and Stenting of Symptomatic Drug-Eluting Stent (ICS-cyper) for the Atherosclerotic Stenosis of Middle Cerebral Symptomatic Severe Intracranial Stenosis Artery with Wingspan System: Evaluation of Won Jung Chung1, Hyun Sin In1, Jin Woo Choi1, Procedural Safety and Technical Considerations Byung Se Choi1, Deok Hee Lee1, Sang Joon Kim1, in Relation to Vascular Morphology Dong Wha Kang2, Sun U Kwon2, Jae Young Koh2, Simon Yu1, Thomas WH Leung2, Esther HY Hung1, Jong S Kim2, Dae Chul Suh1 Wynnie WM Lam1, KS Lawrence Wong2 1 Department of Radiology and Research Institute of Radiology, and 1 2Department of Neurology, Asan Medical Center, Seoul, Korea Departments of Diagnostic Radiology and Organ Imaging, and 2Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong SAR, China Background(s): Use of bare-metal stents (BMS) to treat intracranial stenosis may be associated with significant reste- Background(s): Angioplasty and stenting of symptomatic nosis rates. As drug-eluting stents (DES) have revolutionized atherosclerotic stenosis of middle cerebral artery becomes the treatment of coronary artery disease and have greatly technically feasible. reduced the risk of restenosis, so it may also reduce the rate Objective(s): The study aims to evaluate the procedure of restenosis in brain ischemia patients. safety and technical considerations of using Gateway Balloon Poster Sessions Objective(s): We report our experience with the feasibil- and Wingspan Stent System (Boston Scientific Corporation). ity and safety of using DES for patients with symptomatic Method(s): The results of the first 24 patients of this on- intracranial stenosis. going prospective study were evaluated. Inclusion criteria Method(s): Among 150 patients in the prospectively col- were: 1) patients presentation with stroke (n=20) or tran- lected angio-database who underwent intracranial stenting to sient ischemic attack (TIA)(n=4), 2) vessel diameter ≧2 treat symptomatic severe (≥70%) intracranial stenosis, ICS- mm, 3) degree of stenosis ≧50%. Average degree of steno- cyper DES was used on 11 patients (age 35-78, mean age sis was 66.2±12.6%, median 66.4%. Average length of lesion 59) between March, 2006 and July, 2006. Usage of DES was 11.3±5.5 mm, median 8.9 mm. Variations in technical was due to the shortage of supply of the BMS in that period. approach and instrumentations, and specific technical prob- We evaluated technical success (≤50% residual stenosis), lems were recorded and correlated with vascular morphology. clinical outcome and restenosis rate. Clinical follow-up data Procedural safety in terms of 30 days morbidity and mor- were supplemented by telephone interviews or medical re- tality was assessed. cords of out patient clinic. Result(s): Technical success in angioplasty and stenting Result(s): There were 11 patients treated with ICS-cyper was 100%. Stenosis involved distal internal carotid artery for stenosis which is located in the: M1 (n=5), intradural and was stented in 2 cases. M2 segment was stenosed and vertebral artery (n=3), distal internal carotid artery (n=2) stented in 1 case. Extra-support of the guiding system with a or basilar artery (n=1). Technical success rate for stent pla- buddy wire was required in 5 case due to vessel tortuosity. cement was 100%. There was no event such as stroke or TIA TIA occurred in one case immediately after cannulation of observed in the 6-months follow-up. At 1-year follow-up, 10 the stenotic lesion due to high grade stenosis. Jamming of patients have had no stroke or TIA. Over a mean period of the nose cone due to excessive angulation occurred in one 20 months (range 12-22 months), 7 patients underwent im- case. Tandom lesions in distal internal carotid artery were aging follow-up by CT angiography (n=3), trans-cranial treated in two cases. Two stents were required in three cases. Doppler (n=3) or trans-femoral cerebral angiography (n= Extension of stent into M2 segment was required in one case. 1). 6 patients did not have any clinical or significant angio- Stent migration during stent deployment due to excessive graphic restenosis. One asymptomatic angiographic restenosis vascular tortuosity occurred in four cases. Fracture of delivery was observed during the follow-up period. system during stent deployment due to excessive vascular tor- Conclusion(s): Our limited experience revealed that DES tuosity occurred in two case. There was no procedure related is technically feasible and safe. Rates of restenosis reduced complication. Mortality and morbidity at 30 days was 0. by using DES needs to be compared with those of BMS in Conclusion(s): The procedure can be performed with great the long-term follow-up. safety and high technical success rate.

Presenting authors are indicated in bold. S103

3rd International Conference on Intracranial Atherosclerosis and Annual Spring Meeting of the Korean Stroke Society POSTER SESSIONS

P099 P100 Drug-Eluting Stenting of Symptomatic Ostial Delayed Intracerebral Hemorrhage after Carotid Vertebral Artery Stenosis: Clinical and Artery Stenting Angiographic Results at 1 Year Follow Up Kwang Deog Jo1, Seung Hoon You2, Soo-Bin Yim1, 1 3 Simon Yu1, Thomas WH Leung2, Judy SY Lam1, Young Joo No , Jong Hyeog Lee Wynnie WM Lam1, KS Lawrence Wong2 Departments of 1Neurology, 2Neurosurgery, and 3Diagnostic Radiology, Gangneung Asan Hospital, University of Ulsan College of Medicine, Departments of 1Diagnostic Radiology and Organ Imaging, and Gangneung, Korea 2Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong SAR, China Background & Significance: Intracerebral hemorrhage is Background(s): Angioplasty and stenting of symptomatic well-known but a rare complication following carotid artery ostial vertebral artery stenosis has been associated with sig- stenting (CAS). Hemorrhage following CAS usually devel- nificant restenosis. ops within several hours to a few days after the procedure. Objective(s): The authors aim to evaluate the safety and We present a case of intracerebral hemorrhage occurring 10 clinical effectiveness of drug-eluting stent for such stenosis. days after CAS. Method(s): This is a prospective study in progress. In- Case: A 69-year-old hypertensive man developed sudden clusion criteria are: 1) atherosclerotic stenosis at ostium of left hemiparesis with clonic partial seizures in the left arm. vertebral artery, 2) presentation with stroke at the corres- Ten days before admission, he underwent CAS for a 70% ponding vascular territory. Five were smokers. Three suffered stenosis of the left common and a 75% stenosis of the prox- from diabetes mellitus. All had hypercholesterolemia. None imal internal carotid artery associated with contralateral had hyperhomocysteinemia. Atherosclerotic stenosis at os- carotid and bilateral vertebral occlusion. There were no pro- tium of vertebral artery was diagnosed with computed to- cedural complications. His blood pressure was maintained mography angiography and digital subtraction angiography below 140/90 mmHg at the time of discharge. He had a (DSA). Degree of stenosis ranged from 20% to 83%, Fifty history of hypothroidism after total laryngectomy with tra- percent of patients had a degree of stenosis ≧50%. Taxus cheostomy for laryngeal cacinoma and right middle cerebral Express Monorail Paclitaxel-Eluting Coronary Stent System artery (MCA) infarction 15 and 3 years ago, respectively. A was used. The patients were followed up clinically and with brain CT at admission showed large right frontal hemorrhage DSA at one year. with encephalomalacia in the territory of the MCA. The Result(s): Technical success rate was 100%. Procedure- patient recovered with a mild left heimiparesis. related complication rate was 0%. Degree of stenosis just Conclusion or Comment: We report the occurrence of after stenting ranged from 0% to 25.4%. At one year after delayed intracerebral hemorrhage after CAS. We sugest that stenting, no one suffered from stroke or transient ischemic it might be related to long standing hypertension and poor attack. Angiographic evidence of intimal hyperplasia was collateral blood flow due to carotid stenosis with contrala- noted in 7 patients. Immediately after treatment, the propor- teral carotid and bilateral vertebral occlusion. tion of patients that had a degree of stenosis ≧50% was 0. At one year after stenting, the restenosis rate of the vertebral artery to a degree of ≧50% luminal narrowing was 0. Conclusion(s): Angioplasty and stenting with Paclitaxel- eluting stents is a safe and effective preventive treatment for symptomatic ostial vertebral artery stenosis. Recurrent ischemic symptoms and angiographic restenosis rate at one year are negligible.

S104 Presenting authors are indicated in bold. Korean J Stroke(Supplement 1) 2008;10

3rd International Conference on Intracranial Atherosclerosis and Annual Spring Meeting of the Korean Stroke Society POSTER SESSIONS

P101 P102 Emergent Middle Cerebral Artery Stenting as Stent-Assisted Thrombolysis in Four Cases Failure of Recanalization after Intra-arterial of Acute Basilar Occlusion Thrombolysis Soo yoon Lee1, Jae-Kwan Cha1, Hyun Sook Kim1, 2 Sung-Il Sohn1, Chul-Ho Sohn2 Myung-Jin Kang 1 2 1Department of Neurology, Dongsan Medical Center, Keiymung University, Departments of Neurology and Radiology, Dong-A University Hospital, Daegu, and Busan, Korea 2Department of Radiology, Seoul University School of Medicine, Seoul, Korea Background & Significance: Acute basilar artery occlu-

sion is a dire condition, which its mortality is up to 75% wi- Background(s): Emergent MCA stenting can be consi- th-in 1 month after its ischemic events. Furthermore, its re- dered as a alternative method when the patients with acute canalization rate by using conventional method is relatively MCA occlusion were not recanalized after IA chemical th- low. Therefore, stent assisted recanalization may improve rombolysis. But emergent intracranial arterial stenting is still recanalization rate and enhance the clinical outcome after a controversy for the safety and efficiency. acute basilar artery occlusion. Objective(s): We evaluated the safety and efficiency for

Case: In this study, we analyzed four cases of acute bas- Poster Sessions emergent MCA stenting in patients with a hyperacute oc-

ilar artery occlusion who were performed stent assisted re- clusion of the MCA. canalization. Four patients with acute basilar artery occlu- Method(s): We reviewed 132 patients treated with IA sion (M : F=3 : 1) were arrived at emergency room. The thrombolysis due to MCA occlusion. Eight of 132 patients mean arrival time was 690 min after their ischemic events were treated with emergency recanalization for the MCA by (range; 300-1,440 min). The median NIHSS was 16 (12- using stent as rescue procedure. All patients were received 23). Two lesions were located at mid portion and other le- emergent MCA stenting placement after reocclusion or fail- sions at proximal portion of basilar artery. After stent assisted ure of recanalization in spite of using IA urokinase or me- recanalization, all four cases showed completed recanali- chanical clot disruption. Early neurological improvement zation (Thrombolysis grade in cerebral infarction=3). After (ENI), death rate, 3 month modified Rankin Scale (mRS) 90 days after their recanalization, three were in excellent for outcome, and preoperative complications were assessed. outcome (mRS 0-2) and one patient died of myocardial ENI was defined when a National Institutes of Health Stroke infarction. Scale (NIHSS) improvement of >4 points at 7 days. Conclusion or Comment: Stent assisted recanalization Result(s): Median initial NIHSS score was 11. Stroke was after acute basilar artery occlusion associated with relative categorized as cardioembolic in 2 (25%) patients, athero- good outcome, despite of initial severe neurologic damage thrombotic in 5 (62.5%) and dissection in 1. The technical su- and their delayed arrival time. These results suggest that ccess rate was 100%. One patients had a blood-brain barrier stenting is an option for acute basilar artery occlusion. disruption at next day. The 30-day combined stroke and death rate was zero. 3 month mRS was 2±2. No immediate complication, thromboembolism, dissection compromising blood flow or vessel rupture occurred during these procedures. Conclusion(s): Emergent MCA stenting can be considered as a alternative method when acute MCA occlusion were not recanalized in spite of IA thrombolysis.

Presenting authors are indicated in bold. S105

3rd International Conference on Intracranial Atherosclerosis and Annual Spring Meeting of the Korean Stroke Society POSTER SESSIONS

P103 P104 Bilateral Spontaneous Carotid Cavernous Fistula Aneurysmal Rupture of Internal Carotid Artery Treated Using Transvenous Embolization Aneurysm Mimicking Pituitary Apoplexy Hyun-jung Jung, Dong-Uk Kim, Jun-Tae Kim, Presented as Intra-Sellar Hemorrhage Seong-Min Choi, Seung-Hwan Lee, Man-Seok Park, Jun Bum Park, Soon Chan Kwon, Hong Bo Sim, Young Kim, Myeong-Kyu Kim, Ki-Hyun Cho Min Jung Kim, In Uk Lyo Department of Neurology, Chonnam National University Hospital, Department of Neurological Surgery, Ulsan University Hospital, Gwangju, Korea University of Ulsan College of Medicine, Ulsan, Korea

Background & Significance: The carotid cavernous fis- Background & Significance: The authors report an in- tula (CCF) is an abnormal communication between the ca- teresting case with a ruptured internal carotid artery aneu- rotid system and the venous cavernous sinus. Bilateral spon- rysm that presented as a sellar haematoma mimicking radio- taneous CCF is rare. In the previous literature, the occurrence logically and clinically a pituitary apoplexy. rate of bilateral traumatic fistula ranged from 0.17-0.01%. Case: A 53-year-old woman presented with a sudden onset However, the incidence of bilateral spontaneous CCF might of severe headache with vomiting. She also complained of be lower than that of traumatic CCF. The precise cause of dizziness and general weakness. Brain CT and MRI showed spontaneous CCF is unknown and the subject of considerable an intrasellar hemorrhage. Hormonal profiles showed within speculation. We present a case with bilateral spontaneous normal limit. At the 3 days after admission, she complained CCF and previous history of left ICA stenosis. of severe headache again and decreased level of consciousness. Case: A 63-year-old woman was admitted to the hospital Brain CT showed diffuse subarachnoid hemorrhage at the because of dizziness, both periorbital pain and exophthalmus. basal cistern. The cerebral angiography demonstrated a pos- She experienced one episode of transient right hemiparesis 2 terior communicating artery aneurysm. Endovascular occlu- years ago. She had severe stenosis of cavenous portion of sion of the aneurysm was performed by use of coils. Post- left ICA which determined by conventional angiogram and operatively she was uneventful and neurologically intact. treated with aspirin medication. A month before on admission, Conclusion or Comment: The clinical features, image she developed exophthalmus on the left side and left con- findings of such a case and the importance of differential junctival injection. Angiography revealed an anomalous con- diagnosis in the acute stage are emphasized. nection between both ECA, right ICA and cavernous sinus, briefly a bilateral Barrow type D CCF. The patient was treated with transvenous embolization by detachable balloon. The chemosis and proptosis gradually improved after transvenous embolization and carotid angiogram after 1 month demonstrated the occlusion of both CCF. Conclusion or Comment: We report a case of bilateral spontaneous CCF and also reviewed the previous literatures.

S106 Presenting authors are indicated in bold. Korean J Stroke(Supplement 1) 2008;10

3rd International Conference on Intracranial Atherosclerosis and Annual Spring Meeting of the Korean Stroke Society POSTER SESSIONS

Functional Recovery Functional Recovery

P105 P106 Natural History of Incidental Intracranial Long-Term Effect of rTMS on Motor Recovery Aneurysm in Patients with Ischemic Stroke of Stroke Patients Yoon-Sang Oh, A-Hyun Cho, Seung-Jae Lee, Bohyun Joen1, Suk Hun Ohn1, Young Bum Kim1, Young-Min Shon, Dong Won Yang, Beum Saeng Kim Ji-Sung You1, Gyoung-Moon Kim2, Yun-Hee Kim1, 1 Department of Neurology, The Catholic University of Korea, Davaajav Byambajav St. Mary’s Hospital, Seoul, Korea 1Department of Physical Medicine and Rehabilitation, Division for Neurorehabilitation, and 2Department of Neurology, Stroke and Cerebrovascular Center, Background(s): In cases of incidental cerebral aneurysm Samsung Medical Center, Sungkyunkwan University School of Medicine, which was found during ischemic-stroke work-up, physi- Seoul, Korea cians get to be concerned about the risk of rupture in the Background(s): Repetitive transcranial magnetic stimu- context of antithrombotic use and compensatory increased

lation (rTMS) has been extensively used to stimulate the ce- Poster Sessions blood pressure.

rebral cortex in a noninvasive manner for modulating the Objective(s): We investigated the natural history of inci- cortical excitability. However, long-term effect of rTMS on dentally found aneurysm in patients with ischemic stroke and the motor recovery of stroke is not yet delineated. who continued conventional stroke management. Objective(s): We investigated the long-term effect of rTMS Method(s): We consecutively included ischemic stroke on the recovery of motor function in hemiparetic patients patients who were admitted. CT angiography was used to after stroke. analyze the size, site, shape of cerebral aneurysm. The ana- Method(s): Seventeen patients with subacute hemiparetic tomical relationship between the aneurysm and ischemic le- stroke (mean age 57.3 years) were enrolled and randomly sion was identified. We reviewed demographics, stroke divided into the real and sham stimulation groups. rTMS subtype, use of anti-thrombotics, development of hemor- was applied over the contralateral primary motor cortex us- rhage during admission. Clinical outcome at 3 months was ing the Magstim Rapid2 stimulator. Ten Hz rTMS at the in- obtained. tensity of 80% of resting motor threshold was applied for 5 Result(s): Of total 241 patients, incidental cerebral an- seconds prior to the motor training which lasted 55 seconds. eurysms were found in 12 (4.97%) patients. The cerebral This train was repeated 20 times at each session for 10 days. aneurysm was located at middle cerebral artery bifurcation Sham stimulation was delivered with the coil placing per- in 7 patients, distal internal carotid artery in 3, basilar artery pendicularly to the scalp. Motor performances were assessed in 1, and distal vertebral artery in 1. The diameter of aneu- by Motricity index (MI), Functional Ambulatory Category rysm ranged from 2.27 to 8.06 mm. The number of aneurysm (FAC), Box and Block test (BBT), Fugel-Myer Assessment, larger than 7 mm was 5. All were saccular aneurysm. The Grip strength (GS), and Modified Barthel Index, which mea- most common stroke mechanism was large vessel disease sured 4 times; before, just after, at 2 months, and at 3 months (in 9). Ischemic infarction occurred distal to the aneurysm after rTMS treatment. site in 1 patient. All patients except one who had cancer were Result(s): Both groups showed significant improvement taking antiplatelet agent. No aneurysmal rupture or subarach- in all measures after treatment compared with pretreatment noid hemorrhage happened during hospital days and until 3 status. However, real rTMS group showed significantly better months after discharge. motor outcomes measured by Fugel-Myer Assessment score Conclusion(s): There was no rupture of incidentally found and GS than sham stimulation group. No side effect was no- aneurysm in patients with ischemic stroke during their first 3 ticed in both groups. months. Large cohort study and long-term follow up are Conclusion(s): rTMS can be proposed as a safe method of facilitating motor recovery in subacute stroke patients. required. [Supported by the Korean Science and Engineering Foundation (KO- SEF) grant funded by the Korea government (MOST)(No. M1064400 0022-06N4400-02210) and the Samsung Biomedical Research Institute (C-A7-407-1)].

Presenting authors are indicated in bold. S107

3rd International Conference on Intracranial Atherosclerosis and Annual Spring Meeting of the Korean Stroke Society POSTER SESSIONS

P107 P108 Standardization and Reliability of Korean Version The Change of Neuroplasticity of Brain after of Frenchay Aphasia Screening Test (K-FAST) Extracranial Intracranial Bypass Surgery Sung-Bom Pyun1, Yumi Hwang1, Jiwan Ha1, Hoyoung Lee1, in the Patients of Cerebral Infarction 2 Kunu Park Seung Don Yoo1, Jae Seung Bang2 1 2 Departments of Physical Medicine and Rehabilitation and Neurology, Departments of 1Rehabilitation Medicine, and 2Neurosurgery, Korea University Medical Center, Seoul, Korea East West Neo Medical Center, Seoul, Korea

Background(s): About 25-30% of stroke patients are Background(s): When occlusive lesions are inaccessible suffering from aphasia. Early assessment of aphasia using to direct surgical intervention, the extracranial-intracranial simple standardized test is important for diagnosing, manag- (EC-IC) bypass procedure has been advocated as a prophy- ing, and evaluating improvement in stroke patients. Frenchay lactic intervention to increase perfusion of the brain. aphasia screening test (FAST, 2nd ed., Enderby P. et al, Objective(s): We investigate the change of reserve ca- 2006) is reliable and most widely used test for screening of pacity and neuroplasticity before and after bypass surgery in aphasia and it can evaluate expression, comprehension, read- the patients of ischemic stroke. ing and writing within 10-15 minutes. In Korea, standardized Method(s): 11 patients with Right MCA infarction (n=4), aphasia screening test for Korean people who use Hangul, left MCA infarction (n=5), Right internal carotid occlusion Korean alphabetic system, was not yet developed. (n=1), right MCA, ACA, PCA infarction (n=1) were par- Objective(s): This study was designed to develop and ticipated in this study. These patients had a mean age of 55.9 standardize Korean version of FAST (K-FAST) and to in- ±11.6, onset to operation duration 6.1±3.01 weeks. The vestigate the reliability. reserve capacity of brain was evaluated by diamox SPECT Method(s): The ‘river scene’ in the original FAST was and 3D perfusion CT. Clinical outcome were assessed by changed and the items not suitable for Korean environment NIHSS, modified Barthel Index. Repeated transcranial mag- were substituted. Translation and reverse-translation was per- netic stimulation and functional MRI were done in a case formed in user instruction. K-FAST consists of same format with aphasia. as that of FAST (short form; expression and comprehension, Result(s): The preserved and improved lesions of brain 20 points; full form, plus reading and writing 30 points). were evaluated in 6 of 11 patients by diamox SPECT and The K-FAST was standardized in 240 healthy adults (age, perfusion CT, no interval changes in 3 of 11, and perilesional ≥45, male; 102, female 138) according to age group and new lesion in 2 of 11. Clinical outcomes of these patients education level. The reliability and validity was analyzed in were significantly improved in all cases (p=0.05). Interest- 53 aphasic patients after stroke and the K-FAST scores were ingly, the perilesional areas in left MCA infarction was more compared to the Korean version of Western Aphasia Batter activated than the area of right Broca homologue using fMRI (K-WAB). and the speech production of the patient was impaired after Result(s): Mean K-FAST scores decreased as age increas- the stimulation of rTMS on right Broca homologue. ed and decrease of education years. Post-hoc results classified Conclusion(s): We suggest the EC-IC bypass surgery age groups into 45-64, 65-74, and 74 years, mean scores of could be useful treatment from the viewpoint of change of full version were 27.1, 25.1, and 20.4 points, cut-off values neuroplasticity and preservation of blood supply to ischemic were 25, 21 and 17 points, respectively. The correlation brain. coefficient between K-FAST and K-WAB results in aphasic patients were r=0.910 (p=0.00) in short version, and r= 0.904 (p=0.00) in full version. Conclusion(s): The K-FAST is a reliable and valid test for screening of aphasia after stroke. K-FAST can be easily used in diagnosis and follow up of aphasic patients.

S108 Presenting authors are indicated in bold. Korean J Stroke(Supplement 1) 2008;10

3rd International Conference on Intracranial Atherosclerosis and Annual Spring Meeting of the Korean Stroke Society POSTER SESSIONS

P109 P110 Effect of Robot-Assisted Gait Therapy on The Effect of Neuromuscular Electrical Cardiopulmonary Fitness in Subacute Stimulation on the Trunk Control in Hemiplegic Stroke Patients Stroke Patients Min Su Kim1, Jung Phil Huh1, Chinwook Chung1, Yong mi Kim1, Min Ho Chun1, Wang Hun Ahn1, Bohyun Joen1, Hee Jun Shin1, Hyun Keun Ha1, Si Hyun Kang2 2 2 Peter Kang Woo Lee , Yun-Hee Kim Departments of Rehabilitation Medicine, 1Asan Medical Center, and Departments of Physical Medicine and Rehabilitation, 2Chung-Ang University Medical Center, Seoul, Korea 1 Samsung Medical Center and 2Sungkyunkwan University School of Medicine, Seoul, Korea Background(s): The effectiveness of neuromuscular elec-

trical stimulation over the trunk has been investigated in spinal Background(s): The aerobic exercise after stroke is bene- cord injury, spastic diplegic cerebral palsy and scoliosis. ficial to sensorimotor recovery and restoration of cardiopul- Objective(s): This study was designed to determine the monary function; however, there are limitations on execution

effectiveness of neuromuscular electrical stimulation over the of active rehabilitation in early stage of stroke. Robot-as- trunk in improving balance during early hemiparetic stroke sisted gait training was recently developed to enable the par- rehabilitation. alyzed patients simulate the normal gait in spite of their mo- Poster Sessions : Method(s) Nineteen hemiparetic stroke subjects, within 1 tor weakness. months of onset, inpatient of our rehabilitation hospital, were Objective(s): We investigated the effect of robot-assisted assigned randomly to two groups. Both group had physical gait training on restoration of cardiopulmonary and metabol- therapy for 3 weeks. ES group received had additional elec- ic rates compared to the conventional rehabilitation therapy. trical stimulation over the posterior back muscle. ES group Method(s): Eighteen hemiplegic stroke patients whose was applied 30 minutes, 5 days per week for 3 weeks. Out- onset is within three months participated and randomly di- come measurements included Berg balance scale, Postural vided into two groups. The robot group was trained with the assessment scale for stroke patients, Trunk control test, Mod- Lokomat® driven gait orthosis for 30 minutes per day for ten ified Bathel index. They were recorded before treatment and days while the control group received same sessions of con- after treatment. ventional gait training by physical therapist. We measured Result(s): There was no difference of these values at ini- the exercise capacity, cardiopulmonary function, and ventila- tial evaluation between the two groups. Following 3 weeks tion and gas exchange effects with K4b2 before and after the of intensive therapy, the changes of Trunk control test sig- training. nificantly higher in ES group statistically when compared Result(s): Before the training, there was no difference in with those of the control group. The change of Berg balance exercise capacity, cardiopulmonary function, gas exchange scale, Postural assessment scale for stroke patients, Modified capacity, and Functional Ambulation Category (FAC) between Bathel index was improved in ES group, but not statistically two groups. Though the improvement was proved in all mea- compared with that of control group. sures after the training in both groups, the robot group showed Conclusion(s): This study suggests that neuromuscular significantly better recovery rate in FAC, maximal oxygen electrical stimulation over the trunk become a beneficial ther- consumption, and anaerobic threshold improvement rate. apeutic technique in improving the balance in acute hemi- Conclusion(s): The aerobic exercises in the subacute stage paretic stroke patients. of stroke help restoration of the exercise capacity and cardiopulmonary function, nevertheless, the robot-assisted gait training seemed to be more beneficial than conventional gait training for this purposes.

Presenting authors are indicated in bold. S109

3rd International Conference on Intracranial Atherosclerosis and Annual Spring Meeting of the Korean Stroke Society POSTER SESSIONS

P111 P112 The Effect of Functional Electrical Stimulation on Clinical Outcome Prediction by Motor Evoked the Recovery of Lower Motor Function Potentials of the Upper and Lower Extremity after in Hemiplegic Patients with Stroke Acute Ischemic Stroke Yong-Il Shin, Chung-Yong Yang, Tae-Jin Kim, Jin-Hoon Lee Yeong Bae Lee1, Yeong Bae Seo1, Ji Won Yang1, 2 1 1 Department of Rehabilitation Medicine, Wonkwang University Hospital, Ju Kang Lee , Young Hee Sung , Ki Hyung Park , 1 1 Iksan, Korea Hyeon Mi Park , Dong Jin Shin Departments of 1Neurology and 2Rehabilitation Medicine, Gachon University of Medicine and Science, Gil Medical Center, Background(s): Gait rehabilitation in hemiplegic patients Incheon, Korea with stroke requires substantial effort. Preliminary studies indicate potential beneficial effects of using multichannel func- Background(s): Several clinical and demographic vari- tional electrical stimulation for gait rehabilitation in stroke ables factor have been identified in predicting the functional patients. outcome after acute ischemic stroke. but these parameters Objective(s): To examine whether functional electrical are not sensitive enough, and the evaluation of clinical symp- stimulation (FES), given after subacute stage, was more ef- toms is partly subjective. fective in improving motor and walking ability of the lower Objective(s): The use of Motor evoked potentials (MEPs) extremities than standard rehabilitation alone. assess objectively and quantitatively the integrity of the motor Method(s): Fifty subjects, 56.66 years old and 113.49 pathways. We assessed the value of upper & lower extremity days after stroke, were assigned randomly to 1 of 2 groups; MEPs in predicting motor recovery, in particular, severe mo- FES group receiving standard rehabilitation with FES (n tor deficit patients. =25), control group receiving standard rehabilitation alone Method(s): Stroke severity and outcome was assessed (n=25). FES was applied 20 minutes concomitant with using National Institute of NIHSS, mRS, BI at admission rehabilitation, 5 days per week for 4 weeks. Outcome mea- and in 4 weeks. They were treated according to current rec- surements included composite muscle strength, modified ommendations for ischemic stroke management and received Ashworth scale, Brunnstrum stage, motricity index, walking appropriate neurorehabilitation during hospitalization. All index for spinal cord index (WISCI), 10 meter walking test patients was performed MEPs in adductor pollicis brevis, (10 MWT), and lower extremity circumference ratios (in- adductor hallucis muscle during the acute stage (within 1 cluding thigh and calf). They were assessed before treat- months after stroke, mean 23.11 days±10.12). ment and at 4 weeks after treatment. Result(s): The median NIHSS score was 15.1 and mRS Result(s): No significant differences were found in the was 4.2 at admission. After one month later, 5 patients (56%) baseline measurements. After 4 weeks of treatment, there was showed significant motor recovery (NIHSS improvement a significant improvement in the increasing rate of muscle ≧5). However meaningful functional recovery was not seen strength, Brunnstrum stage, thigh circumference ratio, WISCI, at all of them. The improvement of mRS more than 2 was and 10 MWT in the FES group, when compared with the seen in only 4 patients (44%) of them. The sensitivity of control group (p<0.05). predicting value of motor recovery was 100%, while the func- Conclusion(s): Twenty sessions of FES, applied to sub- tional recovery was 66.6%. The specificity of motor recovery jects with after subacute stroke plus standard rehabilitation, predicting value was 66.7%, functional recovery predicting improved their motor and walking ability. value was 80%. Conclusion(s): In predicting motor recovery of the upper & lower extremity, the sensitivity and specificity was high for patients with hemiplegia. It seems justified to use MEPs prognostically in theses patients in clinical practice.

S110 Presenting authors are indicated in bold. Korean J Stroke(Supplement 1) 2008;10

3rd International Conference on Intracranial Atherosclerosis and Annual Spring Meeting of the Korean Stroke Society POSTER SESSIONS

P113 P114 Longitudinal Changes of Structural and Improvement of Cognitive Function Functional Brain Connectivity in Subcortical after Carotid Stent Stroke Patients Ji Hee Lee, Jun Young Lee, Eung Seok Oh, Jung Su Moon, Chang-hyun Park1,2,3, Yun H Park1, Ji Sung You1, Hyeon Jeong Kim, Jei Kim Bo-Hyun Jun1, Woo-Kyung Yoo4, Suk Hoon Ohn4, Yun-Hee Kim1 Department of Neurology, Chungnam National University Hospital, Daejeon, Korea 1Department of Physical Medicine and Rehabilitation, Samsung Medical Center, Seoul, 2Samsung Biomedical Research Institute, Seoul, 3Department of Physics, Korea Advanced Institute of Science and Background(s): Carotid stent intervention is usually per- Technology, Daejeon, and formed to decrease the risk of stroke recurrence. Cognition 4Department of Physical Medicine and Rehabilitation, Hallym University Sacred Heart Hospital, Anyang, Korea improvement is also expected by the improvement of the intracranial hemodynamic changes after carotid intervention. Background(s): Organization of the human brain is com- However, the cognition changes have not been well known prised in different modalities of structural and functional after the carotid intervention. connectivity which are mutually interrelated. As recovery Objective(s): The present study was performed to eval- from stroke may be attributed to reorganization of the brain, uate the change of electrophysiological cognitive function Poster Sessions organizational changes with respect to structural and func- after carotid stent intervention. tional connectivity of the brain deserve to investigate for Method(s): We included 41 carotid stenosis patients, who better understanding of stroke patients. received carotid stent intervention to prevent recurrence risk Objective(s): We searched for longitudinal changes of of cerebral infarction. The latency and amplitude of P300 structural and functional brain connectivity in stroke patients, event related potential of before-carotid stent were compared corresponding to good or poor recovery after stroke. with the P300 data of after-carotid intervention. To evaluate Method(s): Three stroke patients with subcortical lesions the influences of previous hemodynamic alteration and pa- who showed different patterns of motor recovery were in- renchymal lesions to the electrophysiological cognition ch- cluded in this study. Acquisition of resting-state functional anges, the relationship of P300 changes with the severity of MRI (fMRI) and diffusion tensor imaging (DTI) were per- carotid stenosis and the presence of previous subcortical formed at 3.0T Philips Achieva scanner in each patient four white matter lesions or infarcted lesions were analyzed. times over six months after stroke: within two weeks after Result(s): Only P300 latency was significantly shortened stroke, and thereafter at one, three, and six months after stroke. after carotid intervention even though P300 amplitude showed The Fugl-Meyer Assessment (FMA) score was used to no significant change after the intervention. Interestingly, the describe the level of motor recovery after stroke. P300 latency was prolonged in patients having severer sub- Result(s): The patient with good motor recovery showed cortical white matter changes rather than milder ones. The more preservation of the corticospinal track and the func- improvement of P300 latency had no correlation with the tional motor network in the lesion side at early period of severity of stenosis and the present of previous subcortical or stroke compared with the patient with poor motor recovery. cortical infarction. Changes in structural and functional connectivity were com- Conclusion(s): The present study showed the beneficial plementary for brain reorganization and corresponded with effects on cognitive improvement by the carotid stent inter- temporal patterns of motor recovery after stroke. vention. The cognitive dysfunction could be expected in pa- Conclusion(s): The patients with different motor recovery tients having severer subcortical lesion than patients having showed contrasting changes of functional and structural milder ones. connectivity. Search for structural and functional connectivity of the brain in stroke patients can be helpful for un- veiling the mechanism of stroke recovery based on brain reorganization.

[Supported by the Korean Science and Engineering Foundation (KOS- EF) grant funded by the Korea government (No.M10644000022-06 N4400-02210) and the Samsung Biomedical Research Institute (C-A7- 407-1)].

Presenting authors are indicated in bold. S111

3rd International Conference on Intracranial Atherosclerosis and Annual Spring Meeting of the Korean Stroke Society POSTER SESSIONS

P115 P116 Change of Respiratory Function in Acute Cognitive Dysfunction in Patient with Posterior Hemiplegic Stroke Patients Inferior Cerebellar Artery Territory Infarction Bo ryun Kim1, Min Ho Chun1, Si Hyun Kang2 Boram Lee, Soo Joo Lee, Jong Un Chun, Soo Jin Yoon, Departments of Rehabilitation Medicine, 1Asan Medical Center and Gun Sei Oh 2 Chung-Ang University Hospital, Seoul, Korea Department of Neurology, Eulji University Hospital, Daejeon, Korea

Background(s): Respiratory dysfunction can be occurred Background & Significance: There has been a growing as paralysis of lesioned diaphragm and other respiratory mus- interest in the role of the cerebellum in cognitive functions. cles. Neuroimaging studies have shown the cerebellum to be acti- Objective(s): To investigate the change of respiratory func- vated in a number of cognitive paradigms including working tion and the relationship between pulmonary function and memory and spatial episodic memory. Disruption of cogni- functional improvement in acute hemiplegic stroke patients. tive and affective functions after cerebellar damage has been Method(s): 13 acute stroke patients were enrolled in this attributed to disconnection of cerebrocerebellar projections. study. To evaluate hemi-diaphragmatic paralysis, we checked Case: A 56 year-old man with hypertension was admitted chest X-rays in the inspiration and expiration position of all due to sudden onset of dizziness and gait disturbance. Neu- patients. When diaphragmatic paralysis was suspected, fluo- rological examination revealed ataxia and disequilibrium. roscopy of diaphragm was conducted. To evaluate respira- Brain MRI showed Rt PICA territory infarctions. Four mon- tory function, pulmonary function test and peak cough flow ths later, he complained that he was forgetful and could not were performed 3 weeks before and after a conventional re- find the road to hospital or home. Follow up brain MRI sh- habilitation period. To evaluate correlation of functional per- owed no interval change and neuropychologic test revealed formance, motor and pulmonary function, Motricity index, impaired visuospatial working and episodic memory. and Modified Barthel Index were checked also 3 weeks be- Conclusion or Comment: Previous study have defined a fore and after the period. pattern of behavioral abnormalities after cerebellar pathol- Result(s): 18 stroke subjects received the pulmonary ogy called the cerebellar cognitive affective syndrome that function test, but only 13 passed. Only one of them was diag- comprise impairments of executive functions, difficulties with nosed as diaphragmatic paralysis. At the initial evaluation, spatial cognitive including visual-spatial organization, and maximal inspiratory pressure (MIP) and maximal expiratory memory and personality changes with blunting of affect or pressure (MEP) were reduced. Female patients generally inappropriate behavior. One could hypothesize that lesions in showed lower pulmonary function scores, especially at max- the posterior parts of the cerebellum which are supplied by imal inspiratory pressure, peak expiratory flow rate (PEF), the PICA should be more disruptive to cognitive perfor- and peak cough flow (PCF). PEF, MIP, MEP and PCF were mance and affective regulation than those in other parts of significantly improved after 3 weeks. Improvements of forc- the cerebellum. Anatomic and electrophysiologic evidence ed vital capacity (FVC) and forced expiratory volume in 1 points to the existence of segregated cortico-cerebellar circuits second (FEV1) and MIP were correlated with those of Mod- connecting the cerebellum to associative and paralimbic cor- ified Barthel Index. tical areas. We report the case of memory impairment mainly Conclusion(s): Decline in respiratory function could be in the area of visual-spatial working and episodic memory in occurred in acute hemiplegic stroke patients, because res- patient with the PICA territory lesion. piratory function may be correlated with functional improvement. Therefore, the evaluation of respiratory function and respiratory muscle strengthening should be considered in acute stage.

S112 Presenting authors are indicated in bold. Korean J Stroke(Supplement 1) 2008;10

3rd International Conference on Intracranial Atherosclerosis and Annual Spring Meeting of the Korean Stroke Society POSTER SESSIONS

P117 Intracranial Large Artery Disease is an Independent Risk Factor for 6-Month Vascular Outcomes among Ethnic South Asian Ischemic Stroke Patients 1 2 3 Deidre De Silva , Fung-Peng Woon , Hui-Yi Gan , Christopher Chen4, Hui-Meng Chang1, Meng-Cheong Wong5 1Department of Neurology, Singapore General Hospital Campus, National Neuroscience Institute, 2Department of Research, National Heart Centre, 3Neurovascular Laboratory, Singapore General Hospital, 4Department of Pharmacology, National University of Singapore, and 5National Medical Research Council, Singapore

Background(s): Intracranial large artery disease (ICLAD)

is common among ethnic South Asian ischemic stroke patients. ICLAD carries a poor prognosis among ethnic Chinese, but there is no such data for ethnic South Asians. Poster Sessions

Objective(s): We studied the impact of ICLAD on 6- month vascular outcomes among ethnic South Asians ischemic stroke patients. Method(s): We prospectively recruited consecutive ethnic South Asian ischemic stroke patients. ICLAD was assessed by transcranial color-coded Doppler or magnetic resonance angiography. Vascular outcomes at 6-months, including recurrent stroke, transient ischemic attack, myocardial infarction and vascular mortality were ascertained via telephone assessment, blinded to ICLAD status. Result(s): Among the 240 patients recruited, 216 had adequate assessment of intracranial large arteries, of which 94% (202) had vascular outcome at 6 months ascertained. ( ) The prevalence of ICLAD was 52% 105 patients and incidence of 6-month vascular outcomes 8% (16 patients). At 6 months, the incidence of vascular outcomes was 12% among patients with ICLAD and 3% without ICLAD (p=0.018). Male gender (p=0.043) and coronary artery disease (p= 0.001) were associated with vascular outcomes at 6 months. There were no associations between 6-month vascular outcome with age, hypertension, diabetes, atrial fibrillation, smoking and stroke subtype. In binary regression analysis using gender, coronary artery disease and ICLAD as variables, ( = ) ICLAD p 0.045 was independently associated with vascular outcome at 6 months.

Conclusion(s): ICLAD is an independent predictor of subsequent vascular events within 6 months among ethnic

South Asians ischemic stroke patients.

Presenting authors are indicated in bold. S113 Interesting Case Discussion

3rd International Conference on Intracranial Atherosclerosis and Annual Spring Meeting of the Korean Stroke Society INTERESTING CASE DISCUSSION

Interesting Case Discussion For Note Taking

Interesting Case Discussion Discussion Case Interesting

Presenting authors are indicated in bold. S117

3rd International Conference on Intracranial Atherosclerosis and Annual Spring Meeting of the Korean Stroke Society INTERESTING CASE DISCUSSION

Interesting Case Discussion For Note Taking

S118 Presenting authors are indicated in bold. Korean J Stroke(Supplement 1) 2008;10

3rd International Conference on Intracranial Atherosclerosis and Annual Spring Meeting of the Korean Stroke Society INTERESTING CASE DISCUSSION

Interesting Case Discussion For Note Taking

Interesting Case Discussion Discussion Case Interesting

Presenting authors are indicated in bold. S119 Author Index

3rd International Conference on Intracranial Atherosclerosis and Annual Spring Meeting of the Korean Stroke Society AUTHOR INDEX

A Cho, A-Hyun 69,69,107 G Cho, Hyun-Ji 80,84 Ahn, Jin Young 37,68 Cho, Hyun Ji 81 Gan, Hui-Yi 57,113 Ahn, Moo Young 76,85 Cho, Hyun 83,91 Garami, Zsolt 14 Ahn, Seong Hwan 63 Cho, Ki-Hyun 35,47,106 Go, Hoyeon 101 Ahn, Sung-Ho 82 Cho, Ki H 41 Gu, Yuening 102 Ahn, Tae Beom 70 Cho, Ki Hyun 61,69 Guzman, Raphael 28 Ahn, Wang Hun 109 Cho, Kwang Ho 89 Alger, Jeffry R 35,67 Cho, Kyung-Hee 79 H Arenillas, Juan F 26,33 Cho, Kyung-Suck 97 Arsovska, Anita 78 Cho, Philza 86,89 Ha, Hyun Keun 109 Cho, YJ 38 Ha, Jiwan 108 B Cho, Yong-Jin 40,66,96 Ha, Sam-Yeol 58,94 Choi, Byung Se 39,103 Hacke, Werner 36,67 Bae, Gwangho 101 Choi, Hye-Yeon 43,59,73,81,84 Hah, Jungsang 72 Bae, Hee-Joon 35,45,61,66,38 Choi, Jae-Hwan 83 Han, Chang-ho 56 Bae, Hyo-Jin 92 Choi, Jay Chol 44 Han, Ho Seong 101 Bae, Myung Hoon 68 Choi, Jeong Kwon 60,62 Han, Hyun Jeong 88 Bae, Su Jin 60,62 Choi, Jin Woo 39,103 Han, Jing Hao 40 Bahn, Jae-Joon 99 Choi, Jong Hwan 95 Han, Jinghao 19 Bahn, Jae-Jun 42,56 Choi, Jun Young 71,79 Han, MK 38 Baik, Jong Sam 72 Choi, Kwang-Dong 82,83 Han, Moon-Ku 40,45,66 Baik, Seung-Kuk 98 Choi, Nak C 41 Han, Sang Won 72 Balucani, Clotilde 36,67 Choi, Seong-Min 47,106 Han, Seol-Heui 80 Ban, Jae-Jun 44 Choi, Seong Min 69 Han, Sunjung 87 Bang, Jae Seung 108 Choi, Seung Ho 42 Han, Weon Cheol 95 Bang, Oh Young 10,34,35,55,67 Choi, Yun Ju 69 Hao, Qing 36 Baroque, Alejandro 37,60 Chon, Jin Mann 94 Hatazawa, Jun 18 Beach, Thomas 14 Chon, Joung-Min 78 Heo, Jae-Hyeok 37,68 Bell-Stephens, Teresa E 28 Choo, In Seong 63 Heo, Ji Hoe 43,59,73,77,81,84 Belohlavek, Malek 14 Chu, Kon 42,44,56,65,99 Heo, Sung Hyuk 42,70,96 Bonovich, David C 5,33 Chun, Jong-Un 39 Hong, Ji Man 71,79 Byambajav, Davaajav 107 Chun, Jong Un 112 Hong, Keun-Sik 35,40,66,96 Chun, Min Ho 109,112 Hong, KS 38 C Chung, Chin-Sang 34,35,67,94 Hong, Seung Ho 60 Chung, Chinwook 109 Hsu, Chung-Y 58

Caplan, Louis R 11 Chung, Curie 88 Huang, Hai-Wei 34 Author Index Cariaga, Agnes 74 Chung, Kyung Cheon 70,96 Huang, Hua 102 Cha, Jae-Kwan 46,61,92,98,105 Chung, Pil-Wook 58,75,81 Huang, Mei Lic 34 Cha, Jae-Kwon 35 Chung, So-Ryoung 62 Huh, Jung Phil 109 Cha, Jae K 41 Chung, Won Jung 103 Huh, Pil-Woo 97 Cha, Jeong Min 66 Colacion, Jessie 73 Hung, Esther HY 103 Chan, Anne YY 102 Hwang, Pyoung-Han 100 Chan, Lung 58 E Hwang, Yangha 98 Chang, Dae-Il 70,96 Hwang, Yumi 108 Chang, Hui-Meng 57,113 Esh, Chera 14 Chang, Hyuk 89 Espiritu, Ma Geraldine S 73,74 I Chang, Jun-Young 44,65 Changchit, Siriprang 64 F ICAS, China Collaborative Group 33 Chen, Christopher 19,57,113 Im, Woo-Seok 44 Chen, Sien-Tsong 58 Fang, Yannan 90 In, Hyun Sin 39,103 CHEN, Xiang-Yan 7,36 Feng, Ling 33 Cheung, TF 38 Fiorella, David 25 J Chimowitz, Marc 24 Fisher, Mark 7 Chiou, Hong-Yi 58 FU, Xian 34 Jamora, Roland Dominic G 73,74 Chiu, Hou-Chang 58 Jang, Dong-Kyu 97

S123

3rd International Conference on Intracranial Atherosclerosis and Annual Spring Meeting of the Korean Stroke Society AUTHOR INDEX

Jang, Hyun Chan 66 Kim, DE 38 Kim, Suk Jae 35,67 Jang, Il Mi 76,85 Kim, Doheui 85 Kim, Sung-Min 88 Jang, Min Uk 37,68 Kim, Dong-Hyun 42,44,56 Kim, Sung Kwan 92 Jeng, Jiann-Shing 13,58 Kim, Dong-Uk 106 Kim, Sunyoung 86,89 Jeon, Hyung-Won 46,98 Kim, Eui-Jong 70 Kim, Tae-Jin 110 Jeong, Seok-Young 100 Kim, Eung-Gyu 35 Kim, Tae-Wan 84 Jeong, Seul-Ki 71,76,100 Kim, Eung Gyu 41,61,92 Kim, Tae Wan 95 Jeong, SW 38 Kim, Gyeong-Moon 34,35,67,94,107 Kim, Yeong-In 62 Ji, Hyun-Young 69 Kim, Hahn Young 80 Kim, Yo S 41 Ji, Ki-Hwan 68 Kim, Hak Jin 83 Kim, Yo Sik 89 Jiang, Wei-Jian 20 Kim, Ho Sung 71 Kim, Yong-Bum 58 Jin, Gong-Yong 71 Kim, Hoo Won 63 Kim, Yong-Duk 93 Jo, Kwang Deog 104 Kim, HY 38 Kim, Yong-Sun 98 Jo, Soo-Jin 46 Kim, Hyeon Jeong 111 Kim, Yong Bum 75,81 Joen, Bohyun 107,109 Kim, Hyeyun 88 Kim, Yong Dae 77 Jose, C San 38 Kim, Hyun-Sook 46 Kim, Yong J 41 Jun, Bo-Hyun 111 Kim, Hyun Sook 105 Kim, Yong Jae 59,61 Jung, Dae Soo 82,83 Kim, Hyun Y 100 Kim, Yong mi 109 Jung, Hyun-jung 106 Kim, Jae-Kyu 47 Kim, Youn-Sil 55 Jung, Hyun-Suk 34 Kim, Jae Guk 39 Kim, Young-Dae 84 Jung, Julee 87 Kim, Jae Il 86 Kim, Young-Hyun 76,100 Jung, Keun-Hwa 42,44,56,65,99 Kim, Jaeseng 93 Kim, Young-Shin 93 Jung, Min-Kyung 66 Kim, Je 61 Kim, Young Bum 107 Jung, San 46 Kim, Jei 57,111 Kim, Young Dae 43,59,73,81 Jung, Yeonkyung 89 Kim, Jeong-Min 99 Kim, Young Eun 74 Jung, Yeunkyung 86 Kim, Jeong Yeon 72 Kim, Young 106 Jung, Yo Han 43,59,73,77 Kim, Ji Soo 82,83 Kim, Youngjin 87 Kim, Ji Sun 76,85 Kim, Yu-Kyeong 40 K Kim, Jin-Hee 42,44,56,99 Kim, Yun-Hee 107,109,111 Kim, Jin Ho 63 Kim, Yun J 100 Kalaw, Angelito Jonas L 37 Kim, Jin 55 Ko, Sang-Bae 90 Kang, Daeryoung 56 Kim, Jong S 12,38,39,43,61 Ko, Young Bae 75 Kang, Dong-Wha 15,38,39,40,63 63,79, 80,93,103 Ko, Youngchai 45 66,79,80,103 Kim, Joon-Tae 47,69 Koh, Imseok 86,89 Kang, Ji-Hoon 44 Kim, Joong-Seok 62 Koh, Jae Young 39,103 Kang, Kyung-Mook 99 Kim, Jun-Tae 106 Koh, Seong-Ho 65,100 Kang, Kyung-Muk 99 Kim, Jung Eun 93 Kong, Kyunghwan 101 Kang, Kyusik 64 Kim, Jung Hoon 101 Koo, Ja-Seong 35,40,41,66,88 Kang, MJ 98 Kim, Kee-Won 55 Koo, Jaseong 61 Kang, Myung-Jin 46,105 Kim, Ki-Joo 100 Koo, JS 38 Kang, Sa-Yoon 44 Kim, Ki-Ju 76 Kwan, Ji-Hyun 91 Kang, Si Hyun 109,112 Kim, Ki-Tae 97 Kwon, Hyung-Min 42,45 Kang, Suk Y 43 Kim, KM 38 Kwon, Jee-Hyun 83 Kang, Sunwon 87 Kim, Manho 42,44,56,65,99 Kwon, Keun-Sang 71 Kang, Yeonwook 91 Kim, Min Jung 106 Kwon, Miseon 93 Kaste, Markku 36,67 Kim, Min Ky 37,68 Kwon, Oh-Sang 58 Kim, Beum Saeng 69,107 Kim, Min Su 109 Kwon, Ohyun 41,88 Kim, Bo ryun 112 Kim, Myeong-Kyu 47,69,106 Kwon, Soon Chan 106 Kim, Bum-Soo 62 Kim, Nam Keun 60,62 Kwon, Sun U 33,35,38,39 Kim, Byeong-Chae 47,69 Kim, Nayoung 41 63,79,80,103 Kim, Byung-Kun 41,88 Kim, Ok Joon 60,62 Kim, Byung-Su 34 Kim, Sang Joon 39,103 L Kim, Chi-Kyung 45 Kim, Seo Hyun 66,78 Kim, Dae-Hyun 57 Kim, Seung H 100 Lam, Judy SY 104 Kim, Dae Hyeon 77 Kim, Seung Min 84 Lam, Wynnie WM 38,102,103,104 Kim, Dal-Soo 97 Kim, Sucjoo 88 Lau, Alex 36

S124 Korean J Stroke(Supplement 1) 2008;10

3rd International Conference on Intracranial Atherosclerosis and Annual Spring Meeting of the Korean Stroke Society AUTHOR INDEX

Lau, Alexander YL 102 Lee, Seung-Koo 16 Nam, Jungmoo 88 Lau, Helena 33 Lee, Seung Han 69 Navarro, Carmelita V 37 Lee, Boram 39,112 Lee, SH 38 Navarro, Jose C 17,37,38,60 Lee, Byung-Chul 35,38,46,66,74,91 Lee, Soo Joo 39,112 Nidhinandana, Samart 64 Lee, Byung Hee 39 Lee, Soo yoon 92,105 No, Young Joo 104 Lee, Chang-Min 86 Lee, Soon-Tae 42,44,56,65,99 Lee, Dae-Yeol 100 Lee, Su-Ho 64 O Lee, Dain 98 Lee, Sun A 70,96 Lee, Deok Hee 39,103 Lee, Sung-Soo 78 Oh, Doyeun 60,62 Lee, Dong Woo 84 Lee, Sung Hun 92 Oh, Eung-Seok 57 Lee, Eugene 80 Lee, Sung Ik 95 Oh, Eung Seok 77,111 Lee, Eun-Ja 88 Lee, Sung Soo 66 Oh, Gun-Sei 39,112 Lee, Geun Ho 86 Lee, Sungik 87 Oh, Jeeyoung 80 Lee, Hak Seung 89 Lee, Tae-Hong 82 Oh, Mi Sun 35,46,74 Lee, Hoyoung 108 Lee, Won-Sik 84 Oh, Se-Jin 82 Lee, Hyung Suk 101 Lee, Woong-Woo 45 Oh, Sechul 100 Lee, Jae-Hong 93 Lee, Yeong Bae 110 Oh, Sun-Young 76,100 Lee, Jae-Hyuk 79 Lee, Yong-Seok 27,35,40,45,61 Oh, Yoon-Sang 107 Lee, Jae ho 60,62 Lee, Young-Hoon 57 Ohn, Suk Hoon 111 Lee, Jae Hyuk 71 Lee, Young-Joo 65 Ohn, Suk Hun 107 Lee, Jae Jung 73 Lee, Young Ha 96 Ohrr, Heechoul 56 Lee, Jaikyoo 87 Lee, Young Hoon 77 Ovbiagele, Bruce 55 Lee, Jeong 68 Lee, Young J 100 Lee, JH 38 Lee, YS 38 P Lee, Ji-Hee 57 Lee, Yu-Sil 46 Lee, Ji-Yong 66,78 Leung, Howan 36,40 Paik, Nam-Jong 29 Lee, Ji Hee 77,111 Leung, Thomas WH 103,104 Park, Chang-hyun 111 Lee, Jin-Hoon 110 Leung, Thomas 36,38,102 Park, Chun-Kun 97 Lee, Jong Hyeog 104 Leung, Wai hong 40 Park, Hee-Kwon 42,44,56,65,99 Lee, Jongyun 86,89 Leys, Didier 36,67 Park, Hyeon Mi 110 Lee, Ju-ah 101 Li, Hua 90 Park, Hyun Young 89 Lee, Ju Hun 46 Li, Qianning 102 Park, Hyung Jun 84 Lee, Ju Kang 110 Li, Xianliang 90 Park, Jae Hyeon 72 Lee, Jun-Young 57 Liebeskind, David S 35,55,67 Park, Jaeseol 91 Lee, Jun Young 77,111 Lien, Li-Ming 58 Park, Jeong-Eun 44 Lee, Jun 41,61,72,87 Lim, Jae-Sung 44,65,99 Park, Ji-Young 88

Lee, Juneyong 61 Lim, Jung Chul 92 Park, Jin-Ho 45 Author Index Lee, Jung Seok 44 Lim, Mi-Hye 76,100 Park, Jin-Kyu 97

Lee, JungJu 41,88 Lin, Rui Jin 34 Park, JM 38 Lee, KB 38 Lokin, Johnny K 37,60 Park, Jong-Ho 88 Lee, Kee Ook 93 Lyo, In Uk 106 Park, Jong-Moo 40,41,66,88 Lee, Kwang-Soo 62 Park, Jun Bum 106 Lee, Kwang Ho 34,35,61,67,94 M Park, Jung-Hyun 45 Lee, Kyu-Yong 65,100 Park, Jung-Wook 97 Lee, Kyung Bok 76,85 Min, Ju-Hong 58 Park, Jung Hyeon 72 Lee, Marco 28 Mok, CT 38 Park, Key Chung 70,96 Lee, Peter Kang Woo 109 Mok, Vincent 36 Park, Ki Hyung 110 Lee, Sang-Bong 62 Moon, Heui-Soo 58,75,81 Park, Kunu 108 Lee, Sang-Rok 71 Moon, Jung Su 111 Park, Kwang-yeol 58,75,81 Lee, Sang Kun 42,44,56,65,99 Moon, So Young 101 Park, Kyu-Hyun 82 Lee, Sejin 72,87 Park, Kyung Won 92 Lee, Seung-Chul 65 N Park, Man-Seok 47,106 Lee, Seung-Han 47 Park, Man S 41 Lee, Seung-Hoon 42,45,64,90 Na, Sang-Jun 93 Park, Man Seok 69 Lee, Seung-Hwan 106 Na, Sung Kyu 37 Park, Meeyoung 72 Lee, Seung-Jae 62,69,107 Nam, Hyo Suk 43,59,73,77,81 Park, Minsu 87

S125

3rd International Conference on Intracranial Atherosclerosis and Annual Spring Meeting of the Korean Stroke Society AUTHOR INDEX

Park, Sang-Won 84 Silva, Deidre De 57,113 Yang, Dong Won 69,107 Park, Sang Hyun 66,78 Sim, Hong Bo 106 Yang, Hyun Duk 95 Park, Sang Ok 75 Sohn, Chul-Ho 105 Yang, Hyun Woo 92 Park, Sea Mi 63 Sohn, Sung-Il 84,105 Yang, Hyunduk 87 Park, Seong-Ho 40 Son, Il Hong 95 Yang, Ji Won 110 Park, Sung-Pa 98 Son, Ilhong 87 Yang, Mi Hwa 45 Park, Sung Tae 75 Song, Eun-Cheol 42,44,56,99 Yang, Tae-Ho 76,100 Park, Tai Hwan 37,68 Song, Hee-Young 61 Yang, Tae-il 82 Park, Yun H 111 Song, Young-Mok 86 Yang, Young Soon 85 Peng, Dan xin 34 Soo, Yannie OY 38 Yeh, Shin-Joe 58 Popovski, Ante 78 Steinberg, Gary K 28 Yi, Sang Hun 70 Poungvarin, N 38 Suh, Bum-Chun 58,75,81 Yi, Sung Eun 79 Pyun, Sung-Bom 108 Suh, Chung-Kyu 98 Yim, Seong Jin 72 Suh, Dae Chul 39,75,103 Yim, Soo-Bin 104 R Suk, Seung-Han 61 Yoo, A R 100 Sung, Young Hee 110 Yoo, Bong G 41 Rabo, Carter 60 Suwanwela, NC 38 Yoo, Do-Sung 97 Ratanakorn, D 38 Yoo, Seung Don 94,108 Ren, Li 90 T Yoo, Woo-Kyung 111 Rha, Joung-Ho 35,38,40,68 Yook, Ji-Won 82 Ringelstein, Bernd 36,67 Tan, Shuang Quan 34 Yoon, Byung-Woo 42,45,64,90 Roh, Hakjae 76,85 Tang, Sung-Chun 13 Yoon, Geum Jin 69 Roh, Jae-Kyu 35,42,44,56,65,99 Turan, Tanya 33 Yoon, Kyung Hwan 75 Roher, Alex 14 Yoon, Seunghwan 86,89 Ryu, Wi-Sun 45 V Yoon, Soo-Jin 39,112 Yoon, Sung Sang 70,96 S Viereck, Jason 33 Yoon, Woong 47 You, Ji-Sung 107 Sabbagh, Marwan 14 W You, Ji Sung 111 Saver, Jeffrey L 55 You, Seung Hoon 104 Seo, Hyun-Jin 83,91 Wang, Xiaojuan 90 You, Yong 36 Seo, Jin-Young 76,100 Wang, Yongjun 33 Youn, Young Chul 58 Seo, Man-Wook 76,100 Won, Yoo-Dong 97 Yu, Huijeong 101 Seo, Yeong Bae 110 Wong, KS Lawrence 6,19,33,34,36 Yu, In-Kyu 39 Seok, Jin Myoung 35 38,40, 102,103,104 Yu, Kyung-Ho 35,38,46,66,74,91 Shim, Mi Sup 101 Wong, Meng-Cheong 57,113 Yu, Simon CH 38,102 Shin, Byoung-Soo 55,76,100 Woo, Henry 25 Yu, Simon 103,104 Shin, Chae-won 45 Woon, Fung-Peng 57,113 Yu, Younggi 101 Shin, Dong Ick 101 Yum, Kyu Sun 93 Shin, Dong Jin 110 X Shin, Hee Jun 109 Z Shin, Jun-Hyun 46 Xiong, Li 40 Shin, Kyoung Hwa 79 Zhang, Aiwu 90 Shin, Yong-Il 110 Y Shon, Young-Min 69,107 Shuai, Jie 102 Yang, Chung-Yong 110

S126 Korean J Stroke(Supplement 1) 2008;10