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Abstract
Intracerebral hemorrhage (ICH) is a neurologic injury resulting in significant morbidity and mortality. Statins play a significant role in primary and secondary prevention of cardiovascular and cerebrovascular ischemic events. Despite clear benefits of statins in ischemic stroke, post hoc analyses of some studies suggest there may be a link between statin therapy and development of ICH. Direct pharmacologic effects of decreased serum levels of total cholesterol and low-density lipoproteins in conjunction with pleiotropic effects are thought to be linked to this possible increase in ICH risk. In the face of the potential of statins to increase the risk of ICH, recent evidence suggests that statins may also have beneficial effects on patient outcomes when continued or initiated following an ICH. This discordance in findings and the overall lack of well-designed prospective clinical trials increase the complexity of clinical decision making when utilizing statin therapy in patients with, or at risk for, ICH. This review evaluates the pharmacologic effects of statin therapy and describes how these effects translate to both risks and benefits in ICH. The current literature regarding the effects of statin therapy on clinical outcomes in ICH is evaluated to help guide clinicians with decisions regarding initiation, continuation, or discontinuation of statin therapy in patients with ICH.
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Affiliation(s)
- Edward T Van Matre
- Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO, USA
| | - Deb S Sherman
- Department of Pharmacy, University of Colorado Hospital, Aurora, CO, USA
| | - Tyree H Kiser
- Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO, USA
- Department of Pharmacy, University of Colorado Hospital, Aurora, CO, USA
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Wu Y, Chen T. An Up-to-Date Review on Cerebral Microbleeds. J Stroke Cerebrovasc Dis 2016; 25:1301-6. [PMID: 27085816 DOI: 10.1016/j.jstrokecerebrovasdis.2016.03.005] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2015] [Revised: 02/20/2016] [Accepted: 03/04/2016] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Cerebral microbleeds (CMBs) are small cerebrovascular lesions. More and more CMBs have been found in patients with ischemic stroke, dementia, and cerebral amyloid angiopathy, as well as some normal elderly populations. The objective of this study is to summarize the main risk factor, impairment, and therapy of CMBs. METHODS We searched and scanned all the literature with the keyword "cerebral microbleeds" or "CMBs" in the database of PubMed and Elsevier. RESULTS The risks factors for CMBs are complicated, including those that cause large-vessel disease, such as hypertension and old age, and those that cause small-vessel disease, such as amyloid deposits, endothelial lesions, and atrial fibrillation. Moreover, drugs and therapies used to treat cerebrovascular diseases such as statin, intravenous thrombolysis, and coumarin may also increase risk of CMBs. The relationship between antiplatelet treatment and CMBs is now unclear. Gene polymorphisms have been considered to be associated with CMBs. Gene mutations involving collagen type IV alpha 1 and collagen type IV alpha 2, sortilin-related receptor gene, forkhead box C1, and paired-like homeodomain 2 were reported to affect CMBs with the modification of corresponding proteins and functions. The cognition impairment caused by CMBs draws great attention. White matter deterioration is the possible answer. However, different studies could not reach the same conclusion on the damage of cognition of CMBs. CONCLUSIONS Further research is needed to provide effectual therapeutic proposals for CMBs, which differ from the treatment for large-artery disease and dementia.
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Affiliation(s)
- Yan Wu
- Neurology Department, First Affiliated Hospital of Kunming Medical School, Kunming, China
| | - Tao Chen
- Neurology Department, First Affiliated Hospital of Kunming Medical School, Kunming, China.
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Lower Serum Caveolin-1 Is Associated with Cerebral Microbleeds in Patients with Acute Ischemic Stroke. OXIDATIVE MEDICINE AND CELLULAR LONGEVITY 2016; 2016:9026787. [PMID: 27119011 PMCID: PMC4826928 DOI: 10.1155/2016/9026787] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/17/2015] [Revised: 02/02/2016] [Accepted: 03/13/2016] [Indexed: 11/18/2022]
Abstract
Caveolin-1 (Cav-1) plays pivotal roles in the endothelial damage following stroke. The present study aimed to investigate whether serum Cav-1 level is associated with the presence of cerebral small vessel disease (cSVD) in patients with acute ischemic stroke. To this end, 156 patients were consecutively enrolled. Cranial magnetic resonance imaging was analyzed to determine the surrogates of cSVD, including cerebral microbleeds (CMBs), silent lacunar infarcts (SLIs), and white matter hyperintensities (WMHs). After adjusting for potential confounders, patients with low Cav-1 level had a higher risk of CMBs than patients with high Cav-1 level (OR: 4.05, 95% CI: 1.77-9.30). However, there was no relationship between Cav-1 and the presence of SLIs or WMHs. When CMBs were stratified by location and number, a similar association was found in patients with deep or infratentorial CMBs (OR: 4.04, 95% CI: 1.59-10.25) and with multiple CMBs (OR: 3.18, 95% CI: 1.16-8.72). These results suggest lower serum Cav-1 levels may be associated with CMBs, especially those that are multiple and located in deep brain or infratentorial structures, in patients with acute ischemic stroke. Cav-1 may be involved in the pathophysiology of CMBs, and may act as a potential target for treating cSVD.
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Johansson E, Ambarki K, Birgander R, Bahrami N, Eklund A, Malm J. Cerebral microbleeds in idiopathic normal pressure hydrocephalus. Fluids Barriers CNS 2016; 13:4. [PMID: 26860218 PMCID: PMC4748449 DOI: 10.1186/s12987-016-0028-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2015] [Accepted: 02/03/2016] [Indexed: 11/25/2022] Open
Abstract
Background A vascular disease could be involved in pathophysiology of normal pressure hydrocephalus (INPH). If so, there should be an association between INPH and cerebral microbleeds (CMB). This study aims to analyze if CMB are associated with INPH. Methods In this case-control study we included 14 patients with INPH (mean age 76 years, 60 % female) and 41 healthy controls (HeCo; mean age 71 years, 60 % female). All were investigated with magnetic resonance imaging (MRI) using a T2*-sequence. The MRI exams were reviewed by two neuroradiologists for the presence of CMBs; the prevalence of findings of two or more CMBs was compared between INPH group and control group. After investigation, INPH patients underwent shunt surgery. Results Two or more CMB were detected more frequently in the INPH group compared to HeCo (n = 6, 43 % vs. n = 4, 10 %; p = 0.01). Among the participants where MRI revealed CMB, the number of CMB was higher among the INPH patients than the HeCo (median 8; IQR 2-34 vs. median 1; IQR 1–2; p = 0.005). Conclusions This study supports a vascular component to the pathophysiology of INPH.
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Affiliation(s)
- Elias Johansson
- Department of Pharmacology and Clinical Neuroscience, Norrlands Universitetssjukhus, Umeå University, S-901 85, Umeå, Sweden.
| | - Khalid Ambarki
- Department of Radiation Sciences, Umeå University, Umeå, Sweden. .,Centre for Biomedical Engineering and Physics, Umeå University, Umeå, Sweden.
| | | | - Nazila Bahrami
- Department of Radiation Sciences, Umeå University, Umeå, Sweden.
| | - Anders Eklund
- Department of Radiation Sciences, Umeå University, Umeå, Sweden. .,Centre for Biomedical Engineering and Physics, Umeå University, Umeå, Sweden.
| | - Jan Malm
- Department of Pharmacology and Clinical Neuroscience, Norrlands Universitetssjukhus, Umeå University, S-901 85, Umeå, Sweden.
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High Prevalence of Cerebral Microbleeds in Inner City Young Stroke Patients. J Stroke Cerebrovasc Dis 2016; 25:733-8. [PMID: 26775270 DOI: 10.1016/j.jstrokecerebrovasdis.2015.11.022] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2015] [Revised: 10/26/2015] [Accepted: 11/22/2015] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Data on cerebral microbleeds (CMBs) in younger populations are lacking, particularly in young stroke patients. We sought to characterize CMBs in an inner city cohort of young adults with stroke. METHODS CMB presence, count, and topography were assessed on magnetic resonance imaging (MRI) scans of 104 young stroke patients (≤49 years) presenting to Boston Medical Center between January 2006 and February 2010. Subsequent MRIs were assessed for the occurrence of new microbleeds in 29 patients. We performed cross-sectional analysis comparing baseline characteristics between patients with and without microbleeds, and between predefined microbleed burden and topography categories. We performed additional analysis to assess the determinants of new microbleeds on repeat MRI. RESULTS Microbleeds were present in 17% of the sample. Male sex (odds ratio [OR] 5.7, 95% confidence interval [CI] 1.0-32.6, P = .049), hypertension (OR 6.2, 95% CI 1.2-32, P = .03), moderate-severe white matter hyperintensities on MRI (OR 5.8, 95% CI 1.6-29.0, P = .01), and intracerebral hemorrhage (ICH; OR 5.0, 95% CI 1.2-20, P = .03) were over-represented in patients with microbleeds. Patients who developed new microbleeds on repeat MRI (14%) had higher microbleed counts on baseline MRI (50% versus 0% ≥ 3 CMBs, P = .02), history of illicit drug use (75% versus 24%, P = .08), positive serum toxicology for cocaine (67% versus 13%, P = .11), ICH as their presenting stroke subtype (50% versus 8%, P = .08), and over-representation of moderate-severe white matter hyperintensities (75% versus 20%, P = .05). CONCLUSIONS Results from this inner city cohort suggest that microbleeds are prevalent in young stroke patients and are largely associated with modifiable risk factors.
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Polyakova TA, Arablinsky AV, Levin OS. Do cerebral microbleeds increase the risk of hemorrhagic complications of thrombolytic therapy? Zh Nevrol Psikhiatr Im S S Korsakova 2016; 116:41-45. [DOI: 10.17116/jnevro20161166241-45] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Schindlbeck KA, Santaella A, Galinovic I, Krause T, Rocco A, Nolte CH, Villringer K, Fiebach JB. Spot Sign in Acute Intracerebral Hemorrhage in Dynamic T1-Weighted Magnetic Resonance Imaging. Stroke 2015; 47:417-23. [PMID: 26715459 DOI: 10.1161/strokeaha.115.011570] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2015] [Accepted: 11/18/2015] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE In computed tomographic imaging of acute intracerebral hemorrhage spot sign on computed tomographic angiography has been established as a marker for hematoma expansion and poor clinical outcome. Although, magnetic resonance imaging (MRI) can accurately visualize acute intracerebral hemorrhage, a corresponding MRI marker is lacking to date. METHODS We prospectively examined 50 consecutive patients with acute intracerebral hemorrhage within 24 hours of symptom onset. The MRI protocol consisted of a standard stroke protocol and dynamic contrast-enhanced T1-weighted imaging with a time resolution of 7.07 s/batch. Stroke scores were assessed at admission and at time of discharge. Volume measurements of hematoma size and spot sign were performed with MRIcron. RESULTS Contrast extravasation within sites of the hemorrhage (MRI spot sign) was seen in 46% of the patients. Patients with an MRI spot sign had a significantly shorter time to imaging than those without (P<0.001). The clinical outcome measured by the modified Rankin Scale was significantly worse in patients with spot sign compared with those without (P≤0.001). Hematoma expansion was observed in the spot sign group compared with the nonspot sign group, although the differences were not significant. CONCLUSIONS Spot sign can be detected using MRI on postcontrast T1-weighted and dynamic T1-weighted images. It is associated with worse clinical outcome. The time course of contrast extravasation in dynamic T1 images indicates that these spots represent ongoing bleeding.
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Affiliation(s)
- Katharina A Schindlbeck
- From the Department of Neurology, Charité - Universitätsmedizin Berlin, Berlin, Germany (K.A.S., A.R., C.H.N.); International Graduate Program Medical Neurosciences, Berlin, Germany (A.S.); and Center for Stroke Research Berlin (CSB), Berlin, Germany (I.G., T.K., K.V., J.B.F.).
| | - Anna Santaella
- From the Department of Neurology, Charité - Universitätsmedizin Berlin, Berlin, Germany (K.A.S., A.R., C.H.N.); International Graduate Program Medical Neurosciences, Berlin, Germany (A.S.); and Center for Stroke Research Berlin (CSB), Berlin, Germany (I.G., T.K., K.V., J.B.F.)
| | - Ivana Galinovic
- From the Department of Neurology, Charité - Universitätsmedizin Berlin, Berlin, Germany (K.A.S., A.R., C.H.N.); International Graduate Program Medical Neurosciences, Berlin, Germany (A.S.); and Center for Stroke Research Berlin (CSB), Berlin, Germany (I.G., T.K., K.V., J.B.F.)
| | - Thomas Krause
- From the Department of Neurology, Charité - Universitätsmedizin Berlin, Berlin, Germany (K.A.S., A.R., C.H.N.); International Graduate Program Medical Neurosciences, Berlin, Germany (A.S.); and Center for Stroke Research Berlin (CSB), Berlin, Germany (I.G., T.K., K.V., J.B.F.)
| | - Andrea Rocco
- From the Department of Neurology, Charité - Universitätsmedizin Berlin, Berlin, Germany (K.A.S., A.R., C.H.N.); International Graduate Program Medical Neurosciences, Berlin, Germany (A.S.); and Center for Stroke Research Berlin (CSB), Berlin, Germany (I.G., T.K., K.V., J.B.F.)
| | - Christian H Nolte
- From the Department of Neurology, Charité - Universitätsmedizin Berlin, Berlin, Germany (K.A.S., A.R., C.H.N.); International Graduate Program Medical Neurosciences, Berlin, Germany (A.S.); and Center for Stroke Research Berlin (CSB), Berlin, Germany (I.G., T.K., K.V., J.B.F.)
| | - Kersten Villringer
- From the Department of Neurology, Charité - Universitätsmedizin Berlin, Berlin, Germany (K.A.S., A.R., C.H.N.); International Graduate Program Medical Neurosciences, Berlin, Germany (A.S.); and Center for Stroke Research Berlin (CSB), Berlin, Germany (I.G., T.K., K.V., J.B.F.)
| | - Jochen B Fiebach
- From the Department of Neurology, Charité - Universitätsmedizin Berlin, Berlin, Germany (K.A.S., A.R., C.H.N.); International Graduate Program Medical Neurosciences, Berlin, Germany (A.S.); and Center for Stroke Research Berlin (CSB), Berlin, Germany (I.G., T.K., K.V., J.B.F.)
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Charidimou A, Shoamanesh A, Wilson D, Gang Q, Fox Z, Jäger HR, Benavente OR, Werring DJ. Cerebral microbleeds and postthrombolysis intracerebral hemorrhage risk Updated meta-analysis. Neurology 2015; 85:927-4. [PMID: 26296519 DOI: 10.1212/wnl.0000000000001923] [Citation(s) in RCA: 58] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE We performed a systematic review and meta-analysis to assess whether the presence of cerebral microbleeds (CMBs) on pretreatment MRI scans of patients with acute ischemic stroke treated with thrombolysis is associated with an increased risk of symptomatic intracerebral hemorrhage (ICH). METHODS We searched PubMed for relevant studies and calculated pooled odds ratios (ORs) for symptomatic ICH, using the Mantel–Haenszel fixed-effects method, among individuals with vs without CMBs on pretreatment MRI scans. To minimize potential bias, sensitivity analysis was performed including studies providing data on patients treated only with IV thrombolysis. RESULTS Ten eligible studies including 2,028 patients were pooled in meta-analysis. The overall prevalence of CMBs was 23.3%. Among patients with CMBs, 40 of 472 (8.5%; 95%confidence interval [CI]: 6.1%–11.4%) experienced a symptomatic ICH after thrombolysis compared with 61 of 1,556 patients (3.9%; 95% CI: 3%–5%) without CMBs. The pooled OR of ICH across all studies was 2.26 (95%CI: 1.46–3.49; p , 0.0001). Eight studies, including 1,704 patients (n 5 401 with CMBs), provided data on patients treated with IV thrombolysis only; OR for the presence of CMBs and the development of symptomatic ICH was 2.87 (95%CI: 1.76–4.69; p , 0.0001). CONCLUSIONS Our meta-analysis of the available published data demonstrates an increased risk of symptomatic ICH after thrombolysis for acute ischemic stroke in patients with CMBs. However, we cannot fully exclude bias or confounding, so our results should be considered hypothesis generating. Detecting CMBs should not prevent thrombolytic treatment based on present evidence. Further analyses, taking into account CMB number and location, as well as measures of functional outcome, are needed.
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Cai J, Fu J, Yan S, Hu H, Lin C. Clinical Outcome in Acute Ischemic Stroke Patients With Microbleeds After Thrombolytic Therapy: A Meta-Analysis. Medicine (Baltimore) 2015; 94:e2379. [PMID: 26717385 PMCID: PMC5291626 DOI: 10.1097/md.0000000000002379] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
It remains unclear whether preexisting cerebral microbleeds (CMBs) increase the risks of worse functional outcome after thrombolytic therapy. We performed a systematic review and meta-analysis to assess the risk of unfavorable outcome in patients with acute ischemic stroke and CMBs.We searched EMBASE, PubMed, and Web of Science for relevant studies assessing functional outcome in the patients with CMBs following thrombolytic therapy. Fixed-effects and random-effects models were performed.Five eligible studies including 1974 patients were pooled in meta-analysis. The prevalence of CMBs was 24.3%. The pooled analysis demonstrates odds ratio for preexisting CMBs and the achievement of favorable outcome to be 0.69 (95% CI 0.56-0.86; P = 0.001) with no evidence of statistical heterogeneity (I = 46.7%, P = 0.112).Our meta-analysis of available published data demonstrates an increased risk of worse functional outcome after thrombolytic therapy for acute ischemic stroke in patients with pre-existing CMBs. Future studies are needed to determine whether the risk outweigh the expected benefit of reperfusion therapies.
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Affiliation(s)
- Jing Cai
- From the Neurosurgerical Intensive Care Unit, the 2nd Affiliated Hospital of Zhejiang University (JC); Department of Neurology, the 4th Affiliated Hospital of Zhejiang University (JF); Department of Neurology (SY, HH); and Department of Surgical Oncology, the 2nd Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China (CL)
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[Troponin elevation in ischemic stroke patients]. Med Klin Intensivmed Notfmed 2015; 112:222-226. [PMID: 26564181 DOI: 10.1007/s00063-015-0116-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2015] [Revised: 08/28/2015] [Accepted: 10/01/2015] [Indexed: 10/22/2022]
Abstract
Cerebrovascular and cardiovascular diseases are major causes of death and disability worldwide. Ischemic stroke is a frequent complication in cardiac diseases and, vice versa, cardiac complications commonly cause early clinical worsening and death after stroke. In the emergency setting, cardiac biomarkers (preferably troponin, cTn) are measured frequently in patients presenting with acute ischemic stroke. The measurement of cTn is recommended by the guidelines for early management of patients with acute ischemic stroke from the American Heart Association. In case of pathologic cTn elevation, physicians are confronted with diagnostic and therapeutic uncertainties. Up-to-date recommendations on interpretation and consecutive actions remain ambiguous because cTn elevations may originate from causes other than acute coronary disease and because clinical signs and symptoms of acute coronary disease may be obscured by neurological deficits of the stroke. The application of modern, high-sensitive cTn assays that detect even minor cTn elevations has rather aggravated the dilemma of how to interpret this finding in patients with ischemic stroke.This article gives an overview on possible mechanisms of the frequently observed cTn elevation in ischemic stroke patients and offers help on interpretation and meaningful actions.
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Yan S, Jin X, Zhang X, Zhang S, Liebeskind DS, Lou M. Extensive cerebral microbleeds predict parenchymal haemorrhage and poor outcome after intravenous thrombolysis. J Neurol Neurosurg Psychiatry 2015; 86:1267-72. [PMID: 25632155 DOI: 10.1136/jnnp-2014-309857] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2014] [Accepted: 12/22/2014] [Indexed: 11/04/2022]
Abstract
PURPOSE Thrombolysis-related haemorrhagic transformation (HT) subtypes may have different prognostic implications. We aimed to analyse the impact of cerebral microbleeds (CMBs) burden on HT subtypes and outcome after intravenous thrombolysis. METHODS We retrospectively examined clinical and radiological data from 333 consecutive patients with acute ischaemic stroke who underwent susceptibility-weighted imaging before intravenous thrombolysis. Logistic regression analysis was used to determine the impact of CMBs on HT subtypes and neurological outcome. RESULTS We observed 596 CMBs in 119 (39.7%) patients on initial gradient-recalled echo scans. HT occurred in 88 (29.3%) patients, among which 62 were haemorrhagic infarction and 26 were parenchymal haemorrhage (PH). Logistic regression analysis indicated that the presence of extensive (≥ 3) CMBs was independently associated with PH (OR 6.704; 95% CI 2.054 to 21.883; p = 0.002) and poor clinical outcome (OR 2.281; 95% CI 1.022 to 5.093; p = 0.044). CONCLUSIONS The presence of extensive (≥ 3) CMBs increased the risk of PH 24 h after intravenous thrombolysis, and predicted poor clinical outcome independently.
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Affiliation(s)
- Shenqiang Yan
- Department of Neurology, The 2nd Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China
| | - Xinchun Jin
- Department of Neurology, The 2nd Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China
| | - Xuting Zhang
- Department of Neurology, The 2nd Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China
| | - Sheng Zhang
- Department of Neurology, The 2nd Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China
| | - David S Liebeskind
- University of California-Los Angeles Stroke Center, Los Angeles, California, USA
| | - Min Lou
- Department of Neurology, The 2nd Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China
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Vo KD, Yoo AJ, Gupta A, Qiao Y, Vagal AS, Hirsch JA, Yousem DM, Lum C. Multimodal Diagnostic Imaging for Hyperacute Stroke. AJNR Am J Neuroradiol 2015; 36:2206-13. [PMID: 26427831 DOI: 10.3174/ajnr.a4530] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
In April 2015, the American Roentgen Ray Society and the American Society of Neuroradiology cosponsored a unique program designed to evaluate the state of the art in the imaging work-up of acute stroke. This topic has grown in importance because of the recent randomized controlled trials demonstrating the clear efficacy of endovascular stroke treatment. The authors, who were participants in that symposium, will highlight the points of emphasis in this article.
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Affiliation(s)
- K D Vo
- From the Mallinckrodt Institute of Radiology (K.D.V.), Washington University School of Medicine, St. Louis, Missouri
| | - A J Yoo
- Division of Neurointervention (A.J.Y.), Texas Stroke Institute, Plano, Texas
| | - A Gupta
- Department of Radiology and Feil Family Brain and Mind Research Institute (A.G.), Weill Cornell Medical College, New York, New York
| | - Y Qiao
- Department of Radiology (Y.Q.), Johns Hopkins School of Medicine, Baltimore, Maryland
| | - A S Vagal
- Department of Radiology (A.S.V.), University of Cincinnati Medical Center, Cincinnati, Ohio
| | - J A Hirsch
- NeuroInterventional Radiology (J.A.H.), Massachusetts General Hospital, Boston, Massachusetts
| | - D M Yousem
- Department of Radiology (D.M.Y.), Johns Hopkins Medical Institution, Baltimore, Maryland
| | - C Lum
- Interventional Neuroradiology (C.L.), Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontaria, Canada
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Saini M, Suministrado MSP, Hilal S, Dong YH, Venketasubramanian N, Ikram MK, Chen C. Prevalence and Risk Factors of Acute Incidental Infarcts. Stroke 2015; 46:2722-7. [DOI: 10.1161/strokeaha.115.009963] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2015] [Accepted: 07/22/2015] [Indexed: 11/16/2022]
Affiliation(s)
- Monica Saini
- From the Department of Pharmacology, National University of Singapore, Singapore, Singapore (M.S., M.S.P.S., S.H., Y.H.D., C.C.); Department of Medicine, Changi General Hospital, Singapore, Singapore (M.S.); Memory Aging and Cognition Centre, National University Health System, Singapore, Singapore (M.S.P.S., S.H., Y.H.D., N.V., M.K.I., C.C.); Raffles Neuroscience Centre, Department of Neurology, Raffles Hospital, Singapore, Singapore (N.V.); Singapore Eye Research Institute, Singapore National Eye
| | - Ma Serrie P. Suministrado
- From the Department of Pharmacology, National University of Singapore, Singapore, Singapore (M.S., M.S.P.S., S.H., Y.H.D., C.C.); Department of Medicine, Changi General Hospital, Singapore, Singapore (M.S.); Memory Aging and Cognition Centre, National University Health System, Singapore, Singapore (M.S.P.S., S.H., Y.H.D., N.V., M.K.I., C.C.); Raffles Neuroscience Centre, Department of Neurology, Raffles Hospital, Singapore, Singapore (N.V.); Singapore Eye Research Institute, Singapore National Eye
| | - Saima Hilal
- From the Department of Pharmacology, National University of Singapore, Singapore, Singapore (M.S., M.S.P.S., S.H., Y.H.D., C.C.); Department of Medicine, Changi General Hospital, Singapore, Singapore (M.S.); Memory Aging and Cognition Centre, National University Health System, Singapore, Singapore (M.S.P.S., S.H., Y.H.D., N.V., M.K.I., C.C.); Raffles Neuroscience Centre, Department of Neurology, Raffles Hospital, Singapore, Singapore (N.V.); Singapore Eye Research Institute, Singapore National Eye
| | - Yan Hong Dong
- From the Department of Pharmacology, National University of Singapore, Singapore, Singapore (M.S., M.S.P.S., S.H., Y.H.D., C.C.); Department of Medicine, Changi General Hospital, Singapore, Singapore (M.S.); Memory Aging and Cognition Centre, National University Health System, Singapore, Singapore (M.S.P.S., S.H., Y.H.D., N.V., M.K.I., C.C.); Raffles Neuroscience Centre, Department of Neurology, Raffles Hospital, Singapore, Singapore (N.V.); Singapore Eye Research Institute, Singapore National Eye
| | - Narayanaswamy Venketasubramanian
- From the Department of Pharmacology, National University of Singapore, Singapore, Singapore (M.S., M.S.P.S., S.H., Y.H.D., C.C.); Department of Medicine, Changi General Hospital, Singapore, Singapore (M.S.); Memory Aging and Cognition Centre, National University Health System, Singapore, Singapore (M.S.P.S., S.H., Y.H.D., N.V., M.K.I., C.C.); Raffles Neuroscience Centre, Department of Neurology, Raffles Hospital, Singapore, Singapore (N.V.); Singapore Eye Research Institute, Singapore National Eye
| | - Mohammad K. Ikram
- From the Department of Pharmacology, National University of Singapore, Singapore, Singapore (M.S., M.S.P.S., S.H., Y.H.D., C.C.); Department of Medicine, Changi General Hospital, Singapore, Singapore (M.S.); Memory Aging and Cognition Centre, National University Health System, Singapore, Singapore (M.S.P.S., S.H., Y.H.D., N.V., M.K.I., C.C.); Raffles Neuroscience Centre, Department of Neurology, Raffles Hospital, Singapore, Singapore (N.V.); Singapore Eye Research Institute, Singapore National Eye
| | - Christopher Chen
- From the Department of Pharmacology, National University of Singapore, Singapore, Singapore (M.S., M.S.P.S., S.H., Y.H.D., C.C.); Department of Medicine, Changi General Hospital, Singapore, Singapore (M.S.); Memory Aging and Cognition Centre, National University Health System, Singapore, Singapore (M.S.P.S., S.H., Y.H.D., N.V., M.K.I., C.C.); Raffles Neuroscience Centre, Department of Neurology, Raffles Hospital, Singapore, Singapore (N.V.); Singapore Eye Research Institute, Singapore National Eye
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65
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Abstract
In acute stroke, imaging provides different technologies to demonstrate stroke subtype, tissue perfusion and vessel patency. In this review, we highlight recent clinical studies that are likely to guide therapeutic decisions. Clot length in computed tomography (CT) and clot burden in MR, imaging of leptomeningeal collaterals and indicators for active bleeding are illustrated. Imaging-based concepts for treatment of stroke at awakening and pre-hospital treatment in specialized ambulances offer new potentials to improve patient outcome.
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Affiliation(s)
- Heinrich J Audebert
- Department of Neurology and Center for Stroke Research Berlin (CSB), Charité-Universitätsmedizin Berlin, Campus Benjamin Franklin, Hindenburgdamm 30, 12200, Berlin, Germany,
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Turc G, Sallem A, Moulin S, Tisserand M, Machet A, Edjlali M, Baron JC, Leclerc X, Leys D, Mas JL, Cordonnier C, Oppenheim C. Microbleed Status and 3-Month Outcome After Intravenous Thrombolysis in 717 Patients With Acute Ischemic Stroke. Stroke 2015; 46:2458-63. [DOI: 10.1161/strokeaha.115.009290] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2015] [Accepted: 05/13/2015] [Indexed: 12/22/2022]
Abstract
Background and Purpose—
Whether cerebral microbleeds (CMBs) detected on pretreatment magnetic resonance imaging increase the risks of symptomatic intracranial hemorrhage (sICH) and, most importantly, poor outcome in patients treated by intravenous thrombolysis for acute ischemic stroke is still debated. We assessed the effect of CMB presence and burden on 3-month modified Rankin Scale and sICH in a multicentric cohort.
Methods—
We analyzed prospectively collected data of consecutive patients solely treated by intravenous thrombolysis for acute ischemic stroke, in 2 centers where magnetic resonance imaging is the first-line pretreatment imaging. Neuroradiologists blinded to clinical data rated CMBs on T2* sequence using a validated scale. Logistic regressions were used to assess relationships between CMBs and 3-month modified Rankin Scale or sICH.
Results—
Among 717 patients, 150 (20.9%) had ≥1 CMBs. CMB burden was associated with worse modified Rankin Scale in univariable shift analysis (odds ratio, 1.07; 95% confidence interval, 1.00–1.15 per 1-CMB increase;
P
=0.049), but significance was lost after adjustment for age, hypertension, and atrial fibrillation (odds ratio, 1.03; 95% confidence interval, 0.96–1.11 per 1-CMB increase;
P
=0.37). Results remained nonsignificant when taking into account CMB location or presumed underlying vasculopathy. The incidence of sICH ranged from 3.8% to 9.1%, depending on the definition. Neither CMB presence, burden, location, nor presumed underlying vasculopathy was independently associated with sICH.
Conclusions—
Poor outcome or sICH was not associated with CMB presence or burden on pre–intravenous thrombolysis magnetic resonance imaging after adjustment for confounding factors. An individual patient data meta-analysis is needed to determine whether a subgroup of patients with CMBs carries an independent risk of poor outcome that might outweigh the expected benefit of intravenous thrombolysis.
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Affiliation(s)
- Guillaume Turc
- From the Departments of Neurology (G.T., J.-C.B., J.-L.M.) and Radiology (M.T., A.M., C.O.), Hôpital Sainte-Anne, Université Paris Descartes, Sorbonne Paris Cité, INSERM UMR S894, DHU Neurovasc, Paris, France; and Departments of Neurology (S.M., D.L., C.C.) and Radiology (A.S., M.E., X.L.), Lille University Hospital and Université de Lille, UDSL, INSERM U1171, Lille, France
| | - Asmaa Sallem
- From the Departments of Neurology (G.T., J.-C.B., J.-L.M.) and Radiology (M.T., A.M., C.O.), Hôpital Sainte-Anne, Université Paris Descartes, Sorbonne Paris Cité, INSERM UMR S894, DHU Neurovasc, Paris, France; and Departments of Neurology (S.M., D.L., C.C.) and Radiology (A.S., M.E., X.L.), Lille University Hospital and Université de Lille, UDSL, INSERM U1171, Lille, France
| | - Solène Moulin
- From the Departments of Neurology (G.T., J.-C.B., J.-L.M.) and Radiology (M.T., A.M., C.O.), Hôpital Sainte-Anne, Université Paris Descartes, Sorbonne Paris Cité, INSERM UMR S894, DHU Neurovasc, Paris, France; and Departments of Neurology (S.M., D.L., C.C.) and Radiology (A.S., M.E., X.L.), Lille University Hospital and Université de Lille, UDSL, INSERM U1171, Lille, France
| | - Marie Tisserand
- From the Departments of Neurology (G.T., J.-C.B., J.-L.M.) and Radiology (M.T., A.M., C.O.), Hôpital Sainte-Anne, Université Paris Descartes, Sorbonne Paris Cité, INSERM UMR S894, DHU Neurovasc, Paris, France; and Departments of Neurology (S.M., D.L., C.C.) and Radiology (A.S., M.E., X.L.), Lille University Hospital and Université de Lille, UDSL, INSERM U1171, Lille, France
| | - Alexandre Machet
- From the Departments of Neurology (G.T., J.-C.B., J.-L.M.) and Radiology (M.T., A.M., C.O.), Hôpital Sainte-Anne, Université Paris Descartes, Sorbonne Paris Cité, INSERM UMR S894, DHU Neurovasc, Paris, France; and Departments of Neurology (S.M., D.L., C.C.) and Radiology (A.S., M.E., X.L.), Lille University Hospital and Université de Lille, UDSL, INSERM U1171, Lille, France
| | - Myriam Edjlali
- From the Departments of Neurology (G.T., J.-C.B., J.-L.M.) and Radiology (M.T., A.M., C.O.), Hôpital Sainte-Anne, Université Paris Descartes, Sorbonne Paris Cité, INSERM UMR S894, DHU Neurovasc, Paris, France; and Departments of Neurology (S.M., D.L., C.C.) and Radiology (A.S., M.E., X.L.), Lille University Hospital and Université de Lille, UDSL, INSERM U1171, Lille, France
| | - Jean-Claude Baron
- From the Departments of Neurology (G.T., J.-C.B., J.-L.M.) and Radiology (M.T., A.M., C.O.), Hôpital Sainte-Anne, Université Paris Descartes, Sorbonne Paris Cité, INSERM UMR S894, DHU Neurovasc, Paris, France; and Departments of Neurology (S.M., D.L., C.C.) and Radiology (A.S., M.E., X.L.), Lille University Hospital and Université de Lille, UDSL, INSERM U1171, Lille, France
| | - Xavier Leclerc
- From the Departments of Neurology (G.T., J.-C.B., J.-L.M.) and Radiology (M.T., A.M., C.O.), Hôpital Sainte-Anne, Université Paris Descartes, Sorbonne Paris Cité, INSERM UMR S894, DHU Neurovasc, Paris, France; and Departments of Neurology (S.M., D.L., C.C.) and Radiology (A.S., M.E., X.L.), Lille University Hospital and Université de Lille, UDSL, INSERM U1171, Lille, France
| | - Didier Leys
- From the Departments of Neurology (G.T., J.-C.B., J.-L.M.) and Radiology (M.T., A.M., C.O.), Hôpital Sainte-Anne, Université Paris Descartes, Sorbonne Paris Cité, INSERM UMR S894, DHU Neurovasc, Paris, France; and Departments of Neurology (S.M., D.L., C.C.) and Radiology (A.S., M.E., X.L.), Lille University Hospital and Université de Lille, UDSL, INSERM U1171, Lille, France
| | - Jean-Louis Mas
- From the Departments of Neurology (G.T., J.-C.B., J.-L.M.) and Radiology (M.T., A.M., C.O.), Hôpital Sainte-Anne, Université Paris Descartes, Sorbonne Paris Cité, INSERM UMR S894, DHU Neurovasc, Paris, France; and Departments of Neurology (S.M., D.L., C.C.) and Radiology (A.S., M.E., X.L.), Lille University Hospital and Université de Lille, UDSL, INSERM U1171, Lille, France
| | - Charlotte Cordonnier
- From the Departments of Neurology (G.T., J.-C.B., J.-L.M.) and Radiology (M.T., A.M., C.O.), Hôpital Sainte-Anne, Université Paris Descartes, Sorbonne Paris Cité, INSERM UMR S894, DHU Neurovasc, Paris, France; and Departments of Neurology (S.M., D.L., C.C.) and Radiology (A.S., M.E., X.L.), Lille University Hospital and Université de Lille, UDSL, INSERM U1171, Lille, France
| | - Catherine Oppenheim
- From the Departments of Neurology (G.T., J.-C.B., J.-L.M.) and Radiology (M.T., A.M., C.O.), Hôpital Sainte-Anne, Université Paris Descartes, Sorbonne Paris Cité, INSERM UMR S894, DHU Neurovasc, Paris, France; and Departments of Neurology (S.M., D.L., C.C.) and Radiology (A.S., M.E., X.L.), Lille University Hospital and Université de Lille, UDSL, INSERM U1171, Lille, France
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67
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Affiliation(s)
- David J. Werring
- From the Stroke Research Centre, Department of Brain Repair and Rehabilitation, UCL Institute of Neurology, National Hospital for Neurology and Neurosurgery, Queen Square, London, United Kingdom
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Scheitz JF, Erdur H, Tütüncü S, Fiebach JB, Audebert HJ, Endres M, Nolte CH. National Institutes of Health Stroke Scale for Prediction of Proximal Vessel Occlusion in Anterior Circulation Stroke. Int J Stroke 2015. [DOI: 10.1111/ijs.12556] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Jan F. Scheitz
- Klinik für Neurologie, Charité – Universitätsmedizin Berlin, Campus Benjamin Franklin, Berlin, Germany
- Center for Stroke Research Berlin, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Hebun Erdur
- Klinik für Neurologie, Charité – Universitätsmedizin Berlin, Campus Benjamin Franklin, Berlin, Germany
| | - Serdar Tütüncü
- Klinik für Neurologie, Charité – Universitätsmedizin Berlin, Campus Benjamin Franklin, Berlin, Germany
- Center for Stroke Research Berlin, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Jochen B. Fiebach
- Klinik für Neurologie, Charité – Universitätsmedizin Berlin, Campus Benjamin Franklin, Berlin, Germany
- Center for Stroke Research Berlin, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Heinrich J. Audebert
- Klinik für Neurologie, Charité – Universitätsmedizin Berlin, Campus Benjamin Franklin, Berlin, Germany
- Center for Stroke Research Berlin, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Matthias Endres
- Klinik für Neurologie, Charité – Universitätsmedizin Berlin, Campus Benjamin Franklin, Berlin, Germany
- Center for Stroke Research Berlin, Charité – Universitätsmedizin Berlin, Berlin, Germany
- Excellence Cluster NeuroCure, Charité – Universitätsmedizin Berlin, Berlin, Germany
- Deutsches Zentrum für Neurodegenerative Erkrankungen (DZNE), Berlin, Germany
- Berlin Institute of Health (BIH), Berlin, Germany
| | - Christian H. Nolte
- Klinik für Neurologie, Charité – Universitätsmedizin Berlin, Campus Benjamin Franklin, Berlin, Germany
- Center for Stroke Research Berlin, Charité – Universitätsmedizin Berlin, Berlin, Germany
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69
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Kim BJ, Lee SH. Prognostic Impact of Cerebral Small Vessel Disease on Stroke Outcome. J Stroke 2015; 17:101-10. [PMID: 26060797 PMCID: PMC4460329 DOI: 10.5853/jos.2015.17.2.101] [Citation(s) in RCA: 57] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2014] [Revised: 01/07/2015] [Accepted: 01/20/2015] [Indexed: 12/13/2022] Open
Abstract
Cerebral small vessel disease (SVD), which includes white matter hyperintensities (WMHs), silent brain infarction (SBI), and cerebral microbleeds (CMBs), develops in a conjunction of cumulated injuries to cerebral microvascular beds, increased permeability of blood-brain barriers, and chronic oligemia. SVD is easily detected by routine neuroimaging modalities such as brain computed tomography or magnetic resonance imaging. Research has revealed that the presence of SVD markers may increase the risk of future vascular events as well as deteriorate functional recovery and neurocognitive trajectories after stroke, and such an association could also be applied to hemorrhagic stroke survivors. Currently, the specific mechanistic processes leading to the development and manifestation of SVD risk factors are unknown, and further studies with novel methodological tools are warranted. In this review, recent studies regarding the prognostic impact of WMHs, SBI, and CMBs on stroke survivors and briefly summarize the pathophysiological concepts underlying the manifestation of cerebral SVD.
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Affiliation(s)
- Beom Joon Kim
- Department of Neurology and Cerebrovascular Center, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Seung-Hoon Lee
- Department of Neurology, Seoul National University Hospital, Seoul, Korea
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70
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Mok V, Kim JS. Prevention and Management of Cerebral Small Vessel Disease. J Stroke 2015; 17:111-22. [PMID: 26060798 PMCID: PMC4460330 DOI: 10.5853/jos.2015.17.2.111] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2015] [Revised: 04/07/2015] [Accepted: 04/07/2015] [Indexed: 01/22/2023] Open
Abstract
Lacunar infarcts/lacunes, white matter hyperintensities (WMH), and cerebral microbleeds (CMBs) are considered various manifestations of cerebral small vessel disease (SVD). Since the exact mechanisms of these manifestations differ, their associated risk factors differ. High blood pressure is the most consistent risk factor for all of these manifestations. However, a "J curve" phenomenon in terms of blood pressure probably exists for WMH. The association between cholesterol levels and lacunar infarcts/lacunes or WMH was less consistent and sometimes conflicting; a low cholesterol level probably increases the risk of CMBs. Homocysteinemia appears to be associated with WMH. It is noteworthy that the risk factors profile may also differ between different lacunar patterns and CMBs located at different parts of the brain. Thrombolysis, antihypertensives, and statins are used to treat patients with symptomatic lacunar infarction, just as in those with other stroke subtypes. However, it should be remembered that bleeding risks increase in patients with extensive WMH and CMBs after thrombolysis therapy. According to the Secondary Prevention of Small Subcortical Strokes trial results, a blood pressure reduction to <130 mmHg is recommended in patients with symptomatic lacunar infarction. However, an excessive blood pressure decrease may induce cognitive decline in older patients with extensive WMH. Dual antiplatelet therapy (aspirin plus clopidogrel) should be avoided because of the excessive risk of intracerebral hemorrhage. Although no particular antiplatelet is recommended, drugs such as cilostazol or triflusal may have advantages for patients with SVD since they are associated with less frequent bleeding complications than aspirin.
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Affiliation(s)
- Vincent Mok
- Division of Neurology, Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Jong S Kim
- Stroke Center and Department of Neurology, University of Ulsan, Asan Medical Center, Seoul, Korea
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71
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Shi ZS, Duckwiler GR, Jahan R, Tateshima S, Gonzalez NR, Szeder V, Saver JL, Kim D, Ali LK, Starkman S, Vespa PM, Salamon N, Villablanca JP, Viñuela F, Feng L, Loh Y, Liebeskind DS. Mechanical thrombectomy for acute ischemic stroke with cerebral microbleeds. J Neurointerv Surg 2015; 8:563-7. [DOI: 10.1136/neurintsurg-2015-011765] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2015] [Accepted: 04/27/2015] [Indexed: 11/04/2022]
Abstract
BackgroundThe influence of cerebral microbleeds (CMBs) on post-thrombolytic hemorrhagic transformation (HT) in patients with acute ischemic stroke remains controversial.ObjectiveTo investigate the association of CMBs with HT and clinical outcomes among patients with large-vessel occlusion strokes treated with mechanical thrombectomy.MethodsWe analyzed patients with acute stroke treated with Merci Retriever, Penumbra system or stent-retriever devices. CMBs were identified on pretreatment T2-weighted, gradient-recall echo MRI. We analyzed the association of the presence, burden, and distribution of CMBs with HT, procedural complications, in-hospital mortality, and clinical outcome.ResultsCMBs were detected in 37 (18.0%) of 206 patients. Seventy-three foci of microbleeds were identified. Fourteen patients (6.8%) had ≥2 CMBs, only 1 patient had ≥5 CMBs. Strictly lobar CMBs were found in 12 patients, strictly deep CMBs in 12 patients, strictly infratentorial CMBs in 2 patients, and mixed CMBs in 11 patients. There were no significant differences between patients with CMBs and those without CMBs in the rates of overall HT (37.8% vs 45.6%), parenchymal hematoma (16.2% vs 19.5%), procedure-related vessel perforation (5.4% vs 7.1%), in-hospital mortality (16.2% vs 18.3%), and modified Rankin Scale score 0–3 at discharge. CMBs were not independently associated with HT or in-hospital mortality in patients treated with either thrombectomy or intravenous thrombolysis followed by thrombectomy.ConclusionsPatients with CMBs are not at increased risk for HT and mortality following mechanical thrombectomy for acute stroke. Excluding such patients from mechanical thrombectomy is unwarranted. The risk of HT in patients with ≥5 CMBs requires further study.
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72
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Charidimou A, Nicoll JAR, McCarron MO. Thrombolysis-related intracerebral hemorrhage and cerebral amyloid angiopathy: accumulating evidence. Front Neurol 2015; 6:99. [PMID: 26005432 PMCID: PMC4424854 DOI: 10.3389/fneur.2015.00099] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2015] [Accepted: 04/23/2015] [Indexed: 12/17/2022] Open
Affiliation(s)
- Andreas Charidimou
- Department of Neurology, Massachussetts General Hospital , Boston, MA , USA
| | - James A R Nicoll
- Department of Neuropathology, University of Southampton , Southampton , UK
| | - Mark O McCarron
- Department of Neurology, Altnagelvin Hospital , Londonderry , UK
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73
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Marchidann A, Balucani C, Levine SR. Expansion of Intravenous Tissue Plasminogen Activator Eligibility Beyond National Institute of Neurological Disorders and Stroke and European Cooperative Acute Stroke Study III Criteria. Neurol Clin 2015; 33:381-400. [DOI: 10.1016/j.ncl.2015.01.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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