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Wang X, Arima H, Heeley E, Delcourt C, Huang Y, Wang J, Stapf C, Robinson T, Woodward M, Chalmers J, Anderson CS. Magnitude of blood pressure reduction and clinical outcomes in acute intracerebral hemorrhage: intensive blood pressure reduction in acute cerebral hemorrhage trial study. Hypertension 2015; 65:1026-32. [PMID: 25801872 DOI: 10.1161/hypertensionaha.114.05044] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2014] [Accepted: 02/27/2015] [Indexed: 11/16/2022]
Abstract
UNLABELLED Evidence supports early intensive blood pressure (BP) lowering in acute intracerebral hemorrhage, but uncertainty persists over whether potential benefits and harms vary according to the magnitude of BP reduction. We aimed to determine whether larger systolic BP (SBP) reductions were associated with better outcomes in participants of the Intensive Blood Pressure Reduction in Acute Cerebral Hemorrhage Trial (INTERACT2). INTERACT2 was an international, open, blinded end point, randomized controlled trial of patients with spontaneous intracerebral hemorrhage (<6 hours) and elevated SBP (150-220 mm Hg) assigned to intensive (target SBP <140 mm Hg) or guideline-recommended (SBP <180 mm Hg) treatment. Associations of BP reduction (baseline minus average of achieved SBP) during 3 time periods post randomization (15-60 minutes, 1-24 hours, and 2-7 days) on poor outcome (death or major disability) at 90 days were analyzed in multivariable logistic regression models with odds ratios and 95% confidence intervals. Larger SBP reductions within the first hour after randomization were associated with lower risks of poor outcome: compared with minimal reduction (<10 mm Hg), odds ratios were 0.80 (95% confidence interval, 0.63-1.02) for moderate (10-20 mm Hg) and 0.65 (0.52-0.82) for large (≥20 mm Hg) reductions (P trend <0.01). Similar associations were also observed for SBP reductions during 1 to 24 hours (P<0.01) and 2 to 7 days (P 0.02). No heterogeneity in associations for patients above or below baseline SBP 180 mm Hg was reported (P>0.30). Optimal recovery from intracerebral hemorrhage was observed in hypertensive patients who achieved the greatest SBP reductions (≥20 mm Hg) in the first hour and maintained for 7 days. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov. Unique identifier: NCT00716079.
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Affiliation(s)
- Xia Wang
- From the George Institute for Global Health, Neurological and Mental Health Division, University of Sydney, Royal Prince Alfred Hospital, Sydney, Australia (X.W., H.A., E.H., C.D., M.W., J.C., C.S.A.); Department of Neurology, Peking University First Hospital, Beijing, China (Y.H.); Centre for Epidemiological Studies and Clinical Trials, The Shanghai Institute of Hypertension, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China (J.W.); Department of Neurology, APHP-Hôpital Lariboisière and DHU NeuroVasc Paris-Sorbonne, Université Paris Diderot-Sorbonne Paris Cité, Paris, France (C.S.); and Department of Cardiovascular Sciences and NIHR Biomedical Research Unit in Cardiovascular Disease, University of Leicester, Leicester, United Kingdom (T.R.)
| | - Hisatomi Arima
- From the George Institute for Global Health, Neurological and Mental Health Division, University of Sydney, Royal Prince Alfred Hospital, Sydney, Australia (X.W., H.A., E.H., C.D., M.W., J.C., C.S.A.); Department of Neurology, Peking University First Hospital, Beijing, China (Y.H.); Centre for Epidemiological Studies and Clinical Trials, The Shanghai Institute of Hypertension, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China (J.W.); Department of Neurology, APHP-Hôpital Lariboisière and DHU NeuroVasc Paris-Sorbonne, Université Paris Diderot-Sorbonne Paris Cité, Paris, France (C.S.); and Department of Cardiovascular Sciences and NIHR Biomedical Research Unit in Cardiovascular Disease, University of Leicester, Leicester, United Kingdom (T.R.)
| | - Emma Heeley
- From the George Institute for Global Health, Neurological and Mental Health Division, University of Sydney, Royal Prince Alfred Hospital, Sydney, Australia (X.W., H.A., E.H., C.D., M.W., J.C., C.S.A.); Department of Neurology, Peking University First Hospital, Beijing, China (Y.H.); Centre for Epidemiological Studies and Clinical Trials, The Shanghai Institute of Hypertension, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China (J.W.); Department of Neurology, APHP-Hôpital Lariboisière and DHU NeuroVasc Paris-Sorbonne, Université Paris Diderot-Sorbonne Paris Cité, Paris, France (C.S.); and Department of Cardiovascular Sciences and NIHR Biomedical Research Unit in Cardiovascular Disease, University of Leicester, Leicester, United Kingdom (T.R.)
| | - Candice Delcourt
- From the George Institute for Global Health, Neurological and Mental Health Division, University of Sydney, Royal Prince Alfred Hospital, Sydney, Australia (X.W., H.A., E.H., C.D., M.W., J.C., C.S.A.); Department of Neurology, Peking University First Hospital, Beijing, China (Y.H.); Centre for Epidemiological Studies and Clinical Trials, The Shanghai Institute of Hypertension, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China (J.W.); Department of Neurology, APHP-Hôpital Lariboisière and DHU NeuroVasc Paris-Sorbonne, Université Paris Diderot-Sorbonne Paris Cité, Paris, France (C.S.); and Department of Cardiovascular Sciences and NIHR Biomedical Research Unit in Cardiovascular Disease, University of Leicester, Leicester, United Kingdom (T.R.)
| | - Yining Huang
- From the George Institute for Global Health, Neurological and Mental Health Division, University of Sydney, Royal Prince Alfred Hospital, Sydney, Australia (X.W., H.A., E.H., C.D., M.W., J.C., C.S.A.); Department of Neurology, Peking University First Hospital, Beijing, China (Y.H.); Centre for Epidemiological Studies and Clinical Trials, The Shanghai Institute of Hypertension, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China (J.W.); Department of Neurology, APHP-Hôpital Lariboisière and DHU NeuroVasc Paris-Sorbonne, Université Paris Diderot-Sorbonne Paris Cité, Paris, France (C.S.); and Department of Cardiovascular Sciences and NIHR Biomedical Research Unit in Cardiovascular Disease, University of Leicester, Leicester, United Kingdom (T.R.)
| | - Jiguang Wang
- From the George Institute for Global Health, Neurological and Mental Health Division, University of Sydney, Royal Prince Alfred Hospital, Sydney, Australia (X.W., H.A., E.H., C.D., M.W., J.C., C.S.A.); Department of Neurology, Peking University First Hospital, Beijing, China (Y.H.); Centre for Epidemiological Studies and Clinical Trials, The Shanghai Institute of Hypertension, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China (J.W.); Department of Neurology, APHP-Hôpital Lariboisière and DHU NeuroVasc Paris-Sorbonne, Université Paris Diderot-Sorbonne Paris Cité, Paris, France (C.S.); and Department of Cardiovascular Sciences and NIHR Biomedical Research Unit in Cardiovascular Disease, University of Leicester, Leicester, United Kingdom (T.R.)
| | - Christian Stapf
- From the George Institute for Global Health, Neurological and Mental Health Division, University of Sydney, Royal Prince Alfred Hospital, Sydney, Australia (X.W., H.A., E.H., C.D., M.W., J.C., C.S.A.); Department of Neurology, Peking University First Hospital, Beijing, China (Y.H.); Centre for Epidemiological Studies and Clinical Trials, The Shanghai Institute of Hypertension, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China (J.W.); Department of Neurology, APHP-Hôpital Lariboisière and DHU NeuroVasc Paris-Sorbonne, Université Paris Diderot-Sorbonne Paris Cité, Paris, France (C.S.); and Department of Cardiovascular Sciences and NIHR Biomedical Research Unit in Cardiovascular Disease, University of Leicester, Leicester, United Kingdom (T.R.)
| | - Thompson Robinson
- From the George Institute for Global Health, Neurological and Mental Health Division, University of Sydney, Royal Prince Alfred Hospital, Sydney, Australia (X.W., H.A., E.H., C.D., M.W., J.C., C.S.A.); Department of Neurology, Peking University First Hospital, Beijing, China (Y.H.); Centre for Epidemiological Studies and Clinical Trials, The Shanghai Institute of Hypertension, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China (J.W.); Department of Neurology, APHP-Hôpital Lariboisière and DHU NeuroVasc Paris-Sorbonne, Université Paris Diderot-Sorbonne Paris Cité, Paris, France (C.S.); and Department of Cardiovascular Sciences and NIHR Biomedical Research Unit in Cardiovascular Disease, University of Leicester, Leicester, United Kingdom (T.R.)
| | - Mark Woodward
- From the George Institute for Global Health, Neurological and Mental Health Division, University of Sydney, Royal Prince Alfred Hospital, Sydney, Australia (X.W., H.A., E.H., C.D., M.W., J.C., C.S.A.); Department of Neurology, Peking University First Hospital, Beijing, China (Y.H.); Centre for Epidemiological Studies and Clinical Trials, The Shanghai Institute of Hypertension, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China (J.W.); Department of Neurology, APHP-Hôpital Lariboisière and DHU NeuroVasc Paris-Sorbonne, Université Paris Diderot-Sorbonne Paris Cité, Paris, France (C.S.); and Department of Cardiovascular Sciences and NIHR Biomedical Research Unit in Cardiovascular Disease, University of Leicester, Leicester, United Kingdom (T.R.)
| | - John Chalmers
- From the George Institute for Global Health, Neurological and Mental Health Division, University of Sydney, Royal Prince Alfred Hospital, Sydney, Australia (X.W., H.A., E.H., C.D., M.W., J.C., C.S.A.); Department of Neurology, Peking University First Hospital, Beijing, China (Y.H.); Centre for Epidemiological Studies and Clinical Trials, The Shanghai Institute of Hypertension, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China (J.W.); Department of Neurology, APHP-Hôpital Lariboisière and DHU NeuroVasc Paris-Sorbonne, Université Paris Diderot-Sorbonne Paris Cité, Paris, France (C.S.); and Department of Cardiovascular Sciences and NIHR Biomedical Research Unit in Cardiovascular Disease, University of Leicester, Leicester, United Kingdom (T.R.)
| | - Craig S Anderson
- From the George Institute for Global Health, Neurological and Mental Health Division, University of Sydney, Royal Prince Alfred Hospital, Sydney, Australia (X.W., H.A., E.H., C.D., M.W., J.C., C.S.A.); Department of Neurology, Peking University First Hospital, Beijing, China (Y.H.); Centre for Epidemiological Studies and Clinical Trials, The Shanghai Institute of Hypertension, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China (J.W.); Department of Neurology, APHP-Hôpital Lariboisière and DHU NeuroVasc Paris-Sorbonne, Université Paris Diderot-Sorbonne Paris Cité, Paris, France (C.S.); and Department of Cardiovascular Sciences and NIHR Biomedical Research Unit in Cardiovascular Disease, University of Leicester, Leicester, United Kingdom (T.R.).
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Tanaka E, Koga M, Kobayashi J, Kario K, Kamiyama K, Furui E, Shiokawa Y, Hasegawa Y, Okuda S, Todo K, Kimura K, Okada Y, Okata T, Arihiro S, Sato S, Yamagami H, Nagatsuka K, Minematsu K, Toyoda K. Blood pressure variability on antihypertensive therapy in acute intracerebral hemorrhage: the Stroke Acute Management with Urgent Risk-factor Assessment and Improvement-intracerebral hemorrhage study. Stroke 2014; 45:2275-9. [PMID: 24968929 DOI: 10.1161/strokeaha.114.005420] [Citation(s) in RCA: 77] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE The associations between early blood pressure (BP) variability and clinical outcomes in patients with intracerebral hemorrhage after antihypertensive therapy, recently clarified by a post hoc analysis of Intensive Blood Pressure Reduction in Acute Cerebral Hemorrhage Trial 2 (INTERACT2), were confirmed using the Stroke Acute Management with Urgent Risk-factor Assessment and Improvement (SAMURAI)-intracerebral hemorrhage study cohort. METHODS Patients with hyperacute (<3 hours from onset) intracerebral hemorrhage with initial systolic BP (SBP) >180 mm Hg were registered in a prospective, multicenter, observational study. All patients received antihypertensive therapy based on a predefined standardized protocol to lower and maintain SBP between 120 and 160 mm Hg using intravenous nicardipine. BPs were measured hourly during the initial 24 hours. BP variability was determined as SD and successive variation. The associations between BP variability and hematoma expansion (>33%), neurological deterioration within 72 hours, and unfavorable outcome (modified Rankin Scale, 4-6) at 3 months were assessed. RESULTS Of the 205 patients, 33 (16%) showed hematoma expansion, 14 (7%) showed neurological deterioration, and 81 (39%) had unfavorable outcomes. The SD and successive variation of SBP were 13.8 (interquartile range, 11.5-16.8) and 14.9 (11.7-17.7) mm Hg, respectively, and those of diastolic BP were 9.4 (7.5-11.2) and 13.1 (11.2-15.9) mm Hg, respectively. On multivariate regression analyses, neurological deterioration was associated with the SD of SBP (odds ratio, 2.75; 95% confidence interval, 1.45-6.12 per quartile) and the successive variation of SBP (2.37; 1.32-4.83), and unfavorable outcome was associated with successive variation of SBP (1.42; 1.04-1.97). Hematoma expansion was not associated with any BP variability. CONCLUSIONS SBP variability during the initial 24 hours of acute intracerebral hemorrhage was independently associated with neurological deterioration and unfavorable outcomes. Stability of antihypertensive therapy may improve clinical outcomes.
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Affiliation(s)
- Eijirou Tanaka
- From the Department of Cerebrovascular Medicine (E.T., J.K., T.O., S.S., K.M., K.T.), Division of Stroke Care Unit (M.K., S.A.), and Department of Neurology (H.Y, K.N.), National Cerebral and Cardiovascular Center, Suita, Japan; Division of Cardiovascular Medicine, Department of Medicine, Jichi Medical University School of Medicine, Shimotsuke, Japan (K. Kario); Department of Neurosurgery and Stroke Center, Nakamura Memorial Hospital, Sapporo, Japan (K. Kamiyama); Department of Stroke Neurology, Kohnan Hospital, Sendai, Japan (E.F.); Department of Neurosurgery and Stroke Center, Kyorin University School of Medicine, Mitaka, Japan (Y.S.); Department of Neurology, St Marianna University School of Medicine, Kawasaki, Japan (Y.H.); Department of Neurology, NHO Nagoya Medical Center, Nagoya, Japan (S.O.); Department of Neurology, Stroke Center, Kobe City Medical Center General Hospital, Kobe, Japan (H.Y.); Department of Stroke Medicine, Kawasaki Medical School, Kurashiki, Japan (K. Kimura); and Department of Cerebrovascular Medicine, NHO Kyushu Medical Center, Fukuoka, Japan (Y.O.)
| | - Masatoshi Koga
- From the Department of Cerebrovascular Medicine (E.T., J.K., T.O., S.S., K.M., K.T.), Division of Stroke Care Unit (M.K., S.A.), and Department of Neurology (H.Y, K.N.), National Cerebral and Cardiovascular Center, Suita, Japan; Division of Cardiovascular Medicine, Department of Medicine, Jichi Medical University School of Medicine, Shimotsuke, Japan (K. Kario); Department of Neurosurgery and Stroke Center, Nakamura Memorial Hospital, Sapporo, Japan (K. Kamiyama); Department of Stroke Neurology, Kohnan Hospital, Sendai, Japan (E.F.); Department of Neurosurgery and Stroke Center, Kyorin University School of Medicine, Mitaka, Japan (Y.S.); Department of Neurology, St Marianna University School of Medicine, Kawasaki, Japan (Y.H.); Department of Neurology, NHO Nagoya Medical Center, Nagoya, Japan (S.O.); Department of Neurology, Stroke Center, Kobe City Medical Center General Hospital, Kobe, Japan (H.Y.); Department of Stroke Medicine, Kawasaki Medical School, Kurashiki, Japan (K. Kimura); and Department of Cerebrovascular Medicine, NHO Kyushu Medical Center, Fukuoka, Japan (Y.O.).
| | - Junpei Kobayashi
- From the Department of Cerebrovascular Medicine (E.T., J.K., T.O., S.S., K.M., K.T.), Division of Stroke Care Unit (M.K., S.A.), and Department of Neurology (H.Y, K.N.), National Cerebral and Cardiovascular Center, Suita, Japan; Division of Cardiovascular Medicine, Department of Medicine, Jichi Medical University School of Medicine, Shimotsuke, Japan (K. Kario); Department of Neurosurgery and Stroke Center, Nakamura Memorial Hospital, Sapporo, Japan (K. Kamiyama); Department of Stroke Neurology, Kohnan Hospital, Sendai, Japan (E.F.); Department of Neurosurgery and Stroke Center, Kyorin University School of Medicine, Mitaka, Japan (Y.S.); Department of Neurology, St Marianna University School of Medicine, Kawasaki, Japan (Y.H.); Department of Neurology, NHO Nagoya Medical Center, Nagoya, Japan (S.O.); Department of Neurology, Stroke Center, Kobe City Medical Center General Hospital, Kobe, Japan (H.Y.); Department of Stroke Medicine, Kawasaki Medical School, Kurashiki, Japan (K. Kimura); and Department of Cerebrovascular Medicine, NHO Kyushu Medical Center, Fukuoka, Japan (Y.O.)
| | - Kazuomi Kario
- From the Department of Cerebrovascular Medicine (E.T., J.K., T.O., S.S., K.M., K.T.), Division of Stroke Care Unit (M.K., S.A.), and Department of Neurology (H.Y, K.N.), National Cerebral and Cardiovascular Center, Suita, Japan; Division of Cardiovascular Medicine, Department of Medicine, Jichi Medical University School of Medicine, Shimotsuke, Japan (K. Kario); Department of Neurosurgery and Stroke Center, Nakamura Memorial Hospital, Sapporo, Japan (K. Kamiyama); Department of Stroke Neurology, Kohnan Hospital, Sendai, Japan (E.F.); Department of Neurosurgery and Stroke Center, Kyorin University School of Medicine, Mitaka, Japan (Y.S.); Department of Neurology, St Marianna University School of Medicine, Kawasaki, Japan (Y.H.); Department of Neurology, NHO Nagoya Medical Center, Nagoya, Japan (S.O.); Department of Neurology, Stroke Center, Kobe City Medical Center General Hospital, Kobe, Japan (H.Y.); Department of Stroke Medicine, Kawasaki Medical School, Kurashiki, Japan (K. Kimura); and Department of Cerebrovascular Medicine, NHO Kyushu Medical Center, Fukuoka, Japan (Y.O.)
| | - Kenji Kamiyama
- From the Department of Cerebrovascular Medicine (E.T., J.K., T.O., S.S., K.M., K.T.), Division of Stroke Care Unit (M.K., S.A.), and Department of Neurology (H.Y, K.N.), National Cerebral and Cardiovascular Center, Suita, Japan; Division of Cardiovascular Medicine, Department of Medicine, Jichi Medical University School of Medicine, Shimotsuke, Japan (K. Kario); Department of Neurosurgery and Stroke Center, Nakamura Memorial Hospital, Sapporo, Japan (K. Kamiyama); Department of Stroke Neurology, Kohnan Hospital, Sendai, Japan (E.F.); Department of Neurosurgery and Stroke Center, Kyorin University School of Medicine, Mitaka, Japan (Y.S.); Department of Neurology, St Marianna University School of Medicine, Kawasaki, Japan (Y.H.); Department of Neurology, NHO Nagoya Medical Center, Nagoya, Japan (S.O.); Department of Neurology, Stroke Center, Kobe City Medical Center General Hospital, Kobe, Japan (H.Y.); Department of Stroke Medicine, Kawasaki Medical School, Kurashiki, Japan (K. Kimura); and Department of Cerebrovascular Medicine, NHO Kyushu Medical Center, Fukuoka, Japan (Y.O.)
| | - Eisuke Furui
- From the Department of Cerebrovascular Medicine (E.T., J.K., T.O., S.S., K.M., K.T.), Division of Stroke Care Unit (M.K., S.A.), and Department of Neurology (H.Y, K.N.), National Cerebral and Cardiovascular Center, Suita, Japan; Division of Cardiovascular Medicine, Department of Medicine, Jichi Medical University School of Medicine, Shimotsuke, Japan (K. Kario); Department of Neurosurgery and Stroke Center, Nakamura Memorial Hospital, Sapporo, Japan (K. Kamiyama); Department of Stroke Neurology, Kohnan Hospital, Sendai, Japan (E.F.); Department of Neurosurgery and Stroke Center, Kyorin University School of Medicine, Mitaka, Japan (Y.S.); Department of Neurology, St Marianna University School of Medicine, Kawasaki, Japan (Y.H.); Department of Neurology, NHO Nagoya Medical Center, Nagoya, Japan (S.O.); Department of Neurology, Stroke Center, Kobe City Medical Center General Hospital, Kobe, Japan (H.Y.); Department of Stroke Medicine, Kawasaki Medical School, Kurashiki, Japan (K. Kimura); and Department of Cerebrovascular Medicine, NHO Kyushu Medical Center, Fukuoka, Japan (Y.O.)
| | - Yoshiaki Shiokawa
- From the Department of Cerebrovascular Medicine (E.T., J.K., T.O., S.S., K.M., K.T.), Division of Stroke Care Unit (M.K., S.A.), and Department of Neurology (H.Y, K.N.), National Cerebral and Cardiovascular Center, Suita, Japan; Division of Cardiovascular Medicine, Department of Medicine, Jichi Medical University School of Medicine, Shimotsuke, Japan (K. Kario); Department of Neurosurgery and Stroke Center, Nakamura Memorial Hospital, Sapporo, Japan (K. Kamiyama); Department of Stroke Neurology, Kohnan Hospital, Sendai, Japan (E.F.); Department of Neurosurgery and Stroke Center, Kyorin University School of Medicine, Mitaka, Japan (Y.S.); Department of Neurology, St Marianna University School of Medicine, Kawasaki, Japan (Y.H.); Department of Neurology, NHO Nagoya Medical Center, Nagoya, Japan (S.O.); Department of Neurology, Stroke Center, Kobe City Medical Center General Hospital, Kobe, Japan (H.Y.); Department of Stroke Medicine, Kawasaki Medical School, Kurashiki, Japan (K. Kimura); and Department of Cerebrovascular Medicine, NHO Kyushu Medical Center, Fukuoka, Japan (Y.O.)
| | - Yasuhiro Hasegawa
- From the Department of Cerebrovascular Medicine (E.T., J.K., T.O., S.S., K.M., K.T.), Division of Stroke Care Unit (M.K., S.A.), and Department of Neurology (H.Y, K.N.), National Cerebral and Cardiovascular Center, Suita, Japan; Division of Cardiovascular Medicine, Department of Medicine, Jichi Medical University School of Medicine, Shimotsuke, Japan (K. Kario); Department of Neurosurgery and Stroke Center, Nakamura Memorial Hospital, Sapporo, Japan (K. Kamiyama); Department of Stroke Neurology, Kohnan Hospital, Sendai, Japan (E.F.); Department of Neurosurgery and Stroke Center, Kyorin University School of Medicine, Mitaka, Japan (Y.S.); Department of Neurology, St Marianna University School of Medicine, Kawasaki, Japan (Y.H.); Department of Neurology, NHO Nagoya Medical Center, Nagoya, Japan (S.O.); Department of Neurology, Stroke Center, Kobe City Medical Center General Hospital, Kobe, Japan (H.Y.); Department of Stroke Medicine, Kawasaki Medical School, Kurashiki, Japan (K. Kimura); and Department of Cerebrovascular Medicine, NHO Kyushu Medical Center, Fukuoka, Japan (Y.O.)
| | - Satoshi Okuda
- From the Department of Cerebrovascular Medicine (E.T., J.K., T.O., S.S., K.M., K.T.), Division of Stroke Care Unit (M.K., S.A.), and Department of Neurology (H.Y, K.N.), National Cerebral and Cardiovascular Center, Suita, Japan; Division of Cardiovascular Medicine, Department of Medicine, Jichi Medical University School of Medicine, Shimotsuke, Japan (K. Kario); Department of Neurosurgery and Stroke Center, Nakamura Memorial Hospital, Sapporo, Japan (K. Kamiyama); Department of Stroke Neurology, Kohnan Hospital, Sendai, Japan (E.F.); Department of Neurosurgery and Stroke Center, Kyorin University School of Medicine, Mitaka, Japan (Y.S.); Department of Neurology, St Marianna University School of Medicine, Kawasaki, Japan (Y.H.); Department of Neurology, NHO Nagoya Medical Center, Nagoya, Japan (S.O.); Department of Neurology, Stroke Center, Kobe City Medical Center General Hospital, Kobe, Japan (H.Y.); Department of Stroke Medicine, Kawasaki Medical School, Kurashiki, Japan (K. Kimura); and Department of Cerebrovascular Medicine, NHO Kyushu Medical Center, Fukuoka, Japan (Y.O.)
| | - Kenichi Todo
- From the Department of Cerebrovascular Medicine (E.T., J.K., T.O., S.S., K.M., K.T.), Division of Stroke Care Unit (M.K., S.A.), and Department of Neurology (H.Y, K.N.), National Cerebral and Cardiovascular Center, Suita, Japan; Division of Cardiovascular Medicine, Department of Medicine, Jichi Medical University School of Medicine, Shimotsuke, Japan (K. Kario); Department of Neurosurgery and Stroke Center, Nakamura Memorial Hospital, Sapporo, Japan (K. Kamiyama); Department of Stroke Neurology, Kohnan Hospital, Sendai, Japan (E.F.); Department of Neurosurgery and Stroke Center, Kyorin University School of Medicine, Mitaka, Japan (Y.S.); Department of Neurology, St Marianna University School of Medicine, Kawasaki, Japan (Y.H.); Department of Neurology, NHO Nagoya Medical Center, Nagoya, Japan (S.O.); Department of Neurology, Stroke Center, Kobe City Medical Center General Hospital, Kobe, Japan (H.Y.); Department of Stroke Medicine, Kawasaki Medical School, Kurashiki, Japan (K. Kimura); and Department of Cerebrovascular Medicine, NHO Kyushu Medical Center, Fukuoka, Japan (Y.O.)
| | - Kazumi Kimura
- From the Department of Cerebrovascular Medicine (E.T., J.K., T.O., S.S., K.M., K.T.), Division of Stroke Care Unit (M.K., S.A.), and Department of Neurology (H.Y, K.N.), National Cerebral and Cardiovascular Center, Suita, Japan; Division of Cardiovascular Medicine, Department of Medicine, Jichi Medical University School of Medicine, Shimotsuke, Japan (K. Kario); Department of Neurosurgery and Stroke Center, Nakamura Memorial Hospital, Sapporo, Japan (K. Kamiyama); Department of Stroke Neurology, Kohnan Hospital, Sendai, Japan (E.F.); Department of Neurosurgery and Stroke Center, Kyorin University School of Medicine, Mitaka, Japan (Y.S.); Department of Neurology, St Marianna University School of Medicine, Kawasaki, Japan (Y.H.); Department of Neurology, NHO Nagoya Medical Center, Nagoya, Japan (S.O.); Department of Neurology, Stroke Center, Kobe City Medical Center General Hospital, Kobe, Japan (H.Y.); Department of Stroke Medicine, Kawasaki Medical School, Kurashiki, Japan (K. Kimura); and Department of Cerebrovascular Medicine, NHO Kyushu Medical Center, Fukuoka, Japan (Y.O.)
| | - Yasushi Okada
- From the Department of Cerebrovascular Medicine (E.T., J.K., T.O., S.S., K.M., K.T.), Division of Stroke Care Unit (M.K., S.A.), and Department of Neurology (H.Y, K.N.), National Cerebral and Cardiovascular Center, Suita, Japan; Division of Cardiovascular Medicine, Department of Medicine, Jichi Medical University School of Medicine, Shimotsuke, Japan (K. Kario); Department of Neurosurgery and Stroke Center, Nakamura Memorial Hospital, Sapporo, Japan (K. Kamiyama); Department of Stroke Neurology, Kohnan Hospital, Sendai, Japan (E.F.); Department of Neurosurgery and Stroke Center, Kyorin University School of Medicine, Mitaka, Japan (Y.S.); Department of Neurology, St Marianna University School of Medicine, Kawasaki, Japan (Y.H.); Department of Neurology, NHO Nagoya Medical Center, Nagoya, Japan (S.O.); Department of Neurology, Stroke Center, Kobe City Medical Center General Hospital, Kobe, Japan (H.Y.); Department of Stroke Medicine, Kawasaki Medical School, Kurashiki, Japan (K. Kimura); and Department of Cerebrovascular Medicine, NHO Kyushu Medical Center, Fukuoka, Japan (Y.O.)
| | - Takuya Okata
- From the Department of Cerebrovascular Medicine (E.T., J.K., T.O., S.S., K.M., K.T.), Division of Stroke Care Unit (M.K., S.A.), and Department of Neurology (H.Y, K.N.), National Cerebral and Cardiovascular Center, Suita, Japan; Division of Cardiovascular Medicine, Department of Medicine, Jichi Medical University School of Medicine, Shimotsuke, Japan (K. Kario); Department of Neurosurgery and Stroke Center, Nakamura Memorial Hospital, Sapporo, Japan (K. Kamiyama); Department of Stroke Neurology, Kohnan Hospital, Sendai, Japan (E.F.); Department of Neurosurgery and Stroke Center, Kyorin University School of Medicine, Mitaka, Japan (Y.S.); Department of Neurology, St Marianna University School of Medicine, Kawasaki, Japan (Y.H.); Department of Neurology, NHO Nagoya Medical Center, Nagoya, Japan (S.O.); Department of Neurology, Stroke Center, Kobe City Medical Center General Hospital, Kobe, Japan (H.Y.); Department of Stroke Medicine, Kawasaki Medical School, Kurashiki, Japan (K. Kimura); and Department of Cerebrovascular Medicine, NHO Kyushu Medical Center, Fukuoka, Japan (Y.O.)
| | - Shoji Arihiro
- From the Department of Cerebrovascular Medicine (E.T., J.K., T.O., S.S., K.M., K.T.), Division of Stroke Care Unit (M.K., S.A.), and Department of Neurology (H.Y, K.N.), National Cerebral and Cardiovascular Center, Suita, Japan; Division of Cardiovascular Medicine, Department of Medicine, Jichi Medical University School of Medicine, Shimotsuke, Japan (K. Kario); Department of Neurosurgery and Stroke Center, Nakamura Memorial Hospital, Sapporo, Japan (K. Kamiyama); Department of Stroke Neurology, Kohnan Hospital, Sendai, Japan (E.F.); Department of Neurosurgery and Stroke Center, Kyorin University School of Medicine, Mitaka, Japan (Y.S.); Department of Neurology, St Marianna University School of Medicine, Kawasaki, Japan (Y.H.); Department of Neurology, NHO Nagoya Medical Center, Nagoya, Japan (S.O.); Department of Neurology, Stroke Center, Kobe City Medical Center General Hospital, Kobe, Japan (H.Y.); Department of Stroke Medicine, Kawasaki Medical School, Kurashiki, Japan (K. Kimura); and Department of Cerebrovascular Medicine, NHO Kyushu Medical Center, Fukuoka, Japan (Y.O.)
| | - Shoichiro Sato
- From the Department of Cerebrovascular Medicine (E.T., J.K., T.O., S.S., K.M., K.T.), Division of Stroke Care Unit (M.K., S.A.), and Department of Neurology (H.Y, K.N.), National Cerebral and Cardiovascular Center, Suita, Japan; Division of Cardiovascular Medicine, Department of Medicine, Jichi Medical University School of Medicine, Shimotsuke, Japan (K. Kario); Department of Neurosurgery and Stroke Center, Nakamura Memorial Hospital, Sapporo, Japan (K. Kamiyama); Department of Stroke Neurology, Kohnan Hospital, Sendai, Japan (E.F.); Department of Neurosurgery and Stroke Center, Kyorin University School of Medicine, Mitaka, Japan (Y.S.); Department of Neurology, St Marianna University School of Medicine, Kawasaki, Japan (Y.H.); Department of Neurology, NHO Nagoya Medical Center, Nagoya, Japan (S.O.); Department of Neurology, Stroke Center, Kobe City Medical Center General Hospital, Kobe, Japan (H.Y.); Department of Stroke Medicine, Kawasaki Medical School, Kurashiki, Japan (K. Kimura); and Department of Cerebrovascular Medicine, NHO Kyushu Medical Center, Fukuoka, Japan (Y.O.)
| | - Hiroshi Yamagami
- From the Department of Cerebrovascular Medicine (E.T., J.K., T.O., S.S., K.M., K.T.), Division of Stroke Care Unit (M.K., S.A.), and Department of Neurology (H.Y, K.N.), National Cerebral and Cardiovascular Center, Suita, Japan; Division of Cardiovascular Medicine, Department of Medicine, Jichi Medical University School of Medicine, Shimotsuke, Japan (K. Kario); Department of Neurosurgery and Stroke Center, Nakamura Memorial Hospital, Sapporo, Japan (K. Kamiyama); Department of Stroke Neurology, Kohnan Hospital, Sendai, Japan (E.F.); Department of Neurosurgery and Stroke Center, Kyorin University School of Medicine, Mitaka, Japan (Y.S.); Department of Neurology, St Marianna University School of Medicine, Kawasaki, Japan (Y.H.); Department of Neurology, NHO Nagoya Medical Center, Nagoya, Japan (S.O.); Department of Neurology, Stroke Center, Kobe City Medical Center General Hospital, Kobe, Japan (H.Y.); Department of Stroke Medicine, Kawasaki Medical School, Kurashiki, Japan (K. Kimura); and Department of Cerebrovascular Medicine, NHO Kyushu Medical Center, Fukuoka, Japan (Y.O.)
| | - Kazuyuki Nagatsuka
- From the Department of Cerebrovascular Medicine (E.T., J.K., T.O., S.S., K.M., K.T.), Division of Stroke Care Unit (M.K., S.A.), and Department of Neurology (H.Y, K.N.), National Cerebral and Cardiovascular Center, Suita, Japan; Division of Cardiovascular Medicine, Department of Medicine, Jichi Medical University School of Medicine, Shimotsuke, Japan (K. Kario); Department of Neurosurgery and Stroke Center, Nakamura Memorial Hospital, Sapporo, Japan (K. Kamiyama); Department of Stroke Neurology, Kohnan Hospital, Sendai, Japan (E.F.); Department of Neurosurgery and Stroke Center, Kyorin University School of Medicine, Mitaka, Japan (Y.S.); Department of Neurology, St Marianna University School of Medicine, Kawasaki, Japan (Y.H.); Department of Neurology, NHO Nagoya Medical Center, Nagoya, Japan (S.O.); Department of Neurology, Stroke Center, Kobe City Medical Center General Hospital, Kobe, Japan (H.Y.); Department of Stroke Medicine, Kawasaki Medical School, Kurashiki, Japan (K. Kimura); and Department of Cerebrovascular Medicine, NHO Kyushu Medical Center, Fukuoka, Japan (Y.O.)
| | - Kazuo Minematsu
- From the Department of Cerebrovascular Medicine (E.T., J.K., T.O., S.S., K.M., K.T.), Division of Stroke Care Unit (M.K., S.A.), and Department of Neurology (H.Y, K.N.), National Cerebral and Cardiovascular Center, Suita, Japan; Division of Cardiovascular Medicine, Department of Medicine, Jichi Medical University School of Medicine, Shimotsuke, Japan (K. Kario); Department of Neurosurgery and Stroke Center, Nakamura Memorial Hospital, Sapporo, Japan (K. Kamiyama); Department of Stroke Neurology, Kohnan Hospital, Sendai, Japan (E.F.); Department of Neurosurgery and Stroke Center, Kyorin University School of Medicine, Mitaka, Japan (Y.S.); Department of Neurology, St Marianna University School of Medicine, Kawasaki, Japan (Y.H.); Department of Neurology, NHO Nagoya Medical Center, Nagoya, Japan (S.O.); Department of Neurology, Stroke Center, Kobe City Medical Center General Hospital, Kobe, Japan (H.Y.); Department of Stroke Medicine, Kawasaki Medical School, Kurashiki, Japan (K. Kimura); and Department of Cerebrovascular Medicine, NHO Kyushu Medical Center, Fukuoka, Japan (Y.O.)
| | - Kazunori Toyoda
- From the Department of Cerebrovascular Medicine (E.T., J.K., T.O., S.S., K.M., K.T.), Division of Stroke Care Unit (M.K., S.A.), and Department of Neurology (H.Y, K.N.), National Cerebral and Cardiovascular Center, Suita, Japan; Division of Cardiovascular Medicine, Department of Medicine, Jichi Medical University School of Medicine, Shimotsuke, Japan (K. Kario); Department of Neurosurgery and Stroke Center, Nakamura Memorial Hospital, Sapporo, Japan (K. Kamiyama); Department of Stroke Neurology, Kohnan Hospital, Sendai, Japan (E.F.); Department of Neurosurgery and Stroke Center, Kyorin University School of Medicine, Mitaka, Japan (Y.S.); Department of Neurology, St Marianna University School of Medicine, Kawasaki, Japan (Y.H.); Department of Neurology, NHO Nagoya Medical Center, Nagoya, Japan (S.O.); Department of Neurology, Stroke Center, Kobe City Medical Center General Hospital, Kobe, Japan (H.Y.); Department of Stroke Medicine, Kawasaki Medical School, Kurashiki, Japan (K. Kimura); and Department of Cerebrovascular Medicine, NHO Kyushu Medical Center, Fukuoka, Japan (Y.O.)
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