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Fusco L, Palamà Z, Scarà A, Borrelli A, Robles AG, De Masi De Luca G, Romano S, Sciarra L. Management of cerebral amyloid angiopathy and atrial fibrillation: We are still far from precision medicine. World J Cardiol 2024; 16:231-239. [PMID: 38817646 PMCID: PMC11135332 DOI: 10.4330/wjc.v16.i5.231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2023] [Revised: 01/29/2024] [Accepted: 04/09/2024] [Indexed: 05/23/2024] Open
Abstract
The use of anticoagulation therapy could prove to be controversial when trying to balance ischemic stroke and intracranial bleeding risks in patients with concurrent cerebral amyloid angiopathy (CAA) and atrial fibrillation (AF). In fact, CAA is an age-related cerebral vasculopathy that predisposes patients to intracerebral hemorrhage. Nevertheless, many AF patients require oral systemic dose-adjusted warfarin, direct oral anticoagulants (such as factor Xa inhibitors) or direct thrombin inhibitors to control often associated with cardioembolic stroke risk. The prevalence of both CAA and AF is expected to rise, due to the aging of the population. This clinical dilemma is becoming increasingly common. In patients with coexisting AF and CAA, the risks/benefits profile of anticoagulant therapy must be assessed for each patient individually due to the lack of a clear-cut consensus with regard to its risks in scientific literature. This review aims to provide an overview of the management of patients with concomitant AF and CAA and proposes the implementation of a risk-based decision-making algorithm.
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Affiliation(s)
- Liuba Fusco
- Department of Cardiology, University Hospital of Northamptonshire, Northampton NN1 5BD, United Kingdom
| | - Zefferino Palamà
- Department of Cardiology, Casa di Cura Villa Verde, Taranto 70124, Italy
- Department of Life, Health and Environmental Sciences, University of l'Aquila, L'Aquila 67100, Italy.
| | - Antonio Scarà
- Department of Cardiology, GVM Care and Research, San Carlo di Nancy Hospital, Rome 00100, Italy
| | - Alessio Borrelli
- Department of Cardiology, GVM Care and Research, San Carlo di Nancy Hospital, Rome 00100, Italy
| | - Antonio Gianluca Robles
- Department of Life, Health and Environmental Sciences, University of l'Aquila, L'Aquila 67100, Italy
| | - Gabriele De Masi De Luca
- Department of Life, Health and Environmental Sciences, University of l'Aquila, L'Aquila 67100, Italy
| | - Silvio Romano
- Department of Life, Health and Environmental Sciences, University of l'Aquila, L'Aquila 67100, Italy
| | - Luigi Sciarra
- Department of Life, Health and Environmental Sciences, University of l'Aquila, L'Aquila 67100, Italy
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Bétrisey S, Haller ML, Efthimiou O, Speierer A, Del Giovane C, Moutzouri E, Blum MR, Aujesky D, Rodondi N, Gencer B. Lipid-Lowering Therapy and Risk of Hemorrhagic Stroke: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. J Am Heart Assoc 2024; 13:e030714. [PMID: 38323514 PMCID: PMC11010101 DOI: 10.1161/jaha.123.030714] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2023] [Accepted: 12/12/2023] [Indexed: 02/08/2024]
Abstract
BACKGROUND There is debate over whether statins increase risk of hemorrhagic stroke, so we assessed current evidence, including data from new statin trials and trials of nonstatin low-density lipoprotein-cholesterol (LDL-C)- and triglyceride-lowering therapies. METHODS AND RESULTS We performed a systematic review of large randomized clinical trials (≥1000 patients with ≥2 years follow-up) of LDL-C-lowering therapy (statin, ezetimibe, and PCSK-9 [proprotein convertase subtilisin/kexin type 9] inhibitor) and triglyceride-lowering therapy (omega-3 supplements and fibrate) that reported hemorrhagic stroke as an outcome. We searched MEDLINE, Embase, and Cochrane Library up to July 2, 2021 and updated a meta-analysis of cardiovascular statin trials published in 2012. Among our several subgroup analyses, we looked at difference depending on stroke status and also depending on age. We identified 37 trials for LDL-C lowering (284 301 participants) and 11 for triglyceride lowering (120 984 participants). Overall, we found a higher risk of hemorrhagic stroke for LDL-C lowering, risk ratio (RR) 1.16 (95% CI, 1.01-1.32, P=0.03). For statins (33 trials, 216 258 participants), RR=1.17 (95% CI, 1.01-1.36); for PCSK-9 inhibitors (2 trials, 46 488 participants), RR=0.86 (95% CI, 0.43-1.74); and for ezetimibe (2 trials, 21 555 participants), RR=1.14 (95% CI, 0.64-2.03). In statin trials of patients with previous stroke/transient ischemic attack, RR was 1.46 (95% CI, 1.05-2.04), and in trials with mean age ≥65 years old, RR=1.34 (95% CI, 1.04-1.73) (Pint=0.14 and Pint=0.23 respectively); for triglyceride lowering (11 trials, 120 984 participants), RR=1.05 (95% CI, 0.86-1.30). CONCLUSIONS We found evidence for a small increased risk of hemorrhagic stroke events with LDL-C-lowering therapies but no clear evidence for triglyceride-lowering therapies. REGISTRATION URL: https://www.crd.york.ac.uk/prospero; Unique identifier: CRD42021275363.
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Affiliation(s)
- Sylvain Bétrisey
- Department of General Internal Medicine, InselspitalBern University Hospital, University of BernSwitzerland
- Institute of Primary Health Care (BIHAM)University of BernSwitzerland
| | - Moa Lina Haller
- Department of General Internal Medicine, InselspitalBern University Hospital, University of BernSwitzerland
- Institute of Primary Health Care (BIHAM)University of BernSwitzerland
| | - Orestis Efthimiou
- Institute of Primary Health Care (BIHAM)University of BernSwitzerland
- Institute of Social and Preventive Medicine (ISPM)University of BernSwitzerland
| | - Alexandre Speierer
- Department of General Internal Medicine, InselspitalBern University Hospital, University of BernSwitzerland
- Institute of Primary Health Care (BIHAM)University of BernSwitzerland
| | - Cinzia Del Giovane
- Institute of Primary Health Care (BIHAM)University of BernSwitzerland
- Department of Medical and Surgical Sciences for Children and AdultsUniversity Hospital of Modena and Reggio EmiliaModenaMOItaly
| | - Elisavet Moutzouri
- Department of General Internal Medicine, InselspitalBern University Hospital, University of BernSwitzerland
- Institute of Primary Health Care (BIHAM)University of BernSwitzerland
- Department of General Internal Medicine, Spital EmmentalBurgdorfSwitzerland
| | - Manuel R. Blum
- Department of General Internal Medicine, InselspitalBern University Hospital, University of BernSwitzerland
- Institute of Primary Health Care (BIHAM)University of BernSwitzerland
| | - Drahomir Aujesky
- Department of General Internal Medicine, InselspitalBern University Hospital, University of BernSwitzerland
| | - Nicolas Rodondi
- Department of General Internal Medicine, InselspitalBern University Hospital, University of BernSwitzerland
- Institute of Primary Health Care (BIHAM)University of BernSwitzerland
| | - Baris Gencer
- Institute of Primary Health Care (BIHAM)University of BernSwitzerland
- Department of CardiologyGeneva University Hospital (HUG), University of GenevaGenevaSwitzerland
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3
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Helven C, Burel J, Vannier M, Maltête D, Ozkul-Wermester O, Hermary C, Wallon D, Grangeon L. Impact of previous statin use on first intracerebral hemorrhage in cerebral amyloid angiopathy. Rev Neurol (Paris) 2023; 179:1074-1080. [PMID: 37598087 DOI: 10.1016/j.neurol.2023.02.071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2022] [Revised: 01/29/2023] [Accepted: 02/25/2023] [Indexed: 08/21/2023]
Abstract
OBJECTIVES Statins have been associated with an increased risk of spontaneous intracerebral hemorrhage (ICH), but without dedicated study in cerebral amyloid angiopathy (CAA). We aimed to evaluate the association between previous statin treatment and radiological hemorrhagic lesions in a CAA population during a first lobar ICH event. MATERIALS AND METHODS We retrospectively included all patients meeting the modified Boston criteria for probable CAA and admitted for a first lobar ICH between 2010 and 2021 at Rouen University Hospital. Patients were classified as having previous statin treatment or not. We compared the ICH volume, the number of associated cerebral microbleeds (CMBs), and cortical superficial siderosis (CSS) according to previous statin treatment or not. We also compared functional outcomes and ICH recurrence during the follow-up period between the two groups. RESULTS We included 99 patients, 27 of whom had statin treatment prior to their ICH. The ICH volume and the number of CMBs did not differ between groups. Disseminated CSS was initially more frequent in the statin group (88% versus 57%; P=0.019), but this was no longer significant after adjustment for antiplatelet treatment (P=0.13). The long-term outcome was similar between the two groups with no increased risk of ICH recurrence in the statin-treated group (29.63% versus 23.61%, P=0.54). CONCLUSIONS Previous statin treatment was not associated with more severe hemorrhagic lesions in CAA in terms of ICH volume or number of microbleeds, but a trend for increased disseminated CSS was highlighted, which will require further larger studies.
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Affiliation(s)
- C Helven
- Department of Neurology, Rouen University Hospital, 76000 Rouen, France.
| | - J Burel
- Department of Radiology, Rouen University Hospital, 76000 Rouen, France
| | - M Vannier
- Department of Biostatistics, University of Rouen, Rouen University Hospital, 76000 Rouen, France
| | - D Maltête
- Department of Neurology, Rouen University Hospital, 76000 Rouen, France
| | - O Ozkul-Wermester
- Department of Neurology, Rouen University Hospital, 76000 Rouen, France
| | - C Hermary
- Department of Radiology, Rouen University Hospital, 76000 Rouen, France
| | - D Wallon
- Department of Neurology, Rouen University Hospital, 76000 Rouen, France; Inserm U1245, CNR-MAJ, Normandy Center for Genomic and Personalized Medicine, Department of Neurology, CHU of Rouen, University of Rouen Normandie, 76000 Rouen, France
| | - L Grangeon
- Department of Neurology, Rouen University Hospital, 76000 Rouen, France; Inserm U1245, CNR-MAJ, Normandy Center for Genomic and Personalized Medicine, Department of Neurology, CHU of Rouen, University of Rouen Normandie, 76000 Rouen, France
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Gaist D, García Rodríguez LA, Hallas J, Hald SM, Möller S, Høyer BB, Selim M, Goldstein LB. Association of Statin Use With Risk of Stroke Recurrence After Intracerebral Hemorrhage. Neurology 2023; 101:e1793-e1806. [PMID: 37648526 PMCID: PMC10634647 DOI: 10.1212/wnl.0000000000207792] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Accepted: 07/12/2023] [Indexed: 09/01/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Survivors of spontaneous intracerebral hemorrhage (ICH) may have indications for statin therapy. The effect of statins on the risk of subsequent hemorrhagic and ischemic stroke (IS) in this setting is uncertain. We sought to determine the risk of any stroke (ischemic stroke, IS or recurrent ICH), IS, and recurrent ICH associated with statin use among ICH survivors. METHODS Using the Danish Stroke Registry, we identified all patients admitted to a hospital in Denmark (population 5.8 million) with a first-ever ICH between January 2003 and December 2021 who were aged 50 years or older and survived >30 days. Patients were followed up until August 2022. Within this cohort, we conducted 3 nested case-control analyses for any stroke, IS, and recurrent ICH. We matched controls for age, sex, time since first-ever ICH, and history of prior IS. The primary exposure was statin use before or on the date of subsequent stroke or the equivalent date in matched controls. Using conditional logistic regression, we calculated adjusted odds ratios (aORs) and corresponding 95% confidence intervals (CIs) for any stroke, IS, and recurrent ICH associated with statin exposure. RESULTS We identified 1,959 patients with any stroke (women 45.3%; mean [SD] age, 72.6 [9.7] years) who were matched to 7,400 controls; 1,073 patients with IS (women 42.0%; mean [SD] age, 72.4 [10.0] years) who were matched to 4,035 controls and 984 patients with recurrent ICH (women 48.7%; mean [SD] age, 72.7 [9.2] years) who were matched to 3,755 controls. Statin exposure was associated with a lower risk of both any stroke (cases 38.6%, controls 41.1%; aOR 0.88; 95% CI 0.78-0.99) and IS (cases 39.8%, controls 41.8%, aOR 0.79; 95% CI 0.67-0.92), but was not associated with recurrent ICH risk (cases 39.1%, controls 40.8%, aOR 1.05; 95% CI 0.88-1.24). DISCUSSION Exposure to statins was not associated with an increased risk of recurrent ICH but was associated with a lower risk of any stroke, largely due to a lower risk of IS. Confirmation of these findings in randomized trials is needed. CLASSIFICATION OF EVIDENCE This study provides Class III evidence that statin use in patients with ICH is associated with a lower risk of any stroke and IS and not with increased risk of recurrent ICH.
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Affiliation(s)
- David Gaist
- From the Research Unit for Neurology (D.G., S.M.H.), Odense University Hospital; University of Southern Denmark, Odense, Denmark; Centro Español Investigación Farmacoepidemiológica (L.A.G.R.), Madrid, Spain; Department of Clinical Pharmacology (J.H.), Pharmacy and Environmental Medicine, University of Southern Denmark; Open Patient Data Explorative Network (OPEN) (S.M.), Odense University Hospital; Odense Patient Data Explorative Network (OPEN) (B.B.H.), Odense University Hospital, Denmark; Beth Israel Deaconess Medical Center (M.S.), Harvard Medical School; and Department of Neurology and Kentucky Neuroscience Institute (L.B.G.), University of Kentucky, Lexington.
| | - Luis Alberto García Rodríguez
- From the Research Unit for Neurology (D.G., S.M.H.), Odense University Hospital; University of Southern Denmark, Odense, Denmark; Centro Español Investigación Farmacoepidemiológica (L.A.G.R.), Madrid, Spain; Department of Clinical Pharmacology (J.H.), Pharmacy and Environmental Medicine, University of Southern Denmark; Open Patient Data Explorative Network (OPEN) (S.M.), Odense University Hospital; Odense Patient Data Explorative Network (OPEN) (B.B.H.), Odense University Hospital, Denmark; Beth Israel Deaconess Medical Center (M.S.), Harvard Medical School; and Department of Neurology and Kentucky Neuroscience Institute (L.B.G.), University of Kentucky, Lexington
| | - Jesper Hallas
- From the Research Unit for Neurology (D.G., S.M.H.), Odense University Hospital; University of Southern Denmark, Odense, Denmark; Centro Español Investigación Farmacoepidemiológica (L.A.G.R.), Madrid, Spain; Department of Clinical Pharmacology (J.H.), Pharmacy and Environmental Medicine, University of Southern Denmark; Open Patient Data Explorative Network (OPEN) (S.M.), Odense University Hospital; Odense Patient Data Explorative Network (OPEN) (B.B.H.), Odense University Hospital, Denmark; Beth Israel Deaconess Medical Center (M.S.), Harvard Medical School; and Department of Neurology and Kentucky Neuroscience Institute (L.B.G.), University of Kentucky, Lexington
| | - Stine Munk Hald
- From the Research Unit for Neurology (D.G., S.M.H.), Odense University Hospital; University of Southern Denmark, Odense, Denmark; Centro Español Investigación Farmacoepidemiológica (L.A.G.R.), Madrid, Spain; Department of Clinical Pharmacology (J.H.), Pharmacy and Environmental Medicine, University of Southern Denmark; Open Patient Data Explorative Network (OPEN) (S.M.), Odense University Hospital; Odense Patient Data Explorative Network (OPEN) (B.B.H.), Odense University Hospital, Denmark; Beth Israel Deaconess Medical Center (M.S.), Harvard Medical School; and Department of Neurology and Kentucky Neuroscience Institute (L.B.G.), University of Kentucky, Lexington
| | - Sören Möller
- From the Research Unit for Neurology (D.G., S.M.H.), Odense University Hospital; University of Southern Denmark, Odense, Denmark; Centro Español Investigación Farmacoepidemiológica (L.A.G.R.), Madrid, Spain; Department of Clinical Pharmacology (J.H.), Pharmacy and Environmental Medicine, University of Southern Denmark; Open Patient Data Explorative Network (OPEN) (S.M.), Odense University Hospital; Odense Patient Data Explorative Network (OPEN) (B.B.H.), Odense University Hospital, Denmark; Beth Israel Deaconess Medical Center (M.S.), Harvard Medical School; and Department of Neurology and Kentucky Neuroscience Institute (L.B.G.), University of Kentucky, Lexington
| | - Birgit Bjerre Høyer
- From the Research Unit for Neurology (D.G., S.M.H.), Odense University Hospital; University of Southern Denmark, Odense, Denmark; Centro Español Investigación Farmacoepidemiológica (L.A.G.R.), Madrid, Spain; Department of Clinical Pharmacology (J.H.), Pharmacy and Environmental Medicine, University of Southern Denmark; Open Patient Data Explorative Network (OPEN) (S.M.), Odense University Hospital; Odense Patient Data Explorative Network (OPEN) (B.B.H.), Odense University Hospital, Denmark; Beth Israel Deaconess Medical Center (M.S.), Harvard Medical School; and Department of Neurology and Kentucky Neuroscience Institute (L.B.G.), University of Kentucky, Lexington
| | - Magdy Selim
- From the Research Unit for Neurology (D.G., S.M.H.), Odense University Hospital; University of Southern Denmark, Odense, Denmark; Centro Español Investigación Farmacoepidemiológica (L.A.G.R.), Madrid, Spain; Department of Clinical Pharmacology (J.H.), Pharmacy and Environmental Medicine, University of Southern Denmark; Open Patient Data Explorative Network (OPEN) (S.M.), Odense University Hospital; Odense Patient Data Explorative Network (OPEN) (B.B.H.), Odense University Hospital, Denmark; Beth Israel Deaconess Medical Center (M.S.), Harvard Medical School; and Department of Neurology and Kentucky Neuroscience Institute (L.B.G.), University of Kentucky, Lexington
| | - Larry B Goldstein
- From the Research Unit for Neurology (D.G., S.M.H.), Odense University Hospital; University of Southern Denmark, Odense, Denmark; Centro Español Investigación Farmacoepidemiológica (L.A.G.R.), Madrid, Spain; Department of Clinical Pharmacology (J.H.), Pharmacy and Environmental Medicine, University of Southern Denmark; Open Patient Data Explorative Network (OPEN) (S.M.), Odense University Hospital; Odense Patient Data Explorative Network (OPEN) (B.B.H.), Odense University Hospital, Denmark; Beth Israel Deaconess Medical Center (M.S.), Harvard Medical School; and Department of Neurology and Kentucky Neuroscience Institute (L.B.G.), University of Kentucky, Lexington
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Banerjee G, Collinge J, Fox NC, Lashley T, Mead S, Schott JM, Werring DJ, Ryan NS. Clinical considerations in early-onset cerebral amyloid angiopathy. Brain 2023; 146:3991-4014. [PMID: 37280119 PMCID: PMC10545523 DOI: 10.1093/brain/awad193] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Revised: 04/16/2023] [Accepted: 05/01/2023] [Indexed: 06/08/2023] Open
Abstract
Cerebral amyloid angiopathy (CAA) is an important cerebral small vessel disease associated with brain haemorrhage and cognitive change. The commonest form, sporadic amyloid-β CAA, usually affects people in mid- to later life. However, early-onset forms, though uncommon, are increasingly recognized and may result from genetic or iatrogenic causes that warrant specific and focused investigation and management. In this review, we firstly describe the causes of early-onset CAA, including monogenic causes of amyloid-β CAA (APP missense mutations and copy number variants; mutations of PSEN1 and PSEN2) and non-amyloid-β CAA (associated with ITM2B, CST3, GSN, PRNP and TTR mutations), and other unusual sporadic and acquired causes including the newly-recognized iatrogenic subtype. We then provide a structured approach for investigating early-onset CAA, and highlight important management considerations. Improving awareness of these unusual forms of CAA amongst healthcare professionals is essential for facilitating their prompt diagnosis, and an understanding of their underlying pathophysiology may have implications for more common, late-onset, forms of the disease.
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Affiliation(s)
- Gargi Banerjee
- MRC Prion Unit at University College London (UCL), Institute of Prion Diseases, UCL, London, W1W 7FF, UK
| | - John Collinge
- MRC Prion Unit at University College London (UCL), Institute of Prion Diseases, UCL, London, W1W 7FF, UK
| | - Nick C Fox
- Dementia Research Centre, Department of Neurodegenerative Disease, UCL Queen Square Institute of Neurology, London, WC1N 3BG, UK
- UK Dementia Research Institute at UCL, London, WC1E 6BT, UK
| | - Tammaryn Lashley
- The Queen Square Brain Bank for Neurological Disorders, Department of Clinical and Movement Disorders, UCL Queen Square Institute of Neurology, London, W1 1PJ, UK
- Department of Neurodegenerative Disease, UCL Queen Square Institute of Neurology, London, WC1N 3BG, UK
| | - Simon Mead
- MRC Prion Unit at University College London (UCL), Institute of Prion Diseases, UCL, London, W1W 7FF, UK
| | - Jonathan M Schott
- Dementia Research Centre, Department of Neurodegenerative Disease, UCL Queen Square Institute of Neurology, London, WC1N 3BG, UK
- UK Dementia Research Institute at UCL, London, WC1E 6BT, UK
| | - David J Werring
- Stroke Research Centre, Department of Brain Repair and Rehabilitation, UCL Queen Square Institute of Neurology, London, WC1N 3BG, UK
| | - Natalie S Ryan
- Dementia Research Centre, Department of Neurodegenerative Disease, UCL Queen Square Institute of Neurology, London, WC1N 3BG, UK
- UK Dementia Research Institute at UCL, London, WC1E 6BT, UK
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Chang Y, Eom S, Kim M, Song TJ. Medical Management of Dyslipidemia for Secondary Stroke Prevention: Narrative Review. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:776. [PMID: 37109734 PMCID: PMC10141044 DOI: 10.3390/medicina59040776] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 04/13/2023] [Accepted: 04/14/2023] [Indexed: 04/29/2023]
Abstract
Dyslipidemia is a major risk factor for stroke, following hypertension, diabetes, and smoking, and is an important risk factor for the prevention and treatment of coronary artery disease and peripheral vascular disease, including stroke. Recent guidelines recommend considering low-density lipoprotein cholesterol (LDL-C)-lowering therapies, such as statins (preferably), ezetimibe, or proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors to prevent the occurrence or recurrence of stroke, adhering to the "lower is better" approach. In this review, we examined the evidence supporting lipid-lowering medications like statins, ezetimibe, and PCSK9 inhibitors for secondary stroke prevention and dyslipidemia management in different stroke subtypes. Stroke guidelines advocate for administering the maximum tolerable dose of statins as the primary treatment and as soon as possible despite the potential for new-onset diabetes mellitus and possible muscle and liver toxicity due to their demonstrated benefits in secondary prevention of cardiovascular diseases and mortality reduction. When statin use is insufficient for LDL lowering, ezetimibe and PCSK9 inhibitors are recommended as complementary therapies. It is essential to establish lipid-lowering therapy goals based on the stroke subtype and the presence of comorbidities.
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Affiliation(s)
- Yoonkyung Chang
- Department of Neurology, Mokdong Hospital, College of Medicine, Ewha Womans University, Seoul 07985, Republic of Korea
| | - Soojeong Eom
- Department of Medicine, College of Medicine, Ewha Womans University, Seoul 07804, Republic of Korea
| | - Minjeong Kim
- Department of Medicine, College of Medicine, Ewha Womans University, Seoul 07804, Republic of Korea
| | - Tae-Jin Song
- Department of Neurology, Seoul Hospital, College of Medicine, Ewha Womans University, Seoul 07804, Republic of Korea
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7
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Åivo J, Ruuskanen JO, Tornio A, Rautava P, Kytö V. Lack of Statin Therapy and Outcomes After Ischemic Stroke: A Population-Based Study. Stroke 2023; 54:781-790. [PMID: 36748465 PMCID: PMC10561684 DOI: 10.1161/strokeaha.122.040536] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Revised: 12/22/2022] [Accepted: 01/18/2023] [Indexed: 02/08/2023]
Abstract
BACKGROUND Statin treatment is effective at preventing adverse vascular events after ischemic stroke (IS). However, many patients fail to use statins after IS. We studied the impact of not using statins after IS on adverse outcomes. METHODS IS patients (n=59 588) admitted to 20 Finnish hospitals were retrospectively studied. Study data were combined from national registries on hospital admissions, mortality, cancer diagnoses, prescription medication purchases, and permissions for special reimbursements for medications. Usage of prescription medication was defined as drug purchase within 90 days after hospital discharge. Ongoing statin use during follow-up was analyzed in 90-day intervals. Differences in baseline features, comorbidities, other medications, and recanalization therapies were balanced with inverse probability of treatment weighting. Median follow-up was 5.7 years. RESULTS Statin therapy was not used by 27.1% of patients within 90 days after IS discharge, with women and older patients using statins less frequently. The average proportion of patients without ongoing statin during the 12-year follow-up was 36.0%. Patients without early statins had higher all-cause mortality at 1 year (7.5% versus 4.4% in patients who did use statins; hazard ratio [HR], 1.74 [CI, 1.61-1.87]) and 12 years (56.8% versus 48.6%; HR, 1.37 [CI, 1.33-1.41]). Cumulative incidence of major adverse cerebrovascular or cardiovascular event was higher at 1 year (subdistribution HR, 1.36 [CI, 1.29-1.43]) and 12 years (subdistribution HR, 1.21 [CI, 1.18-1.25]) without early statin use. Cardiovascular death, recurrent IS, and myocardial infarction were more frequent without early statin use. Early statin use was not associated with hemorrhagic stroke during follow-up. Lack of ongoing statin during follow-up was associated with risk of death in time-dependent analysis (adjusted HR, 3.03 [CI, 2.96-3.23]). CONCLUSIONS Lack of statin treatment after IS is associated with adverse long-term outcomes. Measures to further improve timely statin use after IS are needed.
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Affiliation(s)
- Julia Åivo
- Neurocenter, Department of Neurology, Turku University Hospital and University of Turku, Finland (J.Å., J.O.R.)
| | - Jori O. Ruuskanen
- Neurocenter, Department of Neurology, Turku University Hospital and University of Turku, Finland (J.Å., J.O.R.)
| | - Aleksi Tornio
- Integrative Physiology and Pharmacology, Institute of Biomedicine, University of Turku, Finland (A.T.)
- Unit of Clinical Pharmacology, Turku University Hospital, Finland (A.T.)
| | - Päivi Rautava
- Department of Public Health, University of Turku, Finland (P.R.)
- Turku Clinical Research Centre, Turku University Hospital, Finland (P.R., V.K.)
| | - Ville Kytö
- Turku Clinical Research Centre, Turku University Hospital, Finland (P.R., V.K.)
- Heart Center, Turku University Hospital and University of Turku, Finland (V.K.)
- Research Center of Applied and Preventive Cardiovascular Medicine, University of Turku, Finland (V.K.)
- Center for Population Health Research, Turku University Hospital and University of Turku, Finland (V.K.)
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Li J, Li G, Zhu Y, Lei X, Chen G, Zhang J, Sun X. Role of LDL-C level alteration in increased mortality risks in spontaneous intracerebral hemorrhage patients: Systematic review and meta-analysis. Front Neurol 2023; 14:1114176. [PMID: 36925942 PMCID: PMC10011101 DOI: 10.3389/fneur.2023.1114176] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Accepted: 02/13/2023] [Indexed: 03/06/2023] Open
Abstract
Background Current studies indicate a contradictory relationship between decreased mortality risks of spontaneous intracerebral hemorrhage (sICH) and elevated low-density lipoprotein cholesterol (LDL-C) levels. Thus, this meta-analysis was designed to examine the involvement of high LDL-C levels in a lower mortality risk of sICH patients. Methods PubMed, Cochrane, and Embase databases were searched up to the date of August 3rd, 2022. Pooled odds ratio (OR) with a 95% confidence interval (CI) was estimated for the higher vs. lower serum LDL-C level groups. Subgroup and sensitivity analyses were also carried out. Egger's test was applied to detect any potential publication bias. Results Of 629 citations reviewed, 8 eligible cohort studies involving 83,013 patients were enrolled in this meta-analysis. Compared with lower serum LDL-C levels containing patients, higher serum LDL-C patients exhibited significantly decreased risks of 3-month mortality (OR: 0.51; 95%CI: 0.33-0.78; I2 = 47.8%); however, the LDL-C level change wasn't significantly associated with in-hospital mortality risks (OR: 0.92; 95%CI: 0.63-1.33; I2 = 91.4%) among sICH subjects. All studies included were classified as high-quality investigations. Conclusions This meta-analysis suggests a higher LDL-C level may decrease the mortality risk in sICH patients. LDL-C level increase is inversely associated with the 3-month mortality risks in these patients but not significantly correlated with the in-hospital mortality risks. Further well-designed prospective studies with extended follow-up periods are needed to confirm these findings and explore underlying cross-talks. Systematic review registration https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42022318318, identifier: PROSPERO 2022 CRD42022318318.
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Affiliation(s)
- Jing Li
- Department of Neurosurgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Gang Li
- Department of Neurosurgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Yajun Zhu
- Department of Neurosurgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Xingwei Lei
- Department of Neurosurgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Guihu Chen
- Department of Neurosurgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Jiachun Zhang
- Department of Neurosurgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Xiaochuan Sun
- Department of Neurosurgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
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9
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Song Y, Liu X, Yuan J, Sha Z, Jiang W, Liu M, Qian Y, Gao C, Gong Z, Luo H, Zhou X, Huang J, Jiang R, Quan W. Atorvastatin combined with low-dose dexamethasone improves the neuroinflammation and survival in mice with intracerebral hemorrhage. Front Neurosci 2022; 16:967297. [PMID: 36071715 PMCID: PMC9441757 DOI: 10.3389/fnins.2022.967297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2022] [Accepted: 07/22/2022] [Indexed: 11/13/2022] Open
Abstract
Intracerebral hemorrhage (ICH) is a fatal disease with high mortality and poor prognosis that triggers multiple severe brain injuries associated with an inflammatory cascade response that cannot be treated with any effective medication. Atorvastatin (ATO) suppresses inflammation, alleviates brain trauma, and eliminates subdural hematoma. Dexamethasone (DXM) also has the capacity to inhibit inflammation. Thus, we combined ATO with low-dose DXM to treat ICH mice in vivo to examine whether the combined treatment can inhibit secondary inflammation around the cerebral hemorrhage and decrease overall mortality. Compared to the monotherapy by either ATO or DXM, the combined treatment significantly improves the survivorship of the ICH mice, accelerates their recovery of impaired neurological function, and modulates the circulating cytokines, oxidative products, and apoptosis. Moreover, the benefit of ATO-DXM combination therapy was most pronounced on day 3 after dosing compared to ATO or DXM alone. Thus, early administration of ATO combined with low-dose-DXM promotes better survival of ICH and improves neurological function by reducing neuroinflammation and brain edema in their early phase.
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Affiliation(s)
- Yiming Song
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
- The State Key Laboratory of Neurotrauma Repair and Regeneration, Ministry of Education, Tianjin, China
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Xuanhui Liu
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
- The State Key Laboratory of Neurotrauma Repair and Regeneration, Ministry of Education, Tianjin, China
| | - Jiangyuan Yuan
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
- The State Key Laboratory of Neurotrauma Repair and Regeneration, Ministry of Education, Tianjin, China
| | - Zhuang Sha
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
- The State Key Laboratory of Neurotrauma Repair and Regeneration, Ministry of Education, Tianjin, China
| | - Weiwei Jiang
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
- The State Key Laboratory of Neurotrauma Repair and Regeneration, Ministry of Education, Tianjin, China
| | - Mingqi Liu
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
- The State Key Laboratory of Neurotrauma Repair and Regeneration, Ministry of Education, Tianjin, China
| | - Yu Qian
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
- The State Key Laboratory of Neurotrauma Repair and Regeneration, Ministry of Education, Tianjin, China
| | - Chuang Gao
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
- The State Key Laboratory of Neurotrauma Repair and Regeneration, Ministry of Education, Tianjin, China
| | - Zhitao Gong
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
- The State Key Laboratory of Neurotrauma Repair and Regeneration, Ministry of Education, Tianjin, China
| | - Hongliang Luo
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
- The State Key Laboratory of Neurotrauma Repair and Regeneration, Ministry of Education, Tianjin, China
| | - Xin Zhou
- Department of Cardiology, Tianjin Medical University General Hospital, Tianjin, China
| | - Jinhao Huang
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
- The State Key Laboratory of Neurotrauma Repair and Regeneration, Ministry of Education, Tianjin, China
- *Correspondence: Jinhao Huang,
| | - Rongcai Jiang
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
- The State Key Laboratory of Neurotrauma Repair and Regeneration, Ministry of Education, Tianjin, China
- Rongcai Jiang,
| | - Wei Quan
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
- The State Key Laboratory of Neurotrauma Repair and Regeneration, Ministry of Education, Tianjin, China
- Wei Quan,
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10
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Abstract
Hyperlipidemia is common in patients with intracerebral hemorrhage (ICH). Accumulating evidence indicates that patients with ICH are at risk for future hemorrhage recurrence, cardiovascular disease, and ischemic stroke and highlights the importance of secondary prevention of vascular events after ICH. Although the benefits of intensive treatment of hyperlipidemia for reducing ischemic cardiac and vascular events in patients with ischemic stroke are well established, the benefit versus harm in patients with ICH are less clear. Epidemiological studies suggest that hyperlipidemia is protective against ICH and that intensive lowering of lipids is associated with increased risk for ICH. Similarly, although currently available lipid-lowering treatments have been thoroughly studied in patients with ischemic cardiac and vascular disease, only few randomized trials of these therapies included a very small number of patients with history of ICH. Thus, limiting any definitive conclusions regarding the safety and net benefit of these treatments in ICH populations. Currently, there is no consensus regarding the optimal strategy for management of hyperlipidemia after ICH. In this article, we review relevant literature to outline the competing risks and benefits of lipid-lowering treatments in this vulnerable patient population. We suggest a treatment paradigm based on available data but note that data from dedicated randomized trials are needed to build the necessary evidence to guide optimal lipid-lowering strategy in patients with a history of ICH.
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Affiliation(s)
- Ashkan Shoamanesh
- Department of Medicine, McMaster University, Population Health Research Institute, Hamilton, ON, Canada (A.S.)
| | - Magdy Selim
- Stroke Division, Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (M.S.)
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11
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Yan L, Wang X, Wang T, Shu L, Li Y, Dmytriw AA, Yang K, Xu R, Bai X, Yang B, Lu X, Ma Y, Jiao L. Statins for people with intracerebral hemorrhage. Hippokratia 2022. [DOI: 10.1002/14651858.cd014929] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- Lin Yan
- Department of Neurosurgery; Xuanwu Hospital, Capital Medical University; Beijing China
| | - Xue Wang
- Medical Library of Xuanwu Hospital; Xuanwu Hospital, Capital Medical University; Beijing China
| | - Tao Wang
- Department of Neurosurgery; Xuanwu Hospital, Capital Medical University; Beijing China
| | - Liqi Shu
- Department of Neurology; The Warren Alpert Medical School of Brown University; Providence Rhode Island USA
| | - Ye Li
- Department of Neurosurgery; Xuanwu Hospital, Capital Medical University; Beijing China
| | - Adam A Dmytriw
- Department of Medical Imaging; University of Toronto; Toronto Canada
| | - Kun Yang
- Department of Evidence-based Medicine; Xuanwu Hospital, Capital Medical University; Beijing China
| | - Ran Xu
- Department of Neurosurgery; Xuanwu Hospital, Capital Medical University; Beijing China
| | - Xuesong Bai
- Department of Neurosurgery; Xuanwu Hospital, Capital Medical University; Beijing China
| | - Bin Yang
- Department of Neurosurgery; Xuanwu Hospital, Capital Medical University; Beijing China
| | - Xia Lu
- Department of Neurosurgery; Xuanwu Hospital, Capital Medical University; Beijing China
| | - Yan Ma
- Department of Neurosurgery; Xuanwu Hospital, Capital Medical University; Beijing China
| | - Liqun Jiao
- Department of Neurosurgery; Xuanwu Hospital, Capital Medical University; Beijing China
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12
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The Association between Low Levels of Low Density Lipoprotein Cholesterol and Intracerebral Hemorrhage: Cause for Concern? J Clin Med 2022; 11:jcm11030536. [PMID: 35159988 PMCID: PMC8836670 DOI: 10.3390/jcm11030536] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2021] [Revised: 12/27/2021] [Accepted: 01/18/2022] [Indexed: 12/24/2022] Open
Abstract
Excessive levels of low-density lipoprotein cholesterol (LDL-C) in the blood are a known risk factor for atherosclerosis, and a common target of treatment for primary and secondary prevention of cerebrocardiovascular disease. As lipid lowering agents including statins, ezetimibe and anti-proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors have shown good therapeutic results, the guidelines are constantly lowering the "optimal" LDL-C goals. However, old and new data point towards an association between low LDL-C and total cholesterol and intracerebral hemorrhage (ICH). In this review we aimed to shed light on this troubling association and identify the potential risk factors of such a potential adverse reaction. With respect to the data presented, we concluded that in patients with high risk of ICH, a cautious approach and individualized therapy strategy are advised when considering aggressive LDL reduction.
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13
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Puri R, Mehta V, Iyengar SS, Srivastava P, Yusuf J, Pradhan A, Pandian JD, Sharma VK, Renjen PN, Muruganathan A, Mugundhan K, Srinivasan AV, Shetty S, Narasingan SN, Nair DR, Bansal M, Prabhakar D, Varma M, Paliwal VK, Kapoor A, Mukhopadhyay S, Mehrotra R, Patanwala RM, Aggarwal R, Mahajan K, Kumar S, Bardoloi N, Pareek KK, Manoria PC, Pancholia AK, Nanda R, Wong ND, Duell PB. Management of Dyslipidaemia for the Prevention of Stroke: Clinical Practice Recommendations from the Lipid Association of India. Curr Vasc Pharmacol 2021; 20:134-155. [PMID: 34751121 DOI: 10.2174/1570161119666211109122231] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Revised: 08/21/2021] [Accepted: 09/28/2021] [Indexed: 02/08/2023]
Abstract
Stroke is the second most common cause of death worldwide. The rates of stroke are increasing in less affluent countries predominantly because of a high prevalence of modifiable risk factors. The Lipid Association of India (LAI) has provided a risk stratification algorithm for patients with ischaemic stroke and recommended low density lipoprotein cholesterol (LDL-C) goals for those in a very high risk group and extreme risk group (category A) of <50 mg/dl (1.3 mmol/l) while the LDL-C goal for extreme risk group (category B) is ≤30 mg/dl (0.8 mmol/l). High intensity statins are the first-line lipid lowering therapy. Non-statin therapy like ezetimibe and proprotein convertase subtilisin kexin type 9 (PCSK9) inhibitors may be added as an adjunct to statins in patients who do not achieve LDL-C goals statins alone. In acute ischaemic stroke, high intensity statin therapy improves neurological and functional outcomes regardless of thrombolytic therapy. Although conflicting data exist regarding increased risk of intracerebral haemorrhage (ICH) with statin use, the overall benefit risk ratio favors long-term statin therapy necessitating detailed discussion with the patient. Patients who have statins withdrawn while being on prior statin therapy at the time of acute ischaemic stroke have worse functional outcomes and increased mortality. LAI recommends that statins be continued in such patients. In patients presenting with ICH, statins should not be started in the acute phase but should be continued in patients who are already taking statins. ICH patients, once stable, need risk stratification for atherosclerotic cardiovascular disease (ASCVD).
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Affiliation(s)
| | - Vimal Mehta
- Department of Cardiology, G. B. Pant Institute of Postgraduate Medical Education and Research, New Delhi. 0
| | - S S Iyengar
- Department of Cardiology, Manipal Hospital, Bangalore, Karnataka. India
| | - Padma Srivastava
- Department of Neurology, Neurosciences Centre, AIIMS, New Delhi. India
| | - Jamal Yusuf
- Department of Cardiology, G. B. Pant Institute of Postgraduate Medical Education and Research, New Delhi. India
| | - Akshaya Pradhan
- Department of Cardiology King George's Medical University, Lucknow, U.P. India
| | | | - Vijay K Sharma
- Yong Loo Lin School of Medicine, National University of Singapore and National University Hospital. Singapore
| | - P N Renjen
- Department of Neurology, Indraprastha Apollo Hospital, New Delhi. India
| | - A Muruganathan
- Consultant Internal Medicine, AG Hospital, Tirupur, Tamil Nadu. India
| | - K Mugundhan
- Department of Neurology, Govt, Stanley Medical College, Chennai. India
| | - A V Srinivasan
- Department of Neurology, The Tamil Nadu,Dr MGR Medical University. India
| | - Sadanand Shetty
- Department of Cardiology, K.J Somaiya Super Speciality Institute Sion (East), Mumbai. India
| | - S N Narasingan
- The Tamil Nadu Dr MGR Medical University and Managing Director, SNN Specialities Clinic, Chennai, Tamil Nadu. India
| | - Devaki R Nair
- Department of Lipidology and Chemical pathologist, Royal Free Hospital, London. United Kingdom
| | - Manish Bansal
- Department of Cardiology, Medanta Hospital, Gurugram, Haryana. India
| | - D Prabhakar
- Department of Cardiology, Apollo Hospitals, Chennai, Tamil Nadu. India
| | - Mukul Varma
- Department of Neurology, Indraprastha Apollo Hospital, New Delhi. India
| | | | | | - Saibal Mukhopadhyay
- Department of Cardiology, G. B. Pant Institute of Postgraduate Medical Education and Research, New Delhi. India
| | - Rahul Mehrotra
- Non-Invasive Cardiology, Max Super Speciality Hospital, Saket, New Delhi. India
| | | | - Rajeev Aggarwal
- Jaswant Rai Speciality Hospital, Meerut, Uttar Pradesh. India
| | - Kunal Mahajan
- Department of Cardiology, Indra Gandhi Govt. Medical College and Hospital, Shimla. India
| | - Soumitra Kumar
- Department of Cardiology, Vivekananda Institute of Medical Sciences, Kolkata. India
| | - Neil Bardoloi
- Cardiology, Excel Care Hospital, Guwahati, Assam. India
| | - K K Pareek
- Department of Medicine, S. N. Pareek Hospital, Dadabari, Kota, Rajasthan. India
| | - P C Manoria
- Heart and Critical Care Hospital, Bhopal, Madhya Pradesh. India
| | - A K Pancholia
- Medicine and Preventive Cardiology, Arihant Hospital and Research Center, Indore, Madhya Pradesh. India
| | - Rashmi Nanda
- Consultant Physician and Lipidologist, Cardiac Care Centre, South Extension, New Delhi and Professor and Director University of California Irvine School of Medicine, Irvine, CA. United States
| | - Nathan D Wong
- Heart Disease Prevention Program, Division of Cardiology, University of California Irvine. United States
| | - P Barton Duell
- Knight Cardiovascular Institute and Division of Endocrinology, Diabetes and Clinical Nutrition, Oregon Health and Science University, Portland, OR. United States
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14
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Katsanos AH, Selim MH, Shoamanesh A. Authors' reply to "Statin treatment and cerebral microbleeds: A risk assessment". J Neurol Sci 2021; 432:120037. [PMID: 34716017 DOI: 10.1016/j.jns.2021.120037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Accepted: 10/19/2021] [Indexed: 10/20/2022]
Affiliation(s)
- Aristeidis H Katsanos
- Division of Neurology, McMaster University, Population Health Research Institute, Hamilton, ON, Canada.
| | - Magdy H Selim
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Ashkan Shoamanesh
- Division of Neurology, McMaster University, Population Health Research Institute, Hamilton, ON, Canada
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15
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[Intracerebral hemorrhage under platelet inhibition and oral anticoagulation in patients with cerebral amyloid angiopathy]. DER NERVENARZT 2021; 93:599-604. [PMID: 34652485 PMCID: PMC9200694 DOI: 10.1007/s00115-021-01206-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 09/13/2021] [Indexed: 11/11/2022]
Abstract
Die Durchführung einer oralen Antikoagulation ist bei Patienten mit einer zerebralen Amyloidangiopathie eine therapeutische Herausforderung. Die Assoziation der zerebralen Amyloidangiopathie mit Lobärblutungen, eine hohe Mortalität intrazerebraler Blutungen insbesondere unter oraler Antikoagulation sowie das hohe Rezidivrisiko solcher Blutungen erfordern eine strenge und interdisziplinäre Risiko-Nutzen-Abwägung. Vitamin-K-Antagonisten erhöhen das Risiko für die mit intrazerebralen Blutungen vergesellschaftete Mortalität um 60 % und sollten daher möglichst vermieden bzw. speziellen klinischen Situationen (z. B. mechanischer Aortenklappenersatz) vorbehalten sein. Auch der Einsatz von neuen oralen Antikoagulanzien und Thrombozytenaggregationshemmern bedarf einer strengen Risiko-Nutzen-Abwägung, da auch diese Substanzen das zerebrale Blutungsrisiko erhöhen. Insbesondere bei Patienten mit einer absoluten Arrhyhtmie bei Vorhofflimmern ist der interventionelle Vorhofohrverschluss eine therapeutische Alternative. Darüber hinaus sind weitere klinische Implikationen bei Patienten mit zerebraler Amyloidangiopathie Gegenstand dieser Literaturübersicht, beispielsweise Besonderheiten nach akutem ischämischem Schlaganfall und erforderlicher Sekundärprophylaxe, bei vorherigen intrazerebralen Blutungen und bei Patienten mit kognitiven Defiziten.
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16
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Jones FJS, Sanches PR, Smith JR, Zafar SF, Blacker D, Hsu J, Schwamm LH, Newhouse JP, Westover MB, Moura LMVR. Seizure Prophylaxis After Spontaneous Intracerebral Hemorrhage. JAMA Neurol 2021; 78:1128-1136. [PMID: 34309642 PMCID: PMC8314179 DOI: 10.1001/jamaneurol.2021.2249] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Accepted: 05/10/2021] [Indexed: 12/24/2022]
Abstract
Importance Limited evidence is available concerning optimal seizure prophylaxis after spontaneous intracerebral hemorrhage (sICH). Objective To evaluate which of 4 seizure prophylaxis strategies provides the greatest net benefit for patients with sICH. Design, Setting, and Participants This decision analysis used models to simulate the following 4 common scenarios: (1) a 60-year-old man with low risk of early (≤7 days after stroke) (10%) and late (3.6% or 9.8%) seizures and average risk of short- (9%) and long-term (30%) adverse drug reaction (ADR); (2) an 80-year-old woman with low risk of early (10%) and late (3.6% or 9.8%) seizures and high short- (24%) and long-term (80%) ADR risks; (3) a 55-year-old man with high risk of early (19%) and late (34.8% or 46.2%) seizures and low short- (9%) and long-term (30%) ADR risks; and (4) a 45-year-old woman with high risk of early (19%) and late (34.8% or 46.2%) seizures and high short- (18%) and long-term (60%) ADR risks. Interventions The following 4 antiseizure drug strategies were included: (1) conservative, consisting of short-term (7-day) secondary early-seizure prophylaxis with long-term therapy after late seizure; (2) moderate, consisting of long-term secondary early-seizure prophylaxis or late-seizure therapy; (3) aggressive, consisting of long-term primary prophylaxis; and (4) risk guided, consisting of short-term secondary early-seizure prophylaxis among low-risk patients (2HELPS2B score, 0), short-term primary prophylaxis among patients at higher risk (2HELPS2B score, ≥1), and long-term secondary therapy for late seizure. Main Outcomes and Measures Quality-adjusted life-years (QALYs). Results For scenario 1, the risk-guided strategy (8.13 QALYs) was preferred over the conservative (8.08 QALYs), moderate (8.07 QALYs), and aggressive (7.88 QALYs) strategies. For scenario 2, the conservative strategy (2.18 QALYs) was preferred over the risk-guided (2.17 QALYs), moderate (2.09 QALYs), and aggressive (1.15 QALYs) strategies. For scenario 3, the aggressive strategy (9.21 QALYs) was preferred over the risk-guided (8.98 QALYs), moderate (8.93 QALYs), and conservative (8.77 QALYs) strategies. For scenario 4, the risk-guided strategy (11.53 QALYs) was preferred over the conservative (11.23 QALYs), moderate (10.93 QALYs), and aggressive (8.08 QALYs) strategies. Sensitivity analyses suggested that short-term strategies (conservative and risk guided) are preferred under most scenarios, and the risk-guided strategy performs comparably to or better than alternative strategies in most settings. Conclusions and Relevance This decision analytical model suggests that short-term (7-day) prophylaxis dominates longer-term therapy after sICH. Use of the 2HELPS2B score to guide clinical decisions for initiation of short-term primary vs secondary early-seizure prophylaxis should be considered for all patients after sICH.
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Affiliation(s)
| | - Paula R. Sanches
- Department of Neurology, Massachusetts General Hospital, Boston
- Department of Critical Care Medicine, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Jason R. Smith
- Department of Neurology, Massachusetts General Hospital, Boston
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Sahar F. Zafar
- Department of Neurology, Massachusetts General Hospital, Boston
- Department of Neurology, Harvard Medical School, Boston, Massachusetts
| | - Deborah Blacker
- Department of Epidemiology, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
- Department of Psychiatry, Massachusetts General Hospital, Boston
- Department of Psychiatry, Harvard Medical School, Boston, Massachusetts
| | - John Hsu
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
- Mongan Institute for Health Policy, Department of Medicine, Massachusetts General Hospital, Boston
- Department of Medicine, Harvard Medical School, Boston, Massachusetts
| | - Lee H. Schwamm
- Department of Neurology, Massachusetts General Hospital, Boston
- Department of Neurology, Harvard Medical School, Boston, Massachusetts
| | - Joseph P. Newhouse
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
- Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
- Harvard Kennedy School, Cambridge, Massachusetts
- National Bureau of Economic Research, Cambridge, Massachusetts
| | - Michael B. Westover
- Department of Neurology, Massachusetts General Hospital, Boston
- Department of Neurology, Harvard Medical School, Boston, Massachusetts
| | - Lidia M. V. R. Moura
- Department of Neurology, Massachusetts General Hospital, Boston
- Department of Neurology, Harvard Medical School, Boston, Massachusetts
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17
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Jones FJ, Sanches PR, Smith JR, Zafar SF, Hernandez-Diaz S, Blacker D, Hsu J, Schwamm LH, Westover MB, Moura LM. Anticonvulsant Primary and Secondary Prophylaxis for Acute Ischemic Stroke Patients: A Decision Analysis. Stroke 2021; 52:2782-2791. [PMID: 34126758 PMCID: PMC8384723 DOI: 10.1161/strokeaha.120.033299] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose We examined the impact of 3 anticonvulsant prophylaxis strategies on quality-adjusted life-years (QALYs) among patients with an incident acute ischemic stroke. Methods We created a decision tree to evaluate 3 strategies: (1) long-term primary prophylaxis; (2) short-term secondary prophylaxis after an early seizure with lifetime prophylaxis if persistent or late seizures (LSs) developed; and (3) long-term secondary prophylaxis if either early, late, or persistent seizures developed. The outcome was quality-adjusted life expectancy (QALY). We created 4 base cases to simulate common clinical scenarios: (1) female patient aged 40 years with a 2% or 11% lifetime risk of an LS and a 33% lifetime risk of an adverse drug reaction (ADR); (2) male patient aged 65 years with a 6% or 29% LS risk and 60% ADR risk; (3) male patient aged 50 years with an 18% or 65% LS risk and 33% ADR risk; and (4) female patient aged 80 years with a 29% or 83% LS risk and 80% ADR risk. In sensitivity analyses, we altered the parameters and assumptions. Results Across all 4 base cases, primary prophylaxis yielded the fewest QALYs when compared with secondary prophylaxis. For example, under scenario 1, strategies 2 and 3 resulted in 7.17 QALYs each, but strategy 1 yielded only 6.91 QALYs. Under scenario 4, strategies 2 and 3 yielded 2.85 QALYs compared with 1.40 QALYs for strategy 1. Under scenarios in which patients had higher ADR risks, strategy 2 led to the most QALYs. Conclusions Short-term therapy with continued anticonvulsant prophylaxis only after postischemic stroke seizures arise dominates lifetime primary prophylaxis in all scenarios examined. Our findings reinforce the necessity of close follow-up and discontinuation of anticonvulsant seizure prophylaxis started during acute ischemic stroke hospitalization.
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Affiliation(s)
- Felipe J.S. Jones
- Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts
| | - Paula R. Sanches
- Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts
- Department of Critical Care Medicine, Hospital Israelita Albert Einstein, Sao Paulo, Brazil
| | - Jason R. Smith
- Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts
| | - Sahar F. Zafar
- Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts
- Department of Neurology, Harvard Medical School, Boston, Massachusetts
| | - Sonia Hernandez-Diaz
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Deborah Blacker
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
- Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts
- Department of Psychiatry, Harvard Medical School, Boston, Massachusetts
| | - John Hsu
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts. Department of Medicine, Harvard Medical School, Boston, Massachusetts
- Mongan Institute for Health Policy, Massachusetts General Hospital, Boston, Massachusetts
| | - Lee H. Schwamm
- Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts
- Department of Neurology, Harvard Medical School, Boston, Massachusetts
| | - Michael B. Westover
- Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts
- Department of Neurology, Harvard Medical School, Boston, Massachusetts
| | - Lidia M.V.R. Moura
- Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts
- Department of Neurology, Harvard Medical School, Boston, Massachusetts
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Retta SF, Perrelli A, Trabalzini L, Finetti F. From Genes and Mechanisms to Molecular-Targeted Therapies: The Long Climb to the Cure of Cerebral Cavernous Malformation (CCM) Disease. Methods Mol Biol 2021; 2152:3-25. [PMID: 32524540 DOI: 10.1007/978-1-0716-0640-7_1] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Cerebral cavernous malformation (CCM) is a rare cerebrovascular disorder of genetic origin consisting of closely clustered, abnormally dilated and leaky capillaries (CCM lesions), which occur predominantly in the central nervous system. CCM lesions can be single or multiple and may result in severe clinical symptoms, including focal neurological deficits, seizures, and intracerebral hemorrhage. Early human genetic studies demonstrated that CCM disease is linked to three chromosomal loci and can be inherited as autosomal dominant condition with incomplete penetrance and highly variable expressivity, eventually leading to the identification of three disease genes, CCM1/KRIT1, CCM2, and CCM3/PDCD10, which encode for structurally unrelated intracellular proteins that lack catalytic domains. Biochemical, molecular, and cellular studies then showed that these proteins are involved in endothelial cell-cell junction and blood-brain barrier stability maintenance through the regulation of major cellular structures and mechanisms, including endothelial cell-cell and cell-matrix adhesion, actin cytoskeleton dynamics, autophagy, and endothelial-to-mesenchymal transition, suggesting that they act as pleiotropic regulators of cellular homeostasis, and opening novel therapeutic perspectives. Indeed, accumulated evidence in cellular and animal models has eventually revealed that the emerged pleiotropic functions of CCM proteins are mainly due to their ability to modulate redox-sensitive pathways and mechanisms involved in adaptive responses to oxidative stress and inflammation, thus contributing to the preservation of cellular homeostasis and stress defenses.In this introductory review, we present a general overview of 20 years of amazing progress in the identification of genetic culprits and molecular mechanisms underlying CCM disease pathogenesis, and the development of targeted therapeutic strategies.
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Affiliation(s)
- Saverio Francesco Retta
- Department of Clinical and Biological Science, School of Medicine and Surgery, University of Torino, Orbassano (Torino), Italy. .,CCM Italia Research Network, Torino, Italy.
| | - Andrea Perrelli
- Department of Clinical and Biological Science, School of Medicine and Surgery, University of Torino, Orbassano (Torino), Italy.,CCM Italia Research Network, Torino, Italy
| | - Lorenza Trabalzini
- CCM Italia Research Network, Torino, Italy.,Department of Biotechnology, Chemistry and Pharmacy, University of Siena, Siena, Italy
| | - Federica Finetti
- CCM Italia Research Network, Torino, Italy.,Department of Biotechnology, Chemistry and Pharmacy, University of Siena, Siena, Italy
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Sarfo FS, Adamu S, Obese V, Agbenorku M, Opare-Addo PA, Ovbiagele B. Atherosclerotic event risk and risk reduction therapies among Ghanaian hemorrhagic stroke survivors. J Neurol Sci 2021; 424:117389. [PMID: 33773409 DOI: 10.1016/j.jns.2021.117389] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Revised: 03/07/2021] [Accepted: 03/08/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND Intracerebral hemorrhage (ICH) stroke constitute up to 40% of incident strokes in Africa. While ICH patients are at high risk for atherosclerotic events, the risk-benefit of anti-atherosclerotic therapies in this patient population is uncertain. PURPOSE To assess whether utility of statins and/or antithrombotic agents after surviving an ICH correlates with atherosclerotic risk of an observational cohort. METHODS We analyzed data in a stroke registry prospectively collected on consecutively encountered stroke survivors seen at an out-patient clinic in Ghana between January 2018 and March 2020. We collected baseline demographic and clinical details, including diagnosis of ICH, co-morbidities, and key atherosclerotic risk reduction therapies (statins and anti-platelet drugs). We computed ischemic vascular risk using the Framingham Risk Score (FRS) to classify patients into low, intermediate and high vascular risk. RESULTS Of 1101 stroke survivors seen during the period, 244 (22.2%) had ICH. Vascular risk profiles were low (n = 86; 35.2%), intermediate (n = 71; 29.1%) and high (n = 87; 35.7%). Utility of statin use was 76.7% (low risk), 84.5% (intermediate risk), and 87.4% (high risk), p = 0.16 while antiplatelet use trended with atherosclerotic risk being 9.3% (low risk), 25.4% (intermediate risk), and high risk (34.5%), p = 0.0004. Independent factors associated with statin use were hypertension (OR 8.80; 95% CI: 2.34-33.11) and cigarette smoking (OR 0.29; 95% CI: 0.09-0.89) while antiplatelet drug use was associated with age (OR 1.43; 95% CI: 1.06-1.92) and time from index stroke (OR: 1.02; 95% CI: 1.01-1.02). CONCLUSION Approximately two-thirds of ICH survivors in this African sample had intermediate to high risk of future atherosclerotic events. Clinical trials on the timing, safety, and efficacy of statins and antiplatelet drugs among ICH survivors could help better guide risk mitigation in this population.
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Affiliation(s)
- Fred Stephen Sarfo
- Kwame Nkrumah University of Science and Technology, Kumasi, Ghana; Komfo Anokye Teaching Hospital, Kumasi, Ghana.
| | | | - Vida Obese
- Komfo Anokye Teaching Hospital, Kumasi, Ghana
| | | | | | - Bruce Ovbiagele
- Department of Neurology, University of California, San Francisco, USA
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20
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Amorim E, McGraw CM, Westover MB. A Theoretical Paradigm for Evaluating Risk-Benefit of Status Epilepticus Treatment. J Clin Neurophysiol 2020; 37:385-392. [PMID: 32890059 DOI: 10.1097/wnp.0000000000000753] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Aggressive treatment of status epilepticus with anesthetic drugs can provide rapid seizure control, but it might lead to serious medical complications and worse outcomes. Using a decision analysis approach, this concise review provides a framework for individualized decision making about aggressive and nonaggressive treatment in status epilepticus. The authors propose and review the most relevant parameters guiding the risk-benefit analysis of treatment aggressiveness in status epilepticus and present real-world-based case examples to illustrate how these tools could be used at the bedside and serve to guide future research in refractory status epilepticus treatment.
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Affiliation(s)
- Edilberto Amorim
- Department of Neurology, University of California, San Francisco, San Francisco, California, U.S.A.,Neurology Service, Zuckerberg San Francisco General Hospital, San Francisco, California, U.S.A.,Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts, U.S.A.; and.,Computer Science and Artificial Intelligence Laboratory, Massachusetts Institute of Technology, Cambridge, Massachusetts, U.S.A
| | - Chris M McGraw
- Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts, U.S.A.; and
| | - M Brandon Westover
- Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts, U.S.A.; and
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21
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Ribe AR, Vestergaard CH, Vestergaard M, Pedersen HS, Prior A, Lietzen LW, Brynningsen PK, Fenger-Grøn M. Statins and Risk of Intracerebral Hemorrhage in Individuals With a History of Stroke. Stroke 2020; 51:1111-1119. [DOI: 10.1161/strokeaha.119.027301] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Background and Purpose—
It has been suggested that statins increase the risk of intracerebral hemorrhage in individuals with a history of stroke, which has led to a precautionary principle of avoiding statins in patients with prior intracerebral hemorrhage. However, such prescribing reticence may be unfounded and potentially harmful when considering the well-established benefits of statins. This study is so far the largest to explore the statin-associated risk of intracerebral hemorrhage in individuals with prior stroke.
Methods—
We conducted a population-based, propensity score–matched cohort study using information from Danish national registers. We included all individuals initiating statin treatment after a first-time stroke diagnosis (intracerebral hemorrhage, N=2728 or ischemic stroke, N=52 964) during 2002 to 2016. For up to 10 years of follow-up, they were compared with a 1:5 propensity score–matched group of statin nonusers with the same type of first-time stroke. The difference between groups was measured by adjusted hazard ratios for intracerebral hemorrhage calculated by type of first-time stroke as a function of time since statin initiation.
Results—
Within the study period, 118 new intracerebral hemorrhages occurred among statin users with prior intracerebral hemorrhage and 319 new intracerebral hemorrhages in users with prior ischemic stroke. The risk of intracerebral hemorrhage was similar for statin users and nonusers when evaluated among those with prior intracerebral hemorrhage, and it was reduced by half in those with prior ischemic stroke. These findings were consistent over time since statin initiation and could not be explained by concomitant initiation of other medications, by dilution of treatment effect (due to changes in exposure status over time), or by healthy initiator bias.
Conclusions—
This large study found no evidence that statins increase the risk of intracerebral hemorrhage in individuals with prior stroke; perhaps the risk is even lower in the subgroup of individuals with prior ischemic stroke.
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Affiliation(s)
- Anette Riisgaard Ribe
- From the Research Unit for General Practice, Aarhus, Denmark (A.R.R., C.H.V., M.V., H.S.P., A.P., M.F.-G.)
| | - Claus Høstrup Vestergaard
- From the Research Unit for General Practice, Aarhus, Denmark (A.R.R., C.H.V., M.V., H.S.P., A.P., M.F.-G.)
| | - Mogens Vestergaard
- From the Research Unit for General Practice, Aarhus, Denmark (A.R.R., C.H.V., M.V., H.S.P., A.P., M.F.-G.)
- Department of Public Health, Aarhus University, Denmark (M.V., M.F.-G.)
| | - Henrik Schou Pedersen
- From the Research Unit for General Practice, Aarhus, Denmark (A.R.R., C.H.V., M.V., H.S.P., A.P., M.F.-G.)
| | - Anders Prior
- From the Research Unit for General Practice, Aarhus, Denmark (A.R.R., C.H.V., M.V., H.S.P., A.P., M.F.-G.)
| | | | | | - Morten Fenger-Grøn
- From the Research Unit for General Practice, Aarhus, Denmark (A.R.R., C.H.V., M.V., H.S.P., A.P., M.F.-G.)
- Department of Public Health, Aarhus University, Denmark (M.V., M.F.-G.)
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Association between Serum Lipid and Hematoma Expansion after Spontaneous Intracerebral Hemorrhage in Chinese Patients. J Stroke Cerebrovasc Dis 2020; 29:104793. [PMID: 32224203 DOI: 10.1016/j.jstrokecerebrovasdis.2020.104793] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2020] [Revised: 02/22/2020] [Accepted: 02/26/2020] [Indexed: 01/05/2023] Open
Abstract
OBJECTIVES Although several studies have shown that interventions to lower blood lipid concentration may reduce the risk of coronary arterial disease and ischemic stroke, the correlation between serum lipid levels and hemorrhagic stroke remains controversial. To clarify any possible association between serum lipid and hematoma expansion, we examined various serum lipid indices in patients with and without early hematoma expansion. METHODS Data of 572 intracerebral hemorrhage (ICH) patients from the cerebral small vessel disease cohort of Peking Union Medical College Hospital were retrospectively analyzed. Patients who finished the baseline brain computed tomography (CT) examination within 6 h post-ictus and the follow-up CT within 48 h after initial CT were included in the study. Hematoma expansion was delimited as an enlargement of hemorrhage volume over 33% or 12.5 mL between baseline and subsequent CT. Both uni- and multivariate logistic regression analyses were conducted to explore the association between early hematoma growth and various serum lipid indices, including triglycerides, total cholesterol (TC), high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol (LDL-C), non-HDL-C, ratios of LDL-C/HDL-C and LDL-C/TC, as well as other demographic and clinical features. RESULTS Out of 157 patients included in the analysis, hematoma growth occurred in 45 (28.7%). Only higher baseline systolic blood pressure was found to be correlated with an increased risk of hematoma growth based on both univariate (odds ratio [OR] 1.014, 95% confidence interval [CI]: 1.002-1.026, P = .024) and multivariate logistic regression analyses (OR 1.022, 95%CI: 1.008-1.037, P = .003). No associations were detected between the various serum lipid indices examined and other clinical features with a likelihood of early hematoma growth between groups or within various subgroups defined by different characteristics including age, gender, baseline Glasgow Coma Scale score, systolic blood pressure, intraventricular extension, and hematoma location. CONCLUSIONS No association between various indices of serum lipid and hematoma growth was identified among patients and subgroups with spontaneous ICH in the Chinese population; these findings may help to guide lipid management after ICH. However, further multi-centered, larger scale studies are expected to verify our results.
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Abstract
PURPOSE OF REVIEW Hyperlipidemia is a key therapeutic target for stroke risk modification. The goal of this review is to highlight available treatment options and review their efficacy in the setting of general cardiovascular disease and after most subtypes of ischemic stroke and hemorrhagic stroke. RECENT FINDINGS Statins remain first-line in the management of hyperlipidemia to prevent stroke. In recent trials of patients with pre-existing atherosclerotic vascular disease, new agents, most notably PCSK9 inhibitors and ezetimibe, added additional stroke risk reduction when combined with statins. Risk of stroke can be significantly reduced by understanding that hyperlipidemia is a key therapeutic target, particularly in patients with cardiovascular disease, and by identifying patients who may benefit from aggressive LDL-C reduction with statins ± novel agents.
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Affiliation(s)
- Daniel C Brooks
- Department of Internal Medicine, Division of Neurology, Stamford Health Medical Group and Stamford Hospital, Stamford, CT, USA
| | - Joseph L Schindler
- Department of Neurology, Yale University School of Medicine, P.O. Box 208018, New Haven, CT, 06520-8018, USA.
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Newman CB, Preiss D, Tobert JA, Jacobson TA, Page RL, Goldstein LB, Chin C, Tannock LR, Miller M, Raghuveer G, Duell PB, Brinton EA, Pollak A, Braun LT, Welty FK. Statin Safety and Associated Adverse Events: A Scientific Statement From the American Heart Association. Arterioscler Thromb Vasc Biol 2019; 39:e38-e81. [PMID: 30580575 DOI: 10.1161/atv.0000000000000073] [Citation(s) in RCA: 375] [Impact Index Per Article: 75.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
One in 4 Americans >40 years of age takes a statin to reduce the risk of myocardial infarction, ischemic stroke, and other complications of atherosclerotic disease. The most effective statins produce a mean reduction in low-density lipoprotein cholesterol of 55% to 60% at the maximum dosage, and 6 of the 7 marketed statins are available in generic form, which makes them affordable for most patients. Primarily using data from randomized controlled trials, supplemented with observational data where necessary, this scientific statement provides a comprehensive review of statin safety and tolerability. The review covers the general patient population, as well as demographic subgroups, including the elderly, children, pregnant women, East Asians, and patients with specific conditions such as chronic disease of the kidney and liver, human immunodeficiency viral infection, and organ transplants. The risk of statin-induced serious muscle injury, including rhabdomyolysis, is <0.1%, and the risk of serious hepatotoxicity is ≈0.001%. The risk of statin-induced newly diagnosed diabetes mellitus is ≈0.2% per year of treatment, depending on the underlying risk of diabetes mellitus in the population studied. In patients with cerebrovascular disease, statins possibly increase the risk of hemorrhagic stroke; however, they clearly produce a greater reduction in the risk of atherothrombotic stroke and thus total stroke, as well as other cardiovascular events. There is no convincing evidence for a causal relationship between statins and cancer, cataracts, cognitive dysfunction, peripheral neuropathy, erectile dysfunction, or tendonitis. In US clinical practices, roughly 10% of patients stop taking a statin because of subjective complaints, most commonly muscle symptoms without raised creatine kinase. In contrast, in randomized clinical trials, the difference in the incidence of muscle symptoms without significantly raised creatinine kinase in statin-treated compared with placebo-treated participants is <1%, and it is even smaller (0.1%) for patients who discontinued treatment because of such muscle symptoms. This suggests that muscle symptoms are usually not caused by pharmacological effects of the statin. Restarting statin therapy in these patients can be challenging, but it is important, especially in patients at high risk of cardiovascular events, for whom prevention of these events is a priority. Overall, in patients for whom statin treatment is recommended by current guidelines, the benefits greatly outweigh the risks.
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25
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Kaiser J, Schebesch KM, Brawanski A, Linker RA, Schlachetzki F, Wagner A. Long-Term Follow-Up of Cerebral Amyloid Angiopathy-Associated Intracranial Hemorrhage Reveals a High Prevalence of Atrial Fibrillation. J Stroke Cerebrovasc Dis 2019; 28:104342. [PMID: 31521517 DOI: 10.1016/j.jstrokecerebrovasdis.2019.104342] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2019] [Revised: 06/17/2019] [Accepted: 08/06/2019] [Indexed: 12/13/2022] Open
Abstract
GOAL Cerebral amyloid angiopathy (CAA) is the second-most common cause of nontraumatic intracerebral hemorrhages (ICH), surpassed only by uncontrolled hypertension. We characterized the percentage, risk factors, and comorbidities of patients suffering from CAA-related ICH in relation to long-term outcomes. MATERIAL AND METHODS We performed retrospective analyses and clinical follow-ups of individuals suffering from ICH who were directly admitted to neurosurgery between 2002 and 2016. FINDINGS Seventy-four of 174 (42%) spontaneous nontraumatic lobar ICH cases leastwise satisfied the modified Boston criteria definition for at least "possible CAA." Females suffered a higher risk of CAA-caused ICH (42 of 74, 56.8%, P= .035). Atrial fibrillation as a major comorbidity was observed in 19 patients (25.7%). Recovery (decrease of modified Rankin scale [mRS]) was highest during hospitalization in the acute clinic. One-year mortality was as follows: 14 of 25 patients (56%) with probable CAA without supporting pathology, 6 of 18, and 8 of 31 patients with supporting pathology and possible CAA, respectively. Only 10 of 74 (13.6%) had favorable long-term outcomes (mRS ≤2). Increasing numbers of lobar hemorrhages, low initial Glasgow Coma Scale, and subarachnoid hemorrhage were significantly associated with poor survivability, whereas statins, antithrombotic agents, an intraventricular hemorrhage, and midline shift played seemingly minor roles. CONCLUSIONS Symptomatic ICH is a serious stage in CAA progression with high mortality. The high incidence of concurrent atrial fibrillation in these patients may support data on more widespread vascular pathology in CAA.
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Affiliation(s)
- Johanna Kaiser
- Department of Neurology, University of Regensburg, Regensburg, Germany
| | | | - Alexander Brawanski
- Department of Neurosurgery, University Clinic Regensburg, Regensburg, Germany
| | - Ralf A Linker
- Department of Neurology, University of Regensburg, Regensburg, Germany
| | | | - Andrea Wagner
- Department of Neurology, University of Regensburg, Regensburg, Germany.
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26
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Lin MS, Lin YS, Chang ST, Wang PC, Chien-Chia Wu V, Lin WY, Chung CM. Effect of initiating statin therapy on long-term outcomes of patients with dyslipidemia after intracerebral hemorrhage. Atherosclerosis 2019; 288:137-145. [PMID: 31374467 DOI: 10.1016/j.atherosclerosis.2019.07.009] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2019] [Revised: 06/17/2019] [Accepted: 07/10/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND AIMS Intracerebral hemorrhage (ICH) has a higher mortality than ischemic stroke. Statin is beneficial for stroke, but high potency statin treatment has been associated with the risk of hemorrhagic stroke. The aim of this study was to assess the impact of initiating statin therapy after ICH on cardiovascular outcomes. METHODS Dyslipidemic patients were retrieved from the ICH population from the National Health Insurance Research Database in Taiwan. We retrospectively compared patients prescribed with and without statin treatment after ICH. Outcomes of interest were mortality, myocardial infarction, ischemic stroke, and hemorrhagic stroke during 5 years of follow-up. RESULTS Of 17,980 adult patients with ICH and dyslipidemia, 8927 were eligible for analysis over the study period, including 1613 patients receiving statin therapy and 7314 patients not taking statins. After propensity score matching, the mean age was 61.2 ± 12.2 years in the statin group and 61.6 ± 13.0 years in the non-statin group. Hypertension was dominant, followed by diabetes mellitus, and the mean estimated NIHSS score was 12.9. The patients who received statin therapy were associated with lower risks of all-cause mortality (12.7% vs. 21.3%; hazard ratio [HR], 0.54; 95% confidence interval [CI], 0.45-0.65), cardiovascular death (4.0% vs. 7.1%; HR, 0.54; 95% CI, 0.39-0.75) and ICH (5.4% vs. 8.5%; HR, 0.62; 95% CI, 0.46-0.83) compared to those who did not receive statins. CONCLUSIONS Initiating statin therapy after ICH was associated with a decreased risk of recurrent ICH and mortality for dyslipidemia patients.
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Affiliation(s)
- Ming-Shyan Lin
- Division of Cardiology, Chang Gung Memorial Hospital, Chiayi, Taiwan
| | - Yu-Sheng Lin
- Division of Cardiology, Chang Gung Memorial Hospital, Chiayi, Taiwan; Department of Medicine, College of Medicine, Chang Gung University, Taoyuan County, Taiwan
| | - Shih-Tai Chang
- Division of Cardiology, Chang Gung Memorial Hospital, Chiayi, Taiwan
| | - Po-Chang Wang
- Division of Cardiology, Chang Gung Memorial Hospital, Chiayi, Taiwan
| | | | - Wey-Yil Lin
- Department of Neurology, Taiwan Landseed Hospital, Taoyuan, Taiwan
| | - Chang-Min Chung
- Division of Cardiology, Chang Gung Memorial Hospital, Chiayi, Taiwan; Department of Medicine, College of Medicine, Chang Gung University, Taoyuan County, Taiwan.
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Kulesh AA, Drobakha VE, Shestakov VV. Cerebral small vessel disease: classification, clinical manifestations, diagnosis, and features of treatment. NEUROLOGY, NEUROPSYCHIATRY, PSYCHOSOMATICS 2019. [DOI: 10.14412/2074-2711-2019-3s-4-17] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
The paper considers the relevance of the problem of cerebral small vessel disease (CSVD) that is an important cause of ischemic and hemorrhagic stroke, associated with the development of cognitive impairment and complications of antithrombotic therapy. It presents briefly the current issues of etiology and pathogenesis of the disease. Sporadic non-amyloid microangiopathy, cerebral amyloid angiopathy, and cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL) are discussed in detail from the point of view of their clinical presentation, neuroimaging, and features of therapeutic tactics. An algorithm for diagnosing CSVD in patients admitted to hospital for stroke and a differentiated approach to their treatment are proposed. Consideration of the neuroimaging manifestations of CSVD is noted to be necessary for the safe and more effective treatment of patients with cerebrovascular diseases.
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Affiliation(s)
- A. A. Kulesh
- Acad. E.A. Vagner Perm State Medical University, Ministry of Health of Russia
| | - V. E. Drobakha
- Acad. E.A. Vagner Perm State Medical University, Ministry of Health of Russia
| | - V. V. Shestakov
- Acad. E.A. Vagner Perm State Medical University, Ministry of Health of Russia
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Wang K, Zhou HJ, Wang M. CCM3 and cerebral cavernous malformation disease. Stroke Vasc Neurol 2019; 4:67-70. [PMID: 31338212 PMCID: PMC6613868 DOI: 10.1136/svn-2018-000195] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2018] [Revised: 01/22/2019] [Accepted: 02/12/2019] [Indexed: 01/24/2023] Open
Abstract
Cerebral cavernous malformations (CCMs) are vascular lesions characterised by enlarged and irregular structure of small blood vessels in the brain, which can result in increased risk of stroke, focal neurological defects and seizures. Three different genes, CCM1/Krev/Rap1 Interacting Trapped 1, CCM2/MGC4607 and CCM3/PDCD10, are associated with the CCMs’ progression, and mutations in one of three CCM genes cause CCM disease. These three CCM proteins have similar function in maintaining the normal structure of small blood vessels. However, CCM3 mutation results in a more severe form of the disease which may suggest that CCM3 has unique biological function in the vasculature. The current review focuses on the signalling pathways mediated by CCM3 in regulating endothelial cell junction, proliferation, migration and permeability. These findings may offer potential therapeutic strategies for the treatment of CCMs.
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Affiliation(s)
- Kang Wang
- Interdepartmental Program in Vascular Biology and Therapeutics, Department of Pathology, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Huanjiao Jenny Zhou
- Interdepartmental Program in Vascular Biology and Therapeutics, Department of Pathology, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Min Wang
- Interdepartmental Program in Vascular Biology and Therapeutics, Department of Pathology, Yale University School of Medicine, New Haven, Connecticut, USA
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29
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Ribe AR, Vestergaard CH, Vestergaard M, Fenger-Grøn M, Pedersen HS, Lietzen LW, Brynningsen PK. Statins and Risk of Intracerebral Haemorrhage in a Stroke-Free Population: A Nationwide Danish Propensity Score Matched Cohort Study. EClinicalMedicine 2019; 8:78-84. [PMID: 31193616 PMCID: PMC6537517 DOI: 10.1016/j.eclinm.2019.02.007] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Revised: 02/20/2019] [Accepted: 02/25/2019] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND Statins may increase the risk of intracerebral haemorrhage (ICH) in individuals with previous stroke. It remains unclear whether this applies to individuals with no history of stroke. This study is the first to explore the statin-associated risk of ICH in stroke-free individuals while considering the timing of statin initiation. METHODS We conducted a population-based, propensity score matched cohort study using information from five Danish national registers. We included all stroke-free individuals initiating statins in 2004-2013 and a propensity score matched group of non-users. Adjusted hazard ratios (aHRs) for ICH risk among statin users compared to non-users were calculated as a function of time since statin initiation. FINDINGS 519,894 stroke-free individuals initiating statins and their 1:5 matched stroke-free reference subjects were included and followed for up to ten years. During this period, 1409 ICHs occurred in statin users. Statin users had an overall aHR of 0.85 (95% confidence interval: 0.80-0.90) compared to non-users, but this risk was modified by time since statin initiation. Statin users and non-users had similar ICH risk during the first six months after statin initiation. Hereafter, statin users had a 22-35% lower risk throughout the study period. INTERPRETATION Statin users had lower ICH risk than non-users from six months after statin initiation. This finding could not be explained by healthy initiator bias or differences between users and non-users in terms of sociodemographic characteristics, comorbidity, or parallel treatment regimens. Our study suggests that statin use in stroke-free populations is associated with reduced ICH risk. FUNDING The Novo Nordisk Foundation.
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Affiliation(s)
- Anette Riisgaard Ribe
- Research Unit for General Practice, Aarhus, Denmark
- Corresponding author at: Research Unit for General Practice, Bartholins Allé 2, 8000 Aarhus C, Denmark.
| | | | - Mogens Vestergaard
- Research Unit for General Practice, Aarhus, Denmark
- Department of Public Health, Aarhus University, Aarhus, Denmark
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Ziff OJ, Banerjee G, Ambler G, Werring DJ. Statins and the risk of intracerebral haemorrhage in patients with stroke: systematic review and meta-analysis. J Neurol Neurosurg Psychiatry 2019; 90:75-83. [PMID: 30150320 DOI: 10.1136/jnnp-2018-318483] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2018] [Revised: 06/21/2018] [Accepted: 07/18/2018] [Indexed: 12/22/2022]
Abstract
OBJECTIVE Whether statins increase the risk of intracerebral haemorrhage (ICH) in patients with a previous stroke remains uncertain. This study addresses the evidence of statin therapy on ICH and other clinical outcomes in patients with previous ischaemic stroke (IS) or ICH. METHODS A systematic literature review and meta-analysis was performed in conformity with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to assess observational and randomised studies comparing statin therapy with control (placebo or no treatment) in patients with a previous ICH or IS. The risk ratios (RR) for the primary outcome (ICH) and secondary outcomes (IS, any stroke, mortality and function) were pooled using random effects meta-analysis according to stroke subtype. RESULTS Forty-three studies with a combined total of 317 291 patient-years of follow-up were included. In patients with previous ICH, statins had no significant impact on the pooled RR for recurrent ICH (1.04, 95% CI 0.86 to 1.25; n=23 695); however, statins were associated with significant reductions in mortality (RR 0.49, 95% CI 0.36 to 0.67; n=89 976) and poor functional outcome (RR 0.71, 95% CI 0.67 to 0.75; n=9113). In patients with previous IS, statins were associated with a non-significant increase in ICH (RR 1.36, 95% CI 0.96 to 1.91; n=103 525), but significantly lower risks of recurrent IS (RR 0.74, 95% CI 0.66 to 0.83; n=53 162), any stroke (RR 0.82, 95% CI 0.67 to 0.99; n=55 260), mortality (RR 0.68, 95% CI 0.50 to 0.92; n=74 648) and poor functional outcome (RR 0.83, 95% CI 0.76 to 0.91; n=34 700). CONCLUSIONS Irrespective of stroke subtype, there were non-significant trends towards future ICH with statins. However, this risk was overshadowed by substantial and significant improvements in mortality and functional outcome among statin users. TRIAL REGISTRATION NUMBER CRD42017079863.
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Affiliation(s)
- Oliver Jonathan Ziff
- Stroke Research Centre, Department of Brain Repair and Rehabilitation, UCL, London, UK.,The National Hospital for Neurology and Neurosurgery, Queen Square, London, UK
| | - Gargi Banerjee
- Stroke Research Centre, Department of Brain Repair and Rehabilitation, UCL, London, UK
| | | | - David J Werring
- Stroke Research Centre, Department of Brain Repair and Rehabilitation, UCL, London, UK .,The National Hospital for Neurology and Neurosurgery, Queen Square, London, UK
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Saliba W, Rennert HS, Barnett-Griness O, Gronich N, Molad J, Rennert G, Auriel E. Association of statin use with spontaneous intracerebral hemorrhage: A cohort study. Neurology 2018; 91:e400-e409. [PMID: 29970405 DOI: 10.1212/wnl.0000000000005907] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2017] [Accepted: 04/19/2018] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To examine the association between statin exposure in a dose-dependent manner and intracerebral hemorrhage (ICH) in a large nationwide study. METHODS The computerized database of the largest health care provider in Israel was used to identify diagnosed ICH among new users of statins, who started statin treatment between 2005 and 2010. We assessed a dose-response relationship between ICH and statins, using the average atorvastatin equivalent daily dose (AAEDD). Multivariable Cox proportional hazard regression models, adjusted for baseline disease risk score, were applied to estimate the hazard ratio of ICH. RESULTS Of the 345,531 included patients, 1,304 were diagnosed with ICH during a median follow-up of 9.5 years (interquartile range 7.6-11.0). Overall, 75.3% of patients had AAEDD <10 mg/d, 19.0% had AAEDD 0-19.9 mg/d, and 5.7% had AAEDD ≥20 mg/d. The corresponding proportions were 81.0%, 15.0%, 4.0% among ICH cases, and 75.3%, 19.0%, 5.7% among non-ICH cases. Compared to those with AAEDD <10 mg/d (reference), the adjusted hazard ratio (HR) for ICH was 0.68 (95% confidence interval [CI] 0.58-0.79) in those with AAEDD 10-19.9 mg/d, and 0.62 (0.47-0.81) in those with AAEDD ≥20 mg/d. Compared to the lowest baseline total cholesterol quartile, the adjusted HR for ICH was 0.71 (95% CI 0.62-0.82), 0.55 (0.47-0.64), and 0.57 (0.49-0.67) in those in the second, third, and highest quartiles, respectively. The results were similar and robust among highly persistent statin users and after controlling for the change in cholesterol level. CONCLUSIONS This study confirms that the risk of ICH decreases with increasing cholesterol levels, but suggests that statin use might be associated with decreased risk of ICH.
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Affiliation(s)
- Walid Saliba
- From the Department of Community Medicine and Epidemiology (W.S., H.S.R., O.B.-G., N.G., G.R.), Statistical Unit (O.B.-G.), Pharmacoepidemiology and Pharmacogenetics Unit (N.G.), and Department of Neurology (E.A.), Lady Davis Carmel Medical Center; Ruth and Bruce Rappaport Faculty of Medicine (W.S., G.R., E.A.), Technion-Israel Institute of Technology, Haifa; and Department of Neurology (J.M.), Tel-Aviv Sourasky Medical Center, Israel
| | - Hedy S Rennert
- From the Department of Community Medicine and Epidemiology (W.S., H.S.R., O.B.-G., N.G., G.R.), Statistical Unit (O.B.-G.), Pharmacoepidemiology and Pharmacogenetics Unit (N.G.), and Department of Neurology (E.A.), Lady Davis Carmel Medical Center; Ruth and Bruce Rappaport Faculty of Medicine (W.S., G.R., E.A.), Technion-Israel Institute of Technology, Haifa; and Department of Neurology (J.M.), Tel-Aviv Sourasky Medical Center, Israel
| | - Ofra Barnett-Griness
- From the Department of Community Medicine and Epidemiology (W.S., H.S.R., O.B.-G., N.G., G.R.), Statistical Unit (O.B.-G.), Pharmacoepidemiology and Pharmacogenetics Unit (N.G.), and Department of Neurology (E.A.), Lady Davis Carmel Medical Center; Ruth and Bruce Rappaport Faculty of Medicine (W.S., G.R., E.A.), Technion-Israel Institute of Technology, Haifa; and Department of Neurology (J.M.), Tel-Aviv Sourasky Medical Center, Israel
| | - Naomi Gronich
- From the Department of Community Medicine and Epidemiology (W.S., H.S.R., O.B.-G., N.G., G.R.), Statistical Unit (O.B.-G.), Pharmacoepidemiology and Pharmacogenetics Unit (N.G.), and Department of Neurology (E.A.), Lady Davis Carmel Medical Center; Ruth and Bruce Rappaport Faculty of Medicine (W.S., G.R., E.A.), Technion-Israel Institute of Technology, Haifa; and Department of Neurology (J.M.), Tel-Aviv Sourasky Medical Center, Israel
| | - Jeremy Molad
- From the Department of Community Medicine and Epidemiology (W.S., H.S.R., O.B.-G., N.G., G.R.), Statistical Unit (O.B.-G.), Pharmacoepidemiology and Pharmacogenetics Unit (N.G.), and Department of Neurology (E.A.), Lady Davis Carmel Medical Center; Ruth and Bruce Rappaport Faculty of Medicine (W.S., G.R., E.A.), Technion-Israel Institute of Technology, Haifa; and Department of Neurology (J.M.), Tel-Aviv Sourasky Medical Center, Israel
| | - Gad Rennert
- From the Department of Community Medicine and Epidemiology (W.S., H.S.R., O.B.-G., N.G., G.R.), Statistical Unit (O.B.-G.), Pharmacoepidemiology and Pharmacogenetics Unit (N.G.), and Department of Neurology (E.A.), Lady Davis Carmel Medical Center; Ruth and Bruce Rappaport Faculty of Medicine (W.S., G.R., E.A.), Technion-Israel Institute of Technology, Haifa; and Department of Neurology (J.M.), Tel-Aviv Sourasky Medical Center, Israel
| | - Eitan Auriel
- From the Department of Community Medicine and Epidemiology (W.S., H.S.R., O.B.-G., N.G., G.R.), Statistical Unit (O.B.-G.), Pharmacoepidemiology and Pharmacogenetics Unit (N.G.), and Department of Neurology (E.A.), Lady Davis Carmel Medical Center; Ruth and Bruce Rappaport Faculty of Medicine (W.S., G.R., E.A.), Technion-Israel Institute of Technology, Haifa; and Department of Neurology (J.M.), Tel-Aviv Sourasky Medical Center, Israel.
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Weber SA, Patel RK, Lutsep HL. Cerebral amyloid angiopathy: diagnosis and potential therapies. Expert Rev Neurother 2018; 18:503-513. [DOI: 10.1080/14737175.2018.1480938] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Affiliation(s)
- Stewart A. Weber
- Department of Neurology, Oregon Health & Science University, Portland, OR, USA
| | - Ranish K. Patel
- Department of Neurology, Oregon Health & Science University, Portland, OR, USA
| | - Helmi L. Lutsep
- Department of Neurology, Oregon Health & Science University, Portland, OR, USA
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Burns JD, Fisher JL, Cervantes-Arslanian AM. Recent Advances in the Acute Management of Intracerebral Hemorrhage. Neurosurg Clin N Am 2018; 29:263-272. [DOI: 10.1016/j.nec.2017.11.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Frol S, Pretnar Oblak J. Early Outcome after Intracranial Hemorrhage Related to Non-Vitamin K Oral Anticoagulants. INTERVENTIONAL NEUROLOGY 2018; 7:19-25. [PMID: 29628941 PMCID: PMC5881142 DOI: 10.1159/000480524] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Intracranial hemorrhage (ICH) is a serious, life-threatening, but fortunately rare complication of non-vitamin K oral anticoagulant (NOAC) therapy. There are limited data on NOAC-related ICH prognosis. METHODS All consecutive patients admitted to a single center due to acute NOAC-related ICH from September 2012 until the beginning of 2017 were included. Risk factors, type of NOAC, and location of ICH were evaluated. Risk for ischemic and bleeding events and clinical status upon admission and at discharge were evaluated using standard scales. RESULTS Thirty-four patients aged 77.8 ± 8.3 years with NOAC-related ICH were included. The main predisposing risk factors were age and arterial hypertension. The median CHA2DS2-VASc score was 3.4 and the median HAS-BLED score was 1.8. Eighteen patients were treated with rivaroxaban, 11 with dabigatran, and 5 with apixaban. Ten patients (29%) had a favorable outcome with a modified Rankin Scale score ≤2 and 13 patients (38%) died. The location of the ICH was mainly intraparenchymal and subdural. CONCLUSIONS Our retrospective single-center study shows that the mortality rate with NOAC-related ICH is <40%, which makes it comparable to that with vitamin K antagonist-related ICH.
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Affiliation(s)
| | - Janja Pretnar Oblak
- Department of Vascular Neurology and Intensive Neurological Therapy, University Medical Center Ljubljana, Ljubljana, Slovenia
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Zhang CY, Huang SR, Wang SY, Shen L, Deng BQ. Clinical Study of Intracranial and Extracranial Atherosclerotic Stenosis in Spontaneous Intracerebral Hemorrhage Patients. J Stroke Cerebrovasc Dis 2018; 27:286-290. [DOI: 10.1016/j.jstrokecerebrovasdis.2017.08.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2017] [Revised: 07/23/2017] [Accepted: 08/10/2017] [Indexed: 10/18/2022] Open
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Martí-Fàbregas J, Medrano-Martorell S, Merino E, Prats-Sánchez L, Marín R, Delgado-Mederos R, Camps-Renom P, Martínez-Domeño A, Gómez-Choco M, Lara L, Casado-Naranjo I, Cánovas D, Torres MJ, Freijo M, Calleja A, Bravo Y, Cocho D, Rodríguez-Campello A, Zandio B, Fuentes B, de Felipe A, Llull L, Maestre J, Hernández M, Garcés M, De Arce-Borda AM, Palomeras E, Rodríguez-Yáñez M, Díaz-Maroto I, Serrano M, Fernández-Domínguez J, Sanahuja J, Purroy F, Zedde M, Delgado-Mengual J, Gich I. Statins do not increase Markers of Cerebral Angiopathies in patients with Cardioembolic Stroke. Sci Rep 2018; 8:1492. [PMID: 29367736 PMCID: PMC5784141 DOI: 10.1038/s41598-018-20055-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2017] [Accepted: 01/11/2018] [Indexed: 12/15/2022] Open
Abstract
We investigated whether pre-treatment with statins is associated with surrogate markers of amyloid and hypertensive angiopathies in patients who need to start long-term oral anticoagulation therapy. A prospective multicenter study of patients naive for oral anticoagulants, who had an acute cardioembolic stroke. MRI was performed at admission to evaluate microbleeds, leukoaraiosis and superficial siderosis. We collected data on the specific statin compound, the dose and the statin intensity. We performed bivariate analyses and a logistic regression to investigate variables associated with microbleeds. We studied 470 patients (age 77.5 ± 6.4 years, 43.7% were men), and 193 (41.1%) of them received prior treatment with a statin. Microbleeds were detected in 140 (29.8%), leukoaraiosis in 388 (82.5%) and superficial siderosis in 20 (4.3%) patients. The presence of microbleeds, leukoaraiosis or superficial siderosis was not related to pre-treatment with statins. Microbleeds were more frequent in patients with prior intracerebral hemorrhage (OR 9.7, 95% CI 1.06–90.9) and in those pre-treated antiplatelets (OR 1.66, 95% CI 1.09–2.53). Prior treatment with statins was not associated with markers of bleeding-prone cerebral angiopathies in patients with cardioembolic stroke. Therefore, previous statin treatment should not influence the decision to initiate or withhold oral anticoagulation if these neuroimaging markers are detected.
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Affiliation(s)
- Joan Martí-Fàbregas
- Department of Neurology, Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute, Barcelona, Spain.
| | | | - Elisa Merino
- Hospital Germans Trias i Pujol, Unitat RM IDI, Badalona, Spain
| | - Luis Prats-Sánchez
- Department of Neurology, Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute, Barcelona, Spain
| | - Rebeca Marín
- Department of Neurology, Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute, Barcelona, Spain
| | - Raquel Delgado-Mederos
- Department of Neurology, Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute, Barcelona, Spain
| | - Pol Camps-Renom
- Department of Neurology, Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute, Barcelona, Spain
| | - Alejandro Martínez-Domeño
- Department of Neurology, Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute, Barcelona, Spain
| | - Manuel Gómez-Choco
- Department of Neurology, Hospital de Sant Joan Despí Moises Broggi, Sant Joan Despí, Spain
| | - Lidia Lara
- Department of Neurology, Hospital de León, León, Spain
| | | | - David Cánovas
- Department of Neurology, Hospital Parc Taulí, Sabadell, Spain
| | - Maria José Torres
- Department of Neurology, Hospital Son Espases, Palma de Mallorca, Spain
| | - Marimar Freijo
- Department of Neurology, Hospital de Basurto, Bilbao, Spain
| | - Ana Calleja
- Department of Neurology, Hospital de Valladolid, Valladolid, Spain
| | - Yolanda Bravo
- Department of Neurology, Hospital de Burgos, Burgos, Spain
| | - Dolores Cocho
- Department of Neurology, Hospital de Granollers, Granollers, Spain
| | | | - Beatriz Zandio
- Department of Neurology, Hospital de Navarra, Pamplona, Spain
| | - Blanca Fuentes
- Department of Neurology, Hospital Universitario La Paz, Instituto de Investigación IdiPaz, Madrid, Spain
| | | | - Laura Llull
- Department of Neurology, Hospital Clínic, Barcelona, Spain
| | - José Maestre
- Department of Neurology, Hospital Virgen de las Nieves, Granada, Spain
| | - María Hernández
- Department of Neurology, Hospital Germans Trias i Pujol, Badalona, Spain
| | - Moisès Garcés
- Department of Neurology, Hospital Verge de la Cinta, Tortosa, Spain
| | | | | | | | | | - Marta Serrano
- Department of Neurology, Hospital de La Rioja, Logroño, Spain
| | | | - Jordi Sanahuja
- Department of Neurology, Hospital Arnau de Vilanova, Lleida, Spain
| | - Francisco Purroy
- Department of Neurology, Hospital Arnau de Vilanova, Lleida, Spain
| | - Marialuisa Zedde
- Department of Neurology, Arcispedale Santa Maria Nuova IRCCS, Reggio Emilia, Italy
| | - Jordi Delgado-Mengual
- Port d'Informació Científica, Institut de Física d'Altes Energies, Campus UAB, Cerdanyola del Vallès, Spain
| | - Ignasi Gich
- Department of Epidemiology, Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute, Barcelona, Spain
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Endres M, Nolte CH, Scheitz JF. Statin Treatment in Patients With Intracerebral Hemorrhage. Stroke 2017; 49:240-246. [PMID: 29191849 DOI: 10.1161/strokeaha.117.019322] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2017] [Revised: 10/23/2017] [Accepted: 10/27/2017] [Indexed: 11/16/2022]
Affiliation(s)
- Matthias Endres
- From the Klinik für Neurologie mit Experimenteller Neurologie and Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Germany (M.E., C.H.N., J.F.S.); DZHK (German Center for Cardiovascular Research), Berlin Site, Germany (M.E., C.H.N., J.F.S.); DZNE (German Center for Neurodegenerative Disease), Berlin Site, Germany (M.E.); and Berlin Institute of Health, Germany (M.E., C.H.N.).
| | - Christian H Nolte
- From the Klinik für Neurologie mit Experimenteller Neurologie and Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Germany (M.E., C.H.N., J.F.S.); DZHK (German Center for Cardiovascular Research), Berlin Site, Germany (M.E., C.H.N., J.F.S.); DZNE (German Center for Neurodegenerative Disease), Berlin Site, Germany (M.E.); and Berlin Institute of Health, Germany (M.E., C.H.N.)
| | - Jan F Scheitz
- From the Klinik für Neurologie mit Experimenteller Neurologie and Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Germany (M.E., C.H.N., J.F.S.); DZHK (German Center for Cardiovascular Research), Berlin Site, Germany (M.E., C.H.N., J.F.S.); DZNE (German Center for Neurodegenerative Disease), Berlin Site, Germany (M.E.); and Berlin Institute of Health, Germany (M.E., C.H.N.)
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Banerjee G, Carare R, Cordonnier C, Greenberg SM, Schneider JA, Smith EE, Buchem MV, Grond JVD, Verbeek MM, Werring DJ. The increasing impact of cerebral amyloid angiopathy: essential new insights for clinical practice. J Neurol Neurosurg Psychiatry 2017; 88:982-994. [PMID: 28844070 PMCID: PMC5740546 DOI: 10.1136/jnnp-2016-314697] [Citation(s) in RCA: 145] [Impact Index Per Article: 20.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2017] [Revised: 04/26/2017] [Accepted: 05/18/2017] [Indexed: 12/29/2022]
Abstract
Cerebral amyloid angiopathy (CAA) has never been more relevant. The last 5 years have seen a rapid increase in publications and research in the field, with the development of new biomarkers for the disease, thanks to advances in MRI, amyloid positron emission tomography and cerebrospinal fluid biomarker analysis. The inadvertent development of CAA-like pathology in patients treated with amyloid-beta immunotherapy for Alzheimer's disease has highlighted the importance of establishing how and why CAA develops; without this information, the use of these treatments may be unnecessarily restricted. Our understanding of the clinical and radiological spectrum of CAA has continued to evolve, and there are new insights into the independent impact that CAA has on cognition in the context of ageing and intracerebral haemorrhage, as well as in Alzheimer's and other dementias. While the association between CAA and lobar intracerebral haemorrhage (with its high recurrence risk) is now well recognised, a number of management dilemmas remain, particularly when considering the use of antithrombotics, anticoagulants and statins. The Boston criteria for CAA, in use in one form or another for the last 20 years, are now being reviewed to reflect these new wide-ranging clinical and radiological findings. This review aims to provide a 5-year update on these recent advances, as well as a look towards future directions for CAA research and clinical practice.
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Affiliation(s)
- Gargi Banerjee
- Stroke Research Centre, Department of Brain Repair and Rehabilitation, UCL Institute of Neurology and the National Hospital for Neurology and Neurosurgery, London, UK
| | - Roxana Carare
- Division of Clinical Neurosciences, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Charlotte Cordonnier
- Department of Neurology, Université de Lille, Inserm U1171, Degenerative and Vascular Cognitive Disorders, Centre Hospitalier Régional Universitaire de Lille, Lille, France
| | - Steven M Greenberg
- J P Kistler Stroke Research Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Julie A Schneider
- Departments of Pathology and Neurological Sciences, Rush Alzheimer's Disease Center, Rush University Medical Center, Chicago, IL, USA
| | - Eric E Smith
- Hotchkiss Brain Institute, Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
| | - Mark van Buchem
- Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Jeroen van der Grond
- Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Marcel M Verbeek
- Radboud University Medical Center, Donders Institute for Brain, Cognition and Behaviour, Nijmegen, The Netherlands.,Departments of Neurology and Laboratory Medicine, Radboud Alzheimer Center, Nijmegen, The Netherlands
| | - David J Werring
- Stroke Research Centre, Department of Brain Repair and Rehabilitation, UCL Institute of Neurology and the National Hospital for Neurology and Neurosurgery, London, UK
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Abstract
Primary intracerebral hemorrhage (ICH) is a common, devastating disease that lacks an effective specific treatment. Mortality is high, functional outcomes are poor, and these have not substantially changed for decades. There is, therefore, considerable opportunity for advancement in the management of ICH. In recent years, a significant amount of research has begun to address this gap. This article is aimed at updating neurologists on the most clinically relevant contemporary research.
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Bohula EA, Wiviott SD, Giugliano RP, Blazing MA, Park JG, Murphy SA, White JA, Mach F, Van de Werf F, Dalby AJ, White HD, Tershakovec AM, Cannon CP, Braunwald E. Prevention of Stroke with the Addition of Ezetimibe to Statin Therapy in Patients With Acute Coronary Syndrome in IMPROVE-IT (Improved Reduction of Outcomes: Vytorin Efficacy International Trial). Circulation 2017; 136:2440-2450. [PMID: 28972004 DOI: 10.1161/circulationaha.117.029095] [Citation(s) in RCA: 86] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2017] [Accepted: 09/12/2017] [Indexed: 11/16/2022]
Abstract
BACKGROUND Patients who experience an acute coronary syndrome are at heightened risk of recurrent ischemic events, including stroke. Ezetimibe improved cardiovascular outcomes when added to statin therapy in patients stabilized after acute coronary syndrome. We investigated the efficacy of the addition of ezetimibe to simvastatin for the prevention of stroke and other adverse cardiovascular events in IMPROVE-IT (Improved Reduction of Outcomes: Vytorin Efficacy International Trial), with a focus on patients with a stroke before randomization. METHODS Patients who experienced acute coronary syndrome were randomized to a placebo/simvastatin or ezetimibe/simvastatin regimen and followed for a median of 6 years. Treatment efficacy was assessed for the entire population and by subgroups for the first and total (first and subsequent) events for the end points of stroke of any etiology, stroke subtypes, and the primary trial end point at 7 years. RESULTS Of 18 144 patients, 641 (3.5%) experienced at least 1 stroke; most were ischemic (527, 82%). Independent predictors of stroke included prior stroke, older age, atrial fibrillation, congestive heart failure, diabetes mellitus, myocardial infarction, and renal dysfunction. There was a nonsignificant reduction in the first event of stroke of any etiology (4.2% versus 4.8%; hazard ratio [HR], 0.86; 95% confidence interval [CI], 0.73-1.00; P=0.052) with ezetimibe/simvastatin versus placebo/simvastatin, driven by a significant 21% reduction in ischemic stroke (3.4% versus 4.1%; HR, 0.79; 95% CI, 0.67-0.94; P=0.008) and a nonsignificant increase in hemorrhagic stroke (0.8% versus 0.6%; HR, 1.38; 95% CI, 0.93-2.04; P=0.11). Evaluating total events, including the first and all recurrent strokes, ezetimibe/simvastatin reduced stroke of any etiology (HR, 0.83; 95% CI, 0.70-0.98; P=0.029) and ischemic stroke (HR, 0.76; 95% CI, 0.63-0.91; P=0.003). Patients who had experienced a stroke prior to randomization were at a higher risk of recurrence and demonstrated an absolute risk reduction of 8.6% for stroke of any etiology (10.2% versus 18.8%; number needed to treat=12; HR, 0.60; 95% CI, 0.38-0.95; P=0.030) and 7.6% for ischemic stroke (8.7% versus 16.3%; number needed to treat=13; HR, 0.52; 95% CI, 0.31-0.86; P=0.011) with ezetimibe added to simvastatin therapy. CONCLUSIONS The addition of ezetimibe to simvastatin in patients stabilized after acute coronary syndrome reduces the frequency of ischemic stroke, with a particularly large effect seen in patients with a prior stroke. CLINICAL TRIAL REGISTRATION URL: https://www.clinicaltrials.gov. Unique identifier: NCT00202878.
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Affiliation(s)
- Erin A Bohula
- TIMI Study Group, Department of Medicine, Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (E.A.B., S.D.W., R.P.G., J.-G.P., S.A.M., C.P.C., E.B.)
| | - Stephen D Wiviott
- TIMI Study Group, Department of Medicine, Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (E.A.B., S.D.W., R.P.G., J.-G.P., S.A.M., C.P.C., E.B.)
| | - Robert P Giugliano
- TIMI Study Group, Department of Medicine, Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (E.A.B., S.D.W., R.P.G., J.-G.P., S.A.M., C.P.C., E.B.)
| | | | - Jeong-Gun Park
- TIMI Study Group, Department of Medicine, Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (E.A.B., S.D.W., R.P.G., J.-G.P., S.A.M., C.P.C., E.B.)
| | - Sabina A Murphy
- TIMI Study Group, Department of Medicine, Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (E.A.B., S.D.W., R.P.G., J.-G.P., S.A.M., C.P.C., E.B.)
| | | | - Francois Mach
- Cardiology Dvision, Geneva University Hospital, Switzerland (F.M.)
| | - Frans Van de Werf
- Departments of Cardiovascular Medicine and Cardiovascular Sciences, University of Leuven, Belgium (F.V.d.F.)
| | | | - Harvey D White
- Green Lane Cardiovascular Service, Auckland City Hospital, Auckland, New Zealand (H.D.W.)
| | | | - Christopher P Cannon
- TIMI Study Group, Department of Medicine, Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (E.A.B., S.D.W., R.P.G., J.-G.P., S.A.M., C.P.C., E.B.)
| | - Eugene Braunwald
- TIMI Study Group, Department of Medicine, Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (E.A.B., S.D.W., R.P.G., J.-G.P., S.A.M., C.P.C., E.B.)
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Discovery of a ROCK inhibitor, FPND, which prevents cerebral hemorrhage through maintaining vascular integrity by interference with VE-cadherin. Cell Death Discov 2017; 3:17051. [PMID: 28845297 PMCID: PMC5563523 DOI: 10.1038/cddiscovery.2017.51] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2017] [Revised: 06/15/2017] [Accepted: 06/16/2017] [Indexed: 02/07/2023] Open
Abstract
Hemorrhagic stroke occurs when a weakened vessel ruptures and bleeds into the surrounding brain, leading to high rates of death and disability worldwide. A series of complex pathophysiological cascades contribute to the risk of hemorrhagic stroke, and no therapies have proven effective to prevent hemorrhagic stroke. Stabilization of vascular integrity has been considered as a potential therapeutic target for hemorrhagic stroke. ROCKs, which belong to the serine/threonine protein kinase family and participate in the organization of actin cytoskeleton, have become attractive targets for the treatment of strokes. In this study, in vitro enzyme-based assays revealed that a new compound (FPND) with a novel scaffold identified by docking-based virtual screening could inhibit ROCK1 specifically at low micromolar concentration. Molecular modeling showed that FPND preferentially interacted with ROCK1, and the difference between the binding affinity of FPND toward ROCK1 and ROCK2 primarily resulted from non-polar contributions. Furthermore, FPND significantly prevented statin-induced cerebral hemorrhage in a zebrafish model. In addition, in vitro studies using the xCELLigence RTCA system, immunofluorescence and western blotting revealed that FPND prevented statin-induced cerebral hemorrhage by enhancing endothelial cell–cell junctions through inhibiting the ROCK-mediated VE-cadherin signaling pathway. As indicated by the extremely low toxicity of FPND against mice, it is safe and can potentially prevent vascular integrity loss-related diseases, such as hemorrhagic stroke.
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Siddiqui FM, Langefeld CD, Moomaw CJ, Comeau ME, Sekar P, Rosand J, Kidwell CS, Martini S, Osborne JL, Stutzman S, Hall C, Woo D. Use of Statins and Outcomes in Intracerebral Hemorrhage Patients. Stroke 2017; 48:2098-2104. [PMID: 28663510 PMCID: PMC5659292 DOI: 10.1161/strokeaha.117.017358] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2017] [Revised: 05/05/2017] [Accepted: 06/02/2017] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND PURPOSE Statin use may be associated with improved outcome in intracerebral hemorrhage patients. However, the topic remains controversial. Our analysis examined the effect of prior, continued, or new statin use on intracerebral hemorrhage outcomes using the ERICH (Ethnic/Racial Variations of Intracerebral Hemorrhage) data set. METHODS We analyzed ERICH (a multicenter study designed to examine ethnic variations in the risk, presentation, and outcomes of intracerebral hemorrhage) to explore the association of statin use and hematoma growth, mortality, and 3-month disability. We computed subset analyses with respect to 3 statin categories (prior, continued, or new use). RESULTS Two thousand four hundred and fifty-seven enrolled cases (mean age, 62 years; 42% females) had complete data on mortality and 3-month disability (modified Rankin Scale). Among those, 1093 cases were on statins (prior, n=268; continued, n=423; new, n=402). Overall, statin use was associated with reduced mortality and disability without any effect on hematoma growth. This association was primarily driven by continued/new statin use. A multivariate analysis adjusted for age and major predictors for poor outcome showed that continued/new statins users had good outcomes compared with prior users. However, statins may have been continued/started more frequently among less severe patients. When a propensity score was developed based on factors that could influence a physician's decision in prescribing statins and used as a covariate, continued/new statin use was no longer a significant predictor of good outcome. CONCLUSIONS Although statin use, especially continued/new use, was associated with improved intracerebral hemorrhage outcomes, this effect may merely reflect the physician's view of a patient's prognosis rather than a predictor of survival.
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Affiliation(s)
- Fazeel M Siddiqui
- From the Department of Neurology, Southern Illinois University School of Medicine, Springfield (F.M.S.); Center for Public Health Genomics and Department of Biostatistical Sciences, Wake Forest University, Winston-Salem, NC (C.D.L., M.E.C.); Department of Neurology and Rehabilitation Medicine, University of Cincinnati, OH (C.J.M., P.S., J.L.O., D.W.); Center for Genomic Medicine, Massachusetts General Hospital, Boston (J.R.); Departments of Neurology and Medical Imaging, University of Arizona, Tucson (C.S.K.); Michael E. DeBakey VA Medical Center and Department of Neurology, Baylor College of Medicine, Houston, TX (S.M.); and Department of Neurology and Neurotherapeutics, University of Texas Southwestern Medical Center, Dallas (S.S., C.H.).
| | - Carl D Langefeld
- From the Department of Neurology, Southern Illinois University School of Medicine, Springfield (F.M.S.); Center for Public Health Genomics and Department of Biostatistical Sciences, Wake Forest University, Winston-Salem, NC (C.D.L., M.E.C.); Department of Neurology and Rehabilitation Medicine, University of Cincinnati, OH (C.J.M., P.S., J.L.O., D.W.); Center for Genomic Medicine, Massachusetts General Hospital, Boston (J.R.); Departments of Neurology and Medical Imaging, University of Arizona, Tucson (C.S.K.); Michael E. DeBakey VA Medical Center and Department of Neurology, Baylor College of Medicine, Houston, TX (S.M.); and Department of Neurology and Neurotherapeutics, University of Texas Southwestern Medical Center, Dallas (S.S., C.H.)
| | - Charles J Moomaw
- From the Department of Neurology, Southern Illinois University School of Medicine, Springfield (F.M.S.); Center for Public Health Genomics and Department of Biostatistical Sciences, Wake Forest University, Winston-Salem, NC (C.D.L., M.E.C.); Department of Neurology and Rehabilitation Medicine, University of Cincinnati, OH (C.J.M., P.S., J.L.O., D.W.); Center for Genomic Medicine, Massachusetts General Hospital, Boston (J.R.); Departments of Neurology and Medical Imaging, University of Arizona, Tucson (C.S.K.); Michael E. DeBakey VA Medical Center and Department of Neurology, Baylor College of Medicine, Houston, TX (S.M.); and Department of Neurology and Neurotherapeutics, University of Texas Southwestern Medical Center, Dallas (S.S., C.H.)
| | - Mary E Comeau
- From the Department of Neurology, Southern Illinois University School of Medicine, Springfield (F.M.S.); Center for Public Health Genomics and Department of Biostatistical Sciences, Wake Forest University, Winston-Salem, NC (C.D.L., M.E.C.); Department of Neurology and Rehabilitation Medicine, University of Cincinnati, OH (C.J.M., P.S., J.L.O., D.W.); Center for Genomic Medicine, Massachusetts General Hospital, Boston (J.R.); Departments of Neurology and Medical Imaging, University of Arizona, Tucson (C.S.K.); Michael E. DeBakey VA Medical Center and Department of Neurology, Baylor College of Medicine, Houston, TX (S.M.); and Department of Neurology and Neurotherapeutics, University of Texas Southwestern Medical Center, Dallas (S.S., C.H.)
| | - Padmini Sekar
- From the Department of Neurology, Southern Illinois University School of Medicine, Springfield (F.M.S.); Center for Public Health Genomics and Department of Biostatistical Sciences, Wake Forest University, Winston-Salem, NC (C.D.L., M.E.C.); Department of Neurology and Rehabilitation Medicine, University of Cincinnati, OH (C.J.M., P.S., J.L.O., D.W.); Center for Genomic Medicine, Massachusetts General Hospital, Boston (J.R.); Departments of Neurology and Medical Imaging, University of Arizona, Tucson (C.S.K.); Michael E. DeBakey VA Medical Center and Department of Neurology, Baylor College of Medicine, Houston, TX (S.M.); and Department of Neurology and Neurotherapeutics, University of Texas Southwestern Medical Center, Dallas (S.S., C.H.)
| | - Jonathan Rosand
- From the Department of Neurology, Southern Illinois University School of Medicine, Springfield (F.M.S.); Center for Public Health Genomics and Department of Biostatistical Sciences, Wake Forest University, Winston-Salem, NC (C.D.L., M.E.C.); Department of Neurology and Rehabilitation Medicine, University of Cincinnati, OH (C.J.M., P.S., J.L.O., D.W.); Center for Genomic Medicine, Massachusetts General Hospital, Boston (J.R.); Departments of Neurology and Medical Imaging, University of Arizona, Tucson (C.S.K.); Michael E. DeBakey VA Medical Center and Department of Neurology, Baylor College of Medicine, Houston, TX (S.M.); and Department of Neurology and Neurotherapeutics, University of Texas Southwestern Medical Center, Dallas (S.S., C.H.)
| | - Chelsea S Kidwell
- From the Department of Neurology, Southern Illinois University School of Medicine, Springfield (F.M.S.); Center for Public Health Genomics and Department of Biostatistical Sciences, Wake Forest University, Winston-Salem, NC (C.D.L., M.E.C.); Department of Neurology and Rehabilitation Medicine, University of Cincinnati, OH (C.J.M., P.S., J.L.O., D.W.); Center for Genomic Medicine, Massachusetts General Hospital, Boston (J.R.); Departments of Neurology and Medical Imaging, University of Arizona, Tucson (C.S.K.); Michael E. DeBakey VA Medical Center and Department of Neurology, Baylor College of Medicine, Houston, TX (S.M.); and Department of Neurology and Neurotherapeutics, University of Texas Southwestern Medical Center, Dallas (S.S., C.H.)
| | - Sharyl Martini
- From the Department of Neurology, Southern Illinois University School of Medicine, Springfield (F.M.S.); Center for Public Health Genomics and Department of Biostatistical Sciences, Wake Forest University, Winston-Salem, NC (C.D.L., M.E.C.); Department of Neurology and Rehabilitation Medicine, University of Cincinnati, OH (C.J.M., P.S., J.L.O., D.W.); Center for Genomic Medicine, Massachusetts General Hospital, Boston (J.R.); Departments of Neurology and Medical Imaging, University of Arizona, Tucson (C.S.K.); Michael E. DeBakey VA Medical Center and Department of Neurology, Baylor College of Medicine, Houston, TX (S.M.); and Department of Neurology and Neurotherapeutics, University of Texas Southwestern Medical Center, Dallas (S.S., C.H.)
| | - Jennifer L Osborne
- From the Department of Neurology, Southern Illinois University School of Medicine, Springfield (F.M.S.); Center for Public Health Genomics and Department of Biostatistical Sciences, Wake Forest University, Winston-Salem, NC (C.D.L., M.E.C.); Department of Neurology and Rehabilitation Medicine, University of Cincinnati, OH (C.J.M., P.S., J.L.O., D.W.); Center for Genomic Medicine, Massachusetts General Hospital, Boston (J.R.); Departments of Neurology and Medical Imaging, University of Arizona, Tucson (C.S.K.); Michael E. DeBakey VA Medical Center and Department of Neurology, Baylor College of Medicine, Houston, TX (S.M.); and Department of Neurology and Neurotherapeutics, University of Texas Southwestern Medical Center, Dallas (S.S., C.H.)
| | - Sonja Stutzman
- From the Department of Neurology, Southern Illinois University School of Medicine, Springfield (F.M.S.); Center for Public Health Genomics and Department of Biostatistical Sciences, Wake Forest University, Winston-Salem, NC (C.D.L., M.E.C.); Department of Neurology and Rehabilitation Medicine, University of Cincinnati, OH (C.J.M., P.S., J.L.O., D.W.); Center for Genomic Medicine, Massachusetts General Hospital, Boston (J.R.); Departments of Neurology and Medical Imaging, University of Arizona, Tucson (C.S.K.); Michael E. DeBakey VA Medical Center and Department of Neurology, Baylor College of Medicine, Houston, TX (S.M.); and Department of Neurology and Neurotherapeutics, University of Texas Southwestern Medical Center, Dallas (S.S., C.H.)
| | - Christiana Hall
- From the Department of Neurology, Southern Illinois University School of Medicine, Springfield (F.M.S.); Center for Public Health Genomics and Department of Biostatistical Sciences, Wake Forest University, Winston-Salem, NC (C.D.L., M.E.C.); Department of Neurology and Rehabilitation Medicine, University of Cincinnati, OH (C.J.M., P.S., J.L.O., D.W.); Center for Genomic Medicine, Massachusetts General Hospital, Boston (J.R.); Departments of Neurology and Medical Imaging, University of Arizona, Tucson (C.S.K.); Michael E. DeBakey VA Medical Center and Department of Neurology, Baylor College of Medicine, Houston, TX (S.M.); and Department of Neurology and Neurotherapeutics, University of Texas Southwestern Medical Center, Dallas (S.S., C.H.)
| | - Daniel Woo
- From the Department of Neurology, Southern Illinois University School of Medicine, Springfield (F.M.S.); Center for Public Health Genomics and Department of Biostatistical Sciences, Wake Forest University, Winston-Salem, NC (C.D.L., M.E.C.); Department of Neurology and Rehabilitation Medicine, University of Cincinnati, OH (C.J.M., P.S., J.L.O., D.W.); Center for Genomic Medicine, Massachusetts General Hospital, Boston (J.R.); Departments of Neurology and Medical Imaging, University of Arizona, Tucson (C.S.K.); Michael E. DeBakey VA Medical Center and Department of Neurology, Baylor College of Medicine, Houston, TX (S.M.); and Department of Neurology and Neurotherapeutics, University of Texas Southwestern Medical Center, Dallas (S.S., C.H.)
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Abstract
PURPOSE OF REVIEW This article is a practical guide to identifying uncommon causes of stroke and offers guidance for evaluation and management, even when large controlled trials are lacking in these rarer forms of stroke. RECENT FINDINGS Fabry disease causes early-onset stroke, particularly of the vertebrobasilar system; enzyme replacement therapy should be considered in affected patients. Cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL), often misdiagnosed as multiple sclerosis, causes migraines, early-onset lacunar strokes, and dementia. Moyamoya disease can cause either ischemic or hemorrhagic stroke; revascularization is recommended in some patients. Cerebral amyloid angiopathy causes both microhemorrhages and macrohemorrhages, resulting in typical stroke symptoms and progressive dementia. Pregnancy raises the risk of both ischemic and hemorrhagic stroke, particularly in women with preeclampsia/eclampsia. Pregnant women are also at risk for posterior reversible encephalopathy syndrome (PRES), reversible cerebral vasoconstriction syndrome, and cerebral venous sinus thrombosis. Experts recommend that pregnant women with acute ischemic stroke not be systematically denied the potential benefits of IV recombinant tissue plasminogen activator. SUMMARY Neurologists should become familiar with these uncommon causes of stroke to provide future risk assessment and family counseling and to implement appropriate treatment plans to prevent recurrence.
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Block F, Dafotakis M. Cerebral Amyloid Angiopathy in Stroke Medicine. DEUTSCHES ARZTEBLATT INTERNATIONAL 2017; 114:37-42. [PMID: 28179050 DOI: 10.3238/arztebl.2017.0037] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/09/2016] [Revised: 02/09/2016] [Accepted: 09/02/2016] [Indexed: 01/10/2023]
Abstract
BACKGROUND Cerebral amyloid angiopathy (CAA) is a degenerative vasculopathy that is classically associated with lobar intracerebral or sulcal hemorrhage. Its prevalence is estimated at 30% in the seventh decade and 50% in the eighth and ninth decades. In this review, we summarize the risks linked to CAA with respect to the treatment and prevention of stroke. METHODS This review is based on pertinent publications retrieved by a selective search employing the terms "amyloid cerebral angiopathy," "stroke," "intra - cerebral bleeding," and "acute stroke therapy." RESULTS Among patients given systemic lytic treatment for stroke, those who have microhemorrhages tend to have a higher risk of treatment-associated brain hemorrhage. In a meta-analysis, 70% of patients who sustained a hemorrhage after thrombolytic therapy were found to have CAA, compared to only 22% in a control population. Patients with cerebral hemorrhages have microhemorrhages more commonly than patients with transient ischemic attacks (TIA) or infarcts. This was observed among persons under treatment with vitamin K antagonists (odds ratio, 2.7) or platelet aggregation inhibitors (odds ratio, 1.7). Moreover, the apolipoprotein E2 allele is associated with a higher incidence of intracerebral hemorrhage (ICH) under oral anticoagulation. Strict treatment of arterial hypertension can lower the risk of ICH in persons with probable CAA by 77%. On the other hand, the use of statins after a lobar ICH increases the risk for a clinically manifest recurrent hemorrhage from 14% to 22%. CONCLUSION In patients with CAA, arterial hypertension should be tightly controlled. On the other hand, caution should be exercised in prescribing oral anticoagulants or platelet aggregation inhibitors for patients with CAA, or statins for patients who have already sustained a lobar ICH.
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Abstract
The disease known as cerebral cavernous malformations mostly occurs in the central nervous system, and their typical histological presentations are multiple lumen formation and vascular leakage at the brain capillary level, resulting in disruption of the blood-brain barrier. These abnormalities result in severe neurological symptoms such as seizures, focal neurological deficits and hemorrhagic strokes. CCM research has identified ‘loss of function’ mutations of three ccm genes responsible for the disease and also complex regulation of multiple signaling pathways including the WNT/β-catenin pathway, TGF-β and Notch signaling by the ccm genes. Although CCM research is a relatively new and small scientific field, as CCM research has the potential to regulate systemic blood vessel permeability and angiogenesis including that of the blood-brain barrier, this field is growing rapidly. In this review, I will provide a brief overview of CCM pathogenesis and function of ccm genes based on recent progress in CCM research. [BMB Reports 2016; 49(5): 255-262]
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Affiliation(s)
- Jaehong Kim
- Department of Biochemistry, School of Medicine, Gachon University, Incheon 21936; Department of Health Sciences and Technology, Gachon Advanced Institute for Health Science and Technology, Gachon University, Incheon 21999, Korea
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Bulwa ZB, Ward GC, Kramer ON, Rao B, Wichter M. Rapidly Sequential and Fatal Hemorrhaging in a Case of Cerebral Amyloid Angiopathy. AMERICAN JOURNAL OF CASE REPORTS 2016; 17:860-863. [PMID: 27853131 PMCID: PMC5115614 DOI: 10.12659/ajcr.900498] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2016] [Accepted: 08/24/2016] [Indexed: 12/04/2022]
Abstract
BACKGROUND Cerebral amyloid angiopathy (CAA) is an increasingly recognized cause of lobar intracerebral hemorrhage (ICH) and cognitive impairment in the aging population. Magnetic resonance imaging (MRI) of cerebral microbleeds is the most reliable option for clinical diagnosis of suspected CAA. The pathophysiology of microbleeds and ICH in CAA is not well understood, but it is thought to be the result of vessel weakening and rupture secondary to amyloid deposition. Little evidence has been established pertaining to the time course of recurrent CAA-related microbleeds or larger hemorrhages. Although several risk factors have been associated with an increased risk of ICH in CAA, there are no current treatment guidelines for recurrent hemorrhaging in CAA. CASE REPORT We present a rare case of rapidly sequential and fatal lobar hemorrhaging in the setting of suspected CAA, diagnosed by numerous microbleeds on MRI, compounded by the use of subcutaneous heparin in a 63-year-old female patient. CONCLUSIONS This case broadens our understanding of a rarely identified progression of CAA and illustrates the need for further investigation of the use of subcutaneous heparin in the setting of probable CAA.
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Affiliation(s)
- Zachary B. Bulwa
- Department of Internal Medicine, University of Chicago – NorthShore University Health System, Evanston, IL, U.S.A
| | - G. Carter Ward
- Department of Family Medicine, Medical College of Wisconsin, Milwaukee, WI, U.S.A
| | - Owen N. Kramer
- Department of Neurology, University of Illinois at Chicago, Chicago, IL, U.S.A
| | - Birju Rao
- Department of Neurology, University of Illinois at Chicago, Chicago, IL, U.S.A
| | - Melvin Wichter
- Department of Neurology, Advocate Christ Medical Center, Oak Lawn, IL, U.S.A
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Roongpiboonsopit D, Charidimou A, William CM, Lauer A, Falcone GJ, Martinez-Ramirez S, Biffi A, Ayres A, Vashkevich A, Awosika OO, Rosand J, Gurol ME, Silverman SB, Greenberg SM, Viswanathan A. Cortical superficial siderosis predicts early recurrent lobar hemorrhage. Neurology 2016; 87:1863-1870. [PMID: 27694268 DOI: 10.1212/wnl.0000000000003281] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2016] [Accepted: 06/30/2016] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To identify predictors of early lobar intracerebral hemorrhage (ICH) recurrence, defined as a new ICH within 6 months of the index event, in patients with cerebral amyloid angiopathy (CAA). METHODS Participants were consecutive survivors (age ≥55 years) of spontaneous symptomatic probable or possible CAA-related lobar ICH according to the Boston criteria, drawn from an ongoing single-center cohort study. Neuroimaging markers ascertained in CT or MRI included focal (≤3 sulci) or disseminated (>3 sulci) cortical superficial siderosis (cSS), acute convexity subarachnoid hemorrhage (cSAH), cerebral microbleeds, white matter hyperintensities burden and location, and baseline ICH volume. Participants were followed prospectively for recurrent symptomatic ICH. Cox proportional hazards models were used to identify predictors of early recurrent ICH adjusting for potential confounders. RESULTS A total of 292 patients were enrolled. Twenty-one patients (7%) had early recurrent ICH. Of these, 24% had disseminated cSS on MRI and 19% had cSAH on CT scan. In univariable analysis, the presence of disseminated cSS, cSAH, and history of previous ICH were predictors of early recurrent ICH (p < 0.05 for all comparisons). After adjusting for age and history of previous ICH, disseminated cSS on MRI and cSAH on CT were independent predictors of early recurrent ICH (hazard ratio [HR] 3.92, 95% confidence interval [CI] 1.38-11.17, p = 0.011, and HR 3.48, 95% CI 1.13-10.73, p = 0.030, respectively). CONCLUSIONS Disseminated cSS on MRI and cSAH on CT are independent imaging markers of increased risk for early recurrent ICH. These markers may provide additional insights into the mechanisms of ICH recurrence in patients with CAA.
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Affiliation(s)
- Duangnapa Roongpiboonsopit
- From The Hemorrhagic Stroke Research Program, J. Philip Kistler Stroke Research Center (D.R., A.C., A.L., G.J.F., S.M.-R., A.A., A. Vashkevich, M.E.G., S.B.S., S.M.G., A. Viswanathan), and Division of Behavioral Neurology (A.B.), Department of Neurology, Division of Neuropsychiatry, Department of Psychiatry (A.B.), Neuropathology Service, Department of Pathology (C.M.W.), and The Center for Human Genetic Research (G.J.F., J.R.), Massachusetts General Hospital, Harvard Medical School, Boston; Department of Medicine (D.R.), Faculty of Medicine, Naresuan University, Phitsanulok, Thailand; and Human Cortical Physiology and Stroke Neurorehabilitation Section (O.O.A.), NINDS/NIH, Bethesda, MD.
| | - Andreas Charidimou
- From The Hemorrhagic Stroke Research Program, J. Philip Kistler Stroke Research Center (D.R., A.C., A.L., G.J.F., S.M.-R., A.A., A. Vashkevich, M.E.G., S.B.S., S.M.G., A. Viswanathan), and Division of Behavioral Neurology (A.B.), Department of Neurology, Division of Neuropsychiatry, Department of Psychiatry (A.B.), Neuropathology Service, Department of Pathology (C.M.W.), and The Center for Human Genetic Research (G.J.F., J.R.), Massachusetts General Hospital, Harvard Medical School, Boston; Department of Medicine (D.R.), Faculty of Medicine, Naresuan University, Phitsanulok, Thailand; and Human Cortical Physiology and Stroke Neurorehabilitation Section (O.O.A.), NINDS/NIH, Bethesda, MD
| | - Christopher M William
- From The Hemorrhagic Stroke Research Program, J. Philip Kistler Stroke Research Center (D.R., A.C., A.L., G.J.F., S.M.-R., A.A., A. Vashkevich, M.E.G., S.B.S., S.M.G., A. Viswanathan), and Division of Behavioral Neurology (A.B.), Department of Neurology, Division of Neuropsychiatry, Department of Psychiatry (A.B.), Neuropathology Service, Department of Pathology (C.M.W.), and The Center for Human Genetic Research (G.J.F., J.R.), Massachusetts General Hospital, Harvard Medical School, Boston; Department of Medicine (D.R.), Faculty of Medicine, Naresuan University, Phitsanulok, Thailand; and Human Cortical Physiology and Stroke Neurorehabilitation Section (O.O.A.), NINDS/NIH, Bethesda, MD
| | - Arne Lauer
- From The Hemorrhagic Stroke Research Program, J. Philip Kistler Stroke Research Center (D.R., A.C., A.L., G.J.F., S.M.-R., A.A., A. Vashkevich, M.E.G., S.B.S., S.M.G., A. Viswanathan), and Division of Behavioral Neurology (A.B.), Department of Neurology, Division of Neuropsychiatry, Department of Psychiatry (A.B.), Neuropathology Service, Department of Pathology (C.M.W.), and The Center for Human Genetic Research (G.J.F., J.R.), Massachusetts General Hospital, Harvard Medical School, Boston; Department of Medicine (D.R.), Faculty of Medicine, Naresuan University, Phitsanulok, Thailand; and Human Cortical Physiology and Stroke Neurorehabilitation Section (O.O.A.), NINDS/NIH, Bethesda, MD
| | - Guido J Falcone
- From The Hemorrhagic Stroke Research Program, J. Philip Kistler Stroke Research Center (D.R., A.C., A.L., G.J.F., S.M.-R., A.A., A. Vashkevich, M.E.G., S.B.S., S.M.G., A. Viswanathan), and Division of Behavioral Neurology (A.B.), Department of Neurology, Division of Neuropsychiatry, Department of Psychiatry (A.B.), Neuropathology Service, Department of Pathology (C.M.W.), and The Center for Human Genetic Research (G.J.F., J.R.), Massachusetts General Hospital, Harvard Medical School, Boston; Department of Medicine (D.R.), Faculty of Medicine, Naresuan University, Phitsanulok, Thailand; and Human Cortical Physiology and Stroke Neurorehabilitation Section (O.O.A.), NINDS/NIH, Bethesda, MD
| | - Sergi Martinez-Ramirez
- From The Hemorrhagic Stroke Research Program, J. Philip Kistler Stroke Research Center (D.R., A.C., A.L., G.J.F., S.M.-R., A.A., A. Vashkevich, M.E.G., S.B.S., S.M.G., A. Viswanathan), and Division of Behavioral Neurology (A.B.), Department of Neurology, Division of Neuropsychiatry, Department of Psychiatry (A.B.), Neuropathology Service, Department of Pathology (C.M.W.), and The Center for Human Genetic Research (G.J.F., J.R.), Massachusetts General Hospital, Harvard Medical School, Boston; Department of Medicine (D.R.), Faculty of Medicine, Naresuan University, Phitsanulok, Thailand; and Human Cortical Physiology and Stroke Neurorehabilitation Section (O.O.A.), NINDS/NIH, Bethesda, MD
| | - Alessandro Biffi
- From The Hemorrhagic Stroke Research Program, J. Philip Kistler Stroke Research Center (D.R., A.C., A.L., G.J.F., S.M.-R., A.A., A. Vashkevich, M.E.G., S.B.S., S.M.G., A. Viswanathan), and Division of Behavioral Neurology (A.B.), Department of Neurology, Division of Neuropsychiatry, Department of Psychiatry (A.B.), Neuropathology Service, Department of Pathology (C.M.W.), and The Center for Human Genetic Research (G.J.F., J.R.), Massachusetts General Hospital, Harvard Medical School, Boston; Department of Medicine (D.R.), Faculty of Medicine, Naresuan University, Phitsanulok, Thailand; and Human Cortical Physiology and Stroke Neurorehabilitation Section (O.O.A.), NINDS/NIH, Bethesda, MD
| | - Alison Ayres
- From The Hemorrhagic Stroke Research Program, J. Philip Kistler Stroke Research Center (D.R., A.C., A.L., G.J.F., S.M.-R., A.A., A. Vashkevich, M.E.G., S.B.S., S.M.G., A. Viswanathan), and Division of Behavioral Neurology (A.B.), Department of Neurology, Division of Neuropsychiatry, Department of Psychiatry (A.B.), Neuropathology Service, Department of Pathology (C.M.W.), and The Center for Human Genetic Research (G.J.F., J.R.), Massachusetts General Hospital, Harvard Medical School, Boston; Department of Medicine (D.R.), Faculty of Medicine, Naresuan University, Phitsanulok, Thailand; and Human Cortical Physiology and Stroke Neurorehabilitation Section (O.O.A.), NINDS/NIH, Bethesda, MD
| | - Anastasia Vashkevich
- From The Hemorrhagic Stroke Research Program, J. Philip Kistler Stroke Research Center (D.R., A.C., A.L., G.J.F., S.M.-R., A.A., A. Vashkevich, M.E.G., S.B.S., S.M.G., A. Viswanathan), and Division of Behavioral Neurology (A.B.), Department of Neurology, Division of Neuropsychiatry, Department of Psychiatry (A.B.), Neuropathology Service, Department of Pathology (C.M.W.), and The Center for Human Genetic Research (G.J.F., J.R.), Massachusetts General Hospital, Harvard Medical School, Boston; Department of Medicine (D.R.), Faculty of Medicine, Naresuan University, Phitsanulok, Thailand; and Human Cortical Physiology and Stroke Neurorehabilitation Section (O.O.A.), NINDS/NIH, Bethesda, MD
| | - Oluwole O Awosika
- From The Hemorrhagic Stroke Research Program, J. Philip Kistler Stroke Research Center (D.R., A.C., A.L., G.J.F., S.M.-R., A.A., A. Vashkevich, M.E.G., S.B.S., S.M.G., A. Viswanathan), and Division of Behavioral Neurology (A.B.), Department of Neurology, Division of Neuropsychiatry, Department of Psychiatry (A.B.), Neuropathology Service, Department of Pathology (C.M.W.), and The Center for Human Genetic Research (G.J.F., J.R.), Massachusetts General Hospital, Harvard Medical School, Boston; Department of Medicine (D.R.), Faculty of Medicine, Naresuan University, Phitsanulok, Thailand; and Human Cortical Physiology and Stroke Neurorehabilitation Section (O.O.A.), NINDS/NIH, Bethesda, MD
| | - Jonathan Rosand
- From The Hemorrhagic Stroke Research Program, J. Philip Kistler Stroke Research Center (D.R., A.C., A.L., G.J.F., S.M.-R., A.A., A. Vashkevich, M.E.G., S.B.S., S.M.G., A. Viswanathan), and Division of Behavioral Neurology (A.B.), Department of Neurology, Division of Neuropsychiatry, Department of Psychiatry (A.B.), Neuropathology Service, Department of Pathology (C.M.W.), and The Center for Human Genetic Research (G.J.F., J.R.), Massachusetts General Hospital, Harvard Medical School, Boston; Department of Medicine (D.R.), Faculty of Medicine, Naresuan University, Phitsanulok, Thailand; and Human Cortical Physiology and Stroke Neurorehabilitation Section (O.O.A.), NINDS/NIH, Bethesda, MD
| | - M Edip Gurol
- From The Hemorrhagic Stroke Research Program, J. Philip Kistler Stroke Research Center (D.R., A.C., A.L., G.J.F., S.M.-R., A.A., A. Vashkevich, M.E.G., S.B.S., S.M.G., A. Viswanathan), and Division of Behavioral Neurology (A.B.), Department of Neurology, Division of Neuropsychiatry, Department of Psychiatry (A.B.), Neuropathology Service, Department of Pathology (C.M.W.), and The Center for Human Genetic Research (G.J.F., J.R.), Massachusetts General Hospital, Harvard Medical School, Boston; Department of Medicine (D.R.), Faculty of Medicine, Naresuan University, Phitsanulok, Thailand; and Human Cortical Physiology and Stroke Neurorehabilitation Section (O.O.A.), NINDS/NIH, Bethesda, MD
| | - Scott B Silverman
- From The Hemorrhagic Stroke Research Program, J. Philip Kistler Stroke Research Center (D.R., A.C., A.L., G.J.F., S.M.-R., A.A., A. Vashkevich, M.E.G., S.B.S., S.M.G., A. Viswanathan), and Division of Behavioral Neurology (A.B.), Department of Neurology, Division of Neuropsychiatry, Department of Psychiatry (A.B.), Neuropathology Service, Department of Pathology (C.M.W.), and The Center for Human Genetic Research (G.J.F., J.R.), Massachusetts General Hospital, Harvard Medical School, Boston; Department of Medicine (D.R.), Faculty of Medicine, Naresuan University, Phitsanulok, Thailand; and Human Cortical Physiology and Stroke Neurorehabilitation Section (O.O.A.), NINDS/NIH, Bethesda, MD
| | - Steven M Greenberg
- From The Hemorrhagic Stroke Research Program, J. Philip Kistler Stroke Research Center (D.R., A.C., A.L., G.J.F., S.M.-R., A.A., A. Vashkevich, M.E.G., S.B.S., S.M.G., A. Viswanathan), and Division of Behavioral Neurology (A.B.), Department of Neurology, Division of Neuropsychiatry, Department of Psychiatry (A.B.), Neuropathology Service, Department of Pathology (C.M.W.), and The Center for Human Genetic Research (G.J.F., J.R.), Massachusetts General Hospital, Harvard Medical School, Boston; Department of Medicine (D.R.), Faculty of Medicine, Naresuan University, Phitsanulok, Thailand; and Human Cortical Physiology and Stroke Neurorehabilitation Section (O.O.A.), NINDS/NIH, Bethesda, MD
| | - Anand Viswanathan
- From The Hemorrhagic Stroke Research Program, J. Philip Kistler Stroke Research Center (D.R., A.C., A.L., G.J.F., S.M.-R., A.A., A. Vashkevich, M.E.G., S.B.S., S.M.G., A. Viswanathan), and Division of Behavioral Neurology (A.B.), Department of Neurology, Division of Neuropsychiatry, Department of Psychiatry (A.B.), Neuropathology Service, Department of Pathology (C.M.W.), and The Center for Human Genetic Research (G.J.F., J.R.), Massachusetts General Hospital, Harvard Medical School, Boston; Department of Medicine (D.R.), Faculty of Medicine, Naresuan University, Phitsanulok, Thailand; and Human Cortical Physiology and Stroke Neurorehabilitation Section (O.O.A.), NINDS/NIH, Bethesda, MD
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Gurol ME, Becker JA, Fotiadis P, Riley G, Schwab K, Johnson KA, Greenberg SM. Florbetapir-PET to diagnose cerebral amyloid angiopathy: A prospective study. Neurology 2016; 87:2043-2049. [PMID: 27605173 DOI: 10.1212/wnl.0000000000003197] [Citation(s) in RCA: 72] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2016] [Accepted: 07/27/2016] [Indexed: 01/21/2023] Open
Abstract
OBJECTIVE We hypothesized that florbetapir, a Food and Drug Administration-approved PET tracer, could distinguish cerebral amyloid angiopathy (CAA)-related intracerebral hemorrhage (ICH) from hypertensive ICH (HTN-ICH). METHODS We prospectively enrolled survivors of primary ICH related to probable CAA (per Boston Criteria, n = 10) and HTN-ICH (n = 9) without dementia. All patients underwent florbetapir-PET and multimodal MRI, and patients with CAA had additional Pittsburgh compound B (PiB) PET. Amyloid burden was assessed quantitatively (standard uptake value ratio [SUVR]) and visually classified as positive or negative. RESULTS The CAA and HTN-ICH groups had similar age (66.9 vs 67.1), sex, and leukoaraiosis volumes (31 vs 30 mL, all p > 0.8). Florbetapir uptake and PiB retention strongly correlated in patients with CAA both globally within cerebral cortex (r = 0.96, p < 0.001) and regionally in lobar cortices (all r > 0.8, all p ≤ 0.01). Mean global cortical florbetapir uptake was substantially higher in CAA than HTN-ICH (SUVR: 1.41 ± 0.17 vs 1.15 ± 0.08, p = 0.001), as was mean occipital SUVR (1.44 ± 0.12 vs 1.17 ± 0.08, p < 0.001), even after correcting for global SUVR (p = 0.03). Visual rating for positive/negative florbetapir demonstrated perfect interrater agreement (k = 1) and was positive for all 10 patients with CAA vs 1 of 9 HTN-ICH patients (sensitivity 100%, specificity 89%). CONCLUSIONS Florbetapir appears to label vascular amyloid in patients with CAA-related ICH. The approved florbetapir binary visual reading method can have diagnostic value in appropriate clinical settings. CLASSIFICATION OF EVIDENCE This study provides Class II evidence that florbetapir-PET provides a sensitivity of 100% (95% confidence interval [CI] 66%-100%) and specificity of 89% (95% CI 51%-99%) for determination of probable CAA among cognitively normal patients.
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Affiliation(s)
- M Edip Gurol
- From the Hemorrhagic Stroke Research Center, Department of Neurology (M.E.G., P.F., G.R., K.S., S.M.G.), and Division of Nuclear Medicine and Molecular Imaging (J.A.B., K.A.J.), Massachusetts General Hospital, Harvard Medical School, Boston.
| | - J Alex Becker
- From the Hemorrhagic Stroke Research Center, Department of Neurology (M.E.G., P.F., G.R., K.S., S.M.G.), and Division of Nuclear Medicine and Molecular Imaging (J.A.B., K.A.J.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - Panagiotis Fotiadis
- From the Hemorrhagic Stroke Research Center, Department of Neurology (M.E.G., P.F., G.R., K.S., S.M.G.), and Division of Nuclear Medicine and Molecular Imaging (J.A.B., K.A.J.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - Grace Riley
- From the Hemorrhagic Stroke Research Center, Department of Neurology (M.E.G., P.F., G.R., K.S., S.M.G.), and Division of Nuclear Medicine and Molecular Imaging (J.A.B., K.A.J.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - Kristin Schwab
- From the Hemorrhagic Stroke Research Center, Department of Neurology (M.E.G., P.F., G.R., K.S., S.M.G.), and Division of Nuclear Medicine and Molecular Imaging (J.A.B., K.A.J.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - Keith A Johnson
- From the Hemorrhagic Stroke Research Center, Department of Neurology (M.E.G., P.F., G.R., K.S., S.M.G.), and Division of Nuclear Medicine and Molecular Imaging (J.A.B., K.A.J.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - Steven M Greenberg
- From the Hemorrhagic Stroke Research Center, Department of Neurology (M.E.G., P.F., G.R., K.S., S.M.G.), and Division of Nuclear Medicine and Molecular Imaging (J.A.B., K.A.J.), Massachusetts General Hospital, Harvard Medical School, Boston
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Knight RA, Nagaraja TN, Li L, Jiang Q, Tundo K, Chopp M, Seyfried DM. A Prospective Safety Trial of Atorvastatin Treatment to Assess Rebleeding after Spontaneous Intracerebral Hemorrhage: A Serial MRI Investigation. AUSTIN JOURNAL OF CEREBROVASCULAR DISEASE & STROKE 2016; 3:1043. [PMID: 28529979 PMCID: PMC5436718] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
AIM This study was designed to determine any rebleeding after atorvastatin treatment following spontaneous intracerebral hemorrhage (ICH) in a prospective safety trial. PATIENTS Atorvastatin (80 mg/day) therapy was initiated in 6 patients with primary ICH with admission Glasgow Coma Score (GCS) >5 within 24 hours of ictus and continued for 7 days, with the dose tapered and treatment terminated over the next 5 days. Patients were studied longitudinally by multiparametric magnetic resonance imaging (MRI) at three time points: acute (3 to 5 days), subacute (4 to 6 weeks) and chronic (3 to 4 months). Imaging sequences included T1, T2-weighted imaging (T2WI), diffusion tensor imaging (DTI) and contrast-enhanced MRI measures of cerebral perfusion, blood volume and blood-brain barrier (BBB) permeability. Susceptibility weighted imaging (SWI) was used to identify primary ICH and to check for secondary rebleeding. Final outcome was assessed using Glasgow Outcome Score (GOS) at 3-4 months. RESULTS Mean admission GCS was 13.2±4.0 and mean GOS at 3 months was 4.5±0.6. Hemorrhagic lesions were segmented into core and rim areas. Mean lesion volumes decreased significantly between the acute and chronic study time points (p=0.008). Average ipsilateral hemispheric tissue loss at 3 to 4 months was 11.4±4.6 cm3. MRI showed acutely reduced CBF (p=0.004) and CBV (p=0.002) in the rim, followed by steady normalization. Apparent diffusion coefficient of water (ADC) in the rim demonstrated no alterations at any of the time points (p>0.2). The T2 values were significantly elevated in the rim acutely (p=0.02), but later returned to baseline. The ICH core showed sustained low CBF and CBV values concurrent with a small reduction in ADC acutely, but significant ADC elevation at the end suggestive of irreversible injury. CONCLUSION Despite the presence of a small, probably permanent, cerebral lesion in the ICH core, no patients exhibited post-treatment rebleeding. These data suggest that larger, Phase 2 trials are warranted to establish long term clinical safety of atorvastatin in spontaneous ICH.
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Affiliation(s)
- R A Knight
- Department of Neurology, Henry Ford Hospital, USA
- Department of Physics, Oakland University, Rochester, USA
| | - T N Nagaraja
- Department of Neurosurgery, Henry Ford Hospital, USA
| | - L Li
- Department of Neurology, Henry Ford Hospital, USA
| | - Q Jiang
- Department of Neurology, Henry Ford Hospital, USA
| | - K Tundo
- Department of Neurosurgery, Henry Ford Hospital, USA
| | - M Chopp
- Department of Neurology, Henry Ford Hospital, USA
| | - D M Seyfried
- Department of Neurosurgery, Henry Ford Hospital, USA
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