1
|
Haider L, Schrutka L, Tommasino E, Avanzini N, Hauck S, Nowak N, Hengstenberg C, Bonderman D, Thurnher M. Cerebrovascular Involvement in Transthyretin Amyloid Cardiomyopathy. J Clin Med 2024; 13:4474. [PMID: 39124740 PMCID: PMC11312797 DOI: 10.3390/jcm13154474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2024] [Revised: 07/23/2024] [Accepted: 07/25/2024] [Indexed: 08/12/2024] Open
Abstract
Background: Intracardiac thrombosis is common in transthyretin amyloid cardiomyopathy (ATTR-CM), and patients are at risk for thromboembolic events. However, silent cerebral infarcts and the extent of cerebral small vessel disease in patients with cardiac amyloidosis are unknown. Methods: Thirty-two consecutively selected ATTR-CM patients were prospectively studied by cerebral magnetic resonance imaging (cMRI) and compared with 43 CHA2DS2-VASc-matched controls (Co). Structural clinical standard cMRI sequences and features of cerebral vessel involvement were included and quantified by two board certified neuroradiologists in consensus blinded to clinical status. Group differences were estimated using generalized (logistic) linear regression models adjusting for vascular risk factors based on the CHA2DS2-VASc score. Results: The median CHA2DS2-VASc score was 4 for ATTR-CM and Co (p = 0.905). There were no differences between groups in the frequency of current or former smokers (p = 0.755), body-mass-index > 30 (p = 0.106), and hyperlipidemia (p = 0.869). The number of territorial infarcts (4 vs. 0, p = 0.018) was higher in ATTR-CM compared to Co, as was the mean number of cerebral microbleeds (1.4 vs. 0.3, p ≤ 0.001) and the number of Virchow-Robin spaces (43.8 vs. 20.6, p ≤ 0.001). Lacunar lesion presence was higher in ATTR-CM (6 vs. 2, p = 0.054). CHA2DS2-VASc score, atrial fibrillation, anticoagulation, and the interaction term of CHA2DS2-VASc score and atrial fibrillation did not affect the probability of a territorial ischemic lesion or lacunar lesion in logistic regression modeling. Conclusions: In patients with ATTR-CM free from clinically apparent neurological symptoms, cMRI revealed unreported significant small cerebral vessel disease and territorial ischemia. Our findings may support low thresholds for anticoagulation and cMRI in patients with ATTR-CM.
Collapse
Affiliation(s)
- Lukas Haider
- Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, 1090 Vienna, Austria; (L.H.); (E.T.); (S.H.); (N.N.); (M.T.)
| | - Lore Schrutka
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, 1090 Vienna, Austria; (L.S.); (N.A.); (C.H.)
| | - Emanuele Tommasino
- Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, 1090 Vienna, Austria; (L.H.); (E.T.); (S.H.); (N.N.); (M.T.)
| | - Nicolas Avanzini
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, 1090 Vienna, Austria; (L.S.); (N.A.); (C.H.)
| | - Sven Hauck
- Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, 1090 Vienna, Austria; (L.H.); (E.T.); (S.H.); (N.N.); (M.T.)
| | - Nikolaus Nowak
- Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, 1090 Vienna, Austria; (L.H.); (E.T.); (S.H.); (N.N.); (M.T.)
| | - Christian Hengstenberg
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, 1090 Vienna, Austria; (L.S.); (N.A.); (C.H.)
| | - Diana Bonderman
- Department of Cardiology, Clinic Favoriten, 1100 Vienna, Austria
| | - Majda Thurnher
- Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, 1090 Vienna, Austria; (L.H.); (E.T.); (S.H.); (N.N.); (M.T.)
| |
Collapse
|
2
|
Balali P, Hart RG, Smith EE, Saad F, Colorado P, Lemmens R, De Marchis GM, Caso V, Xu L, Heenan L, Connolly SJ, Mundl H, Shoamanesh A. Cerebral microbleeds and asundexian in non-cardioembolic ischemic stroke: Secondary analyses of the PACIFIC-STROKE randomized trial. Int J Stroke 2024; 19:526-535. [PMID: 37950392 PMCID: PMC11134999 DOI: 10.1177/17474930231216339] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2023] [Accepted: 10/04/2023] [Indexed: 11/12/2023]
Abstract
BACKGROUND AND AIMS Cerebral microbleeds are magnetic imaging resonance (MRI) markers of hemorrhage-prone cerebral small vessel disease that predict future risk of ischemic stroke and intracranial hemorrhage (ICrH). There exist concerns about the net benefit of antithrombotic therapy in patients with microbleeds. We aimed to investigate the effects of an oral factor-XIa inhibitor (asundexian), that is hypothesized to inhibit thrombosis without compromising hemostasis, on the development of new microbleeds over time and interactions between microbleeds and asundexian treatment on clinical outcomes. We additionally assessed associations between baseline microbleeds and the risks of clinical and neuroimaging outcomes in patients with non-cardioembolic ischemic stroke. METHODS This is a secondary analysis of the PACIFIC-STROKE, international, multi-center Phase 2b double-blind, randomized clinical trial. PACIFIC-STROKE enrolled patients aged ⩾ 45 years with mild-to-moderate non-cardioembolic ischemic stroke who presented within 48 h of symptom onset for whom antiplatelet therapy was intended. Microbleeds were centrally adjudicated, and participants with an interpretable T2*-weighted sequence at their baseline MRI were included in this analysis. Patients were randomized to asundexian (10/20/50 mg daily) versus placebo plus standard antiplatelet treatment. Regression models were used to estimate the effects of (1) all pooled asundexian doses and (2) asundexian 50 mg daily on new microbleed formation on 26-week MRIs. Cox proportional hazards or regression models were additionally used to estimate interactions between treatment assignment and microbleeds for ischemic stroke/transient ischemic attack (TIA) (primary outcome), and ICrH, all-cause mortality, hemorrhagic transformation (HT), and new microbleeds (secondary outcomes). RESULTS Of 1746 participants (mean age, 67.0 ± 10.0; 34% female) with baseline MRIs, 604 (35%) had microbleeds. During a median follow-up of 10.6 months, 7.0% (n = 122) had ischemic stroke/TIA, 0.5% (n = 8) ICrH, and 2.1% (n = 37) died. New microbleeds developed in 10.3% (n = 155) of participants with adequate follow-up MRIs and HT in 31.4% (n = 345). In the total sample of patients with adequate baseline and 26-week follow-up MRIs (n = 1507), new microbleeds occurred in 10.2% of patients assigned to any asundexian dose and 10.5% of patients assigned to placebo (OR, 0.96; 95% CI, 0.66-1.41). There were no interactions between microbleeds and treatment assignment for any of the outcomes (p for interaction > 0.05). The rates of new microbleeds, HT, and ICrH were numerically less in patients with microbleeds assigned to asundexian relative to placebo. The presence of microbleeds was associated with a higher risk of HT (aOR, 1.6; 95% CI, 1.2-2.1) and new microbleeds (aOR, 4.4; 95% CI, 3.0-6.3). CONCLUSION Factor XIa inhibition with asundexian appears safe in patients with non-cardioembolic ischemic stroke and hemorrhage-prone cerebral small vessel disease marked by microbleeds on MRI. These preliminary findings will be confirmed in the ongoing OCEANIC-STROKE randomized trial. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT04304508.
Collapse
Affiliation(s)
- Pargol Balali
- Department of Neuroscience and Population Health Research Institute, McMaster University, Hamilton, ON, Canada
| | - Robert G Hart
- Division of Neurology, Department of Medicine, McMaster University and Population Health Research Institute, Hamilton, ON, Canada
| | - Eric E Smith
- Departments of Clinical Neurosciences, Radiology and Community Health Sciences and Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
| | - Feryal Saad
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
| | | | - Robin Lemmens
- Divison of Experimental Neurology, Department of Neurosciences, KU Leuven (University of Leuven), Leuven, Belgium
- Department of Neurology, University Hospitals Leuven, Leuven, Belgium
| | - Gian Marco De Marchis
- Department of Neurology and Stroke Center, Kantonsspital St. Gallen, St. Gallen, Switzerland
- Department of Clinical Research, University of Basel, Basel, Switzerland
| | - Valeria Caso
- Stroke Unit, Santa Maria Della Misericordia Hospital, University of Perugia, Perugia, Italy
| | - Lizhen Xu
- Department of Statistics, Population Health Research Institute, Hamilton, ON, Canada
| | - Laura Heenan
- Department of Statistics, Population Health Research Institute, Hamilton, ON, Canada
| | - Stuart J Connolly
- Department of Statistics, Population Health Research Institute, Hamilton, ON, Canada
| | | | - Ashkan Shoamanesh
- Division of Neurology, Department of Medicine, McMaster University and Population Health Research Institute, Hamilton, ON, Canada
| |
Collapse
|
3
|
Aspberg S, Cheng D, von Heijne A, Gigante B, Singer DE. Brain MRI microbleeds and risk of intracranial hemorrhage in atrial fibrillation patients: A Swedish case-control study. J Stroke Cerebrovasc Dis 2024; 33:107629. [PMID: 38325675 DOI: 10.1016/j.jstrokecerebrovasdis.2024.107629] [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: 06/20/2023] [Revised: 01/30/2024] [Accepted: 02/04/2024] [Indexed: 02/09/2024] Open
Abstract
OBJECTIVES Our goal was to quantify the independent association of brain microbleeds with future intracranial hemorrhage (ICrH). Microbleed findings on brain magnetic resonance imaging (MRI) may identify distinctive risk factors for ICrH which could inform the anticoagulant therapy decision for atrial fibrillation (AF) patients. Our study design includes patients with MRIs for numerous reasons, not limited to evaluation of stroke. MATERIALS AND METHODS The source population was all patients with AF from a nationwide Swedish health care register. Case patients had an ICrH between 2006 and 2013 and ≥1 brain MRI for an unrelated condition before the ICrH. Each case was matched to four controls who had a brain MRI without a subsequent ICrH. The MRIs were re-reviewed by neuroradiologists. Associations between MRI findings and subsequent ICrH were assessed using logistic regression, adjusting for comorbidities and antithrombotic medications. RESULTS A total of 78 cases and 312 matched controls were identified; 29 cases and 79 controls had MRI sequences suitable for analysis of microbleeds. Patients with ≥10 microbleeds had a markedly increased risk of ICrH (adjusted odds ratio 14.56; 95 % confidence interval: 2.86-74.16, p < 0.001). All patients with ≥10 microbleeds had microbleeds in the lobar region and ≥10 lobar microbleeds was associated with intracerebral hemorrhages, univariable OR 8.54 (2.01-36.33), p = 0.004. CONCLUSIONS Leveraging a nationwide database with brain imaging obtained prior to ICrH, we identified a strong association between ≥10 microbleeds on brain MRI and subsequent ICrH among AF patients. Lobar brain regions were involved whenever there were ≥10 microbleeds. Brain MRIs may help optimize the anticoagulation decision in selected AF patients.
Collapse
Affiliation(s)
- Sara Aspberg
- Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| | - David Cheng
- Biostatistics Center, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Anders von Heijne
- Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Bruna Gigante
- Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Daniel E Singer
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA.
| |
Collapse
|
4
|
Zhao B, Yuan Y, Li Z, Chen Y, Gao Y, Yang B, Wu J, Jia W. Risk of intracranial hemorrhage in patients using anticoagulant therapy for atrial fibrillation after cerebral microbleeds combined with acute ischemic stroke: a meta-analysis. Front Neurol 2024; 15:1372231. [PMID: 38560733 PMCID: PMC10978779 DOI: 10.3389/fneur.2024.1372231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Accepted: 03/05/2024] [Indexed: 04/04/2024] Open
Abstract
Objective To evaluate intracerebral hemorrhage (ICH) risk in patients with ischemic stroke (IS) and cerebral microbleeds (CMBs) undergoing anticoagulation therapy for non-valvular atrial fibrillation (AF). Methods We conducted a comprehensive search across multiple databases, including Embase, PubMed, Cochrane, UpToDate, Scopus, WOS, and SinoMed. The search covered observational literature published from each database inception until February 1, 2023. We analyzed the prevalence of CMBs during the follow-up period, compared future ICH risk between patients with and without baseline CMBs (CMBs presence/absence, ≧5 CMBs), and examined factors influencing ICH occurrence in patients with CMBs. Also studied recurrent stroke during anticoagulation therapy, the risk of future ICH when white matter hyperintensity (WMH) and CMBs coexist, and the effects of anticoagulants vitamin K antagonists (VKAs) and direct oral anticoagulants (DOACs) on future ICH. Results We included 7 articles involving 5,134 participants. The incidence of CMBs was 24%; baseline CMBs were associated with an increased ICH risk compared to patients without CMBs. ICH-risk was more significant in patients with baseline ≥5 CMBs. After anticoagulant therapy, ICH risk was higher than that of recurrent IS. The risk of future ICH was significantly increased with anticoagulant VKAs compared with NOAC. Conclusion Anticoagulant therapy for ischemic stroke patients with non-valvular AF and CMBs increases future ICH risk. Discontinuing anticoagulation due to ICH risk should be avoided. NOACs are safe and effective for patients with CMBs and IS.
Collapse
Affiliation(s)
- Bingqing Zhao
- Department of Neurology, Beijing Shijingshan Hospital, Shijingshan Teaching Hospital of Capital Medical University, Beijing, China
| | - Ye Yuan
- Department of Neurology, Beijing Shijingshan Hospital, Shijingshan Teaching Hospital of Capital Medical University, Beijing, China
| | - Zheng Li
- Department of Neurology, Beijing Shijingshan Hospital, Shijingshan Teaching Hospital of Capital Medical University, Beijing, China
| | - Ying Chen
- Department of Neurology, Beijing Shijingshan Hospital, Shijingshan Teaching Hospital of Capital Medical University, Beijing, China
| | - Yali Gao
- Department of Neurology, Beijing Shijingshan Hospital, Shijingshan Teaching Hospital of Capital Medical University, Beijing, China
| | - Baoling Yang
- Department of Neurology, Beijing Shijingshan Hospital, Shijingshan Teaching Hospital of Capital Medical University, Beijing, China
| | - Jingyi Wu
- University of Glasgow, Glasgow, United Kingdom
| | - Weihua Jia
- Department of Neurology, Beijing Shijingshan Hospital, Shijingshan Teaching Hospital of Capital Medical University, Beijing, China
| |
Collapse
|
5
|
Tawakul A, Toro AR, Romero JR. Acute cerebral microbleeds detected on high resolution head CT presenting with transient neurologic events. CEREBRAL CIRCULATION - COGNITION AND BEHAVIOR 2024; 6:100207. [PMID: 38312310 PMCID: PMC10837056 DOI: 10.1016/j.cccb.2024.100207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/06/2023] [Revised: 12/26/2023] [Accepted: 01/16/2024] [Indexed: 02/06/2024]
Abstract
Introduction Cerebral microbleeds (CMBs) are deposits of hemosiderin-laden macrophages that can be visualized on T2-weighted MRI sequences as small, ovoid areas of signal void. These markers represent hemorrhagic cerebral small vessel disease and are usually subclinical and asymptomatic. In these cases, we present two patients who presented with symptomatic, acute CMBs. Case description Case 1 involves a 70-year-old male with history of diabetes, hypertension, hyperlipidemia, and obstructive sleep apnea. Five days prior to presentation, this patient reported a transient period of left upper extremity weakness. CT was performed and demonstrated a lesion on CT imaging consistent with an acute CMB in the R centrum semiovale.Case 2 describes an 82-year-old female with history of hypertension, remote large ischemic stroke, and post-stroke epilepsy. Patient described an episode of prolonged left sided shaking consistent with prior seizures despite her consistently taking anti-epileptic drugs. On CT, a small hyperdensity was seen in the R thalamus/internal capsule region consistent with acute CMB. Discussion These two examples demonstrate acute CMBs causing patients to demonstrate symptoms mirroring those of a TIA and experience breakthrough seizures. A TIA would normally be an indication for antiplatelet therapy. Though prior reasoning warns against anticoagulation in patients with CMBs, recent works including the SPS3 (Shoamanesh et al., 2017) and WAKE-UP (Schlemm et al., 2022) trials both showed that the presence of CMB did not significantly affect outcomes after initiating antiplatelet therapy. One should adopt a more personalized approach when deciding the therapeutic intervention of choice in patients with prior CMB.
Collapse
Affiliation(s)
- Abdullah Tawakul
- Department of Medicine, Faculty of Medicine, Umm Al-Qura University, Makkah, Saudi Arabia
- Department of Neurology, Boston University School of Medicine, Boston, MA, 725 Albany St, Boston, MA 02118, United States
| | - Arturo R Toro
- Chobanian Avedisian School of Medicine, Boston University School of Medicine, 715 Albany Street, 72 East Concord St. Boston, MA 02118-2526, United States
| | - José Rafael. Romero
- NHLBI's Framingham Heart Study, Framingham, MA, United States
- Department of Neurology, Boston University School of Medicine, Boston, MA, 725 Albany St, Boston, MA 02118, United States
| |
Collapse
|
6
|
Perosa V, Auger CA, Zanon Zotin MC, Oltmer J, Frosch MP, Viswanathan A, Greenberg SM, van Veluw SJ. Histopathological Correlates of Lobar Microbleeds in False-Positive Cerebral Amyloid Angiopathy Cases. Ann Neurol 2023; 94:856-870. [PMID: 37548609 DOI: 10.1002/ana.26761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Revised: 07/05/2023] [Accepted: 07/31/2023] [Indexed: 08/08/2023]
Abstract
OBJECTIVE A definite diagnosis of cerebral amyloid angiopathy (CAA), characterized by the accumulation of amyloid β in walls of cerebral small vessels, can only be obtained through pathological examination. A diagnosis of probable CAA during life relies on the presence of hemorrhagic markers, including lobar cerebral microbleeds (CMBs). The aim of this project was to study the histopathological correlates of lobar CMBs in false-positive CAA cases. METHODS In 3 patients who met criteria for probable CAA during life, but showed no CAA upon neuropathological examination, lobar CMBs were counted on ex vivo 3T magnetic resonance imaging (MRI) and on ex vivo 7T MRI. Areas with lobar CMBs were next sampled and cut into serial sections, on which the CMBs were then identified. RESULTS Collectively, there were 25 lobar CMBs on in vivo MRI and 22 on ex vivo 3T MRI of the analyzed hemispheres. On ex vivo MRI, we targeted 12 CMBs for sampling, and definite histopathological correlates were retrieved for 9 of them, of which 7 were true CMBs. No CAA was found on any of the serial sections. The "culprit vessels" associated with the true CMBs instead showed moderate to severe arteriolosclerosis. Furthermore, CMBs in false-positive CAA cases tended to be located more often in the juxtacortical or subcortical white matter than in the cortical ribbon. INTERPRETATION These findings suggest that arteriolosclerosis can generate lobar CMBs and that more detailed investigations into the exact localization of CMBs with respect to the cortical ribbon could potentially aid the diagnosis of CAA during life. ANN NEUROL 2023;94:856-870.
Collapse
Affiliation(s)
- Valentina Perosa
- J. Philip Kistler Stroke Research Center, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Corinne A Auger
- MassGeneral Institute for Neurodegenerative Disease, Massachusetts General Hospital, Harvard Medical School, Charlestown, MA, USA
| | - Maria Clara Zanon Zotin
- J. Philip Kistler Stroke Research Center, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Center for Imaging Sciences and Medical Physics, Department of Medical Imaging, Hematology, and Clinical Oncology, Ribeirão Preto Medical School, University of São Paulo, São Paulo, Brazil
| | - Jan Oltmer
- Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Charlestown, MA, USA
| | - Matthew P Frosch
- Department of Neuropathology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Anand Viswanathan
- J. Philip Kistler Stroke Research Center, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Steven M Greenberg
- J. Philip Kistler Stroke Research Center, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Susanne J van Veluw
- J. Philip Kistler Stroke Research Center, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- MassGeneral Institute for Neurodegenerative Disease, Massachusetts General Hospital, Harvard Medical School, Charlestown, MA, USA
| |
Collapse
|
7
|
Lampert J, Power D, Havaldar S, Govindarajulu U, Kawamura I, Maan A, Miller MA, Menon K, Koruth J, Whang W, Bagiella E, Bayes-Genis A, Musikantow D, Turagam M, Bayes de Luna A, Halperin J, Dukkipati SR, Vaid A, Nadkarni G, Glicksberg B, Fuster V, Reddy VY. Interatrial Block Association With Adverse Cardiovascular Outcomes in Patients Without a History of Atrial Fibrillation. JACC Clin Electrophysiol 2023; 9:1804-1815. [PMID: 37354170 DOI: 10.1016/j.jacep.2023.04.006] [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: 12/19/2022] [Revised: 04/11/2023] [Accepted: 04/14/2023] [Indexed: 06/26/2023]
Abstract
BACKGROUND Interatrial block (IAB) is associated with thromboembolism and atrial arrhythmias. However, prior studies included small patient cohorts so it remains unclear whether IAB predicts adverse outcomes particularly in context of atrial fibrillation (AF)/atrial flutter (AFL). OBJECTIVES This study sought to determine whether IAB portends increased stroke risk in a large cohort in the presence or absence of AFAF/AFL. METHODS We performed a 5-center retrospective analysis of 4,837,989 electrocardiograms (ECGs) from 1,228,291 patients. IAB was defined as P-wave duration ≥120 ms in leads II, III, or aVF. Measurements were extracted as .XML files. After excluding patients with prior AF/AFL, 1,825,958 ECGs from 458,994 patients remained. Outcomes were analyzed using restricted mean survival time analysis and restricted mean time lost. RESULTS There were 86,317 patients with IAB and 355,032 patients without IAB. IAB prevalence in the cohort was 19.6% and was most common in Black (26.1%), White (20.9%), and Hispanic (18.5%) patients and least prevalent in Native Americans (9.2%). IAB was independently associated with increased stroke probability (restricted mean time lost ratio coefficient [RMTLRC]: 1.43; 95% CI: 1.35-1.51; tau = 1,895), mortality (RMTLRC: 1.14; 95% CI: 1.07-1.21; tau = 1,924), heart failure (RMTLRC: 1.94; 95% CI: 1.83-2.04; tau = 1,921), systemic thromboembolism (RMTLRC: 1.62; 95% CI: 1.53-1.71; tau = 1,897), and incident AF/AFL (RMTLRC: 1.16; 95% CI: 1.10-1.22; tau = 1,888). IAB was not associated with stroke in patients with pre-existing AF/AFL. CONCLUSIONS IAB is independently associated with stroke in patients with no history of AF/AFL even after adjustment for incident AF/AFL and CHA2DS2-VASc score. Patients are at increased risk of stroke even when AF/AFL is not identified.
Collapse
Affiliation(s)
- Joshua Lampert
- Helmsley Electrophysiology Center, Mount Sinai Hospital, New York, New York, USA. https://twitter.com/joshuamlampertmd
| | - David Power
- Mount Sinai Heart, Mount Sinai Hospital, New York, New York, USA
| | - Shreyas Havaldar
- Hasso Plattner Institute for Digital Health at Mount Sinai, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Usha Govindarajulu
- Center for Biostatistics, Department of Population Health, Mount Sinai Hospital, New York, New York, USA
| | - Iwanari Kawamura
- Helmsley Electrophysiology Center, Mount Sinai Hospital, New York, New York, USA
| | - Abhishek Maan
- Helmsley Electrophysiology Center, Mount Sinai Hospital, New York, New York, USA
| | - Marc A Miller
- Helmsley Electrophysiology Center, Mount Sinai Hospital, New York, New York, USA
| | - Kartikeya Menon
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Jacob Koruth
- Helmsley Electrophysiology Center, Mount Sinai Hospital, New York, New York, USA
| | - William Whang
- Helmsley Electrophysiology Center, Mount Sinai Hospital, New York, New York, USA
| | - Emilia Bagiella
- Center for Biostatistics, Department of Population Health, Mount Sinai Hospital, New York, New York, USA
| | - Antoni Bayes-Genis
- Heart Institute, Hospital Universitario Germans trias I Pujol, Badalona, Spain
| | - Daniel Musikantow
- Helmsley Electrophysiology Center, Mount Sinai Hospital, New York, New York, USA
| | - Mohit Turagam
- Helmsley Electrophysiology Center, Mount Sinai Hospital, New York, New York, USA
| | - Antoni Bayes de Luna
- Cardiovascular Research Foundation, Cardiovascular ICCC-Program, Research Institute Hospital de la Santa Creu i Sant Pau, IIB-Sant Pau, Barcelona, Spain
| | | | - Srinivas R Dukkipati
- Helmsley Electrophysiology Center, Mount Sinai Hospital, New York, New York, USA
| | - Akhil Vaid
- Division of Data-Driven and Digital Medicine (D3M), Icahn School of Medicine at Mount Sinai, New York, New York, USA; The Charles Bronfman Institute of Personalized Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Girish Nadkarni
- Division of Data-Driven and Digital Medicine (D3M), Icahn School of Medicine at Mount Sinai, New York, New York, USA; The Charles Bronfman Institute of Personalized Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Benjamin Glicksberg
- Hasso Plattner Institute for Digital Health at Mount Sinai, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Valentin Fuster
- Mount Sinai Heart, Mount Sinai Hospital, New York, New York, USA
| | - Vivek Y Reddy
- Helmsley Electrophysiology Center, Mount Sinai Hospital, New York, New York, USA.
| |
Collapse
|
8
|
Soo Y, Zietz A, Yiu B, Mok VCT, Polymeris AA, Seiffge D, Ambler G, Wilson D, Leung TWH, Tsang SF, Chu W, Abrigo J, Cheng C, Lee KJ, Lim JS, Shiozawa M, Koga M, Chabriat H, Hennerici M, Wong YK, Mak H, Collet R, Inamura S, Yoshifuji K, Arsava EM, Horstmann S, Purrucker J, Lam BYK, Wong A, Kim YD, Song TJ, Lemmens R, Eppinger S, Gattringer T, Uysal E, Demirelli DS, Bornstein NM, Assayag EB, Hallevi H, Molad J, Nishihara M, Tanaka J, Coutts SB, Kappelle LJ, Al-Shahi Salman R, Jager R, Lip GYH, Goeldlin MB, Panos LD, Mas JL, Legrand L, Karayiannis C, Phan T, Bellut M, Chappell F, Makin S, Hayden D, Williams D, van Dam-Nolen DHK, Nederkoorn PJ, Barbato C, Browning S, Wiegertjes K, Tuladhar AM, Mendyk AM, Köhler S, van Oostenburgge R, Zhou Y, Xu C, Hilal S, Gyanwali B, Chen C, Lou M, Staals J, Bordet R, Kandiah N, de Leeuw FE, Simister R, Hendrikse J, Wardlaw J, Kelly P, Fluri F, Srikanth V, Calvet D, Jung S, Kwa VIH, Smith EE, Hara H, Yakushiji Y, Orken DN, Fazekas F, Thijs V, Heo JH, Veltkamp R, Ay H, Imaizumi T, Lau KK, Jouvent E, Toyoda K, Yoshimura S, Bae HJ, Martí-Fàbregas J, Prats-Sánchez L, Lyrer P, Best J, Werring D, Engelter ST, Peters N. Impact of Cerebral Microbleeds in Stroke Patients with Atrial Fibrillation. Ann Neurol 2023; 94:61-74. [PMID: 36928609 DOI: 10.1002/ana.26642] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Revised: 03/08/2023] [Accepted: 03/14/2023] [Indexed: 03/18/2023]
Abstract
OBJECTIVES Cerebral microbleeds are associated with the risks of ischemic stroke and intracranial hemorrhage, causing clinical dilemmas for antithrombotic treatment decisions. We aimed to evaluate the risks of intracranial hemorrhage and ischemic stroke associated with microbleeds in patients with atrial fibrillation treated with vitamin K antagonists, direct oral anticoagulants, antiplatelets, and combination therapy (i.e. concurrent oral anticoagulant and antiplatelet). METHODS We included patients with documented atrial fibrillation from the pooled individual patient data analysis by the Microbleeds International Collaborative Network. Risks of subsequent intracranial hemorrhage and ischemic stroke were compared between patients with and without microbleeds, stratified by antithrombotic use. RESULTS A total of 7,839 patients were included. The presence of microbleeds was associated with an increased relative risk of intracranial hemorrhage (adjusted hazard ratio [aHR] = 2.74, 95% confidence interval = 1.76-4.26) and ischemic stroke (aHR = 1.29, 95% confidence interval = 1.04-1.59). For the entire cohort, the absolute incidence of ischemic stroke was higher than intracranial hemorrhage regardless of microbleed burden. However, for the subgroup of patients taking combination of anticoagulant and antiplatelet therapy, the absolute risk of intracranial hemorrhage exceeded that of ischemic stroke in those with 2 to 4 microbleeds (25 vs 12 per 1,000 patient-years) and ≥ 11 microbleeds (94 vs 48 per 1,000 patient-years). INTERPRETATION Patients with atrial fibrillation and high burden of microbleeds receiving combination therapy have a tendency of higher rate of intracranial hemorrhage than ischemic stroke, with potential for net harm. Further studies are needed to help optimize stroke preventive strategies in this high-risk group. ANN NEUROL 2023;94:61-74.
Collapse
Affiliation(s)
- Yannie Soo
- Division of Neurology, Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Annaelle Zietz
- Department of Neurology and Stroke Centre, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Brian Yiu
- Division of Neurology, Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Vincent C T Mok
- Division of Neurology, Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong
- Gerald Choa Neuroscience Institute, Margaret K. L. Cheung Research Centre for Management of Parkinsonism, Therese Pei Fong Chow Research Centre for Prevention of Dementia, Lui Che Woo Institute of Innovative Medicine, Li Ka Shing Institute of Health Science, Lau Tat-chuen Research Centre of Brain Degenerative Diseases in Chinese, The Chinese University of Hong Kong, Hong Kong SAR, Hong Kong
| | - Alexandros A Polymeris
- Department of Neurology and Stroke Centre, University Hospital Basel and University of Basel, Basel, Switzerland
| | - David Seiffge
- Department of Neurology, Inselspital, University Hospital Bern, University of Bern, Bern, Switzerland
| | - Gareth Ambler
- Department of Statistical Science, University College London, London, UK
| | - Duncan Wilson
- Stroke Research Centre, Department of Brain Repair and Rehabilitation, UCL Queen Square Institute of Neurology, London, UK, New Zealand Brain Research Institute, Christchurch, New Zealand
| | - Thomas Wai Hong Leung
- Division of Neurology, Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Suk Fung Tsang
- Division of Neurology, Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Winnie Chu
- Department of Imaging and Interventional Radiology, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Jill Abrigo
- Department of Imaging and Interventional Radiology, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Cyrus Cheng
- Division of Neurology, Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Keon-Joo Lee
- Department of Neurology, Korea University Guro Hospital, Seoul, Republic of Korea
| | - Jae-Sung Lim
- Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Masayuki Shiozawa
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Centre, Suita, Japan
| | - Masatoshi Koga
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Centre, Suita, Japan
| | - Hugues Chabriat
- APHP, Lariboisière Hospital, Translational Neurovascular Centre, F-75475 Paris, France, FHU NeuroVasc, Université de Paris and INSERM U1141, Paris, France
| | - Michael Hennerici
- Department of Neurology, University of Heidelberg/Mannheim Hospital, Mannheim, Germany
| | - Yuen Kwun Wong
- Division of Neurology, Department of Medicine, The University of Hong Kong, Hong Kong, Hong Kong
| | - Henry Mak
- Department of Diagnostic Radiology, The University of Hong Kong, Hong Kong, Hong Kong
| | - Roger Collet
- Department of Neurology, Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute, Barcelona, Spain
| | - Shigeru Inamura
- Department of Neurosurgery, Kushiro City General Hospital, Kushiro, Japan
| | - Kazuhisa Yoshifuji
- Department of Neurosurgery, Kushiro City General Hospital, Kushiro, Japan
| | - Ethem Murat Arsava
- Departments of Neurology and Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Solveig Horstmann
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Jan Purrucker
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Bonnie Y K Lam
- Division of Neurology, Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong
- Gerald Choa Neuroscience Institute, Margaret K. L. Cheung Research Centre for Management of Parkinsonism, Therese Pei Fong Chow Research Centre for Prevention of Dementia, Lui Che Woo Institute of Innovative Medicine, Li Ka Shing Institute of Health Science, Lau Tat-chuen Research Centre of Brain Degenerative Diseases in Chinese, The Chinese University of Hong Kong, Hong Kong SAR, Hong Kong
| | - Adrian Wong
- Gerald Choa Neuroscience Institute, Margaret K. L. Cheung Research Centre for Management of Parkinsonism, Therese Pei Fong Chow Research Centre for Prevention of Dementia, Lui Che Woo Institute of Innovative Medicine, Li Ka Shing Institute of Health Science, Lau Tat-chuen Research Centre of Brain Degenerative Diseases in Chinese, The Chinese University of Hong Kong, Hong Kong SAR, Hong Kong
| | - Young Dae Kim
- Department of Neurology, Yonsei University College of Medicine, Seoul, South Korea
| | - Tae-Jin Song
- Department of Neurology, Seoul Hospital, Ewha Womans University College of Medicine, Seoul, South Korea
| | - Robin Lemmens
- Experimental Neurology, Department of Neurosciences, KU Leuven-University of Leuven, Leuven, Belgium
- VIB Center for Brain & Disease Research, Leuven, Belgium
- Department of Neurology, University Hospitals Leuven, Leuven, Belgium
| | - Sebastian Eppinger
- Department of Neurology, Medical University of Graz, Graz, Austria
- Division of Neuroradiology, Vascular and Interventional Radiology, Department of Radiology, Medical University of Graz, Graz, Austria
| | - Thomas Gattringer
- Department of Neurology, Medical University of Graz, Graz, Austria
- Division of Neuroradiology, Vascular and Interventional Radiology, Department of Radiology, Medical University of Graz, Graz, Austria
| | - Ender Uysal
- Antalya Teaching and Research Hospital, Department of Radiology, University of Health Sciences Turkey, Antalya, Turkey
| | - Derya Selçuk Demirelli
- Sisli Hamidiye Etfal Teaching and Research Hospital, Department of Neurology, University of Health Sciences Turkey, Antalya, Turkey
| | - Natan M Bornstein
- Department of Neurology, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Einor Ben Assayag
- Department of Neurology, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Hen Hallevi
- Department of Neurology, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Jeremy Molad
- Department of Neurology, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Masashi Nishihara
- Department of Radiology, Saga University Faculty of Medicine, Saga, Japan
| | - Jun Tanaka
- Department of Cerebrovascular Medicine, St. Mary's Hospital, Kurume, Japan
| | - Shelagh B Coutts
- Calgary Stroke Program, Department of Clinical Neurosciences, Radiology and Community Health Sciences, Hotchkiss Brain Institute, University of Calgary, Calgary, Canada
| | - L Jaap Kappelle
- Department of Neurology and Neurosurgery, University Medical Centre Utrecht and Utrecht University, Utrecht, The Netherlands
| | - Rustam Al-Shahi Salman
- Centre for Clinical Brain Sciences, School of Clinical Sciences, University of Edinburgh, Edinburgh, UK
| | - Rolf Jager
- Lysholm Department of Neuroradiology and the Neuroradiological Academic Unit, Department of Brain Repair and Rehabilitation, UCL Institute of Neurology and the National Hospital for Neurology and Neurosurgery, London, UK
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Martina B Goeldlin
- Department of Neurology, Inselspital, University Hospital Bern, University of Bern, Bern, Switzerland
| | - Leonidas D Panos
- Department of Neurology, Inselspital, University Hospital Bern, University of Bern, Bern, Switzerland
| | - Jean-Louis Mas
- GHU-Paris Psychiatrie et Neurosciences, Neurology Department and Stroke Unit, Sainte-Anne Hospital, and Université de Paris Cité, INSERM U1266, Institute of Psychiatry and Neuroscience of Paris, Paris, France
| | - Laurence Legrand
- GHU-Paris Psychiatrie et Neurosciences, Neuroradiology Department, Sainte-Anne Hospital, and Université Paris Cité, INSERM U1266, Institute of Psychiatry and Neuroscience of Paris, Paris, France
| | - Chris Karayiannis
- Peninsula Clinical School, Peninsula Health, Monash University, Melbourne, Australia
| | - Thanh Phan
- Stroke and Ageing Research Group, School of Clinical Sciences at Monash Health, Monash University, Melbourne, Australia
| | - Maximilian Bellut
- Department of Neurology, University Hospital of Würzburg, Würzburg, Germany
| | - Francesca Chappell
- Centre for Clinical Brain Sciences, Edinburgh Imaging, Edinburgh, UK
- UK Dementia Institute at the University of Edinburgh, Edinburgh, UK
| | - Stephen Makin
- Centre for Rural Health, Institute for Applied Health Sciences, University of Aberdeen, Aberdeen, UK
| | - Derek Hayden
- Acute Medical Unit and Department of Age-related Healthcare, Tallaght University Hospital, Dublin, Ireland
| | - David Williams
- Department of Geriatric and Stroke Medicine, RCSI University of Medicine and Health Sciences Dublin, Ireland and Beaumont Hospital Dublin, Dublin, Ireland
| | - Dianne H K van Dam-Nolen
- Department of Radiology and Nuclear Medicine, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Paul J Nederkoorn
- Department of Neurology, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Carmen Barbato
- Department of Neurology, University of Florence, Firenze, Italy
| | - Simone Browning
- Stroke Research Centre, Department of Brain Repair and Rehabilitation, UCL Queen Square Institute of Neurology, London, UK
- Comprehensive Stroke Service, University College London Hospitals NHS Trust, London, UK
| | - Kim Wiegertjes
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Donders Centre for Medical Neuroscience, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Anil Man Tuladhar
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Donders Centre for Medical Neuroscience, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Anne-Marie Mendyk
- University of Lille, Inserm, CHU de Lille. Lille Neuroscience & Cognition, Lille, France
| | - Sebastian Köhler
- Department of Psychiatry and Neuropsychology, School for Mental Health and Neuroscience (MHeNs), Maastricht University, Maastricht, The Netherlands
| | - Robert van Oostenburgge
- Department of Neurology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Ying Zhou
- Department of Neurology, The Second Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China
| | - Chao Xu
- Department of Neurology, The Second Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China
| | - Saima Hilal
- Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore, Singapore
| | - Bibek Gyanwali
- Memory Aging & Cognition Centre, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Christopher Chen
- Memory Aging & Cognition Centre, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Min Lou
- Department of Neurology, The Second Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China
| | - Julie Staals
- Department of Neurology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Regis Bordet
- University of Lille, Inserm, CHU de Lille. Lille Neuroscience & Cognition, Lille, France
| | - Nagaendran Kandiah
- Dementia Research Centre (Singapore), Lee Kong Chian School of Medicine, Singapore, Singapore
| | - Frank-Erik de Leeuw
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Donders Centre for Medical Neuroscience, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Robert Simister
- Stroke Research Centre, Department of Brain Repair and Rehabilitation, UCL Queen Square Institute of Neurology, London, UK
- Comprehensive Stroke Service, University College London Hospitals NHS Trust, London, UK
| | - Jeroen Hendrikse
- Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Joanna Wardlaw
- Division of Neuroimaging Sciences, Edinburgh Imaging, Edinburgh, UK
- UK Dementia Research Institute, University of Edinburgh and NHS Lothian, Edinburgh, UK
| | - Peter Kelly
- The Neurovascular Research Unit and Health Research Board, Stroke Clinical Trials Network Ireland, University College Dublin, Dublin, Ireland
| | - Felix Fluri
- Department of Neurology, University Hospital of Würzburg, Würzburg, Germany
| | - Velandai Srikanth
- Peninsula Clinical School, Peninsula Health, Monash University, Melbourne, Australia, National Centre for Healthy Ageing, Melbourne, Australia
| | - David Calvet
- GHU-Paris Psychiatrie et Neurosciences, Neurology Department and Stroke Unit, Sainte-Anne Hospital, and Université de Paris Cité, INSERM U1266, Institute of Psychiatry and Neuroscience of Paris, Paris, France
| | - Simon Jung
- Department of Neurology, Inselspital, University Hospital Bern, University of Bern, Bern, Switzerland
| | | | - Eric E Smith
- Calgary Stroke Program, Department of Clinical Neurosciences, Radiology and Community Health Sciences, Hotchkiss Brain Institute, University of Calgary, Calgary, Canada
| | - Hideo Hara
- Division of Neurology, Department of Internal Medicine, Saga University Faculty of Medicine, Saga, Japan
| | - Yusuke Yakushiji
- Department of Neurology, Kansai Medical University, Hirakata, Japan
| | | | - Franz Fazekas
- Department of Neurology, Medical University of Graz, Graz, Austria
| | - Vincent Thijs
- Stroke Division, Florey Institute of Neuroscience and Mental Health, University of Melbourne, Heidelberg, Australia
- A.A. Martinos Center for Biomedical Imaging, Departments of Neurology and Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Ji-Hoe Heo
- Department of Neurology, Yonsei University College of Medicine, Seoul, South Korea
| | - Roland Veltkamp
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
- Department of Neurology, Austin Health, Heidelberg, Australia
| | - Hakan Ay
- Department of Brain Sciences, Imperial College London, London, UK
| | - Toshio Imaizumi
- Department of Neurosurgery, Kushiro City General Hospital, Kushiro, Japan
| | - Kui Kai Lau
- Division of Neurology, Department of Medicine, The University of Hong Kong, Hong Kong, Hong Kong
- State Key Laboratory of Brain and Cognitive Sciences, The University of Hong Kong, Shatin, Hong Kong
| | - Eric Jouvent
- Université de Paris-Assistance Publique Hôpitaux de Paris, Paris, France
- Département de Neurologie, Hôpital Lariboisière, FHU NeuroVasc, INSERM NeuroDiderot U1141, Paris, France
| | - Kazunori Toyoda
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Centre, Suita, Japan
| | - Sohei Yoshimura
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Centre, Suita, Japan
| | - Hee-Joon Bae
- Department of Neurology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Republic of Korea
| | - Joan Martí-Fàbregas
- Department of Neurology, Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute, Barcelona, Spain
| | - Luis Prats-Sánchez
- Department of Neurology, Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute, Barcelona, Spain
| | - Philippe Lyrer
- Department of Neurology and Stroke Centre, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Jonathan Best
- Stroke Research Centre, Department of Brain Repair and Rehabilitation, UCL Queen Square Institute of Neurology, London, UK
- Comprehensive Stroke Service, University College London Hospitals NHS Trust, London, UK
| | - David Werring
- Stroke Research Centre, Department of Brain Repair and Rehabilitation, UCL Queen Square Institute of Neurology, London, UK
- Comprehensive Stroke Service, University College London Hospitals NHS Trust, London, UK
| | - Stefan T Engelter
- Department of Neurology and Stroke Centre, University Hospital Basel and University of Basel, Basel, Switzerland
- Neurology and Neurorehabilitation, University Department of Geriatric Medicine FELIX PLATTER, University of Basel, Basel, Switzerland
| | - Nils Peters
- Department of Neurology and Stroke Centre, University Hospital Basel and University of Basel, Basel, Switzerland
- Neurology and Neurorehabilitation, University Department of Geriatric Medicine FELIX PLATTER, University of Basel, Basel, Switzerland
- Stroke Center, Klinik Hirslanden, Zürich, Switzerland
| |
Collapse
|
9
|
Li Y, Liu X, Chen S, Wang J, Pan C, Li G, Tang Z. Effect of antiplatelet therapy on the incidence, prognosis, and rebleeding of intracerebral hemorrhage. CNS Neurosci Ther 2023; 29:1484-1496. [PMID: 36942509 PMCID: PMC10173719 DOI: 10.1111/cns.14175] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Revised: 03/03/2023] [Accepted: 03/03/2023] [Indexed: 03/23/2023] Open
Abstract
OBJECTIVE Antiplatelet medications are increasingly being used for primary and secondary prevention of ischemic attacks owing to the increasing prevalence of ischemic stroke occurrences. Currently, many patients receive antiplatelet therapy (APT) to prevent thromboembolic events. However, long-term use of APT might also lead to an increased occurrence of intracerebral hemorrhage (ICH) and affect the prognosis of patients with ICH. Furthermore, some research suggest that restarting APT for patients who have previously experienced ICH may result in rebleeding events. The precise relationship between APT and ICH remains unknown. METHODS We searched PubMed for the most recent related literature and summarized the findings from various studies. The search terms included "antiplatelet," "intracerebral hemorrhage," "cerebral microbleeds," "hematoma expansion," "recurrent," and "reinitiate." Clinical studies involving human subjects were ultimately included and interpreted in this review, and animal studies were not discussed. RESULTS When individuals are administered APT, the risk of thrombotic events should be weighted against the risk of bleeding. In general, for some patients' concomitant with risk factors of thrombotic events, the advantages of antiplatelet medication may outweigh the inherent risk of rebleeding. However, the use of antiplatelet medications for other patients with a higher risk of bleeding should be carefully evaluated and closely monitored. In the future, a quantifiable system for assessing thrombotic risk and bleeding risk will be necessary. After evaluation, the appropriate time to restart APT for ICH patients should be determined to prevent underlying ischemic stroke events. According to the present study results and expert experience, most patients now restart APT at around 1 week following the onset of ICH. Nevertheless, the precise time to restart APT should be chosen on a case-by-case basis as per the patient's risk of embolic events and recurrent bleeding. More compelling evidence-based medicine evidence is needed in the future. CONCLUSION This review thoroughly discusses the relationship between APT and the development of ICH, the impact of APT on the course and prognosis of ICH patients, and the factors influencing the decision to restart APT after ICH. However, different studies' conclusions are inconsistent due to the differences in quality control. To support future clinical decisions, more large-scale randomized controlled trials are required.
Collapse
Affiliation(s)
- Yunjie Li
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xia Liu
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Shiling Chen
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Jingyi Wang
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Chao Pan
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Gaigai Li
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Zhouping Tang
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| |
Collapse
|
10
|
Zhao JL, Ai CB, Wang L, Yang SJ, Wang J, Yang W, Tang J, Zhang L, Li Y, Yan TQ, Gou S, Xie GG, Xiang Y. A multicenter, prospective, randomized controlled trial of intracranial hemorrhage risk of intensive statin therapy in patients with acute ischemic stroke combined with cerebral microbleeds (CHRISTMAS): Study protocol. Front Neurol 2023; 14:1097078. [PMID: 36846138 PMCID: PMC9948086 DOI: 10.3389/fneur.2023.1097078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2022] [Accepted: 01/26/2023] [Indexed: 02/11/2023] Open
Abstract
Background Low serum levels of major lipid markers have been proved to be significantly associated with increased risks of hemorrhagic stroke (HS) and cerebral microbleeds (CMBs). However, there is no lipid modification guideline telling us how to maintain a balance between the prevention of ischemic stroke recurrence and the prevention of hemorrhagic events, especially in patients with acute ischemic stroke (AIS) and CMBs. Aim The Intracranial Hemorrhage Risk of Intensive Statin Therapy in Patients with Acute Ischemic Stroke combined with Cerebral Microbleeds (CHRISTMAS) trial evaluates the risk of intracranial hemorrhage (i.e., HS and CMBs) of high-dose statin therapy in patients with AIS combined with CMBs. Methods and design This is an investigator-initiated, multicenter, prospective, randomized controlled clinical trial design. Up to 344 eligible patients will be consecutively randomized to receive high-dose or low-dose atorvastatin in 1:1 ratio in 5 stroke centers in China. Outcomes CHRISTMAS trial has co-primary outcomes, namely, hemorrhage risk: the incidence of HS and the changes in degree of CMBs until the end of 36-month follow-up. Discussion The primary hypothesis of this study is that an excessive reduction in serum lipid levels by an intensive statin therapy in AIS patients with CMBs can increase the risk of intracranial hemorrhage. This study will shed light on new clinical decisions regarding the long-term serum lipid management in these patients with dilemma in clinical practice. Clinical trial registration Clinicaltrials.gov, identifier: NCT05589454.
Collapse
Affiliation(s)
- Jia-ling Zhao
- Department of Neurology, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital, Affiliated Hospital of University of Electronic Science and Technology of China, Chengdu, China
| | - Chi-bo Ai
- Department of Neurology, Yunyang County People's Hospital, Chongqing, China
| | - Li Wang
- Department of Neurology, Zigong Third People's Hospital, Zigong, China
| | - Shao-jie Yang
- Department of Neurology, Chengdu Eighth People's Hospital, Chengdu, China
| | - Jian Wang
- Department of Neurology, Ya'an People's Hospital, Yaan, China
| | - Wei Yang
- Department of Neurology, Yunyang County People's Hospital, Chongqing, China
| | - Jie Tang
- Department of Neurology, Zigong Third People's Hospital, Zigong, China
| | - Ling Zhang
- Department of Neurology, Chengdu Eighth People's Hospital, Chengdu, China
| | - Yan Li
- Department of Neurology, Ya'an People's Hospital, Yaan, China
| | - Ting-qi Yan
- Department of Neurology, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital, Affiliated Hospital of University of Electronic Science and Technology of China, Chengdu, China
| | - Shu Gou
- Department of Neurology, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital, Affiliated Hospital of University of Electronic Science and Technology of China, Chengdu, China
| | - Gui-gui Xie
- Department of Neurology, Yunyang County People's Hospital, Chongqing, China
| | - Yang Xiang
- Department of Neurology, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital, Affiliated Hospital of University of Electronic Science and Technology of China, Chengdu, China,*Correspondence: Yang Xiang ✉
| |
Collapse
|
11
|
Blum S, Conen D. Mechanisms and Clinical Manifestations of Cognitive Decline in Atrial Fibrillation Patients: Potential Implications for Preventing Dementia. Can J Cardiol 2023; 39:159-171. [PMID: 36252904 DOI: 10.1016/j.cjca.2022.10.013] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Revised: 10/10/2022] [Accepted: 10/11/2022] [Indexed: 02/07/2023] Open
Abstract
Atrial fibrillation (AF) patients face an approximate 1.5-fold increased risk of cognitive decline compared with the general population. Among poststroke AF patients, the risk of cognitive decline is even higher with an estimated threefold increase. This article provides a narrative review on the current evidence and highlights gaps in knowledge and areas for future research. Although earlier studies hypothesized that the association between AF and cognitive decline is mainly a consequence of previous ischemic strokes, more recent evidence also suggests such an association in AF patients without a history of clinical stroke. Because AF and cognitive decline mainly occur among elderly individuals, it is not surprising that both entities share multiple risk factors. In addition to clinically overt ischemic strokes, silent brain infarcts and other brain injury are likely mechanisms for the increased risk of cognitive decline among AF patients. Oral anticoagulation for stroke prevention in AF patients with additional stroke risk factors is one of the only proven therapies to prevent brain injury. Whether a broader use of oral anticoagulation, or more intense anticoagulation in some patients are beneficial in this context needs to be addressed in future studies. Although direct studies are lacking, it is reasonable to recommend optimal treatment of comorbidities and risk factors for the prevention of cognitive decline and dementia.
Collapse
Affiliation(s)
- Steffen Blum
- Cardiovascular Research Institute Basel, University Hospital Basel, University of Basel, Basel, Switzerland; Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - David Conen
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada.
| |
Collapse
|
12
|
Best JG, Jesuthasan A, Werring DJ. Cerebral small vessel disease and intracranial bleeding risk: Prognostic and practical significance. Int J Stroke 2023; 18:44-52. [PMID: 35658630 PMCID: PMC9806476 DOI: 10.1177/17474930221106014] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Balancing the risks of recurrent ischemia and antithrombotic-associated bleeding, particularly intracranial hemorrhage (ICH), is a key challenge in the secondary prevention of ischemic stroke and transient ischemic attack. In hyperacute ischemic stroke, the use of acute reperfusion therapies is determined by the balance of anticipated benefit and the risk of ICH. Cerebral small vessel disease (CSVD) causes most spontaneous ICH. Here, we review the evidence linking neuroimaging markers of CSVD to antithrombotic and thrombolytic-associated ICH, with emphasis on cerebral microbleeds (CMB). We discuss their role in the prediction of ICH, and practical implications for clinical decision making. Although current observational data suggest CMB presence should not preclude antithrombotic therapy in patients with ischemic stroke or TIA, they are useful for improving ICH risk prediction with potential relevance for determining the optimal secondary prevention strategy, including the use of left atrial appendage occlusion. Following ICH, recommencing antiplatelets is probably safe in most patients, while the inconclusive results of recent randomized controlled trials of anticoagulant use makes recruitment to ongoing trials (including those testing left atrial appendage occlusion) in this area a high priority. Concern regarding CSVD and ICH risk after hyperacute stroke treatment appears to be unjustified in most patients, though some uncertainty remains regarding patients with very high CMB burden and other risk factors for ICH. We encourage careful phenotyping for underlying CSVD in future trials, with the potential to enhance precision medicine in stroke.
Collapse
Affiliation(s)
| | | | - David J Werring
- David J Werring, Stroke Research Centre,
UCL Queen Square Institute of Neurology, University College London, Russell
Square House, 10 - 12 Russell Square, London, WC1B 5EH, UK.
| |
Collapse
|
13
|
Ravn J, Sejbæk T, Bor MV. Managing antithrombotic treatment in a patient with atrial fibrillation and coronary stent with transient neurological symptoms in cerebral amyloid angiopathy. Clin Case Rep 2022; 10:e6624. [PMID: 36523373 PMCID: PMC9748239 DOI: 10.1002/ccr3.6624] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Revised: 10/09/2022] [Accepted: 11/04/2022] [Indexed: 12/15/2022] Open
Abstract
We present the antithrombotic dilemma in a case with atrial fibrillation and a coronary stent and suspected transient ischemic attacks after diagnosed as a probable cerebral amyloid angiopathy and discuss plausible treatment options for the patient based on the available evidence.
Collapse
Affiliation(s)
- Julie Ravn
- Department of NeurologyUniversity Hospital of Southern DenmarkEsbjergDenmark
| | - Tobias Sejbæk
- Department of NeurologyUniversity Hospital of Southern DenmarkEsbjergDenmark
- BRIDGE – Brain Research – Inter‐Disciplinary Guided Excellence, Department of Regional Health ResearchUniversity of Southern DenmarkOdenseDenmark
| | - Mustafa Vakur Bor
- Thrombosis Research, Department of Regional Health ResearchUniversity of Southern DenmarkEsbjergDenmark
- Thrombosis and Anticoagulation Clinic, Department of Clinical BiochemistryUniversity Hospital of SouthernEsbjergDenmark
| |
Collapse
|
14
|
Wagner B, Hert L, Polymeris AA, Schaedelin S, Lieb JM, Seiffge DJ, Traenka C, Thilemann S, Fladt J, Altersberger VL, Zietz A, Dittrich TD, Fisch U, Gensicke H, De Marchis GM, Bonati LH, Lyrer PA, Engelter ST, Peters N. Impact of type of oral anticoagulants in patients with cerebral microbleeds after atrial fibrillation-related ischemic stroke or TIA: Results of the NOACISP-LONGTERM registry. Front Neurol 2022; 13:964723. [PMID: 36203998 PMCID: PMC9531011 DOI: 10.3389/fneur.2022.964723] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Accepted: 08/23/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundCerebral microbleeds (CMBs) may have a differential impact on clinical outcome in stroke patients with atrial fibrillation (AF) treated with different types of oral anticoagulation (OAC).MethodsObservational single-center study on AF-stroke-patients treated with OAC. Magnetic-resonance-imaging was performed to assess CMBs. Outcome measures consisted of recurrent ischemic stroke (IS), intracranial hemorrhage (ICH), death, and their combined analysis. Functional disability was assessed by mRS. Using adjusted logistic regression and Cox proportional-hazards models, we assessed the association of the presence of CMBs and OAC type (vitamin K antagonists [VKAs] vs. direct oral anticoagulants [DOACs]) with clinical outcome.ResultsOf 310 AF-stroke patients treated with OAC [DOACs: n = 234 (75%); VKAs: n = 76 (25%)], CMBs were present in 86 (28%) patients; of these, 66 (77%) received DOACs. In both groups, CMBs were associated with an increased risk for the composite outcome: VKAs: HR 3.654 [1.614; 8.277]; p = 0.002; DOACs: HR 2.230 [1.233; 4.034]; p = 0.008. Patients with CMBs had ~50% higher absolute rates of the composite outcome compared to the overall cohort, with a comparable ratio between treatment groups [VKAs 13/20(65%) vs. DOACs 19/66(29%); p < 0.01]. The VKA-group had a 2-fold higher IS [VKAs:4 (20%) vs. DOACs:6 (9%); p = 0.35] and a 10-fold higher ICH rate [VKAs: 3 (15%) vs. DOACs: 1 (1.5%); p = 0.038]. No significant interaction was observed between type of OAC and presence of CMBs. DOAC-patients showed a significantly better functional outcome (OR 0.40 [0.17; 0.94]; p = 0.04).ConclusionsIn AF-stroke patients treated with OAC, the presence of CMBs was associated with an unfavorable composite outcome for both VKAs and DOACs, with a higher risk for recurrent IS than for ICH. Strokes were numerically higher under VKAs and increased in the presence of CMBs.Clinical trial registrationhttp://www.clinicaltrials.gov, Unique identifier: NCT03826927.
Collapse
Affiliation(s)
- Benjamin Wagner
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Lisa Hert
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
- Department of Intensive Care Medicine, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Alexandros A. Polymeris
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Sabine Schaedelin
- Clinical Trial Unit, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Johanna M. Lieb
- Department of Diagnostic and Interventional Neuroradiology, Clinic for Radiology and Nuclear Medicine, University Hospital Basel and University of Basel, Basel, Switzerland
| | - David J. Seiffge
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Christopher Traenka
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
- Neurology and Neurorehabilitation, University Department of Geriatric Medicine Felix Platter and Department of Clinical Research, University of Basel, Basel, Switzerland
| | - Sebastian Thilemann
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Joachim Fladt
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Valerian L. Altersberger
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Annaelle Zietz
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Tolga D. Dittrich
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Urs Fisch
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Henrik Gensicke
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
- Neurology and Neurorehabilitation, University Department of Geriatric Medicine Felix Platter and Department of Clinical Research, University of Basel, Basel, Switzerland
| | - Gian Marco De Marchis
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Leo H. Bonati
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Philippe A. Lyrer
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Stefan T. Engelter
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
- Neurology and Neurorehabilitation, University Department of Geriatric Medicine Felix Platter and Department of Clinical Research, University of Basel, Basel, Switzerland
| | - Nils Peters
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
- Neurology and Neurorehabilitation, University Department of Geriatric Medicine Felix Platter and Department of Clinical Research, University of Basel, Basel, Switzerland
- Stroke Center, Klinik Hirslanden Zurich, Zurich, Switzerland
- *Correspondence: Nils Peters
| |
Collapse
|
15
|
Embolic infarct topology differs between atrial fibrillation subtypes and embolic stroke of undetermined source. J Stroke Cerebrovasc Dis 2022; 31:106782. [PMID: 36130470 DOI: 10.1016/j.jstrokecerebrovasdis.2022.106782] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Revised: 09/07/2022] [Accepted: 09/10/2022] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND The lack of superiority of anticoagulation over antiplatelet therapy in embolic stroke of undetermined source (ESUS) may be in part due to the misclassification of radiographic ESUS patterns as cardioembolic. In this imaging analysis, we sought to differentiate clinical and radiographic patterns of ESUS patients from patterns in patients with a highly probable cardioembolic source. MATERIALS & METHODS A prospective registry of consecutive adults with acute infarction on diffusion-weighted magnetic resonance imaging was queried. Patients with infarctions due to small vessel disease, large vessel disease, and other causes were excluded. Multivariable logistic regression was used to identify independent predictors of two potentially embolic patterns: (1) multifocal and (2) cortical lesions, comparing patients with ESUS against those with atrial fibrillation (AF). RESULTS Among 1243 screened patients, 343 (27.6%) experienced strokes due to ESUS or AF. Prior to the index stroke, patients with AF as compared to ESUS were older (median 75 vs. 65, p<0.01) and had more heart failure (25.9% vs. 8.4%, p<0.01). The odds of multifocal infarction were the same between patients with ESUS and both AF subtypes (p>0.05), however, cortical involvement was more associated with both AF versus ESUS (77.7% vs. 65.7%, P=0.02). A higher Fazekas grade of white matter disease was inversely associated with cortical infarction among included patients (aOR 0.77, 95% CI 0.62-0.96). CONCLUSION Cortical infarctions were twice as common among patients with AF versus ESUS. Subcortical infarct topography was strongly associated with chronic microvascular ischemic changes and therefore may not represent embolic phenomena. Larger-scale investigations are warranted to discern whether large or multifocal subcortical infarcts ought to be excluded from the ESUS designation.
Collapse
|
16
|
Lim MJR, Zheng Y, Soh RYH, Foo QXJ, Djohan AH, Nga Diong Weng V, Ho JSY, Yeo TT, Sim HW, Yeo TC, Tan HC, Chan MYY, Loh JPY, Sia CH. Symptomatic intracerebral hemorrhage after non-emergency percutaneous coronary intervention: Incidence, risk factors, and association with cardiovascular outcomes. Front Cardiovasc Med 2022; 9:936498. [PMID: 36186990 PMCID: PMC9524143 DOI: 10.3389/fcvm.2022.936498] [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: 05/05/2022] [Accepted: 08/29/2022] [Indexed: 12/04/2022] Open
Abstract
Objective To investigate the incidence, risk factors, and association with cardiovascular outcomes of patients who developed symptomatic intracerebral hemorrhage (ICH) after non-emergency percutaneous coronary intervention (PCI). Methods We conducted a single-institution retrospective study of patients who developed symptomatic ICH after non-emergency PCI. To identify associations between clinical variables and outcomes, Cox-proportional hazards regression models were constructed. Outcomes analyzed include (1) all-cause mortality, (2) acute ischemic stroke (AIS) or transient ischemic attack (TIA), and (3) major adverse cardiovascular events (MACE). Results A total of 1,732 patients were included in the analysis. The mean (±SD) age was 61.1 (±11.3) years, and 1,396 patients (80.6%) were male. The cumulative incidence of symptomatic ICH after non-emergency PCI was 1.3% (22 patients). Age, chronic kidney disease, and prior coronary artery bypass graft surgery were independently associated with a higher risk of ICH after PCI, while hyperlipidemia was independently associated with a lower risk of ICH after PCI. ICH after PCI was independently associated with a higher risk of all-cause mortality and AIS or TIA after PCI. Conclusion Patients who are older, who have chronic kidney disease, and who have had prior coronary artery bypass graft surgery should be monitored for symptomatic ICH after non-emergency PCI.
Collapse
Affiliation(s)
- Mervyn Jun Rui Lim
- Division of Neurosurgery, National University Health System, Singapore, Singapore
- *Correspondence: Mervyn Jun Rui Lim
| | - Yilong Zheng
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Rodney Yu-Hang Soh
- Department of Cardiology, National University Heart Centre, Singapore, Singapore
| | - Qi Xuan Joel Foo
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | | | | | - Jamie Sin-Ying Ho
- Academic Foundation Programme, North Middlesex University Hospital Trust, London, United Kingdom
| | - Tseng Tsai Yeo
- Division of Neurosurgery, National University Health System, Singapore, Singapore
| | - Hui-Wen Sim
- Department of Cardiology, National University Heart Centre, Singapore, Singapore
| | - Tiong-Cheng Yeo
- Department of Cardiology, National University Heart Centre, Singapore, Singapore
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Huay-Cheem Tan
- Department of Cardiology, National University Heart Centre, Singapore, Singapore
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Mark Yan-Yee Chan
- Department of Cardiology, National University Heart Centre, Singapore, Singapore
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Joshua Ping-Yun Loh
- Department of Cardiology, National University Heart Centre, Singapore, Singapore
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Ching-Hui Sia
- Department of Cardiology, National University Heart Centre, Singapore, Singapore
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| |
Collapse
|
17
|
Zhao DX, Gootee E, Johansen MC. Atrial cardiopathy is associated with cerebral microbleeds in ischemic stroke patients. Front Neurol 2022; 13:982926. [PMID: 36119677 PMCID: PMC9475192 DOI: 10.3389/fneur.2022.982926] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Accepted: 08/02/2022] [Indexed: 11/13/2022] Open
Abstract
ObjectiveCerebral microbleeds (CMB) are small accumulations of hemosiderin associated with cerebrovascular risk factors, but whether they are associated with atrial cardiopathy is not known. The goal of this study is to determine, among ischemic stroke patients, the association between study-defined atrial cardiopathy and CMB presence, location, and number.MethodsIschemic stroke patients admitted to Johns Hopkins (2015–2019) with transthoracic echocardiography and electrocardiography were included. Cerebral microbleeds were defined as small, round hypo-intensities on T2* susceptibility weighted imaging or gradient recalled echo magnetic resonance imaging sequences. Atrial cardiopathy was defined as the presence of ≥1: left atrium diameter >4.0 cm (males) or >3.8 cm (females), PR interval >200 ms, or N-terminal pro-B-type natriuretic peptide >250 pg/ml. Binary/Ordinal logistic regression models were used to determine the association between atrial cardiopathy, and cerebral microbleed presence, location (lobar/deep), or number, each, adjusted for potential confounders.ResultsPatients (N = 120) were mean age 60 years (range 22–98), 46% female, 62% black, and 39% were on anti-thrombotic medication at time of admission. 39 (32%) participants had ≥1 cerebral microbleeds. Forty-six (38%) patients had atrial cardiopathy. Atrial cardiopathy was associated with higher odds of having cerebral microbleeds (OR 2.50, 95% CI 1.02–6.15). Atrial cardiopathy was associated with lobar cerebral microbleeds (OR 2.33, 95% CI 1.01–5.37) in univariate analysis but not with deep cerebral microbleeds (OR 0.45, 95% CI 0.13–1.54), with neither association significant after adjustment. There was no difference in risk of having 1 vs. no cerebral microbleeds (RRR 2.51, 95% CI 0.75–8.37) and >1 cerebral microbleed vs none (RRR 2.57, 95% CI 0.87–7.60) among those with atrial cardiopathy.ConclusionsAtrial cardiopathy is associated with the presence, but not burden, of cerebral microbleeds in ischemic stroke patients. We cautiously suggest that atrial cardiopathy, either directly or through shared vascular risk, may contribute to the presence of CMB.
Collapse
|
18
|
Best JG, Cardus B, Klijn CJM, Lip G, Seiffge DJ, Smith EE, Werring DJ. Antithrombotic dilemmas in stroke medicine: new data, unsolved challenges. J Neurol Neurosurg Psychiatry 2022; 93:jnnp-2020-325249. [PMID: 35728935 DOI: 10.1136/jnnp-2020-325249] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Accepted: 05/16/2022] [Indexed: 11/04/2022]
Abstract
Antithrombotic therapy is a key element of secondary prevention in patients who have had an ischaemic stroke or transient ischaemic attack. However, its use in clinical practice is not always straightforward. This review provides an update on certain difficult scenarios in antithrombotic management, with a focus on recent clinical trials and large observational studies. We discuss the approach to patients with an indication for antithrombotic treatment who also have clinical or radiological evidence of previous intracranial bleeding, patients with indications for both anticoagulant and antiplatelet treatment, and patients in whom antithrombotic treatment fails to prevent stroke. We also review the timing of anticoagulation initiation after cardioembolic stroke, and the use of antithrombotics in patients with asymptomatic cerebrovascular disease. Despite a wealth of new evidence, numerous uncertainties remain and we highlight ongoing trials addressing these.
Collapse
Affiliation(s)
- Jonathan G Best
- Stroke Research Centre, UCL Queen Square Institute of Neurology, London, UK
| | - Beatrix Cardus
- Royal Surrey County Hospital, Royal Surrey NHS Foundation Trust, Guildford, UK
| | - Catharina J M Klijn
- Department of Neurology, Radboud University Medical Centre, Donders Institute for Brain, Cognition and Behaviour, Nijmegen, Netherlands
| | - Gregory Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool, UK
- Aalborg Thrombosis Research Unit, Aalborg University, Aalborg, Denmark
| | - David J Seiffge
- Department of Neurology, Inselspital University Hospital, Bern, Switzerland
| | - Eric E Smith
- Calgary Stroke Program, Department of Clinical Neurosciences, Radiology and Community Health Sciences, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
| | - David J Werring
- Stroke Research Centre, UCL Queen Square Institute of Neurology, London, UK
| |
Collapse
|
19
|
Shimizu T, Ueno Y, Tateishi Y, Doijiri R, Kuriki A, Kikuno M, Takekawa H, Shimada Y, Kanemaru K, Kamiya Y, Yamaguchi E, Koga M, Ihara M, Tsujino A, Hirata K, Hasegawa Y, Hattori N, Urabe T. Evaluating the Potential Pathology and Short-Term Outcomes of Cryptogenic Stroke Using the Etiological Classification System. J Atheroscler Thromb 2022; 30:377-389. [PMID: 35691846 PMCID: PMC10067338 DOI: 10.5551/jat.63267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
AIM Various embolic sources and pathogenetic mechanisms underlie cryptogenic stroke (CS). We investigated the association of etiological diversity with short-term outcomes in patients with CS using a modified atherosclerosis (A), small-vessel disease (S), cardiac pathology (C), other causes (O), and dissection (D) (ASCOD) system. METHODS Patients with CS who underwent transesophageal echocardiography were registered in this multicenter, observational study. In the modified classification system, O and D were inapplicable and thus excluded. Instead, atherosclerosis, small-vessel disease, cardiac pathology-CS classification was specifically constructed for the etiological diagnosis of CS. We utilized this system to explore the mechanism of CS by grading each pathology and evaluated its association with poorer modified Rankin Scale scores of 3-6 at hospital discharge. RESULTS A total of 672 patients (68.7±12.8 years, 220 females) were analyzed. In the multiple logistic regression model, female sex (odds ratio [OR], 1.87 [1.15-3.04]; P=0.012), body mass index (OR, 0.93 [0.88-0.99]; P=0.025), National Institute of Health Stroke Scale score (OR, 1.16 [1.12-1.21]; P<0.001), CHADS2 score (OR, 1.56 [1.30-1.86]; P<0.001), D-dimer (OR, 1.04 [1.01-1.08]; P=0.015), diffusion-weighted image (DWI) lesion size (OR, 1.44 [1.10-1.89]; P=0.009), and S+C score (OR, 1.26 [1.03-1.56]; P=0.029) were associated with poor functional outcome at discharge whereas the S+C score was marginally associated with poor functional outcome after excluding 137 patients with a premorbid modified Rankin Scale score of ≥ 3. CONCLUSIONS The coexistence of small-vessel disease and cardiac pathology might be associated with poor in-hospital functional outcome in CS.
Collapse
Affiliation(s)
- Takahiro Shimizu
- Department of Neurology, St. Marianna University School of Medicine
| | - Yuji Ueno
- Department of Neurology, Juntendo University Faculty of Medicine
| | - Yohei Tateishi
- Department of Neurology and Strokology, Nagasaki University Hospital
| | | | - Ayako Kuriki
- Department of Neurology, Showa University Koto Toyosu Hospital
| | - Muneaki Kikuno
- Department of Neurology, Tokyo Medical University.,Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center
| | | | | | - Kodai Kanemaru
- Department of Neurology, Tokyo Medical University.,Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center
| | - Yuki Kamiya
- Department of Neurology, Showa University Koto Toyosu Hospital
| | | | - Masatoshi Koga
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center
| | - Masafumi Ihara
- Department of Neurology, National Cerebral and Cardiovascular Center
| | - Akira Tsujino
- Department of Neurology and Strokology, Nagasaki University Hospital
| | | | | | - Nobutaka Hattori
- Department of Neurology, Juntendo University Faculty of Medicine
| | - Takao Urabe
- Department of Neurology, Juntendo University Urayasu Hospital
| |
Collapse
|
20
|
Lattanzi S, Acampa M, Norata D, Broggi S, Caso V. A critical assessment of the current pharmacotherapy for the treatment of embolic strokes of undetermined source. Expert Opin Pharmacother 2022; 23:905-915. [PMID: 35470761 DOI: 10.1080/14656566.2022.2071125] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION "Embolic stroke of undetermined source" (ESUS) is a term coined to identify non-lacunar stroke whose mechanism is likely to be embolic, and the source remains unidentified. The best antithrombotic treatment for preventing stroke recurrence in this population has not been delineated. AREAS COVERED The authors summarize and critically appraise the currently available evidence about the antithrombotic treatment for preventing stroke recurrence in patients with ESUS. Randomized trials addressing this topic were identified through MEDLINE (accessed by PubMed, as of November 2021, week 4). EXPERT OPINION Recent randomized trials have failed to demonstrate a significant benefit of direct oral anticoagulants over aspirin in reducing the recurrence of cerebral infarctions in unselected cohorts of patients with ESUS. The heterogeneity and often overlap of embolic sources may be possible explanations for the overall absence of a benefit of oral anticoagulants in ESUS as a single homogeneous entity. The results of these trials and their subgroup analyses have provided important cues to understand the pathophysiology of ESUS. They have, furthermore, increased in the interest in researchers in identifying distinct etiological phenotypes within this stroke population. There is a good rationale for ongoing and future investigations in order to tailor antithrombotic treatment according to individual features of patients with ESUS.
Collapse
Affiliation(s)
- Simona Lattanzi
- Neurological Clinic, Department of Experimental and Clinical Medicine, Marche Polytechnic University, Ancona, Italy
| | | | - Davide Norata
- Neurological Clinic, Department of Experimental and Clinical Medicine, Marche Polytechnic University, Ancona, Italy
| | - Serena Broggi
- Neurological Clinic, Department of Experimental and Clinical Medicine, Marche Polytechnic University, Ancona, Italy
| | - Valeria Caso
- Stroke Unit, Santa Maria della Misericordia Hospital, University of Perugia, Perugia, Italy
| |
Collapse
|
21
|
Grory BM, Yaghi S, Cordonnier C, Sposato LA, Romano JG, Chaturvedi S. Advances in Recurrent Stroke Prevention: Focus on Antithrombotic Therapies. Circ Res 2022; 130:1075-1094. [PMID: 35420910 PMCID: PMC9015232 DOI: 10.1161/circresaha.121.319947] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
The past decade has seen significant advances in stroke prevention. These advances include new antithrombotic agents, new options for dyslipidemia treatment, and novel techniques for surgical stroke prevention. In addition, there is greater recognition of the benefits of multifaceted interventions, including the role of physical activity and dietary modification. Despite these advances, the aging of the population and the high prevalence of key vascular risk factors pose challenges to reducing the burden of stroke. Using a cause-based framework, current approaches to prevention of cardioembolic, cryptogenic, atherosclerotic, and small vessel disease stroke are outlined in this paper. Special emphasis is given to recent trials of antithrombotic agents, including studies that have tested combination treatments and responses according to genetic factors.
Collapse
Affiliation(s)
| | | | - Charlotte Cordonnier
- Univ. Lille, Inserm, CHU Lille, U1172 - LilNCog - Lille Neuroscience & Cognition, F-59000 Lille, France
| | | | | | | |
Collapse
|
22
|
Battistin U, AlQassim N, Hallak Y, Mohammed M, Hasan A, Oluwole OJ. Cerebral Amyloid Angiopathy and Atrial Fibrillation: An up to Date Case Report. Neurohospitalist 2022; 12:391-394. [PMID: 35419135 PMCID: PMC8995587 DOI: 10.1177/19418744211067353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Concurrent Cerebral Amyloid Angiopathy (CAA) and Atrial Fibrillation are becoming an increasingly common dilemma in clinical practice due to the aging population and the comorbidities associated with it. In such patients, the physician must appreciate and strike the difficult balance between the risk of ischemic strokes from atrial fibrillation on one hand, and that of intracerebral hemorrhage from coexisting CAA on the other. Anticoagulation is necessary for the former but potentially deleterious for the latter. In this case report, we present the case of a 67-year-old woman with a long history of atrial fibrillation on rivaroxaban who recently began to experience recurrent transient neurological deficits that were later diagnosed as amyloid spells related to concomitant CAA. While there is no clear-cut consensus in published literature on how to best manage these patients regarding the use of anticoagulation, it is recommended to involve a multidisciplinary team for optimal management of these patients.
Collapse
Affiliation(s)
- Umberto Battistin
- College of Medicine, Mohammad Bin Rashid University of Medicine and Health Sciences, Dubai, UAE
| | - Noora AlQassim
- College of Medicine, Mohammad Bin Rashid University of Medicine and Health Sciences, Dubai, UAE
| | - Yusuf Hallak
- College of Medicine, Mohammad Bin Rashid University of Medicine and Health Sciences, Dubai, UAE
| | - Marwa Mohammed
- College of Medicine, Mohammad Bin Rashid University of Medicine and Health Sciences, Dubai, UAE
| | - Ahmedyar Hasan
- College of Medicine, Mohammad Bin Rashid University of Medicine and Health Sciences, Dubai, UAE
| | | |
Collapse
|
23
|
Schlemm L, Braemswig TB, Boutitie F, Vynckier J, Jensen M, Galinovic I, Simonsen CZ, Cheng B, Cho TH, Fiehler J, Puig J, Thijs V, Fiebach J, Muir K, Nighoghossian N, Ebinger M, Pedraza S, Thomalla G, Gerloff C, Endres M, Lemmens R, Nolte CH. Cerebral Microbleeds and Treatment Effect of Intravenous Thrombolysis in Acute Stroke: An Analysis of the WAKE-UP Randomized Clinical Trial. Neurology 2021; 98:e302-e314. [PMID: 34782419 PMCID: PMC8792812 DOI: 10.1212/wnl.0000000000013055] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Accepted: 11/04/2021] [Indexed: 11/17/2022] Open
Abstract
Background and Objectives Cerebral microbleeds (CMBs) are common in patients with acute ischemic stroke and are associated with increased risk of intracerebral hemorrhage (ICH) after intravenous thrombolysis. Whether CMBs modify the treatment effect of thrombolysis is unknown. Methods We performed a prespecified analysis of the prospective randomized controlled multicenter Efficacy and Safety of MRI-Based Thrombolysis in Wake-Up Stroke (WAKE-UP) trial including patients with acute ischemic stroke with unknown time of symptom onset and diffusion-weighted imaging–fluid-attenuated inversion recovery mismatch on MRI receiving alteplase or placebo. Patients were screened and enrolled between September 2012 and June 2017 (with final follow-up in September 2017). Patients were randomized to treatment with IV thrombolysis with alteplase at 0.9 mg/kg body weight or placebo. CMB status (presence, number, and distribution) was assessed after study completion by 3 raters blinded to clinical information following a standardized protocol. Outcome measures were excellent functional outcome at 90 days, defined by modified Rankin Scale (mRS) score ≤1, and symptomatic ICH according to National Institutes of Neurological Disease and Stroke trial criteria 22 to 36 hours after treatment. Results Of 503 patients enrolled in the WAKE-UP trial, 459 (91.3%; 288 [63%] men) were available for analysis. Ninety-eight (21.4%) had at least 1 CMB on baseline imaging; 45 (9.8%) had exactly 1 CMB; 37 (8.1%) had 2 to 4 CMBs; and 16 (3.5%) had ≥5 CMBs. Presence of CMBs was associated with a nonsignificant increased risk of symptomatic ICH (11.2% vs 4.2%; adjusted odds ratio [OR] 2.32, 95% confidence interval [CI] 0.99–5.43, p = 0.052) but had no effect on functional outcome at 90 days (mRS score ≤1: 45.8% vs 50.7%; adjusted OR 0.99, 95% CI 0.59–1.64, p = 0.955). Patients receiving alteplase had better functional outcome (mRS score ≤1: 54.6% vs 44.6%, adjusted OR 1.61, 95% CI 1.07–2.43, p = 0.022) without evidence of heterogeneity in relation to CMB presence (p of the interactive term = 0.546). Results were similar for subpopulations with strictly lobar (presumed cerebral amyloid angiopathy related) or not strictly lobar CMB distribution. Discussion In the randomized-controlled WAKE-UP trial, we saw no evidence of reduced treatment effect of alteplase in patients with acute ischemic stroke with ≥1 CMBs. Additional studies are needed to determine the treatment effect of alteplase and its benefit-harm ratio in patients with a larger number of CMBs. Trial Registration Information ClinicalTrials.gov identifier NCT01525290; ClinicalTrialsRegister.EU identifier 2011-005906-32. Classification of Evidence This study provides Class II evidence that for patients with acute ischemic stroke with unknown time of onset and diffusion-weighted imaging–fluid-attenuated inversion recovery mismatch who received IV alteplase, CMBs are not significantly associated with functional outcome at 90 days.
Collapse
Affiliation(s)
- Ludwig Schlemm
- Klinik und Hochschulambulanz für Neurologie, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health (BIH), Berlin, Germany.,Center for Stroke Research Berlin (CSB), Charité - Universitätsmedizin, Berlin, Germany.,Berlin Institute of Health (BIH), Berlin, Germany
| | - Tim Bastian Braemswig
- Klinik und Hochschulambulanz für Neurologie, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health (BIH), Berlin, Germany.,Center for Stroke Research Berlin (CSB), Charité - Universitätsmedizin, Berlin, Germany.,Berlin Institute of Health (BIH), Berlin, Germany
| | - Florent Boutitie
- Hospices Civils de Lyon, Service de Biostatistique, Lyon, France.,Université Lyon 1 and Centre National de la Recherche Scientifique, UMR 5558, Laboratoire de Biométrie et Biologie Evolutive, Equipe Biostatistique-Santé, Villeurbanne, France
| | - Jan Vynckier
- Department of Neurology, University Hospital Bern, Bern, Switzerland
| | - Märit Jensen
- Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Ivana Galinovic
- Center for Stroke Research Berlin (CSB), Charité - Universitätsmedizin, Berlin, Germany
| | - Claus Z Simonsen
- Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
| | - Bastian Cheng
- Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Tae-Hee Cho
- Department of Stroke Medicine, Université Claude Bernard Lyon 1, and Hospices Civils de Lyon, Lyon, France
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Josep Puig
- Department of Radiology, Hospital Universitari Doctor Josep Trueta, Institut d'Investigació Biomèdica de Girona, Girona, Spain
| | - Vincent Thijs
- Florey Institute of Neuroscience and Mental Health, Heidelberg, VIC, Australia
| | - Jochen Fiebach
- Center for Stroke Research Berlin (CSB), Charité - Universitätsmedizin, Berlin, Germany
| | - Keith Muir
- Institute of Neuroscience and, University of Glasgow, Glasgow, United Kingdom
| | - Norbert Nighoghossian
- Department of Stroke Medicine, Université Claude Bernard Lyon 1, and Hospices Civils de Lyon, Lyon, France
| | - Martin Ebinger
- Center for Stroke Research Berlin (CSB), Charité - Universitätsmedizin, Berlin, Germany.,Department of Neurology, Medical Park Berlin Humboldtmühle, Berlin, Germany
| | - Salvador Pedraza
- Department of Radiology, Hospital Universitari Doctor Josep Trueta, Institut d'Investigació Biomèdica de Girona, Girona, Spain
| | - Götz Thomalla
- Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Christian Gerloff
- Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Matthias Endres
- Klinik und Hochschulambulanz für Neurologie, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health (BIH), Berlin, Germany.,Center for Stroke Research Berlin (CSB), Charité - Universitätsmedizin, Berlin, Germany.,Berlin Institute of Health (BIH), Berlin, Germany
| | - Robin Lemmens
- Department of Neurology, University Hospitals Leuven, Leuven, Belgium.,Department of Neurosciences, Experimental Neurology, KU Leuven-University of Leuven, Leuven, Belgium.,VIB-KU Leuven Center for Brain and Disease Research, Laboratory of Neurobiology, Leuven, Belgium
| | - Christian H Nolte
- Klinik und Hochschulambulanz für Neurologie, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health (BIH), Berlin, Germany .,Center for Stroke Research Berlin (CSB), Charité - Universitätsmedizin, Berlin, Germany.,Berlin Institute of Health (BIH), Berlin, Germany.,German Center for Cardiovascular Research (DZHK), Partner Site Berlin, Berlin, Germany.,German Center for Neurodegenerative Diseases (DZNE), Partner Site Berlin, Berlin, Germany
| | | |
Collapse
|
24
|
Puy L, Cordonnier C. Cerebral Microbleeds and Antithrombotic Treatments-Stop Worrying About Bleeding. JAMA Neurol 2021; 78:9-10. [PMID: 33074292 DOI: 10.1001/jamaneurol.2020.3847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Laurent Puy
- Université Lille, Inserm, CHU Lille, U1172-LilNCog-Lille Neuroscience & Cognition, F-59000 Lille, France
| | - Charlotte Cordonnier
- Université Lille, Inserm, CHU Lille, U1172-LilNCog-Lille Neuroscience & Cognition, F-59000 Lille, France
| |
Collapse
|
25
|
Patel K, Mikhael E, Liu M, Rangaraju S, Ellis D, Duncan A, Belagaje S, Belair T, Henriquez L, Nahab F. Anticoagulation Therapy Reduces Recurrent Stroke in Embolic Stroke of Undetermined Source Patients With Elevated Coagulation Markers or Severe Left Atrial Enlargement. Front Neurol 2021; 12:695378. [PMID: 34163432 PMCID: PMC8215436 DOI: 10.3389/fneur.2021.695378] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Accepted: 05/10/2021] [Indexed: 12/03/2022] Open
Abstract
Background: The objective of this study was to evaluate if anticoagulation therapy reduces recurrent stroke in embolic stroke of undetermined source (ESUS) patients with left atrial enlargement (LAE) or abnormal markers of coagulation and hemostatic activity (MOCHA) compared to antiplatelet therapy. Methods: ESUS patients from January 1, 2017, to June 30, 2019, underwent outpatient cardiac monitoring and the MOCHA profile (serum d-dimer, prothrombin fragment 1.2, thrombin–antithrombin complex, and fibrin monomer). Anticoagulation was offered to patients with abnormal MOCHA (≥2 elevated markers) or left atrial volume index 40 mL/m2. Patients were evaluated for recurrent stroke or major hemorrhage at routine clinical follow-up. We compared this patient cohort (cohort 2) to a historical cohort (cohort 1) who underwent the same protocol but remained on antiplatelet therapy. Results: Baseline characteristics in cohort 2 (n = 196; mean age = 63 ± 16 years, 59% female, 49% non-White) were similar to cohort 1 (n = 42) except that cohort 2 had less diabetes (43 vs. 24%, p = 0.01) and more tobacco use (26 vs. 43%, p = 0.04). Overall, 45 patients (23%) in cohort 2 initiated anticoagulation based on abnormal MOCHA or LAE. During mean follow-up of 13 ± 10 months, cohort 2 had significantly lower recurrent stroke rates than cohort 1 (14 vs. 3%, p = 0.009) with no major hemorrhages. Conclusions: Anticoagulation therapy in a subgroup of ESUS patients with abnormal MOCHA or severe LAE may be associated with a reduced rate of recurrent stroke compared to antiplatelet therapy. A prospective, randomized study is warranted to validate these results.
Collapse
Affiliation(s)
- Kishan Patel
- Department of Neurology, Providence St. Joseph Health, Portland, OR, United States
| | - Elio Mikhael
- Department of Medicine, Saint-Joseph University, Beirut, Lebanon
| | - Michael Liu
- Department of Neurology, Mayo Clinic, Rochester, MN, United States
| | - Srikant Rangaraju
- Department of Neurology, Emory University, Atlanta, GA, United States
| | - Deandra Ellis
- Department of Neurology and Pediatrics, Emory University, Atlanta, GA, United States
| | - Alexander Duncan
- Department of Pathology & Laboratory Medicine, Emory University, Atlanta, GA, United States
| | - Samir Belagaje
- Department of Neurology and Pediatrics, Emory University, Atlanta, GA, United States
| | - Trina Belair
- Department of Neurology and Pediatrics, Emory University, Atlanta, GA, United States
| | - Laura Henriquez
- Department of Neurology and Pediatrics, Emory University, Atlanta, GA, United States
| | - Fadi Nahab
- Department of Neurology and Pediatrics, Emory University, Atlanta, GA, United States
| |
Collapse
|
26
|
Error in P Value in Abstract and Results. JAMA Neurol 2021; 78:120. [PMID: 33252627 DOI: 10.1001/jamaneurol.2020.4698] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
|