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Zhu L, Zhong W, Meng X, Yang X, Zhang W, Tian Y, Li Y. Polymeric nanocarriers delivery systems in ischemic stroke for targeted therapeutic strategies. J Nanobiotechnology 2024; 22:424. [PMID: 39026255 PMCID: PMC11256638 DOI: 10.1186/s12951-024-02673-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Accepted: 06/25/2024] [Indexed: 07/20/2024] Open
Abstract
Ischemic stroke is a complex, high-mortality disease with multifactorial etiology and pathogenesis. Currently, drug therapy is mainly used treat ischemic stroke in clinic, but there are still some limitations, such as limited blood-brain barrier (BBB) penetration efficiency, a narrow treatment time window and drug side effects. Recent studies have pointed out that drug delivery systems based on polymeric nanocarriers can effectively improve the insufficient treatment for ischemic stroke. They can provide neuronal protection by extending the plasma half-life of drugs, enhancing the drug's permeability to penetrate the BBB, and targeting specific structures and cells. In this review, we classified polymeric nanocarriers used for delivering ischemic stroke drugs and introduced their preparation methods. We also evaluated the feasibility and effectiveness and discussed the existing limitations and prospects of polymeric nanocarriers for ischemic stroke treatment. We hoped that this review could provide a theoretical basis for the future development of nanomedicine delivery systems for the treatment of ischemic stroke.
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Affiliation(s)
- Lin Zhu
- Department of Neurosurgery, Ninth People Hospital, Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, 200011, People's Republic of China
| | - Weijie Zhong
- Department of Neurosurgery, Ninth People Hospital, Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, 200011, People's Republic of China
| | - Xuchen Meng
- Department of Neurosurgery, Ninth People Hospital, Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, 200011, People's Republic of China
| | - Xiaosheng Yang
- Department of Neurosurgery, Ninth People Hospital, Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, 200011, People's Republic of China
| | - Wenchuan Zhang
- Department of Neurosurgery, Ninth People Hospital, Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, 200011, People's Republic of China
| | - Yayuan Tian
- Department of Neurosurgery, Ninth People Hospital, Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, 200011, People's Republic of China.
| | - Yi Li
- Department of Neurosurgery, Ninth People Hospital, Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, 200011, People's Republic of China.
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Mbalinda SN, Kaddumukasa M, Najjuma JN, Kaddumukasa M, Nakibuuka J, Burant CJ, Moore S, Blixen C, Katabira ET, Sajatovic M. Stroke Recurrence Rate and Risk Factors Among Stroke Survivors in Sub-Saharan Africa: A Systematic Review. Neuropsychiatr Dis Treat 2024; 20:783-791. [PMID: 38586306 PMCID: PMC10999215 DOI: 10.2147/ndt.s442507] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Accepted: 03/22/2024] [Indexed: 04/09/2024] Open
Abstract
Purpose Evidence supporting secondary stroke in sub-Saharan Africa is scarce. This study describes the incidence of stroke recurrence and associated risk factors in sub-Saharan Africa. Methods and Materials Scientific databases were systematically searched from January 2000 to December 2022 for population-based observational studies, case-control or cohort studies of recurrent stroke involving adults aged 18 years and above in sub-Saharan Africa (SSA). We assessed the quality of the eligible studies using the Critical Appraisal Skills Program (CASP) checklist for observational studies. Results Six studies met the inclusion criteria and were included in this study. Stroke recurrence rates in SSA ranged from 9.4% to 25%. Majority of the studies were conducted from Western Africa and showed that stroke recurrence rates are high within sub-Saharan Africa ranging from 2% to 25%. The known stroke risk factors such as hypertension, chronic alcohol consumption, etc., remained the leading causes of stroke recurrence. The studies reported a higher mortality rate ranging from 20.5 -23% among those with recurrent strokes compared to primary strokes. Conclusion This systematic review is an update and summary of the available literature on stroke recurrence within sub-Saharan Africa. Further studies are warranted to assess the outcomes and burden of stroke recurrence in SSA.
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Affiliation(s)
- Scovia Nalugo Mbalinda
- Department of Nursing, School of Health Sciences, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Mark Kaddumukasa
- Department of Medicine, School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
| | | | - Martin Kaddumukasa
- Department of Nursing, School of Health Sciences, College of Health Sciences, Makerere University, Kampala, Uganda
- Department of Medicine, Mulago Hospital, Kampala, Uganda
| | - Jane Nakibuuka
- Department of Nursing, School of Health Sciences, College of Health Sciences, Makerere University, Kampala, Uganda
- Department of Medicine, Mulago Hospital, Kampala, Uganda
| | - Christopher J Burant
- Louis Stokes VA Medical Center, Geriatric Research Education, and Clinical Center, Cleveland, OH, 44106, USA
| | - Shirley Moore
- Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, OH, 44106, USA
| | - Carol Blixen
- Neurological and Behavioral Outcomes Center, University Hospitals Cleveland Medical Center & Case Western Reserve University School of Medicine, Cleveland, OH, 44106, USA
| | - Elly T Katabira
- Department of Nursing, School of Health Sciences, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Martha Sajatovic
- Neurological and Behavioral Outcomes Center, University Hospitals Cleveland Medical Center & Case Western Reserve University School of Medicine, Cleveland, OH, 44106, USA
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Abstract
BACKGROUND Cerebrolysin is a mixture of low-molecular-weight peptides and amino acids derived from porcine brain, which has potential neuroprotective properties. It is widely used in the treatment of acute ischaemic stroke in Russia, Eastern Europe, China, and other Asian and post-Soviet countries. This is an update of a review first published in 2010 and last updated in 2020. OBJECTIVES To assess the benefits and harms of Cerebrolysin or Cerebrolysin-like agents for treating acute ischaemic stroke. SEARCH METHODS We searched the Cochrane Stroke Trials Register, CENTRAL, MEDLINE, Embase, Web of Science Core Collection, with Science Citation Index, and LILACS in May 2022 and a number of Russian databases in June 2022. We also searched reference lists, ongoing trials registers, and conference proceedings. SELECTION CRITERIA Randomised controlled trials (RCTs) comparing Cerebrolysin or Cerebrolysin-like agents started within 48 hours of stroke onset and continued for any length of time, with placebo or no treatment in people with acute ischaemic stroke. DATA COLLECTION AND ANALYSIS Three review authors independently applied the inclusion criteria, assessed trial quality and risk of bias, extracted data, and applied GRADE criteria to the evidence. MAIN RESULTS Seven RCTs (1773 participants) met the inclusion criteria of the review. In this update we added one RCT of Cerebrolysin-like agent Cortexin, which contributed 272 participants. We used the same approach for risk of bias assessment that was re-evaluated for the previous update: we added consideration of the public availability of study protocols and reported outcomes to the selective outcome reporting judgement, through identification, examination, and evaluation of study protocols. For the Cerebrolysin studies, we judged the risk of bias for selective outcome reporting to be unclear across all studies; for blinding of participants and personnel to be low in three studies and unclear in the remaining four; and for blinding of outcome assessors to be low in three studies and unclear in four studies. We judged the risk of bias for generation of allocation sequence to be low in one study and unclear in the remaining six studies; for allocation concealment to be low in one study and unclear in six studies; and for incomplete outcome data to be low in three studies and high in the remaining four studies. The manufacturer of Cerebrolysin supported three multicentre studies, either totally, or by providing Cerebrolysin and placebo, randomisation codes, research grants, or statisticians. We judged two studies to be at high risk of other bias and the remaining five studies to be at unclear risk of other bias. We judged the study of Cortexin to be at low risk of bias for incomplete outcome data and at unclear risk of bias for all other domains. All-cause death: Cerebrolysin or Cortexin probably result in little to no difference in all-cause death (risk ratio (RR) 0.96, 95% confidence interval (CI) 0.65 to 1.41; 6 trials, 1689 participants; moderate-certainty evidence). None of the included studies reported on poor functional outcome, defined as death or dependence at the end of the follow-up period, early death (within two weeks of stroke onset), quality of life, or time to restoration of capacity for work. Only one study clearly reported on the cause of death: cerebral infarct (four in the Cerebrolysin and two in the placebo group), heart failure (two in the Cerebrolysin and one in the placebo group), pulmonary embolism (two in the placebo group), and pneumonia (one in the placebo group). Non-death attrition (secondary outcome): Cerebrolysin or similar peptide mixtures may result in little to no difference in non-death attrition, but the evidence is very uncertain, with a considerable level of heterogeneity (RR 0.72, 95% CI 0.38 to 1.39; 6 trials, 1689 participants; very low-certainty evidence). Serious adverse events (SAEs): Cerebrolysin probably results in little to no difference in the total number of people with SAEs (RR 1.16, 95% CI 0.81 to 1.66; 3 trials, 1335 participants; moderate-certainty evidence). This comprised fatal SAEs (RR 0.90, 95% CI 0.59 to 1.38; 3 trials, 1335 participants; moderate-certainty evidence) and an increase in the total number of people with non-fatal SAEs (RR 2.39, 95% CI 1.10 to 5.23; 3 trials, 1335 participants; moderate-certainty evidence). In the subgroup of dosing schedule 30 mL for 10 days (cumulative dose 300 mL), the increase was more prominent (RR 2.87, 95% CI 1.24 to 6.69; 2 trials, 1189 participants). Total number of people with adverse events: Cerebrolysin or similar peptide mixtures may result in little to no difference in the total number of people with adverse events (RR 1.03, 95% CI 0.92 to 1.14; 4 trials, 1607 participants; low-certainty evidence). AUTHORS' CONCLUSIONS Moderate-certainty evidence indicates that Cerebrolysin or Cerebrolysin-like peptide mixtures derived from cattle brain probably have no beneficial effect on preventing all-cause death in acute ischaemic stroke. Moderate-certainty evidence suggests that Cerebrolysin probably has no beneficial effect on the total number of people with serious adverse events. Moderate-certainty evidence also indicates a potential increase in non-fatal serious adverse events with Cerebrolysin use.
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Affiliation(s)
- Liliya Eugenevna Ziganshina
- Centre for Knowledge Translation, Federal State Budgetary Educational Institution of Continuing Professional Education "Russian Medical Academy of Continuing Professional Education", The Ministry of Health of the Russian Federation (RMANPO), Moscow, Russian Federation
- Department of Pharmacology, Kazan State Medical University (KSMU), The Ministry of Health of the Russian Federation, Kazan, Russian Federation
- Department of General and Clinical Pharmacology, RUDN University named after Patrice Lumumba, Moscow, Russian Federation
| | - Tatyana Abakumova
- Department of Biochemistry, Biotechnology and Pharmacology, Kazan (Volga region) Federal University, Kazan, Russian Federation
| | - Dilyara Nurkhametova
- Centre for Knowledge Translation, Federal State Budgetary Educational Institution of Continuing Professional Education "Russian Medical Academy of Continuing Professional Education", The Ministry of Health of the Russian Federation (RMANPO), Moscow, Russian Federation
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Bao J, Zhang Y, Li Y, Guo J, He L. Low-to-moderate dose statins improve the functional outcome of acute ischemic stroke with conventional medication treatment. Cardiovasc Diagn Ther 2023; 13:686-699. [PMID: 37675093 PMCID: PMC10478016 DOI: 10.21037/cdt-23-77] [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: 02/25/2023] [Accepted: 06/28/2023] [Indexed: 09/08/2023]
Abstract
Background Low-to-moderate dose statins (LMDSs) are more commonly used among Asian acute ischemic stroke (AIS) patients in clinical practice. However, the correlation between the LMDS use and prognosis has not been evaluated in AIS patients with conventional medication treatment alone. This study aimed to investigate the influence of LMDS on the prognosis of AIS patients and how prognosis and potential prognostic factors interact with different statin doses. Methods This retrospective cohort study included AIS patients who were admitted within 7 days after symptom onset and received conventional medication treatment alone from November 2019 to November 2020 in the Neurology, Department of West China Hospital, Sichuan University. From a total of 782 initial patients, a final cohort of 327 patients was included in the study. These patients were divided into three groups based on statin doses: non-statin (48 patients), LMDS (152 patients), and high-dose statin (HDS) (127 patients). The follow-up period was 3 months after the onset of stroke and the primary outcome was defined as a modified Rankin scale (mRS) score of 0 to 2 at 3 months, secondary outcomes were hemorrhagic transformation (HT) and death within 3 months. Stratified analysis was also conducted to test the robustness of the relationship between the use of different statin doses and functional outcomes in various subgroups. Results Compared with non-statin therapy, both LMDS therapy and HDS therapy were associated with good functional outcomes [odds ratio (OR) =3.68, 95% confidence interval (CI): 1.13-12.01, P=0.0309; OR =3.45, 95% CI: 1.06-11.26, P=0.0402, respectively] and a lower risk of HT (OR =0.30, 95% CI: 0.11-0.86, P=0.0253; OR =0.36, 95% CI: 0.13-0.99, P=0.0488, respectively). However, there was no significant difference in all-cause death within 3 months among the three groups (OR =0.84, 95% CI: 0.29-2.46, P=0.7468; OR =0.76, 95% CI: 0.26-2.22, P=0.6104). Additionally, no significant differences were observed between LMDS therapy and HDS therapy regarding good functional outcomes at 3 months (OR =0.94, 95% CI: 0.50-1.77, P=0.8411) and the occurrence of HT (OR =1.19, 95% CI: 0.47-3.02, P=0.7093). The results of the relationship between different statin doses and 3-month good functional outcome were consistent after interaction tests. Conclusions Our findings provide evidence for the benefit and safety of LMDS therapy in AIS patients with medication treatment alone. LMDS therapy is associated with favorable impacts on 3-month functional outcomes and a reduced risk of HT compared to non-statin therapy. There were no significant differences in achieving 3-month good functional outcome, the risk of HT or death within 3 months were observed between LMDS and HDS therapy in our study. Further studies with prospective design and larger sample sizes are necessary to validate our results.
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Choudhary M, Chaudhari S, Gupta T, Kalyane D, Sirsat B, Kathar U, Sengupta P, Tekade RK. Stimuli-Responsive Nanotherapeutics for Treatment and Diagnosis of Stroke. Pharmaceutics 2023; 15:1036. [PMID: 37111522 PMCID: PMC10141724 DOI: 10.3390/pharmaceutics15041036] [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: 01/26/2023] [Revised: 03/19/2023] [Accepted: 03/20/2023] [Indexed: 04/29/2023] Open
Abstract
Stroke is the second most common medical emergency and constitutes a significant cause of global morbidity. The conventional stroke treatment strategies, including thrombolysis, antiplatelet therapy, endovascular thrombectomy, neuroprotection, neurogenesis, reducing neuroinflammation, oxidative stress, excitotoxicity, hemostatic treatment, do not provide efficient relief to the patients due to lack of appropriate delivery systems, large doses, systemic toxicity. In this context, guiding the nanoparticles toward the ischemic tissues by making them stimuli-responsive can be a turning point in managing stroke. Hence, in this review, we first outline the basics of stroke, including its pathophysiology, factors affecting its development, current treatment therapies, and their limitations. Further, we have discussed stimuli-responsive nanotherapeutics used for diagnosing and treating stroke with challenges ahead for the safe use of nanotherapeutics.
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Affiliation(s)
| | | | | | | | | | | | | | - Rakesh K. Tekade
- National Institute of Pharmaceutical Education and Research (NIPER), Ahmedabad, Department of Pharmaceuticals, Ministry of Chemicals and Fertilizers, Opposite Air Force Station, Palaj, Gandhinagar 382355, Gujarat, India
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Bonura A, Motolese F, Capone F, Iaccarino G, Alessiani M, Ferrante M, Calandrelli R, Lazzaro VD, Pilato F. Smartphone App in Stroke Management: A Narrative Updated Review. J Stroke 2022; 24:323-334. [PMID: 36221935 PMCID: PMC9561218 DOI: 10.5853/jos.2022.01410] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Revised: 07/06/2022] [Accepted: 07/07/2022] [Indexed: 11/16/2022] Open
Abstract
The spread of smartphones and mobile-Health (m-health) has progressively changed clinical practice, implementing access to medical knowledge and communication between doctors and patients. Dedicated software called Applications (or Apps), assists the practitioners in the various phases of clinical practice, from diagnosis to follow-up and therapy management. The impact of this technology is even more important in diseases such as stroke, which are characterized by a complex management that includes several moments: primary prevention, acute phase management, rehabilitation, and secondary prevention. This review aims to evaluate and summarize the available literature on Apps for the clinical management of stroke. We described their potential and weaknesses, discussing potential room for improvement. Medline databases were interrogated for studies concerning guideline-based decision support Apps for stroke management and other medical scenarios from 2007 (introduction of the first iPhone) until January 2022. We found 551 studies. Forty-three papers were included because they fitted the scope of the review. Based on their purpose, Apps were classified into three groups: primary prevention Apps, acute stroke management Apps, and post-acute stroke Apps. We described the aim of each App and, when available, the results of clinical studies. For acute stroke, several Apps have been designed with the primary purpose of helping communication and sharing of patients' clinical data among healthcare providers. However, interactive systems Apps aiming to assist clinicians are still lacking, and this field should be developed because it may improve stroke patients' management.
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Affiliation(s)
- Adriano Bonura
- Neurology, Neurophysiology and Neurobiology Unit, Department of Medicine, Campus Bio Medico University of Rome, Rome, Italy
| | - Francesco Motolese
- Neurology, Neurophysiology and Neurobiology Unit, Department of Medicine, Campus Bio Medico University of Rome, Rome, Italy
| | - Fioravante Capone
- Neurology, Neurophysiology and Neurobiology Unit, Department of Medicine, Campus Bio Medico University of Rome, Rome, Italy
| | - Gianmarco Iaccarino
- Neurology, Neurophysiology and Neurobiology Unit, Department of Medicine, Campus Bio Medico University of Rome, Rome, Italy
| | - Michele Alessiani
- Neurology, Neurophysiology and Neurobiology Unit, Department of Medicine, Campus Bio Medico University of Rome, Rome, Italy
| | - Mario Ferrante
- Neurology, Neurophysiology and Neurobiology Unit, Department of Medicine, Campus Bio Medico University of Rome, Rome, Italy
| | - Rosalinda Calandrelli
- Neuroradiology and Radiology Unit, Diagnostic Imaging, Radiotherapy, Oncology, Haematology Department, Agostino Gemelli University Policlinic (Fondazione Policlinico Universitario Agostino Gemelli) IRCCS, Rome, Italy
| | - Vincenzo Di Lazzaro
- Neurology, Neurophysiology and Neurobiology Unit, Department of Medicine, Campus Bio Medico University of Rome, Rome, Italy
| | - Fabio Pilato
- Neurology, Neurophysiology and Neurobiology Unit, Department of Medicine, Campus Bio Medico University of Rome, Rome, Italy
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Li X, Hou X, Cui Y, Tian X, Wang X, Zhou Z, Chen H. Safety and preliminary efficacy of argatroban plus dual antiplatelet therapy for acute mild to moderate ischemic stroke with large artery atherosclerosis. Brain Behav 2022; 12:e2664. [PMID: 35678020 PMCID: PMC9304821 DOI: 10.1002/brb3.2664] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Revised: 05/12/2022] [Accepted: 05/24/2022] [Indexed: 01/01/2023] Open
Abstract
OBJECTIVE Previous studies suggest the benefit of dual antiplatelet therapy (DAPT) for acute ischemic stroke with large artery atherosclerosis (LAA) etiology, but there is no study about the effect of DAPT plus anticoagulant in this population. METHODS A prospective single arm trial was performed to determine the effect of DAPT combined with argatroban on acute mild to moderate ischemic stroke patients with LAA, which was compared with historical populations. The main outcome was the proportion of early neurological deterioration (END). The secondary outcomes included scores of 0 to 1 and 0 to 2 on the modified Rankin Scale (mRS) at 90 days, and changes in National Institutes of Health Stroke Scale (NIHSS) from baseline to day 7 after admission. The safety outcomes included intracranial hemorrhage at 7 days, organ hemorrhage, and all-cause mortality at 90 days. RESULTS A total of 120 patients with argatroban plus DAPT were prospectively enrolled and 529 patients with only DAPT were retrospectively collected. There was no significant difference in baseline characteristics between groups. Compared with control group, combined treatment group had lower proportion of END (4.2% vs. 10.0%, adjusted p = .046), more reduction in NIHSS score from the baseline to day 7 after admission (1.06 ± 2.03 vs. 0.39 ± 1.97, adjusted p = .003), and higher proportion of mRS (0-2) at 90 days (87.5% vs. 79.2%, adjusted p = .048). No intracranial hemorrhage was found between groups. CONCLUSIONS This is the first report that short-term argatroban combined with DAPT seems to be safe and may effectively prevent END and improve neurological prognosis for acute mild to moderate ischemic stroke patients with LAA; however, interpretation of the conclusion required caution due to nonrandomized controlled trial with medium sample size.
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Affiliation(s)
- Xiao‐Qiu Li
- Department of NeurologyGeneral Hospital of Northern Theater CommandShenyangP.R. China
| | - Xiao‐Wen Hou
- Department of NeurologyGeneral Hospital of Northern Theater CommandShenyangP.R. China
| | - Yu Cui
- Department of NeurologyGeneral Hospital of Northern Theater CommandShenyangP.R. China
| | - Xiao‐Fu Tian
- Department of NeurologyGeneral Hospital of Northern Theater CommandShenyangP.R. China
| | - Xin‐Hong Wang
- Department of NeurologyGeneral Hospital of Northern Theater CommandShenyangP.R. China
| | - Zhong‐He Zhou
- Department of NeurologyGeneral Hospital of Northern Theater CommandShenyangP.R. China
| | - Hui‐Sheng Chen
- Department of NeurologyGeneral Hospital of Northern Theater CommandShenyangP.R. China
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Xia H, Wang Z, Tian M, Liu Z, Zhou Z. Low-Molecular-Weight Heparin Versus Aspirin in Early Management of Acute Ischemic Stroke: A Systematic Review and Meta-Analysis. Front Immunol 2022; 13:823391. [PMID: 35281068 PMCID: PMC8908308 DOI: 10.3389/fimmu.2022.823391] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2021] [Accepted: 02/03/2022] [Indexed: 11/13/2022] Open
Abstract
Objectives To evaluate the difference between low-molecular-weight heparin (LMWH) and aspirin in preventing early neurological deterioration (END) and recurrent ischemic stroke (RIS), post-recovery independence, and safety outcomes in acute ischemic stroke. Materials and Methods We performed systematic searches of the PubMed, Embase, Web of Science, and Cochrane Library databases for full-text articles of randomized controlled trials (RCTs) of LMWH vs. aspirin in the early management of acute ischemic stroke. Information on study design, eligibility criteria, baseline information, and outcomes was extracted. Synthesized relative risks (RRs) with 95% confidence intervals (CIs) are used to present the differences between the two treatments based on fixed-effects models. Results Five RCTs were retrieved from the online databases. The results showed no significant difference in efficacy outcomes between the two groups among unselected patients. Subgroup analysis showed that LMWH was significantly related to a lower incidence of END events [relative risk (RR): 0.44, 95% confidence interval (CI): 0.35-0.56] and reduced occurrence of RIS during treatment (OR: 0.34, 95% CI: 0.16-0.75) in non-cardioembolic stroke. LMWH significantly increased the number of patients with a modified Rankin scale (mRS) score of 0-1 at 6 months in patients with large-artery occlusive disease (LAOD) (RR: 0.50, 95% CI: 0.27-0.91). LMWH had a similar effect on symptomatic intracranial hemorrhage (sICH) and major extracranial hemorrhage during treatment to that of aspirin, except that LMWH was related to an increased likelihood of extracranial hemorrhage. Conclusions In patients with acute non-cardioembolic ischemic stroke, especially that with large-artery stenosis, LMWH treatment significantly reduced the incidence of END and RIS, and improved the likelihood of independence (mRS 0-1) at 6 months compared with those with aspirin treatment. LMWH was related to an increased likelihood of extracranial hemorrhage among all patients; however, the difference in major extracranial hemorrhage and sICH was not significant. Choosing the appropriate patients and paying attention to the start time and duration of treatment are very important in the use of anticoagulation. Systematic Review Registration http://www.crd.york.ac.uk/PROSPERO, identifier CRD42020185446.
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Affiliation(s)
- Hui Xia
- Department of Neurology, China-Japan Friendship Hospital, Beijing, China
| | - Ziyao Wang
- Department of Neurology, China-Japan Friendship Hospital, Beijing, China
| | - Min Tian
- Department of Neurology, China-Japan Friendship Hospital, Beijing, China
| | - Zunjing Liu
- Department of Neurology, China-Japan Friendship Hospital, Beijing, China
| | - Zhenhua Zhou
- Department of Neurology, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, China
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Tang G, Cao Z, Luo Y, Wu S, Sun X. Prognosis associated with asymptomatic intracranial hemorrhage after acute ischemic stroke: a systematic review and meta-analysis. J Neurol 2022; 269:3470-3481. [PMID: 35260949 DOI: 10.1007/s00415-022-11046-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Revised: 02/21/2022] [Accepted: 02/21/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND AND PURPOSE It remains inconclusive whether asymptomatic intracranial hemorrhage (aICH) after acute ischemic stroke is innocuous. We aimed to conduct a meta-analysis assessing the relationship between the aICH and poor neurological outcomes. METHODS We searched PubMed, EMBASE and Web of Science from their inception to 30 November 2021 and performed a meta-analysis on the association between the aICH and neurological prognosis after acute ischemic stroke at 3 months, including poor outcomes (modified Rankin Scale [mRS] score ≥ 2 or mRS ≥ 3) and mortality. RESULTS Fourteen studies were included in the analysis, reporting on a total of 10,915 participants after acute ischemic stroke. The risks of poor outcome (mRS ≥ 2 or mRS ≥ 3) in patients with aICH were significantly higher than patients without ICH (OR 1.70, 95% CI 1.33-2.18; OR 1.43, 95% CI 1.20-1.70, respectively), based on adjusted data. The difference between the two groups was not significant for mortality. The results of subgroup analysis showed aICH were associated with higher ratio of mild poor prognosis (mRS ≥ 2) (OR 1.59, 95% CI 1.11-2.27), but it had no association with functional dependence (mRS ≥ 3) after recanalization. No significant influence of aICH on poor outcome (mRS ≥ 3) was found in non-recanalization group. Further stratified analysis revealed that only aICH with patients receiving endovascular therapy (EVT) could increase the risk of mild poor prognosis (mRS ≥ 2) at 3 months. CONCLUSIONS Our results indicate that compared with patients without ICH, those who developed aICH during the acute stage of ischemic stroke had an increasing risk of worse outcome, especially in patients with endovascular therapy.
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Affiliation(s)
- Guoyi Tang
- Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Zhixin Cao
- Department of Neurology, National Key Clinical Department and Key Discipline of Neurology, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Yuting Luo
- Department of Neurology, National Key Clinical Department and Key Discipline of Neurology, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Shaoqing Wu
- Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China.
| | - Xunsha Sun
- Department of Neurology, National Key Clinical Department and Key Discipline of Neurology, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China.
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No Histological Difference between Large Atherosclerotic and Cardiogenic Embolic Thrombus. OXIDATIVE MEDICINE AND CELLULAR LONGEVITY 2022; 2022:4845264. [PMID: 35281464 PMCID: PMC8916853 DOI: 10.1155/2022/4845264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Revised: 01/17/2022] [Accepted: 01/26/2022] [Indexed: 11/17/2022]
Abstract
Background The continuous development of endovascular treatment technology provides more opportunities for the histological study of thrombus. According to Trial of Org 10 172 in Acute Stroke Treatment (TOAST), clinicians take different strategies in anticoagulant or antiplatelet therapy. There are some patients still suffering from recurrent stroke while they took anticoagulant or antiplatelet drugs regularly for secondary prevention. In view of that, we found that histological analysis of thrombus can provide guidance for secondary prevention. Aim Exploring the histological characteristics differences between large atherosclerotic and cardiogenic embolic thrombosis in order to guide clinical secondary prevention of the two stroke subtypes. Methods A total of 54 patients with acute ischemic stroke were collected from December 2019 to April 2021. Identify stroke subtypes according to TOAST classification. Stain thrombus specimens with hematoxylin-eosin staining, and perform statistical analysis on the components (red blood cells and fibrin/platelets) of thrombus. Results In cardiogenic thrombi, the composition of RBCs was dominant (51.38 ± 18.463%) compared to that of fibrin/platelets (48.62 ± 18.463%). Similarly, among the thrombi of large artery atherosclerotic, RBCs (50.40 ± 20.100%) compared to fibrin/platelets (49.60 ± 20.100%). There was no statistical difference in RBCs or fibrin/platelet composition of both cardiogenic and atherosclerotic thrombi (P = 0.89). Conclusions The histologic composition of thrombi in cardiogenic and atherosclerotic had no statistical difference. These thrombi are all mixed thrombus, which are rich in RBCs, fibrinogen, and platelets. Anticoagulation combined with antiplatelet may be a more effective secondary prevention strategy.
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11
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Wang PF, Sun ZR, Yu JC, Geng N, Liu LY, Zhu LN, Li J, Yuan HC, Zhao GC, Li ZG. Early argatroban and antiplatelet combination therapy in acute non-lacunar single subcortical infarct associated with mild intracranial atherosclerosis. BMC Neurol 2021; 21:440. [PMID: 34753435 PMCID: PMC8579679 DOI: 10.1186/s12883-021-02435-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Accepted: 09/30/2021] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Patients with acute non-lacunar single subcortical infarct (SSI) associated with mild intracranial atherosclerosis (ICAS) have a relatively high incidence of early neurological deterioration (END), resulting in unfavorable functional outcomes. Whether the early administration of argatroban and aspirin or clopidogrel within 6-12 h after symptom onset is effective and safe in these patients is unknown. METHODS A review of the stroke database of Weihai Municipal Hospital, Cheeloo College of Medicine, Shandong University and Qingdao Center Hospital, Qingdao University Medical College in China was undertaken from May 2017 to January 2020 to identify all patients with non-lacunar SSI caused by ICAS within 6-12 h of symptom onset based on MRI screening. Patients were divided into two groups, one comprising those who received argatroban and mono antiplatelet therapy with aspirin or clopidogrel on admission (argatroban group), and the other those who received dual antiplatelet therapy (DAPT) with aspirin and clopidogrel during hospitalization (DAPT group). The primary outcome was recovery by 90 days after stroke based on a modified Rankin scale (mRS) score (0 to 1). The secondary outcome was END incidence within 120 h of admission. Safety outcomes were intracranial hemorrhage (ICH) and major extracranial bleeding. The probability of clinical benefit (mRS score 0-1 at 90 days) was estimated using multivariable logistic regression analysis. RESULTS A total of 304 acute non-lacunar SSI associated with mild ICAS patients were analyzed. At 90 days, 101 (74.2%) patients in the argatroban group and 80 (47.6%) in the DAPT group had an mRS score that improved from 0 to 1 (P < 0.001). The relative risk (95% credible interval) for an mRS score improving from 0 to 1 in the argatroban group was 1.50 (1.05-2.70). END occurred in 10 (7.3%) patients in the argatroban group compared with 37 (22.0%) in the DAPT group (P < 0.001). No patients experienced symptomatic hemorrhagic transformation. CONCLUSIONS Early combined administration of argatroban and an antiplatelet agent (aspirin or clopidogrel) may be beneficial for patients with non-lacunar SSI associated with mild ICAS identified by MRI screening and may attenuate progressive neurological deficits. TRIAL REGISTRATION Our study is a retrospectively registered trial.
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Affiliation(s)
- Peng-Fei Wang
- Department of Neurology, Weihai Municipal Hospital, Cheeloo College of Medicine, Shandong University, No.70, Heping road, Huancui District, Weihai City, 264200, Shandong Province, China
| | - Zhuo-Ran Sun
- Department of Neurology, Weihai Municipal Hospital, Cheeloo College of Medicine, Shandong University, No.70, Heping road, Huancui District, Weihai City, 264200, Shandong Province, China
| | - Jin-Chao Yu
- Department of Neurology, Weihai Municipal Hospital, Cheeloo College of Medicine, Shandong University, No.70, Heping road, Huancui District, Weihai City, 264200, Shandong Province, China
| | - Na Geng
- Department of Neurology, Weihai Municipal Hospital, Cheeloo College of Medicine, Shandong University, No.70, Heping road, Huancui District, Weihai City, 264200, Shandong Province, China
| | - Ling-Yun Liu
- Department of Neurology, Weihai Municipal Hospital, Cheeloo College of Medicine, Shandong University, No.70, Heping road, Huancui District, Weihai City, 264200, Shandong Province, China
| | - Li-Na Zhu
- Department of Neurology, Weihai Municipal Hospital, Cheeloo College of Medicine, Shandong University, No.70, Heping road, Huancui District, Weihai City, 264200, Shandong Province, China
| | - Jing Li
- Department of Neurology, Weihai Municipal Hospital, Cheeloo College of Medicine, Shandong University, No.70, Heping road, Huancui District, Weihai City, 264200, Shandong Province, China
| | - Hai-Cheng Yuan
- Department of Neurology, Qingdao Central Hospital, Qingdao City, 266042, Shandong Province, China
| | - Guo-Chen Zhao
- School of Ocean Engineering, Harbin Institute of Technology at Weihai, Weihai, 264209, China
| | - Zhen-Guang Li
- Department of Neurology, Weihai Municipal Hospital, Cheeloo College of Medicine, Shandong University, No.70, Heping road, Huancui District, Weihai City, 264200, Shandong Province, China.
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12
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Stein J, Katz DI, Black Schaffer RM, Cramer SC, Deutsch AF, Harvey RL, Lang CE, Ottenbacher KJ, Prvu-Bettger J, Roth EJ, Tirschwell DL, Wittenberg GF, Wolf SL, Nedungadi TP. Clinical Performance Measures for Stroke Rehabilitation: Performance Measures From the American Heart Association/American Stroke Association. Stroke 2021; 52:e675-e700. [PMID: 34348470 DOI: 10.1161/str.0000000000000388] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The American Heart Association/American Stroke Association released the adult stroke rehabilitation and recovery guidelines in 2016. A working group of stroke rehabilitation experts reviewed these guidelines and identified a subset of recommendations that were deemed suitable for creating performance measures. These 13 performance measures are reported here and contain inclusion and exclusion criteria to allow calculation of rates of compliance in a variety of settings ranging from acute hospital care to postacute care and care in the home and outpatient setting.
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13
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Li C, Sun T, Jiang C. Recent advances in nanomedicines for the treatment of ischemic stroke. Acta Pharm Sin B 2021; 11:1767-1788. [PMID: 34386320 PMCID: PMC8343119 DOI: 10.1016/j.apsb.2020.11.019] [Citation(s) in RCA: 72] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2020] [Revised: 08/27/2020] [Accepted: 09/13/2020] [Indexed: 12/20/2022] Open
Abstract
Ischemic stroke is a cerebrovascular disease normally caused by interrupted blood supply to the brain. Ischemia would initiate the cascade reaction consisted of multiple biochemical events in the damaged areas of the brain, where the ischemic cascade eventually leads to cell death and brain infarction. Extensive researches focusing on different stages of the cascade reaction have been conducted with the aim of curing ischemic stroke. However, traditional treatment methods based on antithrombotic therapy and neuroprotective therapy are greatly limited for their poor safety and treatment efficacy. Nanomedicine provides new possibilities for treating stroke as they could improve the pharmacokinetic behavior of drugs in vivo, achieve effective drug accumulation at the target site, enhance the therapeutic effect and meanwhile reduce the side effect. In this review, we comprehensively describe the pathophysiology of stroke, traditional treatment strategies and emerging nanomedicines, summarize the barriers and methods for transporting nanomedicine to the lesions, and illustrate the latest progress of nanomedicine in treating ischemic stroke, with a view to providing a new feasible path for the treatment of cerebral ischemia.
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Key Words
- AEPO, asialo-erythropoietin
- APOE, apolipoprotein E
- BBB, blood‒brain barrier
- BCECs, brain capillary endothelial cells
- Blood‒brain barrier
- CAT, catalase
- COX-1, cyclooxygenase-1
- CXCR-4, C-X-C chemokine receptor type 4
- Ce-NPs, ceria nanoparticles
- CsA, cyclosporine A
- DAMPs, damage-associated molecular patterns
- GFs, growth factors
- GPIIb/IIIa, glycoprotein IIb/IIIa
- HMGB1, high mobility group protein B1
- Hb, hemoglobin
- ICAM-1, intercellular adhesion molecule-1
- IL-1β, interleukin-1β
- IL-6, interleukin-6
- Ischemic cascade
- LFA-1, lymphocyte function-associated antigen-1
- LHb, liposomal Hb
- MCAO, middle cerebral artery occlusion
- MMPs, matrix metalloproteinases
- MSC, mesenchymal stem cell
- NF-κB, nuclear factor-κB
- NGF, nerve growth factor
- NMDAR, N-methyl-d-aspartate receptor
- NOS, nitric oxide synthase
- NPs, nanoparticles
- NSCs, neural stem cells
- Nanomedicine
- Neuroprotectant
- PBCA, poly-butylcyanoacrylate
- PCMS, poly (chloromethylstyrene)
- PEG, poly-ethylene-glycol
- PEG-PLA, poly (ethylene-glycol)-b-poly (lactide)
- PLGA NPs, poly (l-lactide-co-glycolide) nanoparticles
- PSD-95, postsynaptic density protein-95
- PSGL-1, P-selectin glycoprotein ligand-1
- RBCs, red blood cells
- RES, reticuloendothelial system
- RGD, Arg-Gly-Asp
- ROS, reactive oxygen species
- Reperfusion
- SDF-1, stromal cell-derived factor-1
- SHp, stroke homing peptide
- SOD, superoxide dismutase
- SUR1-TRPM4, sulfonylurea receptor 1-transient receptor potential melastatin-4
- Stroke
- TEMPO, 2,2,6,6-tetramethylpiperidine-1-oxyl
- TIA, transient ischemic attack
- TNF-α, tumor necrosis factor-α
- Thrombolytics
- cRGD, cyclic Arg-Gly-Asp
- e-PAM-R, arginine-poly-amidoamine ester
- iNOS, inducible nitric oxide synthase
- miRNAs, microRNAs
- nNOS, neuron nitric oxide synthase
- siRNA, small interfering RNA
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14
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Siegal DM, Anand SS. Considerations for use of direct oral anticoagulants in arterial disease. Res Pract Thromb Haemost 2021; 5:S2475-0379(22)01372-3. [PMID: 34095731 PMCID: PMC8162231 DOI: 10.1002/rth2.12502] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Revised: 02/08/2021] [Accepted: 02/12/2021] [Indexed: 11/10/2022] Open
Abstract
Cardiovascular diseases including coronary heart disease, stroke, and peripheral arterial disease were responsible for an estimated 18 million deaths in 2017. Despite advances in management over the past several decades, these patients continue to have substantial risk of subsequent cardiovascular events. We provide a narrative review of randomized clinical trials evaluating direct oral anticoagulants (DOACs) for the treatment of acute coronary syndromes, noncardioembolic ischemic stroke, embolic stroke of undetermined source, and peripheral arterial disease. In these conditions, considerations for use of single antiplatelet therapy, dual antiplatelet therapy, or low-dose DOACs used together with antiplatelet therapy are presented.
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Affiliation(s)
- Deborah M Siegal
- Department of Medicine University of Ottawa Ottawa ON Canada.,Ottawa Hospital Research Institute Ottawa ON Canada
| | - Sonia S Anand
- Department of Medicine McMaster University Hamilton ON Canada.,Department of Health Research Methods, Evidence and Impact McMaster University Hamilton ON Canada.,Population Health Research Institute Hamilton Health Sciences Hamilton ON Canada
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15
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Rahmawati PL, Tini K, Susilawathi NM, Wijayanti IAS, Samatra DP. Pathomechanism and Management of Stroke in COVID-19: Review of Immunopathogenesis, Coagulopathy, Endothelial Dysfunction, and Downregulation of ACE2. J Clin Neurol 2021; 17:155-163. [PMID: 33835735 PMCID: PMC8053537 DOI: 10.3988/jcn.2021.17.2.155] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Revised: 11/24/2020] [Accepted: 11/24/2020] [Indexed: 12/15/2022] Open
Abstract
Coronavirus disease 2019 (COVID-19) can reportedly manifest as an acute stroke, with most cases presenting as large vessel ischemic stroke in patients with or without comorbidities. The exact pathomechanism of stroke in COVID-19 remains ambiguous. The findings of previous studies indicate that the most likely underlying mechanisms are cerebrovascular pathological conditions following viral infection, inflammation-induced endothelial dysfunction, and hypercoagulability. Acute endothelial damage due to inflammation triggers a coagulation cascade, thrombosis propagation, and destabilization of atherosclerosis plaques, leading to large-vessel occlusion and plaque ulceration with concomitant thromboemboli, and manifests as ischemic stroke. Another possible mechanism is the downregulation of angiotensin-converting enzyme 2 as the target action of severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2). Acute stroke management protocols need to be modified during the COVID-19 pandemic in order to adequately manage stroke patients with COVID-19.
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Affiliation(s)
- Putu Lohita Rahmawati
- Department of Neurology, Udayana University, Sanglah General Hospital, Denpasar, Bali, Indonesia.
| | - Kumara Tini
- Department of Neurology, Udayana University, Udayana University Hospital, Bali, Indonesia
| | - Ni Made Susilawathi
- Department of Neurology, Udayana University, Udayana University Hospital, Bali, Indonesia
| | - I A Sri Wijayanti
- Department of Neurology, Udayana University, Udayana University Hospital, Bali, Indonesia
| | - Dpg Purwa Samatra
- Department of Neurology, Udayana University, Udayana University Hospital, Bali, Indonesia
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16
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Alrohimi A, Jickling G, Jeerakathil T, Shuaib A, Khan K, Kate M, Hill MD, Buck B, Butcher K. Protocol for LASER: A Randomized Evaluation and an Associated Registry of Early Anticoagulation With Edoxaban After Ischemic Stroke in Patients With Atrial Fibrillation. Front Neurol 2021; 12:645822. [PMID: 33868150 PMCID: PMC8044522 DOI: 10.3389/fneur.2021.645822] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Accepted: 03/08/2021] [Indexed: 01/01/2023] Open
Abstract
Background: The optimal timing of anticoagulation after stroke in patients with atrial fibrillation (AF) is unknown. Aim and Hypothesis: Our primary aim is to demonstrate the safety of edoxaban initiation within 5 days of AF related stroke. Our secondary aim is to determine predictors of hemorrhagic transformation (HT) after AF related stroke. We hypothesize that the rate of radiological HT will not be increased in patients starting edoxaban within 5 days of AF related stroke, relative to those in whom initiation is delayed. We hypothesize that the risk of HT in patients treated with edoxaban can be predicted using RNA expressed in leukocytes at time of stroke. Methods and Design: LASER (Lixiana Acute Stroke Evaluation Registry) is a randomized controlled trial with an associated registry (clinicaltrials.gov NCT03494530). One hundred and fifty patients with ischemic stroke and AF will undergo baseline Computed Tomography (CT) scan and will be randomized 2:1 within 5 days of symptom onset to early (≤5 days, n = 100) or delayed (6–14 days, n = 50) edoxaban initiation. Participants will undergo clinical assessment and repeat CT at 7 days and clinical assessment at 90 days. Study Outcomes: The primary outcome is the rate of incident radiological HT. Secondary outcomes include symptomatic HT, recurrent ischemic stroke, recurrent sub-clinical infarcts on follow up CT, systemic hemorrhagic complication rate, National Institute of Health Stroke Scale and modified Rankin Scale at day 7 and 90, mortality within 90 days, quality of life assessments at day 90, and predictors of HT, including RNA expression by 6 pre-selected candidate genes. Discussion: Event rates for both HT and recurrent ischemic events, in patients treated with early vs. delayed edoxaban initiation are unknown. The primary study endpoint of LASER is an objective performance criterion relevant to clinical decision making in patients with AF related stroke. This study will provide data required for a definitive safety/efficacy study sample size power calculation.
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Affiliation(s)
- Anas Alrohimi
- Department of Medicine, University of Alberta, Edmonton, AB, Canada.,Department of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Glen Jickling
- Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | | | - Ashfaq Shuaib
- Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Khurshid Khan
- Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Mahesh Kate
- Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Michael D Hill
- Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
| | - Brian Buck
- Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Ken Butcher
- Department of Medicine, University of Alberta, Edmonton, AB, Canada.,Prince of Wales Clinical School, University of New South Wales, Sydney, NSW, Australia
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17
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Lyman GH, Carrier M, Ay C, Di Nisio M, Hicks LK, Khorana AA, Leavitt AD, Lee AYY, Macbeth F, Morgan RL, Noble S, Sexton EA, Stenehjem D, Wiercioch W, Kahale LA, Alonso-Coello P. American Society of Hematology 2021 guidelines for management of venous thromboembolism: prevention and treatment in patients with cancer. Blood Adv 2021; 5:927-974. [PMID: 33570602 PMCID: PMC7903232 DOI: 10.1182/bloodadvances.2020003442] [Citation(s) in RCA: 420] [Impact Index Per Article: 140.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Accepted: 10/29/2020] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Venous thromboembolism (VTE) is a common complication among patients with cancer. Patients with cancer and VTE are at a markedly increased risk for morbidity and mortality. OBJECTIVE These evidence-based guidelines of the American Society of Hematology (ASH) are intended to support patients, clinicians, and other health care professionals in their decisions about the prevention and treatment of VTE in patients with cancer. METHODS ASH formed a multidisciplinary guideline panel balanced to minimize potential bias from conflicts of interest. The guideline development process was supported by updated or new systematic evidence reviews. The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach was used to assess evidence and make recommendations. RESULTS Recommendations address mechanical and pharmacological prophylaxis in hospitalized medical patients with cancer, those undergoing a surgical procedure, and ambulatory patients receiving cancer chemotherapy. The recommendations also address the use of anticoagulation for the initial, short-term, and long-term treatment of VTE in patients with cancer. CONCLUSIONS Strong recommendations include not using thromboprophylaxis in ambulatory patients receiving cancer chemotherapy at low risk of VTE and to use low-molecular-weight heparin (LMWH) for initial treatment of VTE in patients with cancer. Conditional recommendations include using thromboprophylaxis in hospitalized medical patients with cancer, LMWH or fondaparinux for surgical patients with cancer, LMWH or direct oral anticoagulants (DOAC) in ambulatory patients with cancer receiving systemic therapy at high risk of VTE and LMWH or DOAC for initial treatment of VTE, DOAC for the short-term treatment of VTE, and LMWH or DOAC for the long-term treatment of VTE in patients with cancer.
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Affiliation(s)
- Gary H Lyman
- Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, WA
- Department of Medicine, University of Washington School of Medicine, Seattle, WA
| | - Marc Carrier
- Department of Medicine, Ottawa Hospital Research Institute at the University of Ottawa, Ottawa, ON, Canada
| | - Cihan Ay
- Clinical Division of Haematology and Haemostaseology, Department of Medicine I, Comprehensive Cancer Center Vienna, Medical University of Vienna, Vienna, Austria
| | - Marcello Di Nisio
- Department of Medicine and Aging Sciences, University G. D'Annunzio, Chieti, Italy
| | - Lisa K Hicks
- Division of Hematology/Oncology, Department of Medicine, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - Alok A Khorana
- Cleveland Clinic and Case Comprehensive Cancer Center, Cleveland, OH
| | - Andrew D Leavitt
- Department of Laboratory Medicine and
- Division of Hematology/Oncology, Department of Medicine, University of California San Francisco, San Francisco, CA
| | - Agnes Y Y Lee
- Division of Hematology, Department of Medicine, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
- Division of Medical Oncology, BC Cancer, Vancouver site, Provincial Health Services Authority, Vancouver, BC, Canada
| | | | - Rebecca L Morgan
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Simon Noble
- Division of Population Medicine, Cardiff University School of Medicine, Cardiff, United Kingdom
| | | | | | - Wojtek Wiercioch
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Lara A Kahale
- American University of Beirut (AUB) Grading of Recommendations, Assessment, Development and Evaluation (GRADE) Center, American University of Beirut, Beirut, Lebanon; and
| | - Pablo Alonso-Coello
- Cochrane Iberoamérica, Biomedical Research Institute Sant Pau-CIBERESP, Barcelona, Spain
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18
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Liu C, Xie J, Sun S, Li H, Li T, Jiang C, Chen X, Wang J, Le A, Wang J, Li Z, Wang J, Wang W. Hemorrhagic Transformation After Tissue Plasminogen Activator Treatment in Acute Ischemic Stroke. Cell Mol Neurobiol 2020; 42:621-646. [PMID: 33125600 DOI: 10.1007/s10571-020-00985-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Accepted: 10/22/2020] [Indexed: 12/17/2022]
Abstract
Hemorrhagic transformation (HT) is a common complication after thrombolysis with recombinant tissue-type plasminogen activator (rt-PA) in ischemic stroke. In this article, recent research progress of HT in vivo and in vitro studies was reviewed. We have discussed new potential mechanisms and possible experimental models of HT development, as well as possible biomarkers and treatment methods. Meanwhile, we compared and analyzed rodent models, large animal models and in vitro BBB models of HT, and the limitations of these models were discussed. The molecular mechanism of HT was investigated in terms of BBB disruption, rt-PA neurotoxicity and the effect of neuroinflammation, matrix metalloproteinases, reactive oxygen species. The clinical features to predict HT were represented including blood biomarkers and clinical factors. Recent progress in neuroprotective strategies to improve HT after stroke treated with rt-PA is outlined. Further efforts need to be made to reduce the risk of HT after rt-PA therapy and improve the clinical prognosis of patients with ischemic stroke.
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Affiliation(s)
- Chengli Liu
- Department of Traumatic Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, People's Republic of China
| | - Jie Xie
- Department of Traumatic Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, People's Republic of China
| | - Shanshan Sun
- Department of Ultrasound Imaging, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, People's Republic of China
| | - Hui Li
- Department of Traumatic Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, People's Republic of China
| | - Tianyu Li
- Department of Traumatic Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, People's Republic of China
| | - Chao Jiang
- Department of Neurology, The Fifth Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, Henan, People's Republic of China
| | - Xuemei Chen
- Department of Anatomy, College of Basic Medical Sciences, Zhengzhou University, Henan, 450000, People's Republic of China
| | - Junmin Wang
- Department of Anatomy, College of Basic Medical Sciences, Zhengzhou University, Henan, 450000, People's Republic of China
| | - Anh Le
- Washington University in St. Louis, Saint Louis, MO, 63130, USA
| | - Jiarui Wang
- The Johns Hopkins University, Baltimore, MD, 21218, USA
| | - Zhanfei Li
- Department of Traumatic Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, People's Republic of China
| | - Jian Wang
- Department of Anatomy, College of Basic Medical Sciences, Zhengzhou University, Henan, 450000, People's Republic of China.
| | - Wei Wang
- Department of Traumatic Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, People's Republic of China.
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19
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Zhou LS, Li XQ, Zhou ZH, Chen HS. Effect of Argatroban Combined With Dual Antiplatelet Therapy on Early Neurological Deterioration in Acute Minor Posterior Circulation Ischemic Stroke. Clin Appl Thromb Hemost 2020; 26:1076029620904131. [PMID: 32013541 PMCID: PMC7288810 DOI: 10.1177/1076029620904131] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
There is a lack of studies on anticoagulant plus antiplatelet therapy for acute ischemic stroke. The present study made a pilot effort to investigate the efficacy and safety of argatroban plus dual antiplatelet therapy (DAPT) in patients with acute posterior circulation ischemic stroke (PCIS). We retrospectively collected patients diagnosed with acute PCIS according to inclusion/exclusion criteria. According to treatment drugs, patients were divided into an argatroban plus DAPT group and a DAPT group. The primary efficacy end point was the proportion of early neurological deterioration (END). The primary safety outcome was symptomatic intracranial hemorrhage. All outcomes were compared between the 2 groups before and after propensity score matching (PSM). A total of 502 patients were enrolled in the study, including 35 patients with argatroban plus DAPT and 467 patients with DAPT. There was a higher National Institutes of Health Stroke Scale (NIHSS) score in the argatroban plus DAPT group than the DAPT group before PSM (3 vs 2, P = .017). Compared with the DAPT group, the argatroban plus DAPT group had no END (before PSM: 0% vs 6.2%, P = .250; after PSM: 0% vs 5.9%, P = .298). Argatroban plus DAPT yielded a significant decrease in the NIHSS score from baseline to 7 days after hospitalization, compared with that of the DAPT group before PSM (P = .032), but not after PSM (P = .369). No symptomatic intracranial hemorrhage was found in any patient. A short-term combination of argatroban with DAPT appears safe in acute minor PCIS.
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Affiliation(s)
- Ling-Shan Zhou
- Department of Neurology, General Hospital of Northern Theater Command, Shenyang, People's Republic of China
| | - Xiao-Qiu Li
- Department of Neurology, General Hospital of Northern Theater Command, Shenyang, People's Republic of China
| | - Zhong-He Zhou
- Department of Neurology, General Hospital of Northern Theater Command, Shenyang, People's Republic of China
| | - Hui-Sheng Chen
- Department of Neurology, General Hospital of Northern Theater Command, Shenyang, People's Republic of China
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20
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Ye F, Garton HJL, Hua Y, Keep RF, Xi G. The Role of Thrombin in Brain Injury After Hemorrhagic and Ischemic Stroke. Transl Stroke Res 2020; 12:496-511. [PMID: 32989665 DOI: 10.1007/s12975-020-00855-4] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Revised: 09/22/2020] [Accepted: 09/23/2020] [Indexed: 02/06/2023]
Abstract
Thrombin is increased in the brain after hemorrhagic and ischemic stroke primarily due to the prothrombin entry from blood either with a hemorrhage or following blood-brain barrier disruption. Increasing evidence indicates that thrombin and its receptors (protease-activated receptors (PARs)) play a major role in brain pathology following ischemic and hemorrhagic stroke (including intracerebral, intraventricular, and subarachnoid hemorrhage). Thrombin and PARs affect brain injury via multiple mechanisms that can be detrimental or protective. The cleavage of prothrombin into thrombin is the key step of hemostasis and thrombosis which takes place in every stroke and subsequent brain injury. The extravascular effects and direct cellular interactions of thrombin are mediated by PARs (PAR-1, PAR-3, and PAR-4) and their downstream signaling in multiple brain cell types. Such effects include inducing blood-brain-barrier disruption, brain edema, neuroinflammation, and neuronal death, although low thrombin concentrations can promote cell survival. Also, thrombin directly links the coagulation system to the immune system by activating interleukin-1α. Such effects of thrombin can result in both short-term brain injury and long-term functional deficits, making extravascular thrombin an understudied therapeutic target for stroke. This review examines the role of thrombin and PARs in brain injury following hemorrhagic and ischemic stroke and the potential treatment strategies which are complicated by their role in both hemostasis and brain.
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Affiliation(s)
- Fenghui Ye
- Department of Neurosurgery, University of Michigan, R5018 Biomedical Science Research Building, 109 Zina Pitcher Place, Ann Arbor, MI, 48109-2200, USA
| | - Hugh J L Garton
- Department of Neurosurgery, University of Michigan, R5018 Biomedical Science Research Building, 109 Zina Pitcher Place, Ann Arbor, MI, 48109-2200, USA
| | - Ya Hua
- Department of Neurosurgery, University of Michigan, R5018 Biomedical Science Research Building, 109 Zina Pitcher Place, Ann Arbor, MI, 48109-2200, USA
| | - Richard F Keep
- Department of Neurosurgery, University of Michigan, R5018 Biomedical Science Research Building, 109 Zina Pitcher Place, Ann Arbor, MI, 48109-2200, USA
| | - Guohua Xi
- Department of Neurosurgery, University of Michigan, R5018 Biomedical Science Research Building, 109 Zina Pitcher Place, Ann Arbor, MI, 48109-2200, USA.
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21
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Nolte CH, von Rennenberg R, Litmeier S, Scheitz JF, Leistner DM, Blankenberg S, Dichgans M, Katus H, Petzold GC, Pieske B, Regitz-Zagrosek V, Wegscheider K, Zeiher AM, Landmesser U, Endres M. PRediction of acute coronary syndrome in acute ischemic StrokE (PRAISE) - protocol of a prospective, multicenter trial with central reading and predefined endpoints. BMC Neurol 2020; 20:318. [PMID: 32854663 PMCID: PMC7450553 DOI: 10.1186/s12883-020-01903-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Accepted: 08/23/2020] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Current guidelines recommend measurement of troponin in acute ischemic stroke (AIS) patients. In AIS patients, troponin elevation is associated with increased mortality and worse outcome. However, uncertainty remains regarding the underlying pathophysiology of troponin elevation after stroke, particularly regarding diagnostic and therapeutic consequences. Troponin elevation may be caused by coronary artery disease (CAD) and more precisely acute coronary syndrome (ACS). Both have a high prevalence in stroke patients and contribute to poor outcome. Therefore, better diagnostic algorithms are needed to identify those AIS patients likely to have ACS or other manifestations of CAD. METHODS/DESIGN The primary goal of the "PRediction of Acute coronary syndrome in acute Ischemic StrokE" (PRAISE) study is to develop a diagnostic algorithm for prediction of ACS in AIS patients. The primary hypothesis will test whether dynamic high-sensitivity troponin levels determined by repeat measurements (i.e., "rise or fall-pattern") indicate presence of ACS when compared to stable (chronic) troponin elevation. PRAISE is a prospective, multicenter, observational trial with central reading and predefined endpoints guided by a steering committee. Clinical symptoms, troponin levels as well as findings on electrocardiogram, echocardiogram, and coronary angiogram will be recorded and assessed by central academic core laboratories. Diagnosis of ACS will be made by an endpoint adjudication committee. Severe adverse events will be evaluated by a critical event committee. Safety will be judged by a data and safety monitoring board. Follow-up will be conducted at three and twelve months and will record new vascular events (i.e., stroke and myocardial infarction) as well as death, functional and cognitive status. According to sample size calculation, 251 patients have to be included. DISCUSSION PRAISE will prospectively determine the frequency of ACS and characterize cardiac and coronary pathologies in a large, multicenter cohort of AIS patients with troponin elevation. The findings will elucidate the origin of troponin elevation, shed light on its impact on necessary diagnostic procedures and provide data on the safety and diagnostic yield of coronary angiography early after stroke. Thereby, PRAISE will help to refine algorithms and develop guidelines for the cardiac workup in AIS. TRIAL REGISTRATION NCT03609385 registered 1st August 2018.
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Affiliation(s)
- Christian H Nolte
- Klinik für Neurologie mit Experimentelle Neurologie, Charité-Universitätsmedizin Berlin, Hindenburgdamm 30, 12203, Berlin, Germany. .,Center for Stroke Research, Berlin, Germany. .,Berlin Institute of Health (BiH), Berlin, Germany. .,Deutsches Zentrum für Herz-Kreislauf-Forschung e.V. (DZHK), 10785, Berlin, Germany. .,Deutsches Zentrum für Neurodegenerative Erkrankungen (DZNE) - German Center for Neurodegenerative Diseases, 53127, Bonn, Germany.
| | - Regina von Rennenberg
- Klinik für Neurologie mit Experimentelle Neurologie, Charité-Universitätsmedizin Berlin, Hindenburgdamm 30, 12203, Berlin, Germany.,Center for Stroke Research, Berlin, Germany.,Deutsches Zentrum für Neurodegenerative Erkrankungen (DZNE) - German Center for Neurodegenerative Diseases, 53127, Bonn, Germany
| | - Simon Litmeier
- Klinik für Neurologie mit Experimentelle Neurologie, Charité-Universitätsmedizin Berlin, Hindenburgdamm 30, 12203, Berlin, Germany.,Center for Stroke Research, Berlin, Germany.,Deutsches Zentrum für Neurodegenerative Erkrankungen (DZNE) - German Center for Neurodegenerative Diseases, 53127, Bonn, Germany
| | - Jan F Scheitz
- Klinik für Neurologie mit Experimentelle Neurologie, Charité-Universitätsmedizin Berlin, Hindenburgdamm 30, 12203, Berlin, Germany.,Center for Stroke Research, Berlin, Germany.,Berlin Institute of Health (BiH), Berlin, Germany.,Deutsches Zentrum für Herz-Kreislauf-Forschung e.V. (DZHK), 10785, Berlin, Germany
| | - David M Leistner
- Berlin Institute of Health (BiH), Berlin, Germany.,Deutsches Zentrum für Herz-Kreislauf-Forschung e.V. (DZHK), 10785, Berlin, Germany.,Medizinische Klinik für Kardiologie, Campus Benjamin-Franklin, Charite-Universitätsmedizin, 12203, Berlin, Germany
| | - Stephan Blankenberg
- Deutsches Zentrum für Herz-Kreislauf-Forschung e.V. (DZHK), 10785, Berlin, Germany.,Klinik und Poliklinik für Kardiologe, Universitäres Herz- und Gefäßzentrum, Universitätsklinikum, 20246, Hamburg, Germany
| | - Martin Dichgans
- Deutsches Zentrum für Neurodegenerative Erkrankungen (DZNE) - German Center for Neurodegenerative Diseases, 53127, Bonn, Germany.,Institute for Stroke and Dementia Research (ISD), University Hospital, LMU Munich, 81377, Munich, Germany.,German Center for Neurodegenerative Diseases (DZNE, Munich) Partnersite, 81377, Munich, Germany.,Munich Cluster for Systems Neurology (SyNergy), 81377, Munich, Germany
| | - Hugo Katus
- Deutsches Zentrum für Herz-Kreislauf-Forschung e.V. (DZHK), 10785, Berlin, Germany.,Klinik für Kardiologie, Angiologie, Pneumologie, Universitätsklinikum Heidelberg, 69120, Heidelberg, Germany
| | - Gabor C Petzold
- Deutsches Zentrum für Neurodegenerative Erkrankungen (DZNE) - German Center for Neurodegenerative Diseases, 53127, Bonn, Germany.,Sektion für Vaskuläre Neurologie, Klinik und Poliklinik für Neurologie, Universitätsklinikum Bonn, 53105, Bonn, Germany
| | - Burkert Pieske
- Deutsches Zentrum für Herz-Kreislauf-Forschung e.V. (DZHK), 10785, Berlin, Germany.,Medizinische Klinik mit Schwerpunkt Kardiologie, Campus Virchow-Klinikum, Charite-Universitätsmedizin, 13353, Berlin, Germany
| | - Vera Regitz-Zagrosek
- Deutsches Zentrum für Herz-Kreislauf-Forschung e.V. (DZHK), 10785, Berlin, Germany.,Institut für Geschlechterforschung in der Medizin (Gender in Medicine, GiM), Charite-Universitätsmedizin, 10115, Berlin, Germany
| | - Karl Wegscheider
- Institut für Medizinische Biometrie und Epidemiologie, Universitätsklinikum Hamburg-Eppendorf, 20251, Hamburg, Germany
| | - Andreas M Zeiher
- Deutsches Zentrum für Herz-Kreislauf-Forschung e.V. (DZHK), 10785, Berlin, Germany.,Klinik für Kardiologie, Angiologie, Nephrologie, Uniklinik Frankfurt, 60590, Frankfurt am Main, Germany
| | - Ulf Landmesser
- Berlin Institute of Health (BiH), Berlin, Germany.,Deutsches Zentrum für Herz-Kreislauf-Forschung e.V. (DZHK), 10785, Berlin, Germany.,Medizinische Klinik für Kardiologie, Campus Benjamin-Franklin, Charite-Universitätsmedizin, 12203, Berlin, Germany
| | - Matthias Endres
- Klinik für Neurologie mit Experimentelle Neurologie, Charité-Universitätsmedizin Berlin, Hindenburgdamm 30, 12203, Berlin, Germany.,Center for Stroke Research, Berlin, Germany.,Berlin Institute of Health (BiH), Berlin, Germany.,Deutsches Zentrum für Herz-Kreislauf-Forschung e.V. (DZHK), 10785, Berlin, Germany.,Deutsches Zentrum für Neurodegenerative Erkrankungen (DZNE) - German Center for Neurodegenerative Diseases, 53127, Bonn, Germany.,Medizinische Klinik für Kardiologie, Campus Benjamin-Franklin, Charite-Universitätsmedizin, 12203, Berlin, Germany.,Excellence Cluster NeuroCure, 10117, Berlin, Germany
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22
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Abstract
BACKGROUND Cerebrolysin is a mixture of low-molecular-weight peptides and amino acids derived from porcine brain that has potential neuroprotective properties. It is widely used in the treatment of acute ischaemic stroke in Russia, Eastern Europe, China, and other Asian and post-Soviet countries. This is an update of a review first published in 2010 and last updated in 2017. OBJECTIVES To assess the benefits and harms of Cerebrolysin for treating acute ischaemic stroke. SEARCH METHODS We searched the Cochrane Stroke Group Trials Register, CENTRAL, MEDLINE, Embase, Web of Science Core Collection, with Science Citation Index, LILACS, OpenGrey, and a number of Russian databases in October 2019. We also searched reference lists, ongoing trials registers, and conference proceedings. SELECTION CRITERIA Randomised controlled trials (RCTs) comparing Cerebrolysin, started within 48 hours of stroke onset and continued for any length of time, with placebo or no treatment in people with acute ischaemic stroke. DATA COLLECTION AND ANALYSIS Two review authors independently applied the inclusion criteria, assessed trial quality and risk of bias, extracted data, and applied GRADE criteria to the evidence. MAIN RESULTS Seven RCTs (1601 participants) met the inclusion criteria of the review. In this update we re-evaluated risk of bias through identification, examination, and evaluation of study protocols and judged it to be low, unclear, or high across studies: unclear for all domains in one study, and unclear for selective outcome reporting across all studies; low for blinding of participants and personnel in four studies and unclear in the remaining three; low for blinding of outcome assessors in three studies and unclear in four studies. We judged risk of bias to be low in two studies and unclear in the remaining five studies for generation of allocation sequence; low in one study and unclear in six studies for allocation concealment; and low in one study, unclear in one study, and high in the remaining five studies for incomplete outcome data. The manufacturer of Cerebrolysin supported four multicentre studies, either totally, or by providing Cerebrolysin and placebo, randomisation codes, research grants, or statisticians. We judged three studies to be at high risk of other bias and the remaining four studies to be at unclear risk of other bias. All-cause death: we extracted data from six trials (1517 participants). Cerebrolysin probably results in little to no difference in all-cause death: risk ratio (RR) 0.90, 95% confidence interval (CI) 0.61 to 1.32 (6 trials, 1517 participants, moderate-quality evidence). None of the included trials reported on poor functional outcome defined as death or dependence at the end of the follow-up period or early death (within two weeks of stroke onset), or time to restoration of capacity for work and quality of life. Only one trial clearly reported on the cause of death: cerebral infarct (four in the Cerebrolysin and two in the placebo group), heart failure (two in the Cerebrolysin and one in the placebo group), pulmonary embolism (two in the placebo group), and pneumonia (one in the placebo group). Serious adverse events (SAEs): Cerebrolysin probably results in little to no difference in the total number of people with SAEs (RR 1.15, 95% CI 0.81 to 1.65, 4 RCTs, 1435 participants, moderate-quality evidence). This comprised fatal SAEs (RR 0.90, 95% CI 0.59 to 1.38) and an increase in the total number of people with non-fatal SAEs (RR 2.15, 95% CI 1.01 to 4.55, P = 0.047, 4 trials, 1435 participants, moderate-quality evidence). In the subgroup of dosing schedule 30 mL for 10 days (cumulative dose 300 mL), the increase was more prominent: RR 2.86, 95% CI 1.23 to 6.66, P = 0.01 (2 trials, 1189 participants). Total number of people with adverse events: four trials reported on this outcome. Cerebrolysin may result in little to no difference in the total number of people with adverse events: RR 0.97, 95% CI 0.85 to 1.10, P = 0.90, 4 trials, 1435 participants, low-quality evidence. Non-death attrition: evidence from six trials involving 1517 participants suggests that Cerebrolysin results in little to no difference in non-death attrition, with 96 out of 764 Cerebrolysin-treated participants and 117 out of 753 placebo-treated participants being lost to follow-up for reasons other than death (very low-quality evidence). AUTHORS' CONCLUSIONS Moderate-quality evidence indicates that Cerebrolysin probably has little or no beneficial effect on preventing all-cause death in acute ischaemic stroke, or on the total number of people with serious adverse events. Moderate-quality evidence also indicates a potential increase in non-fatal serious adverse events with Cerebrolysin use.
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Affiliation(s)
- Liliya Eugenevna Ziganshina
- Cochrane Russia, Kazan, Russian Federation
- Department of Pharmacology, Kazan State Medical University, Kazan, Russian Federation
| | - Tatyana Abakumova
- Department of Biochemistry, Biotechnology and Pharmacology, Kazan (Volga region) Federal University, Kazan, Russian Federation
| | - Charles Hv Hoyle
- Cochrane Russia, Kazan, Russian Federation
- Deputy Editor-in-Chief, Kazan Medical Journal, Kazan, Russian Federation
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23
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Flach C, Muruet W, Wolfe CDA, Bhalla A, Douiri A. Risk and Secondary Prevention of Stroke Recurrence: A Population-Base Cohort Study. Stroke 2020; 51:2435-2444. [PMID: 32646337 PMCID: PMC7382537 DOI: 10.1161/strokeaha.120.028992] [Citation(s) in RCA: 138] [Impact Index Per Article: 34.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Supplemental Digital Content is available in the text. Background and Purpose: With recent advances in secondary prevention management, stroke recurrence rates may have changed substantially. We aim to estimate risks and trends of stroke recurrence over the past 2 decades in a population-based cohort of patients with stroke. Methods: Patients with a first-ever stroke between 1995 and 2018 in South London, United Kingdom (n=6052) were collected and analyzed. Rates of recurrent stroke with 95% CIs were stratified by 5-year period of index stroke and etiologic TOAST (Trial of ORG 10172 in Acute Stroke Treatment) subtype. Cumulative incidences were estimated and multivariate Cox models applied to examine associations of recurrence and recurrence-free survival. Results: The rate of stroke recurrence at 5 years reduced from 18% (95% CI, 15%–21%) in those who had their stroke in 1995 to 1999 to 12% (10%–15%) in 2000 to 2005, and no improvement since. Recurrence-free survival has improved (35%, 1995–1999; 67%, 2010–2015). Risk of recurrence or death is lowest for small-vessel occlusion strokes and other ischemic causes (36% and 27% at 5 years, respectively). For cardioembolic and hemorrhagic index strokes around half of first recurrences are of the same type (54% and 51%, respectively). Over the whole study period a 54% increased risk of recurrence was observed among those who had atrial fibrillation before the index stroke (hazard ratio, 1.54 [1.09–2.17]). Conclusions: The rate of recurrence reduced until mid-2000s but has not changed over the last decade. The majority of cardioembolic or hemorrhagic strokes that have a recurrence are stroke of the same type indicating that the implementation of effective preventive strategies is still suboptimal in these stroke subtypes.
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Affiliation(s)
- Clare Flach
- King's College London, School of Population Health and Environmental Sciences, United Kingdom (C.F., W.M., C.D.A.W., A.B., A.D.)
| | - Walter Muruet
- King's College London, School of Population Health and Environmental Sciences, United Kingdom (C.F., W.M., C.D.A.W., A.B., A.D.)
| | - Charles D A Wolfe
- King's College London, School of Population Health and Environmental Sciences, United Kingdom (C.F., W.M., C.D.A.W., A.B., A.D.).,National Institute for Health Research Applied Research Collaboration (ARC) South London (C.D.A.W., A.D.), Guy's and St Thomas' National Health Service Foundation Trust and King's College London, United Kingdom
| | - Ajay Bhalla
- King's College London, School of Population Health and Environmental Sciences, United Kingdom (C.F., W.M., C.D.A.W., A.B., A.D.).,Department of Ageing Health and Stroke (A.B.), Guy's and St Thomas' National Health Service Foundation Trust and King's College London, United Kingdom
| | - Abdel Douiri
- King's College London, School of Population Health and Environmental Sciences, United Kingdom (C.F., W.M., C.D.A.W., A.B., A.D.).,National Institute for Health Research Applied Research Collaboration (ARC) South London (C.D.A.W., A.D.), Guy's and St Thomas' National Health Service Foundation Trust and King's College London, United Kingdom
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24
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Wang X, Phan HT, Li J, Reeves MJ, Thrift AG, Cadilhac DA, Sturm J, Konstantinos V, Parmar P, Krishnamurthi R, Barker-Collo S, Feigin V, Cabral NL, Carolei A, Marini C, Sacco S, Correia M, Appelros P, Kõrv J, Vibo R, Yang SC, Carcel C, Woodward M, Sandset EC, Anderson C, Gall S. Sex Differences in Disease Profiles, Management, and Outcomes Among People with Atrial Fibrillation After Ischemic Stroke: Aggregated and Individual Participant Data Meta-Analyses. WOMEN'S HEALTH REPORTS 2020; 1:190-202. [PMID: 33786481 PMCID: PMC7784810 DOI: 10.1089/whr.2020.0029] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Objectives: To examine sex differences in disease profiles, management, and survival at 1 and 5 years after ischemic stroke (IS) among people with atrial fibrillation (AF). Methods: We performed a systematic literature search of reports of AF at IS onset according to sex. We undertook an individual participant data meta-analysis (IPDMA) of nine population-based stroke incidence studies conducted in Australasia, Europe, and South America (1993–2014). Poisson regression was used to estimate women:men mortality rate ratios (MRRs). Study-specific MRRs were combined using random effects meta-analysis. Results: In our meta-analysis based on aggregated data from 101 studies, the pooled AF prevalence was 23% (95% confidence interval [CI]: 22%–25%) in women and 17% (15%–18%) in men. Our IPDMA is of 1,862 IS-AF cases, with women (79.2 ± 9.1, years) being older than men (76.5 ± 9.5, years). Crude pooled mortality rate was greater for women than for men (1-year MRR 1.24; 1.01–1.51; 5-year 1.12; 1.03–1.22). However, the sex difference was greatly attenuated after accounting for age, prestroke function, and stroke severity (1-year 1.09; 0.97–1.22; 5-year 0.98; 0.84–1.16). Women were less likely to have anticoagulant prescription at discharge (odds ratio [OR] 0.94; 95% CI: 0.89–0.98) than men when pooling IPDMA and aggregated data. Conclusions: AF was more prevalent after IS among women than among men. Among IS-AF cases, women were less likely to receive anticoagulant agents at discharge; however, greater mortality rate in women was mostly attributable to prestroke factors. Further information needs to be collected in population-based studies to understand the reasons for lower treatment of AF in women.
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Affiliation(s)
- Xia Wang
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, Australia
| | - Hoang T Phan
- Menzies Institute for Medical Research Tasmania, University of Tasmania, Hobart, Australia.,Department of Health Management and Health Economics, Pham Ngoc Thach University of Medicine, Ho Chi Minh City, Vietnam
| | - Jingwei Li
- Department of Cardiology, People's Liberation Army General Hospital, Beijing, China.,Department of Cardiology, Xinqiao Hospital, Army Military Medical University, Chongqing, China
| | - Mathew J Reeves
- Department of Epidemiology and Biostatistics, Michigan State University, East Lansing, Michigan, USA
| | - Amanda G Thrift
- Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, Australia
| | - Dominique A Cadilhac
- Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, Australia
| | - Jonathan Sturm
- Faculty of Health and Medicine, University of Newcastle, Newcastle, Australia
| | - Vemmos Konstantinos
- Department of Clinical Therapeutics, Alexandra Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Priya Parmar
- National Institute for Stroke and Applied Neurosciences, School of Public Health and Psychosocial Studies, Auckland University of Technology, Auckland, New Zealand
| | - Rita Krishnamurthi
- National Institute for Stroke and Applied Neurosciences, School of Public Health and Psychosocial Studies, Auckland University of Technology, Auckland, New Zealand
| | | | - Valery Feigin
- School of Psychology, University of Auckland, Auckland, New Zealand
| | - Norberto L Cabral
- Clinica Neurológica de Joinville, Joinville Stroke Registry, University of Joinville Region-Univille, Joinville, Brazil
| | - Antonio Carolei
- Department of Biotechnological and Applied Clinical Sciences, Neurological Institute, University of L'Aquila, Italy
| | - Carmine Marini
- Department of Life, Health, and Environmental Sciences, University of L'Aquila, L'Aquila, Italy
| | - Simona Sacco
- Department of Biotechnological and Applied Clinical Sciences, Neurological Institute, University of L'Aquila, Italy
| | - Manuel Correia
- InstitutodeCiênciasBiomédicasdeAbelSalazar, UniversidadedoPorto, Porto, Portugal
| | - Peter Appelros
- Department of Neurology, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Janika Kõrv
- Department of Neurology and Neurosurgery, Institute of Clinical Medicine, University of Tartu, Tartu, Estonia
| | - Riina Vibo
- Department of Neurology and Neurosurgery, Institute of Clinical Medicine, University of Tartu, Tartu, Estonia
| | - Sook Ching Yang
- Department of Cardiology, The Royal Infirmary of Edinburgh, Edinburgh, United Kingdom
| | - Cheryl Carcel
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, Australia.,Department of Neurology, Royal Prince Alfred Hospital, the University of Sydney, Sydney, Australia
| | - Mark Woodward
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, Australia.,The George Institute for Global Health, University of Oxford, Oxford, United Kingdom
| | | | - Craig Anderson
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, Australia.,Department of Cardiology, The Royal Infirmary of Edinburgh, Edinburgh, United Kingdom.,The George Institute China at Peking University Health Science Centre, Beijing, PR China
| | - Seana Gall
- Menzies Institute for Medical Research Tasmania, University of Tasmania, Hobart, Australia
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25
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Escudero-Martinez I, Mazya M, Teutsch C, Lesko N, Gdovinova Z, Barbarini L, Fryze W, Karlinski M, Kobayashi A, Krastev G, Paiva Nunes A, Pasztoova K, Peeters A, Sobolewski P, Vilionskis A, Toni D, Ahmed N. Dabigatran initiation in patients with non-valvular AF and first acute ischaemic stroke: a retrospective observational study from the SITS registry. BMJ Open 2020; 10:e037234. [PMID: 32434935 PMCID: PMC7247395 DOI: 10.1136/bmjopen-2020-037234] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND AND OBJECTIVE The optimal timing for initiation of dabigatran after acute ischaemic stroke (AIS) is not established. We aimed to evaluate initiation timing and clinical outcomes of dabigatran in AIS patients with non-valvular atrial fibrillation (NVAF). DESIGN Retrospective study based on prospectively collected data in SITS (Safe Implementation of Treatment in Stroke) Thrombolysis and Thrombectomy Registry from July 2014 to July 2018. PARTICIPANTS European NVAF patients (≥18 years) hospitalised after first-ever ischaemic stroke. SETTING A multinational, observational monitoring register. INTERVENTION Dabigatran initiation within 3 months after the ischaemic stroke. PRIMARY AND SECONDARY OUTCOMES The primary outcome was time from first-ever ischaemic stroke (index event) to dabigatran initiation. Additional outcomes included physicians' reasons for delaying dabigatran initiation beyond acute hospital discharge and outcomes within 3 months of index event. METHODS We identified patients with NVAF who received dabigatran within 3 months of the index event. We performed descriptive statistics for baseline and demographic data and clinical outcomes after dabigatran initiation. RESULTS In total, 1489 patients with NVAF received dabigatran after AIS treated with thrombolysis and/or thrombectomy. Of these, 1240 had available initiation time. At baseline, median age was 75 years; 53% of patients were women, 15% were receiving an oral anticoagulant, 29% acetylsalicylic acid and 4% clopidogrel. Most patients (82%) initiated dabigatran within 14 days after the index event. Patients initiating earlier had lower stroke severity from median NIHSS 8 (IQR 6-13) if initiated within 7 days to NIHSS 15 (9-19) if initiated between 28 days and 3 months. Most common reasons for delaying initiation were haemorrhagic transformation or intracranial haemorrhage, stroke severity and infarct size. Few thrombotic/haemorrhagic events occurred within 3 months after the index event (20 of 926 patients, 2.2% with the available data). CONCLUSIONS Our findings, together with previous observational studies, indicate that dabigatran initiated within the first days after an AIS is safe in patients treated with intravenous thrombolysis, endovascular thrombectomy or both. TRIAL REGISTRATION NUMBER SITS Thrombolysis and Thrombectomy Registry (NCT03258645).
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Affiliation(s)
- Irene Escudero-Martinez
- Department of Neurology, Hospital Universitario Virgen del Rocio and Instituto de Biomedicina de Sevilla, Seville, Spain
| | - Michael Mazya
- Department of Neurology and Department of Clinical Neuroscience, Karolinska University Hospital and Karolinska Institutet, Stockholm, Sweden
| | - Christine Teutsch
- Medical Department, TA Cardiometabolism and Metabolics, Boehringer Ingelheim International GmbH, Ingelheim, Germany
| | - Norbert Lesko
- Department of Neurology, Faculty of Medicine, Pavol Jozef Šafárik University in Košice, Košice, Slovakia
| | - Zuzana Gdovinova
- Department of Neurology, Faculty of Medicine, Pavol Jozef Šafárik University in Košice, Košice, Slovakia
| | | | - Waldemar Fryze
- Oddział Kliniczny Neurologii, Copernicus PL, M. Kopernika Hospital, Gdańsk, Poland
| | - Michal Karlinski
- Second Department of Neurology, Institute of Psychiatry and Neurology, Warsaw, Poland
| | - Adam Kobayashi
- Faculty of Health Sciences and Physical Education, Kazimierz Pulaski University of Technology and Humanities, Radom, Poland
| | - Georgi Krastev
- Department of Neurology, Faculty Hospital Trnava, Trnava, Slovakia
| | - Ana Paiva Nunes
- Stroke Unit, Centro Hospitalar Lisboa Central, Lisbon, Portugal
| | | | - André Peeters
- Department of Neurology, Cliniques Universitaires St-Luc, Brussels, Belgium
| | - Piotr Sobolewski
- The Faculty of Medicine and Health Sciences, Jan Kochanowski University, Kielce, and Department of Neurology and Stroke Unit, Holy Spirit Specialist Hospital, Sandomierz, Poland
| | - Aleksandras Vilionskis
- Clinic of Neurology and Neurosurgery, Institute of Clinical Medicine, Vilnius University, Stroke Center, Republican Vilnius University Hospital, Vilnius, Lithuania
| | - Danilo Toni
- Department of Human Neurosciences, Sapienza University of Rome, Rome, Italy
| | - Niaz Ahmed
- Department of Neurology and Department of Clinical Neuroscience, Karolinska University Hospital and Karolinska Institutet, Stockholm, Sweden
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Papanikolaou P, Antonopoulos AS, Mastorakou I, Angelopoulos A, Kostoula E, Mystakidi XV, Simantiris S, Galiatsatos N, Oikonomou E, Tousoulis D. Antithrombotic Therapy in Carotid Artery Disease. Curr Pharm Des 2020; 26:2725-2734. [PMID: 32418521 DOI: 10.2174/1381612826666200518111359] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Accepted: 05/08/2020] [Indexed: 12/19/2022]
Abstract
The management of asymptomatic atherosclerotic carotid artery disease and the role of antithrombotic therapy is of increasing importance for stroke prevention. Non-invasive imaging of carotid plaques can identify high-risk plaque features that are associated with the risk of plaque rupture. Carotid plaque necrosis, hemorrhage, fibrous cap thinning, and the presence of foam cells have all been correlated with the risk of rupture and onset of neurological symptoms in patients with carotid stenosis. Antiplatelets are currently recommended for patients with a history of ischemic stroke and/or significant carotid artery stenosis, with aspirin and clopidogrel being the most widely used and studied agents. The role of dual antiplatelet therapy remains controversial. Moreover, there is scarce evidence on the role of newer anticoagulant agents in stable patients with carotid artery stenosis. In this review article, we discuss the pathophysiology of carotid atherosclerosis, the use of non-invasive imaging for detecting the vulnerable carotid plaque and summarize the existing clinical evidence on the use of antiplatelet and antithrombotic agents in carotid artery disease.
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Affiliation(s)
- Paraskevi Papanikolaou
- First Department of Cardiology, Hippokration Hospital, Athens Medical School, Athens, Greece
| | - Alexios S Antonopoulos
- First Department of Cardiology, Hippokration Hospital, Athens Medical School, Athens, Greece
| | - Irene Mastorakou
- Imaging Department - Onassis Cardiac Surgery Centre, Athens, Greece
| | - Andreas Angelopoulos
- First Department of Cardiology, Hippokration Hospital, Athens Medical School, Athens, Greece
| | | | - Xara-Vasiliki Mystakidi
- First Department of Cardiology, Hippokration Hospital, Athens Medical School, Athens, Greece
| | - Spyros Simantiris
- First Department of Cardiology, Hippokration Hospital, Athens Medical School, Athens, Greece
| | - Nikolaos Galiatsatos
- First Department of Cardiology, Hippokration Hospital, Athens Medical School, Athens, Greece
| | - Evangelos Oikonomou
- First Department of Cardiology, Hippokration Hospital, Athens Medical School, Athens, Greece
| | - Dimitris Tousoulis
- First Department of Cardiology, Hippokration Hospital, Athens Medical School, Athens, Greece
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27
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Armahizer M, Blackman A, Plazak M, Brophy GM. Early Acute Ischemic Stroke Management for Pharmacists. Hosp Pharm 2020; 55:12-25. [PMID: 31983762 PMCID: PMC6961150 DOI: 10.1177/0018578718791504] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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28
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Wang Y, Shi Y, Dong Y, Dong Q, Ye T, Fang K. Clinical Risk Factors of Asymptomatic Deep Venous Thrombosis in Patients With Acute Stroke. Clin Appl Thromb Hemost 2020; 25:1076029619868534. [PMID: 31434499 PMCID: PMC6829645 DOI: 10.1177/1076029619868534] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Background: Deep venous thrombosis (DVT) is a common complication after stroke. It is easy to
identify the patients with symptomatic DVT; however, the tool for asymptomatic high-risk
population needs to be further explored. Our aim was to explore the risk factors of
acute stroke patients with asymptomatic DVT. Methods: We performed a prospective observation study among 452 patients with acute stroke who
had a stroke within 14 days. Ultrasound examination of deep veins was repeatedly
performed in each patient for DVT every 7 days during his admission. The dynamic rate of
DVT in acute stroke was analyzed. Then risk factors were compared between DVT patients
and non-DVT patients. The predictive model was explored based on thr cox proportion
model. Results: Asymptomatic DVT was detected in 52 (11.5%) patients with stroke and 85.9% of thrombi
were identified in their distal veins. Patients with longer length of stay
(P = .004), more severe stroke (P = 0.001), higher
level of D-dimer (P = .003), and higher blood glucose level were
associated with higher risk of DVT, while patients with higher triglyceride level
(P = .003) were less likely to have DVT, after adjusting age and sex.
With the median of D-dimer (0.38 FEU mg/L) as cutoff value. Patients with higher level
of D-dimer might have a higher risk of DVT with a significant statistical difference.
Also, the severity of stroke differed DVT risk in Kaplan-Meier model. Using
cox-proportion hazard regression model, asymptomatic DVT could be predicted (area under
the curve 0.852). Conclusion: Our data showed that asymptomatic DVT was common in patients with acute stroke and most
of thrombosis occurred in distal veins. Combination of clinical manifestation and
laboratory results might be helpful predict DVT. DVT prophylaxis should be condisdered
in high risk.
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Affiliation(s)
- Yi Wang
- 1 Department of Neurology, Huashan Hospital, Fudan University, Shanghai, China
| | - Yu Shi
- 1 Department of Neurology, Huashan Hospital, Fudan University, Shanghai, China
| | - Yi Dong
- 1 Department of Neurology, Huashan Hospital, Fudan University, Shanghai, China
| | - Qiang Dong
- 1 Department of Neurology, Huashan Hospital, Fudan University, Shanghai, China.,2 National Clinical Research Center for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai, China.,3 State Key Laboratory of Medical Neurobiology, Fudan University, Shanghai, China
| | - Ting Ye
- 1 Department of Neurology, Huashan Hospital, Fudan University, Shanghai, China
| | - Kun Fang
- 1 Department of Neurology, Huashan Hospital, Fudan University, Shanghai, China
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Hou X, Chen H. Proposed antithrombotic strategy for acute ischemic stroke with large-artery atherosclerosis: focus on patients with high-risk transient ischemic attack and mild-to-moderate stroke. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:16. [PMID: 32055607 DOI: 10.21037/atm.2019.10.111] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
An effective antithrombotic strategy is required to prevent the recurrence and aggravation of large-artery atherosclerosis (LAA) stroke, especially in high-risk transient ischemic attack (TIA) and acute mild ischemic stroke. Based on clinical evidence, atherosclerotic thrombosis theory, antithrombotic treatment guidelines of acute myocardial infarction (AMI), and previous studies, a new antithrombotic strategy "early administration, enhanced therapy, combination therapy, short-term therapy, and sequential therapy" was proposed in this study. Multicenter randomized trials are needed in the future to verify the efficacy of the strategy.
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Affiliation(s)
- Xiaowen Hou
- Department of Neurology, General Hospital of Northern Theater Command, Shenyang 110016, China
| | - Huisheng Chen
- Department of Neurology, General Hospital of Northern Theater Command, Shenyang 110016, China
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30
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King BT, Lawrence PD, Milling TJ, Warach SJ. Optimal delay time to initiate anticoagulation after ischemic stroke in atrial fibrillation (START): Methodology of a pragmatic, response-adaptive, prospective randomized clinical trial. Int J Stroke 2019; 14:977-982. [PMID: 31423922 PMCID: PMC7401695 DOI: 10.1177/1747493019870651] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
RATIONALE An estimated 15% of all strokes are associated with untreated atrial fibrillation. Long-term secondary stroke prevention in atrial fibrillation is anticoagulation, increasingly with non-vitamin K oral anticoagulants. The optimal time to initiate anticoagulation following an atrial fibrillation-related stroke that balances hemorrhagic conversion with recurrent stroke is not yet known. AIMS To determine if there is an optimal delay time to initiate anticoagulation after atrial fibrillation-related stroke that optimizes the composite outcome of hemorrhagic conversion and recurrent ischemic stroke. SAMPLE SIZE ESTIMATES The study will enroll 1500 total subjects split between a mild to moderate stroke cohort (1000) and a severe stroke cohort (500). METHODS AND DESIGN This study is a multi-center, prospective, randomized, pragmatic, adaptive trial that randomizes subjects to four arms of time to start of anticoagulation. The four arms for mild to moderate stroke are: Day 3, Day 6, Day 10, and Day 14. The time intervals for severe stroke are: Day 6, Day 10, Day 14, and Day 21. Allocation involves a response adaptive randomization via interim analyses to favor the arms that have a better risk-benefit profile. STUDY OUTCOMES The primary outcome event is the composite occurrence of an ischemic or hemorrhagic event within 30 days of the index stroke. Secondary outcomes are also collected at 30 and 90 days. DISCUSSION The optimal timing of direct oral anticoagulants post-ischemic stroke requires prospective randomized testing. A pragmatically designed trial with adaptive allocation and randomization to multiple time intervals such as the START trial is best suited to answer this question in order to directly inform current practice on this question.
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Affiliation(s)
- Benjamin T King
- Department of Neurology, University of Texas Dell Medical School, Austin, TX, USA
| | - Patrick D Lawrence
- Department of Neurology, University of Texas Dell Medical School, Austin, TX, USA
| | - Truman J Milling
- Department of Neurology, University of Texas Dell Medical School, Austin, TX, USA
- Seton Healthcare Family, Austin, TX, USA
- Department of Surgery and Perioperative Care, University of Texas Dell Medical School, Austin, TX, USA
| | - Steven J Warach
- Department of Neurology, University of Texas Dell Medical School, Austin, TX, USA
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31
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Kuramatsu JB, Sembill JA, Gerner ST, Sprügel MI, Hagen M, Roeder SS, Endres M, Haeusler KG, Sobesky J, Schurig J, Zweynert S, Bauer M, Vajkoczy P, Ringleb PA, Purrucker J, Rizos T, Volkmann J, Müllges W, Kraft P, Schubert AL, Erbguth F, Nueckel M, Schellinger PD, Glahn J, Knappe UJ, Fink GR, Dohmen C, Stetefeld H, Fisse AL, Minnerup J, Hagemann G, Rakers F, Reichmann H, Schneider H, Wöpking S, Ludolph AC, Stösser S, Neugebauer H, Röther J, Michels P, Schwarz M, Reimann G, Bäzner H, Schwert H, Claßen J, Michalski D, Grau A, Palm F, Urbanek C, Wöhrle JC, Alshammari F, Horn M, Bahner D, Witte OW, Günther A, Hamann GF, Lücking H, Dörfler A, Achenbach S, Schwab S, Huttner HB. Management of therapeutic anticoagulation in patients with intracerebral haemorrhage and mechanical heart valves. Eur Heart J 2019. [PMID: 29529259 PMCID: PMC5950928 DOI: 10.1093/eurheartj/ehy056] [Citation(s) in RCA: 59] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Aims Evidence is lacking regarding acute anticoagulation management in patients after intracerebral haemorrhage (ICH) with implanted mechanical heart valves (MHVs). Our objective was to investigate anticoagulation reversal and resumption strategies by evaluating incidences of haemorrhagic and thromboembolic complications, thereby defining an optimal time-window when to restart therapeutic anticoagulation (TA) in patients with MHV and ICH. Methods and results We pooled individual patient-data (n = 2504) from a nationwide multicentre cohort-study (RETRACE, conducted at 22 German centres) and eventually identified MHV-patients (n = 137) with anticoagulation-associated ICH for outcome analyses. The primary outcome consisted of major haemorrhagic complications analysed during hospital stay according to treatment exposure (restarted TA vs. no-TA). Secondary outcomes comprised thromboembolic complications, the composite outcome (haemorrhagic and thromboembolic complications), timing of TA, and mortality. Adjusted analyses involved propensity-score matching and multivariable cox-regressions to identify optimal timing of TA. In 66/137 (48%) of patients TA was restarted, being associated with increased haemorrhagic (TA = 17/66 (26%) vs. no-TA = 4/71 (6%); P < 0.01) and a trend to decreased thromboembolic complications (TA = 1/66 (2%) vs. no-TA = 7/71 (10%); P = 0.06). Controlling treatment crossovers provided an incidence rate-ratio [hazard ratio (HR) 10.31, 95% confidence interval (CI) 3.67–35.70; P < 0.01] in disadvantage of TA for haemorrhagic complications. Analyses of TA-timing displayed significant harm until Day 13 after ICH (HR 7.06, 95% CI 2.33–21.37; P < 0.01). The hazard for the composite—balancing both complications, was increased for restarted TA until Day 6 (HR 2.51, 95% CI 1.10–5.70; P = 0.03). Conclusion Restarting TA within less than 2 weeks after ICH in patients with MHV was associated with increased haemorrhagic complications. Optimal weighing—between least risks for thromboembolic and haemorrhagic complications—provided an earliest starting point of TA at Day 6, reserved only for patients at high thromboembolic risk. ![]()
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Affiliation(s)
- Joji B Kuramatsu
- Department of Neurology, University of Erlangen-Nuremberg, Schwabachanlage 6, Erlangen 91054, Germany
| | - Jochen A Sembill
- Department of Neurology, University of Erlangen-Nuremberg, Schwabachanlage 6, Erlangen 91054, Germany
| | - Stefan T Gerner
- Department of Neurology, University of Erlangen-Nuremberg, Schwabachanlage 6, Erlangen 91054, Germany
| | - Maximilian I Sprügel
- Department of Neurology, University of Erlangen-Nuremberg, Schwabachanlage 6, Erlangen 91054, Germany
| | - Manuel Hagen
- Department of Neurology, University of Erlangen-Nuremberg, Schwabachanlage 6, Erlangen 91054, Germany
| | - Sebastian S Roeder
- Department of Neurology, University of Erlangen-Nuremberg, Schwabachanlage 6, Erlangen 91054, Germany
| | - Matthias Endres
- Department of Neurology, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Charitéplatz 1, Berlin 10117, Germany.,Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Charitéplatz 1, Berlin 10117, Germany.,German Centre for Cardiovascular Research (DZHK), Oudenarder Straße 16, Berlin 13347, Germany.,German Center for Neurodegenerative Diseases (DZNE), partner site Berlin, Charitéplatz 1, Berlin 10117, Germany
| | - Karl Georg Haeusler
- Department of Neurology, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Charitéplatz 1, Berlin 10117, Germany.,Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Charitéplatz 1, Berlin 10117, Germany
| | - Jan Sobesky
- Department of Neurology, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Charitéplatz 1, Berlin 10117, Germany.,Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Charitéplatz 1, Berlin 10117, Germany
| | - Johannes Schurig
- Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Charitéplatz 1, Berlin 10117, Germany
| | - Sarah Zweynert
- Department of Neurology, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Charitéplatz 1, Berlin 10117, Germany
| | - Miriam Bauer
- Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Charitéplatz 1, Berlin 10117, Germany
| | - Peter Vajkoczy
- Department of Neurosurgery, Charité-Universitätsmedizin Berlin, Augustenburger Platz 1, Berlin 13353, Germany
| | - Peter A Ringleb
- Department of Neurology, Heidelberg University Hospital, INF 400, Heidelberg 69120, Germany
| | - Jan Purrucker
- Department of Neurology, Heidelberg University Hospital, INF 400, Heidelberg 69120, Germany
| | - Timolaos Rizos
- Department of Neurology, Heidelberg University Hospital, INF 400, Heidelberg 69120, Germany
| | - Jens Volkmann
- Department of Neurology, University of Würzburg, Josef-Schneider-Straße 11, Würzburg 97080, Germany
| | - Wolfgang Müllges
- Department of Neurology, University of Würzburg, Josef-Schneider-Straße 11, Würzburg 97080, Germany
| | - Peter Kraft
- Department of Neurology, University of Würzburg, Josef-Schneider-Straße 11, Würzburg 97080, Germany
| | - Anna-Lena Schubert
- Department of Neurology, University of Würzburg, Josef-Schneider-Straße 11, Würzburg 97080, Germany
| | - Frank Erbguth
- Department of Neurology, Community Hospital Nuremberg, Breslauer Str. 201, Nuremberg 90471, Germany
| | - Martin Nueckel
- Department of Neurology, Community Hospital Nuremberg, Breslauer Str. 201, Nuremberg 90471, Germany
| | - Peter D Schellinger
- Department of Neurology and Neurogeriatry, Johannes Wesling Medical Center Minden, UK RUB, Hans-Nolte-Str. 1, Minden 32429, Germany
| | - Jörg Glahn
- Department of Neurology and Neurogeriatry, Johannes Wesling Medical Center Minden, UK RUB, Hans-Nolte-Str. 1, Minden 32429, Germany
| | - Ulrich J Knappe
- Department of Neurosurgery, Johannes Wesling Medical Center Minden, UK RUB, Hans-Nolte-Str. 1, Minden 32429, Germany
| | - Gereon R Fink
- Department of Neurology, University of Cologne, Kerpener Str. 62, Cologne 50937, Germany
| | - Christian Dohmen
- Department of Neurology, University of Cologne, Kerpener Str. 62, Cologne 50937, Germany
| | - Henning Stetefeld
- Department of Neurology, University of Cologne, Kerpener Str. 62, Cologne 50937, Germany
| | - Anna Lena Fisse
- Department of Neurology, University of Münster, Albert-Schweitzer-Campus 1, Münster 48149, Germany
| | - Jens Minnerup
- Department of Neurology, University of Münster, Albert-Schweitzer-Campus 1, Münster 48149, Germany
| | - Georg Hagemann
- Department of Neurology, Community Hospital Helios Klinikum Berlin-Buch, Schwanebecker Chaussee 50, Berlin 13125, Germany
| | - Florian Rakers
- Department of Neurology, Community Hospital Helios Klinikum Berlin-Buch, Schwanebecker Chaussee 50, Berlin 13125, Germany
| | - Heinz Reichmann
- Department of Neurology, University of Dresden, Fetscherstr. 74, Dresden 01307, Germany
| | - Hauke Schneider
- Department of Neurology, University of Dresden, Fetscherstr. 74, Dresden 01307, Germany
| | - Sigrid Wöpking
- Department of Neurology, University of Dresden, Fetscherstr. 74, Dresden 01307, Germany
| | | | - Sebastian Stösser
- Department of Neurology, University of Ulm, Oberer Eselsberg 45, Ulm 89081, Germany
| | - Hermann Neugebauer
- Department of Neurology, University of Ulm, Oberer Eselsberg 45, Ulm 89081, Germany
| | - Joachim Röther
- Department of Neurology, Community Hospital Asklepios Klinik Hamburg Altona, Paul Ehrlich-Strasse 1, Hamburg 22763, Germany
| | - Peter Michels
- Department of Neurology, Community Hospital Asklepios Klinik Hamburg Altona, Paul Ehrlich-Strasse 1, Hamburg 22763, Germany
| | - Michael Schwarz
- Department of Neurology, Community Hospital Klinikum Dortmund, Beurhausstraße 40, Dortmund 44137, Germany
| | - Gernot Reimann
- Department of Neurology, Community Hospital Klinikum Dortmund, Beurhausstraße 40, Dortmund 44137, Germany
| | - Hansjörg Bäzner
- Department of Neurology, Community Hospital Klinikum Stuttgart, Kriegsbergstrasse 60, Stuttgart 70174, Germany
| | - Henning Schwert
- Department of Neurology, Community Hospital Klinikum Stuttgart, Kriegsbergstrasse 60, Stuttgart 70174, Germany
| | - Joseph Claßen
- Department of Neurology, University of Leipzig, Liebigstr. 20, Leipzig 04103, Germany
| | - Dominik Michalski
- Department of Neurology, University of Leipzig, Liebigstr. 20, Leipzig 04103, Germany
| | - Armin Grau
- Department of Neurology, Community Hospital Klinikum der Stadt Ludwigshafen am Rhein, Bremserstraße 79, Ludwigshafen 67063, Germany
| | - Frederick Palm
- Department of Neurology, Community Hospital Klinikum der Stadt Ludwigshafen am Rhein, Bremserstraße 79, Ludwigshafen 67063, Germany
| | - Christian Urbanek
- Department of Neurology, Community Hospital Klinikum der Stadt Ludwigshafen am Rhein, Bremserstraße 79, Ludwigshafen 67063, Germany
| | - Johannes C Wöhrle
- Department of Neurology, Community Hospital Klinikum Koblenz, Kardinal-Krementz-Str. 1-5, Koblenz 56073, Germany
| | - Fahid Alshammari
- Department of Neurology, Community Hospital Klinikum Koblenz, Kardinal-Krementz-Str. 1-5, Koblenz 56073, Germany
| | - Markus Horn
- Department of Neurology, Community Hospital Bad Hersfeld, Seilerweg 29, Bad Hersfeld 36251, Germany
| | - Dirk Bahner
- Department of Neurology, Community Hospital Bad Hersfeld, Seilerweg 29, Bad Hersfeld 36251, Germany
| | - Otto W Witte
- Department of Neurology, University of Jena, Erlanger Allee 101, Jena 07747, Germany
| | - Albrecht Günther
- Department of Neurology, University of Jena, Erlanger Allee 101, Jena 07747, Germany
| | - Gerhard F Hamann
- Department of Neurology and Neurological Rehabilitation, Bezirkskrankenhaus Günzburg, Ludwig-Heilmeyer-Straße 2, 89312 Günzburg, Germany
| | - Hannes Lücking
- Department of Neuroradiology, University of Erlangen-Nuremberg, Schwabachanlage 6, Erlangen 91054, Germany
| | - Arnd Dörfler
- Department of Neuroradiology, University of Erlangen-Nuremberg, Schwabachanlage 6, Erlangen 91054, Germany
| | - Stephan Achenbach
- Department of Cardiology, University of Erlangen-Nuremberg, Ulmenweg 18, Erlangen 91054, Germany
| | - Stefan Schwab
- Department of Neurology, University of Erlangen-Nuremberg, Schwabachanlage 6, Erlangen 91054, Germany
| | - Hagen B Huttner
- Department of Neurology, University of Erlangen-Nuremberg, Schwabachanlage 6, Erlangen 91054, Germany
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Smith M, Reddy U, Robba C, Sharma D, Citerio G. Acute ischaemic stroke: challenges for the intensivist. Intensive Care Med 2019; 45:1177-1189. [PMID: 31346678 DOI: 10.1007/s00134-019-05705-y] [Citation(s) in RCA: 57] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Accepted: 07/17/2019] [Indexed: 12/25/2022]
Abstract
PURPOSE To provide an update about the rapidly developing changes in the critical care management of acute ischaemic stroke patients. METHODS A narrative review was conducted in five general areas of acute ischaemic stroke management: reperfusion strategies, anesthesia for endovascular thrombectomy, intensive care unit management, intracranial complications, and ethical considerations. RESULTS The introduction of effective reperfusion strategies, including IV thrombolysis and endovascular thrombectomy, has revolutionized the management of acute ischaemic stroke and transformed outcomes for patients. Acute therapeutic efforts are targeted to restoring blood flow to the ischaemic penumbra before irreversible tissue injury has occurred. To optimize patient outcomes, secondary insults, such as hypotension, hyperthermia, or hyperglycaemia, that can extend the penumbral area must also be prevented or corrected. The ICU management of acute ischaemic stroke patients, therefore, focuses on the optimization of systemic physiological homeostasis, management of intracranial complications, and neurological and haemodynamic monitoring after reperfusion therapies. Meticulous blood pressure management is of central importance in improving outcomes, particularly in patients that have undergone reperfusion therapies. CONCLUSIONS While consensus guidelines are available to guide clinical decision making after acute ischaemic stroke, there is limited high-quality evidence for many of the recommended interventions. However, a bundle of medical, endovascular, and surgical strategies, when applied in a timely and consistent manner, can improve long-term stroke outcomes.
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Affiliation(s)
- M Smith
- Neurocritical Care Unit, The National Hospital for Neurology and Neurosurgery, University College London Hospitals, Queen Square, London, UK. .,Department of Medical Physics and Biomedical Engineering, University College London, London, UK.
| | - U Reddy
- Neurocritical Care Unit, The National Hospital for Neurology and Neurosurgery, University College London Hospitals, Queen Square, London, UK
| | - C Robba
- Department of Anaesthesia and Intensive Care, Policlinico San Martino IRCCS for Oncology and Neuroscience, Genoa, Italy
| | - D Sharma
- Division of Neuroanesthesiology and Perioperative Neurosciences, Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, USA
| | - G Citerio
- School of Medicine and Surgery, University of Milan-Bicocca, Milan, Italy.,Neurointensive Care Unit, San Gerardo Hospital, ASST-Monza, Monza, MB, Italy
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Dennis M. Does this recent randomised controlled trial of intermittent pneumatic compression devices really indicate that they are ineffective in critical care patients? J Thorac Dis 2019; 11:2195-2197. [PMID: 31372250 DOI: 10.21037/jtd.2019.05.72] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Martin Dennis
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
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35
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Khan MS, Guan D, Kvist S, Ma L, Xie J, Xu S. Transcriptomics and differential gene expression in Whitmania pigra (Annelida: Clitellata: Hirudinida: Hirudinidae): Contrasting feeding and fasting modes. Ecol Evol 2019; 9:4706-4719. [PMID: 31031937 PMCID: PMC6476756 DOI: 10.1002/ece3.5074] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Revised: 02/26/2019] [Accepted: 02/27/2019] [Indexed: 12/04/2022] Open
Abstract
The medicinal utility of leeches has been demonstrated through decades of use in modern hospital settings, mainly as relievers of venous congestion following flap or digit replantation surgery. In the present study, we sequence and annotate (through BLAST- and Gene Ontology-based approaches) the salivary transcriptome of the nonblood feeding hirudinid Whitmania pigra and assess the differential gene expression of anticoagulation factors (through both quantitative real-time PCR [qRT-PCR] and in silico-based methods) during feeding and fasting conditions. This was done in order to evince the diversity of putative anticoagulation factors, as well as estimate the levels of upregulation of genes immediately after feeding. In total, we found sequences with demonstrated orthology (via both phylogenetic analyses and BLAST-based approaches) to seven different proteins that have previously been linked to anticoagulatory capabilities-eglin C, bdellin, granulin, guamerin, hyaluronidase, destabilase I, and lipocalin. All of these were recovered from leeches both in the fasting and in the feeding conditions, but all show signs of upregulation in the feeding leeches. Interestingly, our RNA-seq effort, coupled with a hypergeometric test, indicated that the differentially expressed genes were disproportionately involved in three main immunological pathways (endocytosis, peroxisome regulation, and lysosome regulation). The results and implications of the finding of anticoagulants in this nonblood feeding leech and the putative upregulation of anticoagulation factors after feeding are briefly discussed in an evolutionary context.
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Affiliation(s)
| | - De‐Long Guan
- College of Life SciencesShaanxi Normal UniversityXi'anChina
| | - Sebastian Kvist
- Department of Ecology and Evolutionary BiologyUniversity of TorontoTorontoOntarioCanada
- Department of Natural HistoryRoyal Ontario MuseumTorontoOntarioCanada
| | - Li‐Bin Ma
- College of Life SciencesShaanxi Normal UniversityXi'anChina
| | - Juan‐Ying Xie
- School of Computer ScienceShaanxi Normal UniversityXi'anChina
| | - Sheng‐Quan Xu
- College of Life SciencesShaanxi Normal UniversityXi'anChina
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Schünemann HJ, Cushman M, Burnett AE, Kahn SR, Beyer-Westendorf J, Spencer FA, Rezende SM, Zakai NA, Bauer KA, Dentali F, Lansing J, Balduzzi S, Darzi A, Morgano GP, Neumann I, Nieuwlaat R, Yepes-Nuñez JJ, Zhang Y, Wiercioch W. American Society of Hematology 2018 guidelines for management of venous thromboembolism: prophylaxis for hospitalized and nonhospitalized medical patients. Blood Adv 2018; 2:3198-3225. [PMID: 30482763 PMCID: PMC6258910 DOI: 10.1182/bloodadvances.2018022954] [Citation(s) in RCA: 489] [Impact Index Per Article: 81.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2018] [Accepted: 09/19/2018] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Venous thromboembolism (VTE) is the third most common vascular disease. Medical inpatients, long-term care residents, persons with minor injuries, and long-distance travelers are at increased risk. OBJECTIVE These evidence-based guidelines from the American Society of Hematology (ASH) intend to support patients, clinicians, and others in decisions about preventing VTE in these groups. METHODS ASH formed a multidisciplinary guideline panel balanced to minimize potential bias from conflicts of interest. The McMaster University GRADE Centre supported the guideline-development process, including updating or performing systematic evidence reviews. The panel prioritized clinical questions and outcomes according to their importance for clinicians and adult patients. The Grading of Recommendations Assessment, Development and Evaluation approach was used to assess evidence and make recommendations, which were subject to public comment. RESULTS The panel agreed on 19 recommendations for acutely ill and critically ill medical inpatients, people in long-term care facilities, outpatients with minor injuries, and long-distance travelers. CONCLUSIONS Strong recommendations included provision of pharmacological VTE prophylaxis in acutely or critically ill inpatients at acceptable bleeding risk, use of mechanical prophylaxis when bleeding risk is unacceptable, against the use of direct oral anticoagulants during hospitalization, and against extending pharmacological prophylaxis after hospital discharge. Conditional recommendations included not to use VTE prophylaxis routinely in long-term care patients or outpatients with minor VTE risk factors. The panel conditionally recommended use of graduated compression stockings or low-molecular-weight heparin in long-distance travelers only if they are at high risk for VTE.
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Affiliation(s)
- Holger J Schünemann
- Department of Medicine and
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Mary Cushman
- Department of Medicine and
- Department of Pathology and Laboratory Medicine, University of Vermont Larner College of Medicine and University of Vermont Medical Center, Burlington, VT
| | - Allison E Burnett
- Inpatient Antithrombosis Service, University of New Mexico Health Sciences Center, Albuquerque, NM
| | - Susan R Kahn
- Department of Medicine, McGill University and Lady Davis Institute, Montreal, QC, Canada
| | - Jan Beyer-Westendorf
- Thrombosis Research Unit, Division of Hematology, Department of Medicine I, University Hospital "Carl Gustav Carus," Dresden, Germany
- Kings Thrombosis Service, Department of Hematology, Kings College London, United Kingdom
| | | | - Suely M Rezende
- Department of Internal Medicine, Faculty of Medicine, Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
| | - Neil A Zakai
- Department of Medicine and
- Department of Pathology and Laboratory Medicine, University of Vermont Larner College of Medicine and University of Vermont Medical Center, Burlington, VT
| | - Kenneth A Bauer
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Francesco Dentali
- Department of Medicine and Surgery, Insubria University, Varese, Italy
| | | | - Sara Balduzzi
- Cochrane Italy, Department of Diagnostic, Clinical and Public Health Medicine, University of Modena and Reggio Emilia, Modena, Italy; and
| | - Andrea Darzi
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Gian Paolo Morgano
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Ignacio Neumann
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
- Department of Internal Medicine, School of Medicine, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - Robby Nieuwlaat
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Juan J Yepes-Nuñez
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Yuan Zhang
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Wojtek Wiercioch
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
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Venturelli PM, Appleton JP, Anderson CS, Bath PM. Acute Treatment of Stroke (Except Thrombectomy). Curr Neurol Neurosci Rep 2018; 18:77. [PMID: 30229395 DOI: 10.1007/s11910-018-0883-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
PURPOSE OF REVIEW The management of patients with acute stroke has been revolutionized in recent years with the advent of new effective treatments. In this rapidly evolving field, we provide an update on the management of acute stroke excluding thrombectomy, looking to recent, ongoing, and future trials. RECENT FINDINGS Large definitive trials have provided insight into acute stroke care including broadening the therapeutic window for thrombolysis, alternatives to standard dose alteplase, the use of dual antiplatelet therapy early after minor ischemic stroke, and treating elevated blood pressure in intracerebral hemorrhage. Further ongoing and future trials are eagerly awaited in this ever-expanding area. Although definitive trials have led to improvements in acute stroke care, there remains a need for further research to improve our understanding of pathophysiological mechanisms underlying different stroke types with the potential for treatments to be tailored to the individual.
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Affiliation(s)
- Paula Muñoz Venturelli
- Clinical Research Center, Instituto de Ciencias e Innovación en Medicina, Facultad de Medicina, Clínica Alemana Universidad del Desarrollo, Santiago, Chile.,Department of Neurology and Psychiatry, Clínica Alemana de Santiago, Santiago, Chile.,The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Jason P Appleton
- Stroke Trials Unit, Division of Clinical Neurosciences, University of Nottingham, Nottingham, UK.,Stroke, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Craig S Anderson
- Clinical Research Center, Instituto de Ciencias e Innovación en Medicina, Facultad de Medicina, Clínica Alemana Universidad del Desarrollo, Santiago, Chile. .,The George Institute for Global Health, University of New South Wales, Sydney, Australia. .,The George Institute China at Peking University Health Science Center, Beijing, China.
| | - Philip M Bath
- Stroke Trials Unit, Division of Clinical Neurosciences, University of Nottingham, Nottingham, UK.,Stroke, Nottingham University Hospitals NHS Trust, Nottingham, UK
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Akinseye OA, Shahreyar M, Heckle MR, Khouzam RN. Simultaneous acute cardio-cerebral infarction: is there a consensus for management? ANNALS OF TRANSLATIONAL MEDICINE 2018; 6:7. [PMID: 29404353 DOI: 10.21037/atm.2017.11.06] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Acute ischemic stroke (AIS) and acute myocardial infarction (AMI) are both life-threatening medical conditions with narrow therapeutic time-window that carry grave prognosis if not addressed promptly. The acute management of both condition is well documented in the literature, however the management of a simultaneous presentation of both AIS and AMI is unclear. A delayed intervention of one infarcted territory for the other may result in permanent irreversible morbidity or disability, and even death. In addition, the use of antiplatelet and anticoagulants that are inherently part of an AMI management may increase the risk for hemorrhagic conversion associated with intravenous thrombolysis used in AIS, and the use of a thrombolytic in AIS increases the risk of cardiac wall rupture in the setting of an AMI. Despite this ambiguity, there is no clear evidence-based guideline or clinical studies that have addressed the optimal management of this rare co-occurrence. This review paper examines the existing literature on the management of simultaneous acute cardio-cerebral infarction (CCI) and highlights the existing challenge to management.
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Affiliation(s)
- Oluwaseun A Akinseye
- Department of Medicine, Division of Cardiovascular Diseases, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Muhammad Shahreyar
- Department of Medicine, Division of Cardiovascular Diseases, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Mark R Heckle
- Department of Medicine, Division of Cardiovascular Diseases, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Rami N Khouzam
- Department of Medicine, Division of Cardiovascular Diseases, University of Tennessee Health Science Center, Memphis, Tennessee, USA
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Urimubenshi G, Langhorne P, Cadilhac DA, Kagwiza JN, Wu O. Association between patient outcomes and key performance indicators of stroke care quality: A systematic review and meta-analysis. Eur Stroke J 2017; 2:287-307. [PMID: 31008322 DOI: 10.1177/2396987317735426] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2017] [Accepted: 09/09/2017] [Indexed: 01/09/2023] Open
Abstract
Purpose Translating research evidence into clinical practice often uses key performance indicators to monitor quality of care. We conducted a systematic review to identify the stroke key performance indicators used in large registries, and to estimate their association with patient outcomes. Method We sought publications of recent (January 2000-May 2017) national or regional stroke registers reporting the association of key performance indicators with patient outcome (adjusting for age and stroke severity). We searched Ovid Medline, EMBASE and PubMed and screened references from bibliographies. We used an inverse variance random effects meta-analysis to estimate associations (odds ratio; 95% confidence interval) with death or poor outcome (death or disability) at the end of follow-up. Findings We identified 30 eligible studies (324,409 patients). The commonest key performance indicators were swallowing/nutritional assessment, stroke unit admission, antiplatelet use for ischaemic stroke, brain imaging and anticoagulant use for ischaemic stroke with atrial fibrillation, lipid management, deep vein thrombosis prophylaxis and early physiotherapy/mobilisation. Lower case fatality was associated with stroke unit admission (odds ratio 0.79; 0.72-0.87), swallow/nutritional assessment (odds ratio 0.78; 0.66-0.92) and antiplatelet use for ischaemic stroke (odds ratio 0.61; 0.50-0.74) or anticoagulant use for ischaemic stroke with atrial fibrillation (odds ratio 0.51; 0.43-0.64), lipid management (odds ratio 0.52; 0.38-0.71) and early physiotherapy or mobilisation (odds ratio 0.78; 0.67-0.91). Reduced poor outcome was associated with adherence to swallowing/nutritional assessment (odds ratio 0.58; 0.43-0.78) and stroke unit admission (odds ratio 0.83; 0.77-0.89). Adherence with several key performance indicators appeared to have an additive benefit. Discussion Adherence with common key performance indicators was consistently associated with a lower risk of death or disability after stroke. Conclusion Policy makers and health care professionals should implement and monitor those key performance indicators supported by good evidence.
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Affiliation(s)
- Gerard Urimubenshi
- 1Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK.,College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda
| | - Peter Langhorne
- 1Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Dominique A Cadilhac
- School of Clinical Sciences at Monash Health, Monash University, Clayton, Australia.,The Florey Institute Neuroscience and Mental Health, University of Melbourne, Victoria, Australia
| | - Jeanne N Kagwiza
- College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda
| | - Olivia Wu
- Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
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Kurowski D, Jonczak K, Shah Q, Yaghi S, Marshall RS, Ahmad H, McKinney J, Torres J, Ishida K, Cucchiara B. Safety of Endovascular Intervention for Stroke on Therapeutic Anticoagulation: Multicenter Cohort Study and Meta-Analysis. J Stroke Cerebrovasc Dis 2017; 26:1104-1109. [DOI: 10.1016/j.jstrokecerebrovasdis.2016.12.027] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2016] [Revised: 11/09/2016] [Accepted: 12/26/2016] [Indexed: 10/20/2022] Open
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Sandercock PAG, Leong TS. Low-molecular-weight heparins or heparinoids versus standard unfractionated heparin for acute ischaemic stroke. Cochrane Database Syst Rev 2017; 4:CD000119. [PMID: 28374884 PMCID: PMC6478133 DOI: 10.1002/14651858.cd000119.pub4] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Low-molecular-weight heparins (LMWHs) and heparinoids are anticoagulants that may have more powerful antithrombotic effects than standard unfractionated heparin (UFH) but a lower risk of bleeding complications. This is an update of the original Cochrane Review of these agents, first published in 2001 and last updated in 2008. OBJECTIVES To determine whether antithrombotic therapy with LMWHs or heparinoids is associated with a reduction in the proportion of people who are dead or dependent for activities in daily living compared with UFH. SEARCH METHODS We searched the Cochrane Stroke Group Trials Register (last searched February 2017), the Cochrane Central Register of Controlled Trials (CENTRAL: the Cochrane Library Issue 1, 2017), MEDLINE (1966 to February 2017), and Embase (1980 to February 2017). We also searched trials registers to February 2017: ClinicalTrials.gov, EU Clinical Trials Register, Stroke Trials Registry, ISRCTN Registry and the World Health Organization (WHO) International Clinical Trials Registry Platform. SELECTION CRITERIA Unconfounded randomised trials comparing LMWH or heparinoids with standard UFH in people with acute ischaemic stroke, in which participants were recruited within 14 days of stroke onset. DATA COLLECTION AND ANALYSIS Two review authors independently chose studies for inclusion, assessed risk of bias and trial quality, extracted and analysed the data. Differences were resolved by discussion. MAIN RESULTS We included nine trials involving 3137 participants. We did not identify any new trials for inclusion in this updated review. None of the studies reported data on the primary outcome in sufficient detail to enable analysis for the review. Overall, there was a moderate risk of bias in the included studies. Compared with UFH, there was no evidence of an effect of LMWH or heparinoids on death from all causes during the treatment period (96/1616 allocated LMWH/heparinoid versus 78/1486 allocated UFH; odds ratio (OR) 1.06, 95% CI 0.78 to 1.47; 8 trials, 3102 participants, low quality evidence). LMWH or heparinoid were associated with a significant reduction in deep vein thrombosis (DVT) compared with UFH (OR 0.55, 95% CI 0.44 to 0.70, 7 trials, 2585 participants, low quality evidence). However, the number of the major clinical events such as pulmonary embolism (PE) and intracranial haemorrhage was too small to provide a reliable estimate of the effects. AUTHORS' CONCLUSIONS Treatment with a LMWH or heparinoid after acute ischaemic stroke appears to decrease the occurrence of DVT compared with standard UFH, but there are too few data to provide reliable information on their effects on other important outcomes, including functional outcome, death and intracranial haemorrhage.
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Affiliation(s)
- Peter AG Sandercock
- University of EdinburghCentre for Clinical Brain Sciences (CCBS)The Chancellor's Building49 Little France CrescentEdinburghUKEH16 4SB
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42
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Toni D, Carolei A, Caso V, Consoli D, Del Sette M, Inzitari D, Melis M, Micieli G, Provinciali L, Ricci S, Santalucia P, Toso V. Use of rivaroxaban in patients with stroke. Neurol Sci 2017; 38:745-754. [PMID: 28238163 DOI: 10.1007/s10072-017-2855-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2016] [Accepted: 02/15/2017] [Indexed: 11/28/2022]
Abstract
Rivaroxaban, an inhibitor of Factor Xa, is a direct oral anti-coagulant that has been found to be non-inferior to warfarin in preventing cerebral ischemia in patients with non-valvular atrial fibrillation and in the subgroup of patients with a history of the previous stroke or transient ischemic attack. Vascular neurologists in daily clinical practice may encounter patients taking rivaroxaban or patients who may benefit from its use. In this paper, we review the current clinical indications, contraindications, and clinical management guidelines for rivaroxaban while providing a special focus on neurological aspects and expert opinions on rivaroxaban therapy management in various situations that a neurologist may encounter when treating patients with an ischemic stroke (including those requiring intravenous or intra-arterial reperfusion therapy) and patients with an intracerebral hemorrhage. Since data from clinical trials and real-life data are missing in some clinical situations, strong recommendations are not always available. Nevertheless, practical guidelines should be adopted to maximize benefits from this oral anti-coagulant.
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Affiliation(s)
- Danilo Toni
- Unità di Trattamento Neurovascolare, University La Sapienza Rome, Viale del Policlinico 155, 00161, Rome, Italy.
| | - Antonio Carolei
- Department of Applied Clinical Sciences and Biotechnology, University of L'Aquila, L'Aquila, Italy
| | | | - Domenico Consoli
- U.O. Neurologia e Stroke Unit, PO "G. Jazzolino", Vibo Valentia, VV, Italy
| | - Massimo Del Sette
- S.C. Neurologia, Ente Ospedaliero Ospedali Galliera Genova, Genoa, Italy
| | - Domenico Inzitari
- Department of NEUROFARBA, Neuroscience SectionUniversity of Florence, Florence, Italy.,Institute of Neuroscience, Italian National Research Council, Florence, Italy
| | - Maurizio Melis
- SC Neurologia e Stroke UnitAzienda Ospedaliera G. Brotzu, Cagliari, Italy
| | - Giuseppe Micieli
- Dipartimento di Neurologia d'Urgenza, IRCCS Fondazione Istituto Neurologico Nazionale C. Mondino, Pavia, Italy
| | | | - Stefano Ricci
- UO Neurologia, USL Umbria 1, Sedi di Città di Castello e Branca, Trento, Italy
| | | | - Vito Toso
- Italian Stroke Organisation, Florence, Italy
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Abstract
In the past decade, the definition of stroke has been revised and major advances have been made for its treatment and prevention. For acute ischaemic stroke, the addition of endovascular thrombectomy of proximal large artery occlusion to intravenous alteplase increases functional independence for a further fifth of patients. The benefits of aspirin in preventing early recurrent ischaemic stroke are greater than previously recognised. Other strategies to prevent recurrent stroke now include direct oral anticoagulants as an alternative to warfarin for atrial fibrillation, and carotid stenting as an alternative to endarterectomy for symptomatic carotid stenosis. For acute intracerebral haemorrhage, trials are ongoing to assess the effectiveness of acute blood pressure lowering, haemostatic therapy, minimally invasive surgery, anti-inflammation therapy, and neuroprotection methods. Pharmacological and stem-cell therapies promise to facilitate brain regeneration, rehabilitation, and functional recovery. Despite declining stroke mortality rates, the global burden of stroke is increasing. A more comprehensive approach to primary prevention of stroke is required that targets people at all levels of risk and is integrated with prevention strategies for other diseases that share common risk factors.
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Affiliation(s)
- Graeme J Hankey
- School of Medicine & Pharmacology, The University of Western Australia, Perth, WA, Australia; Department of Neurology, Sir Charles Gairdner Hospital, Perth, WA, Australia; Western Australian Neuroscience Research Institute (WANRI), Perth, WA, Australia.
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44
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Raval AN, Cigarroa JE, Chung MK, Diaz-Sandoval LJ, Diercks D, Piccini JP, Jung HS, Washam JB, Welch BG, Zazulia AR, Collins SP. Management of Patients on Non-Vitamin K Antagonist Oral Anticoagulants in the Acute Care and Periprocedural Setting: A Scientific Statement From the American Heart Association. Circulation 2017; 135:e604-e633. [PMID: 28167634 DOI: 10.1161/cir.0000000000000477] [Citation(s) in RCA: 156] [Impact Index Per Article: 22.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Non-vitamin K oral anticoagulants (NOACs) are now widely used as alternatives to warfarin for stroke prevention in atrial fibrillation and management of venous thromboembolism. In clinical practice, there is still widespread uncertainty on how to manage patients on NOACs who bleed or who are at risk for bleeding. Clinical trial data related to NOAC reversal for bleeding and perioperative management are sparse, and recommendations are largely derived from expert opinion. Knowledge of time of last ingestion of the NOAC and renal function is critical to managing these patients given that laboratory measurement is challenging because of the lack of commercially available assays in the United States. Idarucizumab is available as an antidote to rapidly reverse the effects of dabigatran. At present, there is no specific antidote available in the United States for the oral factor Xa inhibitors. Prothrombin concentrate may be considered in life-threatening bleeding. Healthcare institutions should adopt a NOAC reversal and perioperative management protocol developed with multidisciplinary input.
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Canavero I, Cavallini A, Sacchi L, Quaglini S, Arnò N, Perrone P, DeLodovici ML, Marcheselli S, Micieli G. Safely Addressing Patients with Atrial Fibrillation to Early Anticoagulation after Acute Stroke. J Stroke Cerebrovasc Dis 2016; 26:7-18. [PMID: 27614403 DOI: 10.1016/j.jstrokecerebrovasdis.2016.08.022] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2016] [Revised: 07/25/2016] [Accepted: 08/12/2016] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND It has been widely reported that anticoagulants (ACs) are underused for primary and secondary prevention of ischemic stroke in patients with atrial fibrillation (AFib). Furthermore, precise evidence-based guidelines about the best timing for AC initiation after acute stroke are currently lacking. METHODS AND RESULTS In this retrospective, observational study, we analyzed prescription trends in AFib patients with acute ischemic stroke who were hospitalized in four neurologic stroke units of our region (Lombardia, Italy). In-hospital antithrombotic prescription was performed in highly heterogeneous patterns. A prestroke treatment with AC was the leading factor enhancing AC prescription during hospitalization. The other factors promoting AC were male gender, younger age, lower prestroke disability and stroke severity, and smaller stroke volumes. AFib subtype influenced AC prescription only in AC-naïve patients. Interestingly, Congestive heart failure, Hypertension, Age higher than 75 years, Diabetes, previous Stroke or TIA or thromboembolism, Vascular disease, Age 64-75 years, female Sex (CHA2DS2-VASc) and Hypertension, Abnormal renal and liver function, Stroke, Bleeding, Labile INRs, Elderly, Drugs and alcohol (HAS-BLED) scores were not associated with AC prescription. However, patients who were treated with AC, including early treatment (<48 hours), showed a low rate of bleeding. CONCLUSIONS Our findings potentially suggest that, although apparently neglecting the common risk stratification tools, our neurologists were able to select the more suitable candidates for prompt AC treatment. Further studies are needed to develop new scoring systems to aid ischemic and hemorrhagic risk estimation in the secondary prevention of stroke.
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Affiliation(s)
- Isabella Canavero
- Department of Emergency Neurology and Stroke Unit, National Neurological Institute "Casimiro Mondino" IRCCS, Pavia, Italy.
| | - Anna Cavallini
- Department of Emergency Neurology and Stroke Unit, National Neurological Institute "Casimiro Mondino" IRCCS, Pavia, Italy
| | - Lucia Sacchi
- Department of Electrical, Computer and Biomedical Engineering, University of Pavia, Pavia, Italy
| | - Silvana Quaglini
- Department of Electrical, Computer and Biomedical Engineering, University of Pavia, Pavia, Italy
| | - Natale Arnò
- Department of Emergency Neurology and Stroke Unit, National Neurological Institute "Casimiro Mondino" IRCCS, Pavia, Italy
| | - Patrizia Perrone
- Department of Neurosciences, Neurology Unit, "Ospedale Civile", Legnano, Italy
| | - Maria Luisa DeLodovici
- Stroke Unit, Department of Neurology, "Fondazione Macchi-Ospedale di Circolo", Insubria University, Varese, Italy
| | - Simona Marcheselli
- Emergency Neurology and Stroke Unit, "Istituto Clinico Humanitas", Milan, Italy
| | - Giuseppe Micieli
- Department of Emergency Neurology and Stroke Unit, National Neurological Institute "Casimiro Mondino" IRCCS, Pavia, Italy
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Wang S, Reeves B, Sparkenbaugh EM, Russell J, Soltys Z, Zhang H, Faber JE, Key NS, Kirchhofer D, Granger DN, Mackman N, Pawlinski R. Protective and detrimental effects of neuroectodermal cell-derived tissue factor in mouse models of stroke. JCI Insight 2016; 1. [PMID: 27489885 DOI: 10.1172/jci.insight.86663] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
Within the CNS, a dysregulated hemostatic response contributes to both hemorrhagic and ischemic strokes. Tissue factor (TF), the primary initiator of the extrinsic coagulation cascade, plays an essential role in hemostasis and also contributes to thrombosis. Using both genetic and pharmacologic approaches, we characterized the contribution of neuroectodermal (NE) cell TF to the pathophysiology of stroke. We used mice with various levels of TF expression and found that astrocyte TF activity reduced to ~5% of WT levels was still sufficient to maintain hemostasis after hemorrhagic stroke but was also low enough to attenuate inflammation, reduce damage to the blood-brain barrier, and improve outcomes following ischemic stroke. Pharmacologic inhibition of TF during the reperfusion phase of ischemic stroke attenuated neuronal damage, improved behavioral deficit, and prevented mortality of mice. Our data demonstrate that NE cell TF limits bleeding complications associated with the transition from ischemic to hemorrhagic stroke and also contributes to the reperfusion injury after ischemic stroke. The high level of TF expression in the CNS is likely the result of selective pressure to limit intracerebral hemorrhage (ICH) after traumatic brain injury but, in the modern era, poses the additional risk of increased ischemia-reperfusion injury after ischemic stroke.
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Affiliation(s)
- Shaobin Wang
- McAllister Heart Institute, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Brandi Reeves
- Division of Hematology and Oncology, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Erica M Sparkenbaugh
- McAllister Heart Institute, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Janice Russell
- Department of Molecular and Cellular Physiology, Louisiana State University Health Sciences Center, Shreveport, Louisiana, USA
| | - Zbigniew Soltys
- Department of Neuroanatomy, Institute of Zoology, Jagiellonian University, Krakow, Poland
| | - Hua Zhang
- McAllister Heart Institute, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA; Department of Cell Biology and Physiology, University of North Carolina at Chapel Hill, North Carolina, USA
| | - James E Faber
- McAllister Heart Institute, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA; Department of Cell Biology and Physiology, University of North Carolina at Chapel Hill, North Carolina, USA
| | - Nigel S Key
- McAllister Heart Institute, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA; Division of Hematology and Oncology, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Daniel Kirchhofer
- Department of Early Discovery Biochemistry, Genentech Inc., South San Francisco, California, USA
| | - D Neil Granger
- Department of Molecular and Cellular Physiology, Louisiana State University Health Sciences Center, Shreveport, Louisiana, USA
| | - Nigel Mackman
- McAllister Heart Institute, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA; Division of Hematology and Oncology, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Rafal Pawlinski
- McAllister Heart Institute, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA; Division of Hematology and Oncology, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
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Belleudi V, Sciattella P, Agabiti N, Di Martino M, Di Domenicantonio R, Davoli M, Fusco D. Socioeconomic differences in one-year survival after ischemic stroke: the effect of acute and post-acute care-pathways in a cohort study. BMC Public Health 2016; 16:408. [PMID: 27184959 PMCID: PMC4868039 DOI: 10.1186/s12889-016-3019-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2015] [Accepted: 04/09/2016] [Indexed: 02/05/2023] Open
Abstract
Background The reasons for socioeconomic inequity in stroke mortality are not well understood. The aim of this study was to explore the role of ischemic stroke care-pathways on the association between education level and one-year survival after hospital admission. Methods Hospitalizations for ischemic stroke during 2011/12 were selected from Lazio health data. Patients’ clinical history was defined by retrieving previous hospitalizations and drugs prescriptions. The association between education level and mortality after stroke was studied for acute and post-acute phases using multilevel logistic models (Odds Ratio (OR)). Different scenarios of quality care-pathways were identified considering hospital performance, access to rehabilitation and drug treatment post-discharge. The probability to survive to acute and post-acute phases according to education level and care-pathway scenarios was estimated for a “mean-severity” patient. One-year survival probability was calculated as the product of two probabilities. For each scenario, the 1-year survival probability ratio, university versus elementary education, and its Bootstrap Confidence Intervals (95 % BCI) were calculated. Results We identified 9,958 patients with ischemic stroke, 53.3 % with elementary education level and 3.2 % with university. The mortality was 14.9 % in acute phase and 14.3 % in post-acute phase among survived to the acute phase. The adjusted mortality in acute and post-acute phases decreased with an increase in educational level (OR = 0.90 p-trend < 0.001; OR = 0.85 p-trend < 0.001). For the best care-pathway, the one-year survival probability ratio was 1.06 (95 % BCI = 1.03–1.10), while it was 1.17 (95 % BCI = 1.09–1.25) for the worst. Conclusions Education level was inversely associated with mortality both in acute and post-acute phases. The care-pathway reduces but does not eliminate 1-year survival inequity.
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Affiliation(s)
- Valeria Belleudi
- Department of Epidemiology, Lazio Regional Health Service, Via Cristoforo Colombo, 112, 00147, Rome, Italy
| | - Paolo Sciattella
- Department of Epidemiology, Lazio Regional Health Service, Via Cristoforo Colombo, 112, 00147, Rome, Italy
| | - Nera Agabiti
- Department of Epidemiology, Lazio Regional Health Service, Via Cristoforo Colombo, 112, 00147, Rome, Italy.
| | - Mirko Di Martino
- Department of Epidemiology, Lazio Regional Health Service, Via Cristoforo Colombo, 112, 00147, Rome, Italy
| | - Riccardo Di Domenicantonio
- Department of Epidemiology, Lazio Regional Health Service, Via Cristoforo Colombo, 112, 00147, Rome, Italy
| | - Marina Davoli
- Department of Epidemiology, Lazio Regional Health Service, Via Cristoforo Colombo, 112, 00147, Rome, Italy
| | - Danilo Fusco
- Department of Epidemiology, Lazio Regional Health Service, Via Cristoforo Colombo, 112, 00147, Rome, Italy
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Wang S, Reeves B, Pawlinski R. Astrocyte tissue factor controls CNS hemostasis and autoimmune inflammation. Thromb Res 2016; 141 Suppl 2:S65-7. [DOI: 10.1016/s0049-3848(16)30369-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Dennis M, Caso V, Kappelle LJ, Pavlovic A, Sandercock P. European Stroke Organisation (ESO) guidelines for prophylaxis for venous thromboembolism in immobile patients with acute ischaemic stroke. Eur Stroke J 2016; 1:6-19. [PMID: 31008263 DOI: 10.1177/2396987316628384] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2015] [Accepted: 12/30/2015] [Indexed: 12/22/2022] Open
Abstract
Background Venous thromboembolism (VTE) including deep vein thrombosis (DVT) and pulmonary embolism is a frequent complication in immobile patients with acute ischemic stroke. This guideline document presents the European Stroke Organisation guidelines for the prophylaxis of VTE in immobile patients with acute ischaemic stroke. Guidelines for haemorrhagic stroke have already been published. Methods A multidisciplinary group identified related questions and developed its recommendations based on evidence from randomised controlled trials using the Grading of Recommendations Assessment, Development, and Evaluation approach. This guideline document was reviewed within the European Stroke Organisation and externally and was approved by the European Stroke Organisation Guidelines Committee and the European Stroke Organisation Executive Committee. Results We found mainly moderate quality evidence comprising randomised controlled trials and systematic reviews evaluating graduated compression stockings (GCS), intermittent pneumatic compression (IPC) and prophylactic anticoagulation with unfractionated (UFH) and low molecular weight heparins (LMWH) and heparinoids, but no randomised trials evaluating neuromuscular electrical stimulation (NES). We recommend that clinicians should use IPC in immobile patients, but that they should not use GCS. Prophylactic anticoagulation with UFH (5000U ×2, or ×3 daily) or LMWH or heparinoid should be considered in immobile patients with ischaemic stroke in whom the benefits of reducing the risk of VTE is high enough to offset the increased risks of intracranial and extracranial bleeding associated with their use. Where a judgement has been made that prophylactic anticoagulation is indicated LMWH or heparinoid should be considered instead of UFH because of its greater reduction in risk of DVT, the greater convenience, reduced staff costs and patient comfort associated single vs. multiple daily injections but these advantages should be weighed against the higher risk of extracranial bleeding, higher drug costs and risks in elderly patients with poor renal function associated with LMWH and heparinoids. Conclusions IPC, UFH or LMWH and heparinoids can reduce the risk of VTE in immobile patients with acute ischaemic stroke but further research is required to test whether NES is effective. The strongest evidence is for IPC. Better methods are needed to help stratify patients in the first few weeks after stroke onset, by their risk of VTE and their risk of bleeding on anticoagulants.
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Affiliation(s)
- Martin Dennis
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Valeria Caso
- Stroke Unit, University of Perugia, Perugia, Italy
| | - L Jaap Kappelle
- Department of Neurology and Neurosurgery, Rudolf Magnus Institute for Neuroscience, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - Aleksandra Pavlovic
- Faculty of Medicine, Neurology Clinic, Clinical Center of Serbia, University of Belgrade, Belgrade, Serbia
| | - Peter Sandercock
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
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Abstract
BACKGROUND Puerarin, a form of herbal medicine, is widely used in the treatment of ischaemic stroke in China. OBJECTIVES To assess the effects of puerarin in people with ischaemic stroke. SEARCH METHODS We searched the Cochrane Stroke Group Trials Register and the Chinese Stroke Trials Register (last searched August 2015). In addition, we searched the Cochrane Central Register of Controlled Trials (CENTRAL) (2015, Issue 7), MEDLINE (1948 to August 2015), EMBASE (1980 to August 2015), AMED (the Allied and Complementary Medicine Database, 1985 to August 2015) and the China Biological Medicine Database (CBM-disc 1979 to August 2015). We searched reference lists, relevant clinical trials and research registers and contacted pharmaceutical companies and researchers in an effort to identify further published and unpublished studies. SELECTION CRITERIA Randomised controlled trials (RCTs) or quasi-randomised controlled clinical trials comparing puerarin with placebo or open control (no placebo) in people with ischaemic stroke. DATA COLLECTION AND ANALYSIS Two review authors independently applied the inclusion criteria, assessed trial quality and risk of bias, and extracted the data. MAIN RESULTS We included 20 RCTs with 1574 participants in this updated review. All trials were published in Chinese language journals. We included 14 trials that we had excluded in the previous version of the review after we added a new outcome in this update. Time windows within which the participants were randomised ranged from 4.5 hours to 10 days. Ischaemic stroke was confirmed by computerised tomography (CT) or magnetic resonance imaging (MRI) in 18 trials. Meta-analysis of two trials with 164 participants showed that treatment with puerarin did not reduce death or dependency at final follow-up (RR 0.79, 95% CI 0.45 to 1.36). One trial with 83 participants reported that the mean value of the Barthel Index in the puerarin group was below that in the control group. Meta-analysis of 16 trials with 1305 participants showed that puerarin reduced the proportion of participants without improvement of neurological deficit at the end of follow-up (RR 0.42, 95% CI 0.33 to 0.55). None of the included trials reported serious adverse effects.The quality of evidence was low due to incomplete reporting of the methods and short-term follow-up. AUTHORS' CONCLUSIONS There is not enough evidence to evaluate the effect of puerarin on survival or dependency in people with ischaemic stroke. High quality and large-scale RCTs with long-term follow-up are needed to assess its efficacy.
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Affiliation(s)
- Bian Liu
- Department of Neurology, West China Hospital, Sichuan University, No. 37, Guo Xue Xiang, Chengdu, Sichuan, China, 610041
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