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Pozzi A, Lucà F, Gelsomino S, Abrignani MG, Giubilato S, Di Fusco SA, Rao CM, Cornara S, Caretta G, Ceravolo R, Parrini I, Geraci G, Riccio C, Grimaldi M, Colivicchi F, Oliva F, Gulizia MM. Coagulation Tests and Reversal Agents in Patients Treated with Oral Anticoagulants: The Challenging Scenarios of Life-Threatening Bleeding and Unplanned Invasive Procedures. J Clin Med 2024; 13:2451. [PMID: 38730979 PMCID: PMC11084691 DOI: 10.3390/jcm13092451] [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: 12/31/2023] [Revised: 02/22/2024] [Accepted: 04/07/2024] [Indexed: 05/13/2024] Open
Abstract
In clinical practice, the number of patients treated with direct oral anticoagulants (DOACs) has consistently increased over the years. Since anticoagulant therapy has been associated with an annual incidence of major bleeding (MB) events of approximately 2% to 3.5%, it is of paramount importance to understand how to manage anticoagulated patients with major or life-threatening bleeding. A considerable number of these patients' conditions necessitate hospitalization, and the administration of reversal agents may be imperative to manage and control bleeding episodes effectively. Importantly, effective strategies for reversing the anticoagulant effects of DOACs have been well recognized. Specifically, idarucizumab has obtained regulatory approval for the reversal of dabigatran, and andexanet alfa has recently been approved for reversing the effects of apixaban or rivaroxaban in patients experiencing life-threatening or uncontrolled bleeding events. Moreover, continuous endeavors are being made to develop supplementary reversal agents. In emergency scenarios where specific reversal agents might not be accessible, non-specific hemostatic agents such as prothrombin complex concentrate can be utilized to neutralize the anticoagulant effects of DOACs. However, it is paramount to emphasize that specific reversal agents, characterized by their efficacy and safety, should be the preferred choice when suitable. Moreover, it is worth noting that adherence to the guidelines for the reversal agents is poor, and there is a notable gap between international recommendations and actual clinical practices in this regard. This narrative review aims to provide physicians with a practical approach to managing specific reversal agents.
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Affiliation(s)
- Andrea Pozzi
- Cardiology Division Valduce Hospital, 22100 Como, Italy;
| | - Fabiana Lucà
- Cardiology Department, Grande Ospedale Metropolitano, GOM, AO Bianchi Melacrino Morelli, 89129 Reggio Calabria, Italy (C.M.R.)
| | - Sandro Gelsomino
- Cardiothoracic Department, Maastricht University Hospital, 6229 HX Maastricht, The Netherlands
| | | | - Simona Giubilato
- Cardiology Department, Cannizzaro Hospital, 95126 Catania, Italy;
| | - Stefania Angela Di Fusco
- Clinical and Rehabilitation Cardiology Department, San Filippo Neri Hospital, ASL Roma 1, 00135 Roma, Italy; (S.A.D.F.); (F.C.)
| | - Carmelo Massimiliano Rao
- Cardiology Department, Grande Ospedale Metropolitano, GOM, AO Bianchi Melacrino Morelli, 89129 Reggio Calabria, Italy (C.M.R.)
| | - Stefano Cornara
- Arrhytmia Unit, Division of Cardiology, Ospedale San Paolo, Azienda Sanitaria Locale 2, 17100 Savona, Italy;
| | - Giorgio Caretta
- Sant’Andrea Hospital, ASL 5 Regione Liguria, 19124 La Spezia, Italy;
| | - Roberto Ceravolo
- Cardiology Unit, Giovanni Paolo II Hospital, 97100 Lamezia, Italy;
| | - Iris Parrini
- Cardiology Department, Mauriziano Hospital, 10128 Torino, Italy;
| | - Giovanna Geraci
- Cardiology Unit, S. Antonio Abate Hospital, ASP Trapani, 91016 Erice, Italy;
| | - Carmine Riccio
- Cardiovascular Department, Sant’Anna e San Sebastiano Hospital, 81100 Caserta, Italy;
| | - Massimo Grimaldi
- Department of Cardiology, General Regional Hospital “F. Miulli”, 70021 Bari, Italy;
| | - Furio Colivicchi
- Clinical and Rehabilitation Cardiology Department, San Filippo Neri Hospital, ASL Roma 1, 00135 Roma, Italy; (S.A.D.F.); (F.C.)
| | - Fabrizio Oliva
- Cardiology Unit, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milano, Italy;
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Hwang DY, Kim KS, Muehlschlegel S, Wartenberg KE, Rajajee V, Alexander SA, Busl KM, Creutzfeldt CJ, Fontaine GV, Hocker SE, Madzar D, Mahanes D, Mainali S, Sakowitz OW, Varelas PN, Weimar C, Westermaier T, Meixensberger J. Guidelines for Neuroprognostication in Critically Ill Adults with Intracerebral Hemorrhage. Neurocrit Care 2024; 40:395-414. [PMID: 37923968 PMCID: PMC10959839 DOI: 10.1007/s12028-023-01854-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Accepted: 09/01/2023] [Indexed: 11/06/2023]
Abstract
BACKGROUND The objective of this document is to provide recommendations on the formal reliability of major clinical predictors often associated with intracerebral hemorrhage (ICH) neuroprognostication. METHODS A narrative systematic review was completed using the Grading of Recommendations Assessment, Development, and Evaluation methodology and the Population, Intervention, Comparator, Outcome, Timing, Setting questions. Predictors, which included both individual clinical variables and prediction models, were selected based on clinical relevance and attention in the literature. Following construction of the evidence profile and summary of findings, recommendations were based on Grading of Recommendations Assessment, Development, and Evaluation criteria. Good practice statements addressed essential principles of neuroprognostication that could not be framed in the Population, Intervention, Comparator, Outcome, Timing, Setting format. RESULTS Six candidate clinical variables and two clinical grading scales (the original ICH score and maximally treated ICH score) were selected for recommendation creation. A total of 347 articles out of 10,751 articles screened met our eligibility criteria. Consensus statements of good practice included deferring neuroprognostication-aside from the most clinically devastated patients-for at least the first 48-72 h of intensive care unit admission; understanding what outcomes would have been most valued by the patient; and counseling of patients and surrogates whose ultimate neurological recovery may occur over a variable period of time. Although many clinical variables and grading scales are associated with ICH poor outcome, no clinical variable alone or sole clinical grading scale was suggested by the panel as currently being reliable by itself for use in counseling patients with ICH and their surrogates, regarding functional outcome at 3 months and beyond or 30-day mortality. CONCLUSIONS These guidelines provide recommendations on the formal reliability of predictors of poor outcome in the context of counseling patients with ICH and surrogates and suggest broad principles of neuroprognostication. Clinicians formulating their judgments of prognosis for patients with ICH should avoid anchoring bias based solely on any one clinical variable or published clinical grading scale.
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Affiliation(s)
- David Y Hwang
- Division of Neurocritical Care, Department of Neurology, University of North Carolina School of Medicine, 170 Manning Drive, CB# 7025, Chapel Hill, NC, 27599-7025, USA.
| | - Keri S Kim
- Department of Pharmacy Practice, University of Illinois at Chicago College of Pharmacy, Chicago, IL, USA
| | - Susanne Muehlschlegel
- Division of Neurosciences Critical Care, Departments of Neurology and Anesthesiology/Critical Care Medicine, Johns Hopkins Medicine, Baltimore, MD, USA
| | | | | | | | - Katharina M Busl
- Departments of Neurology and Neurosurgery, College of Medicine, University of Florida, Gainesville, FL, USA
| | | | - Gabriel V Fontaine
- Departments of Pharmacy and Neurosciences, Intermountain Health, Salt Lake City, UT, USA
| | - Sara E Hocker
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
| | - Dominik Madzar
- Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Dea Mahanes
- Departments of Neurology and Neurosurgery, UVA Health, Charlottesville, VA, USA
| | - Shraddha Mainali
- Department of Neurology, Virginia Commonwealth University, Richmond, VA, USA
| | - Oliver W Sakowitz
- Department of Neurosurgery, Neurosurgery Center Ludwigsburg-Heilbronn, Ludwigsburg, Germany
| | | | - Christian Weimar
- Institute of Medical Informatics, Biometry and Epidemiology, University Hospital Essen, Essen, Germany
- BDH-Klinik Elzach, Elzach, Germany
| | - Thomas Westermaier
- Department of Neurosurgery, Helios Amper-Kliniken Dachau, University of Wuerzburg, Würzburg, Germany
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3
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Lucà F, Colivicchi F, Oliva F, Abrignani M, Caretta G, Di Fusco SA, Giubilato S, Cornara S, Di Nora C, Pozzi A, Di Matteo I, Pilleri A, Rao CM, Parlavecchio A, Ceravolo R, Benedetto FA, Rossini R, Calvanese R, Gelsomino S, Riccio C, Gulizia MM. Management of oral anticoagulant therapy after intracranial hemorrhage in patients with atrial fibrillation. Front Cardiovasc Med 2023; 10:1061618. [PMID: 37304967 PMCID: PMC10249073 DOI: 10.3389/fcvm.2023.1061618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Accepted: 04/14/2023] [Indexed: 06/13/2023] Open
Abstract
Intracranial hemorrhage (ICH) is considered a potentially severe complication of oral anticoagulants (OACs) and antiplatelet therapy (APT). Patients with atrial fibrillation (AF) who survived ICH present both an increased ischemic and bleeding risk. Due to its lethality, initiating or reinitiating OACs in ICH survivors with AF is challenging. Since ICH recurrence may be life-threatening, patients who experience an ICH are often not treated with OACs, and thus remain at a higher risk of thromboembolic events. It is worthy of mention that subjects with a recent ICH and AF have been scarcely enrolled in randomized controlled trials (RCTs) on ischemic stroke risk management in AF. Nevertheless, in observational studies, stroke incidence and mortality of patients with AF who survived ICH had been shown to be significantly reduced among those treated with OACs. However, the risk of hemorrhagic events, including recurrent ICH, was not necessarily increased, especially in patients with post-traumatic ICH. The optimal timing of anticoagulation initiation or restarting after an ICH in AF patients is also largely debated. Finally, the left atrial appendage occlusion option should be evaluated in AF patients with a very high risk of recurrent ICH. Overall, an interdisciplinary unit consisting of cardiologists, neurologists, neuroradiologists, neurosurgeons, patients, and their families should be involved in management decisions. According to available evidence, this review outlines the most appropriate anticoagulation strategies after an ICH that should be adopted to treat this neglected subset of patients.
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Affiliation(s)
- Fabiana Lucà
- Cardiology Department, Grande Ospedale Metropolitano di Reggio Calabria, GOM, Azienda Ospedaliera Bianchi Melacrino Morelli, Italy
| | - Furio Colivicchi
- Cardiology Division, San Filippo Neri Hospital, ASL Roma 1, Roma, Italy
| | - Fabrizio Oliva
- De Gasperis Cardio Center, ASST Niguarda Hospital, Milano, Italy
| | | | - Giorgio Caretta
- Cardiology Unit, Sant'Andrea Hospital, ASL 5 Liguria, La Spezia, Italy
| | | | | | - Stefano Cornara
- Cardiology Division San Paolo Hospital, ASL 2, Savona, Italy
| | | | - Andrea Pozzi
- Cardiology Division, Maria della Misericordia di Udine, Italy
| | - Irene Di Matteo
- De Gasperis Cardio Center, ASST Niguarda Hospital, Milano, Italy
| | - Anna Pilleri
- Cardiology Division, Brotzu Hospital, Cagliari, Italy
| | - Carmelo Massimiliano Rao
- Cardiology Department, Grande Ospedale Metropolitano di Reggio Calabria, GOM, Azienda Ospedaliera Bianchi Melacrino Morelli, Italy
| | - Antonio Parlavecchio
- Cardiology Department, Grande Ospedale Metropolitano di Reggio Calabria, GOM, Azienda Ospedaliera Bianchi Melacrino Morelli, Italy
| | - Roberto Ceravolo
- Cardiology Division, Giovanni Paolo II Hospital, Lamezia Terme, Italy
| | - Francesco Antonio Benedetto
- Cardiology Department, Grande Ospedale Metropolitano di Reggio Calabria, GOM, Azienda Ospedaliera Bianchi Melacrino Morelli, Italy
| | | | | | - Sandro Gelsomino
- Cardiothoracic Department, Maastricht University, Maastricht, The Netherlands
| | - Carmine Riccio
- Cardiovascular Department, A.O.R.N. Sant'Anna e San Sebastiano, Caserta, Italy
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4
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Gousias K, Pleger B, Markou M, Grözinger M, Sedaghat S, Pintea B, Schildhauer TA, Martinez R, Hamsen U. Distinct Behavior of Traumatic versus Nontraumatic Intracerebral Hematomas: Different Biology or Impact of Age? J Neurol Surg A Cent Eur Neurosurg 2021; 83:143-152. [PMID: 34126640 DOI: 10.1055/s-0041-1728764] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND AND STUDY AIMS Patients with large intracerebral hematomas (ICH) may demonstrate different demographics and underlying brain and systemic diseases, as well as different radiologic courses and distinct outcomes. It remains unclear whether their different behavior attributes to a different biology of the ICH or to the asymmetric characteristics of the two populations. To analyze and adjust for potential sources of selection and treatment bias, our study compared age-matched patients with traumatic and nontraumatic ICH in a single cohort diagnosed and treated in the same surgical department. MATERIAL AND METHODS We analyzed 135 consecutive patients with traumatic (n = 90) or spontaneous ICH (n = 45) undergoing treatment at a surgical intensive care unit of an urban university hospital. We documented their differences before and after adjustment for age in terms of demographics, the therapies applied, their radiologic (i.e., volume and rate of ICH expansion [HE]) and clinical (patients' outcome at 30 days) course, the length of hospital and ICU stay, as well as the hospital costs. RESULTS Patients with traumatic ICH demonstrated more favorable clinical and radiologic characteristics at admission, that is, higher Glasgow Coma Scale score (p < 0.001), less frequently dilated pupil (p = 0.028), lower Charlson Comorbidity Index (p < 0.001), smaller ICH volume (p < 0.001), noneloquent (p < 0.001) or nonintraventricular (p = 0.003) ICH locations, as well as underwent fewer neurosurgical interventions (p < 0.001) and showed a better outcome (p = 0.041), defined as Glasgow Outcome Scale 4 and 5. After adjustment for age, no different outcomes were observed. Of note, elderly patients on novel oral anticoagulants (NOACs) were more likely to develop an HE compared with those on vitamin K antagonists (VKAs, p = 0.05) after traumatic brain injury (TBI) but not after spontaneous ICH. CONCLUSION Our data reveal a significant heterogeneity within the traumatic series. Whereas younger patients show an excellent outcome, the elderly population of the traumatic cases demonstrates a poor outcome similar to that of the nontraumatic cohort. HE under NOACs rather than under VKAs is more likely in the elderly after TBI. Larger prospective trials are warranted to elucidate the potential individual underlying molecular mechanisms for the development of an ICH and HE in these diseases.
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Affiliation(s)
- Konstantinos Gousias
- Department of Neurosurgery and Neurotraumatology, BG Bergmannsheil University Hospital Bochum, Bochum, Germany.,Department of Neurosurgery, St Marien Academic Hospital Lünen, University of Münster, Lünen, Germany
| | - Burkhard Pleger
- Department of Neurology, BG Bergmannsheil University Hospital Bochum, Bochum, Germany
| | - Markella Markou
- Department of Neurology and Psychotraumatology, BG Hospital Duisburg, Duisburg, Germany
| | - Martin Grözinger
- Department of Radiology, BG Bergmannsheil University Hospital Bochum, Bochum, Germany
| | - Sam Sedaghat
- Department of Radiology, BG Bergmannsheil University Hospital Bochum, Bochum, Germany
| | - Bogdan Pintea
- Department of Neurosurgery and Neurotraumatology, BG Bergmannsheil University Hospital Bochum, Bochum, Germany
| | - Thomas A Schildhauer
- Department of General and Trauma Surgery, BG Bergmannsheil University Hospital Bochum, Bochum, Germany
| | - Ramon Martinez
- Department of Neurosurgery and Neurotraumatology, BG Bergmannsheil University Hospital Bochum, Bochum, Germany
| | - Uwe Hamsen
- Department of General and Trauma Surgery, BG Bergmannsheil University Hospital Bochum, Bochum, Germany
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Prior A, Fiaschi P, Iaccarino C, Stefini R, Battaglini D, Balestrino A, Anania P, Prior E, Zona G. How do you manage ANTICOagulant therapy in neurosurgery? The ANTICO survey of the Italian Society of Neurosurgery (SINCH). BMC Neurol 2021; 21:98. [PMID: 33658003 PMCID: PMC7927258 DOI: 10.1186/s12883-021-02126-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Accepted: 02/23/2021] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Anticoagulant assumption is a concern in neurosurgical patient that implies a delicate balance between the risk of thromboembolism versus the risk of peri- and postoperative hemorrhage. METHODS We performed a survey among 129 different neurosurgical departments in Italy to evaluate practice patterns regarding the management of neurosurgical patients taking anticoagulant drugs. Furthermore, we reviewed the available literature, with the aim of providing a comprehensive but practical summary of current recommendations. RESULTS Our survey revealed that there is a lack of knowledge, mostly regarding the indication and the strategies of anticoagulant reversal in neurosurgical clinical practice. This may be due a lack of national and international guidelines for the care of anticoagulated neurosurgical patients, along with the fact that coagulation and hemostasis are not simple topics for a neurosurgeon. CONCLUSIONS To overcome this issue, establishment of hospital-wide policy concerning management of anticoagulated patients and developed in an interdisciplinary manner are strongly recommended.
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Affiliation(s)
- Alessandro Prior
- Section of Neurosurgery, Department of Neuroscience (DINOGMI) IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Pietro Fiaschi
- Section of Neurosurgery, Department of Neuroscience (DINOGMI) IRCCS Ospedale Policlinico San Martino, Genoa, Italy.
- Università di Genova, Dipartimento di Neuroscienze, Riabilitazione, Oftalmologia, Genetica e Scienze materno infantili (DINOGMI), IRCCS Ospedale Policlinico San Martino, Largo Rosanna Benzi, 1016132, Genoa, Italy.
| | | | - Roberto Stefini
- Department of Neurosurgery, Ospedale Civile di Legnano, Milan, Italy
| | - Denise Battaglini
- Anesthesia and Intensive Care, Policlinico San Martino Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy
- Department of Medicine, University of Barcelona, Barcelona, Spain
| | - Alberto Balestrino
- Section of Neurosurgery, Department of Neuroscience (DINOGMI) IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Pasquale Anania
- Section of Neurosurgery, Department of Neuroscience (DINOGMI) IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Enrico Prior
- Division of Cardiology, Department of Medicine University of Verona, Verona, Italy
| | - Gianluigi Zona
- Section of Neurosurgery, Department of Neuroscience (DINOGMI) IRCCS Ospedale Policlinico San Martino, Genoa, Italy
- Università di Genova, Dipartimento di Neuroscienze, Riabilitazione, Oftalmologia, Genetica e Scienze materno infantili (DINOGMI), IRCCS Ospedale Policlinico San Martino, Largo Rosanna Benzi, 1016132, Genoa, Italy
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Miller MM, Lowe J, Khan M, Azeem MU, Muehlschlegel S, Jun-O'Connell AH, Goddeau RP, Moonis M, Gritters D, Silver B, Henninger N. Clinical and Radiological Characteristics of Vitamin K Versus Non-Vitamin K Antagonist Oral Anticoagulation-Related Intracerebral Hemorrhage. Neurocrit Care 2020; 31:56-65. [PMID: 30690686 DOI: 10.1007/s12028-019-00671-1] [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] [Indexed: 12/01/2022]
Abstract
BACKGROUND/OBJECTIVE Recent studies indicated that functional outcome after intracranial hemorrhage (ICH) related to direct oral anticoagulation (DOAC-ICH) is similar, if not better, than vitamin K antagonist (VKA)-related ICH (VKA-ICH) due to a smaller initial hematoma volume (HV). However, the association with hematoma expansion (HE) and location is not well understood. METHODS We retrospectively analyzed 102 consecutive patients with acute non-traumatic ICH on oral anticoagulation therapy to determine HV and HE stratified by hematoma location, and the relation to the 90-day outcome. RESULTS DOAC-ICH (n = 25) and VKA-ICH (n = 77) had a similar admission HV and HE (unadjusted p > 0.05, each). Targeted reversal strategies were used in 93.5% of VKA-ICH versus 8% of DOAC-ICH. After adjustment, an unfavorable 90-day functional outcome (modified Rankin scale score 4-6) was independently associated with a lower admission Glasgow Coma Scale score (OR 1.63; 95% CI 1.26-2.10; p < 0.001) and greater HV (OR 1.03; 95% confidence interval (CI) 1.00-1.05; p = 0.046). After exclusion of patients without follow-up head computed tomography to allow for adjustment by occurrence of HE, VKA-ICH was associated with an approximately 3.5 times greater odds for a poor 90-day outcome (OR 3.64; 95% CI 1.01-13.09; p = 0.048). However, there was no significant association of the oral anticoagulant strategy with 90-day outcome in the entire cohort (OR 2.85; 95% CI 0.69-11.86; p = 0.15). CONCLUSIONS DOAC use did not relate to worse HE, HV, and functional outcome after ICH, adding to the notion that DOAC is a safe alternative to VKA even in the absence of access to targeted reversal strategies (which are still not universally available).
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Affiliation(s)
- Małgorzata M Miller
- Department of Neurology, University of Massachusetts Medical School, Worcester, MA, USA.
| | - Jessica Lowe
- Division of Neurology, Neuroscience Institute, Spectrum Health, Grand Rapids, MI, USA
| | - Muhib Khan
- Division of Neurology, Neuroscience Institute, Spectrum Health, Grand Rapids, MI, USA
| | - Muhammad U Azeem
- Department of Neurology, University of Massachusetts Medical School, Worcester, MA, USA
| | - Susanne Muehlschlegel
- Department of Neurology, University of Massachusetts Medical School, Worcester, MA, USA.,Department of Surgery, University of Massachusetts Medical School, Worcester, MA, USA.,Department of Anesthesia and Critical Care, University of Massachusetts Medical School, Worcester, MA, USA
| | | | - Richard P Goddeau
- Department of Neurology, University of Massachusetts Medical School, Worcester, MA, USA
| | - Majaz Moonis
- Department of Neurology, University of Massachusetts Medical School, Worcester, MA, USA
| | - Danielle Gritters
- Spectrum Health Office of Research, Spectrum Health, Grand Rapids, MI, USA
| | - Brian Silver
- Department of Neurology, University of Massachusetts Medical School, Worcester, MA, USA
| | - Nils Henninger
- Department of Neurology, University of Massachusetts Medical School, Worcester, MA, USA.,Department of Psychiatry, University of Massachusetts Medical School, Worcester, MA, USA
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7
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Franco L, Paciaroni M, Enrico ML, Scoditti U, Guideri F, Chiti A, De Vito A, Terruso V, Consoli D, Vanni S, Giossi A, Manina G, Nitti C, Re R, Sacco S, Cappelli R, Beyer-Westendorf J, Pomero F, Agnelli G, Becattini C. Mortality in patients with intracerebral hemorrhage associated with antiplatelet agents, oral anticoagulants or no antithrombotic therapy. Eur J Intern Med 2020; 75:35-43. [PMID: 31955918 DOI: 10.1016/j.ejim.2019.12.016] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Revised: 12/16/2019] [Accepted: 12/21/2019] [Indexed: 01/24/2023]
Abstract
The association between preceding treatment with antiplatelet agents (APs), vitamin K antagonists (VKAs) or direct oral anticoagulants (DOACs) and mortality after intracerebral hemorrhage (ICH) remains unclear. The aim of this multicenter, prospective cohort study was to assess the risk for death after ICH in consecutive patients who were on treatment with APs, VKAs, DOACs, or no antithrombotic agent. The primary outcome was in-hospital death by day 30. ICH volume at admission and volume expansion were centrally assessed. Out of 598 study patients, in-hospital death occurred in 21% of patients who were on treatment with APs, 25% with VKAs, 30% with DOACs, and 13% with no antithrombotics. Crude death rate was higher in patients on antithrombotics as compared to patients receiving no antithrombotic agent. At multivariate analysis, age (HR 1.07; 95% CI 1.04-1.10), previous stroke (HR 1.83; 95% CI 1.14-2.93), GCS ≤8 at admission (HR 6.06; 95% CI 3.16-9.74) and GCS 9-12 (HR 3.38; 95% CI 1.81-6.33) were independent predictors of death. Treatment with APs (HR 1.29; 95% CI 0.61-2.76), VKAs (HR 1.42; 95% CI 0.70-2.88) or DOACs (HR 1.28; 95% CI 0.61-2.73) were not predictors of death in the overall study population, in non-trauma associated ICH as well as when GCS was not included in the model. ICH volume and volume expansion were independent predictors of death. In conclusion, preceding treatment with antithrombotic is associated with the severity of ICH. Age, previous stroke and clinical severity at presentation were independent predictors of in-hospital death in patients with ICH.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | - Roberta Re
- Ospedale Maggiore della Carità, Novara, Italy
| | | | | | - Jan Beyer-Westendorf
- University Hospital, Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
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8
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Management of Patients with Acute Subdural Hemorrhage During Treatment with Direct Oral Anticoagulants. Neurocrit Care 2020; 30:322-333. [PMID: 30382531 DOI: 10.1007/s12028-018-0635-4] [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] [Indexed: 10/28/2022]
Abstract
BACKGROUND Anticoagulation therapy is a major risk factor for unfavorable patient outcomes following (traumatic) intracranial hemorrhage. Direct oral anticoagulants (DOAC) are increasingly used for the prevention and treatment of thromboembolic diseases. Data on patients treated for acute subdural hemorrhage (SDH) during anticoagulation therapy with DOAC are limited. METHODS We analyzed the medical records of consecutive patients treated at our institution for acute SDH during anticoagulation therapy with DOAC or vitamin K antagonists (VKA) during a period of 30 months. Patient characteristics such as results of imaging and laboratory studies, treatment modalities and short-term patient outcomes were included. RESULTS A total of 128 patients with preadmission DOAC (n = 65) or VKA (n = 63) intake were compared. The overall 30-day mortality rate of this patient cohort was 27%, and it did not differ between patients with DOAC or VKA intake (26% vs. 27%; p = 1.000). Similarly, the rates of neurosurgical intervention (65%) and intracranial re-hemorrhage (18%) were comparable. Prothrombin complex concentrates were administered more frequently in patients with VKA intake than in patients with DOAC intake (90% vs. 58%; p < 0.0001). DOAC treatment in patients with acute SDH did not increase in-hospital and 30-day mortality rates compared to VKA treatment. CONCLUSIONS These findings support the favorable safety profile of DOAC in patients, even in the setting of intracranial hemorrhage. However, the availability of specific antidotes to DOAC may further improve the management of these patients.
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9
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Roldán Rabadán I, Alonso de Leciñana M, Barba Martín R, Páramo Fernández JA. Security profile of direct anticoagulants. Preferred use in atrial fibrillation. CLINICA E INVESTIGACION EN ARTERIOSCLEROSIS : PUBLICACION OFICIAL DE LA SOCIEDAD ESPANOLA DE ARTERIOSCLEROSIS 2019; 31:263-270. [PMID: 31213323 DOI: 10.1016/j.arteri.2019.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Revised: 02/12/2019] [Accepted: 03/01/2019] [Indexed: 06/09/2023]
Abstract
A multidisciplinary panel of cardiologists, neurologists, internal medicine and specialists in hemostasis and thrombosis has elaborated this document showing recent scientific evidences supporting a better profile of direct oral anticoagulants (DOACs) versus vitaminK antagonists (VKA), as well as the indications of specific antidotes and hemostatic agents to reverse the anticoagulant effects of DOACs. The analysis reinforces the best profile of DOACs and its special benefit in patients with basal high hemorrhagic risk.
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Affiliation(s)
| | | | - Raquel Barba Martín
- Servicio de Medicina Interna, Hospital Universitario Rey Juan Carlos, Móstoles, Madrid, España
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10
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Seiffge DJ, Goeldlin MB, Tatlisumak T, Lyrer P, Fischer U, Engelter ST, Werring DJ. Meta-analysis of haematoma volume, haematoma expansion and mortality in intracerebral haemorrhage associated with oral anticoagulant use. J Neurol 2019; 266:3126-3135. [PMID: 31541341 PMCID: PMC6851029 DOI: 10.1007/s00415-019-09536-1] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2019] [Revised: 09/05/2019] [Accepted: 09/10/2019] [Indexed: 12/24/2022]
Abstract
OBJECTIVE To obtain precise estimates of age, haematoma volume, secondary haematoma expansion (HE) and mortality for patients with intracerebral haemorrhage (ICH) taking oral anticoagulants [Vitamin K antagonists (VKA-ICH) or non-Vitamin K antagonist oral anticoagulants (NOAC-ICH)] and those not taking oral anticoagulants (non-OAC ICH) at ICH symptom onset. METHODS We conducted a systematic review and meta-analysis of studies comparing VKA-ICH or NOAC-ICH or both with non-OAC ICH. Primary outcomes were haematoma volume (in ml), HE, and mortality (in-hospital and 3-month). We calculated odds ratios (ORs) using the Mantel-Haenszel random-effects method and corresponding 95% confidence intervals (95%CI) and determined the mean ICH volume difference. RESULTS We identified 19 studies including data from 16,546 patients with VKA-ICH and 128,561 patients with non-OAC ICH. Only 2 studies reported data on 4943 patients with NOAC-ICH. Patients with VKA-ICH were significantly older than patients with non-OAC ICH (mean age difference: 5.55 years, 95%CI 4.03-7.07, p < 0.0001, I2 = 92%, p < 0.001). Haematoma volume was significantly larger in VKA-ICH with a mean difference of 9.66 ml (95%CI 6.24-13.07 ml, p < 0.00001; I2 = 42%, p = 0.05). HE occurred significantly more often in VKA-ICH (OR 2.96, 95%CI 1.74-4.97, p < 0.00001; I2 = 65%). VKA-ICH was associated with significantly higher in-hospital mortality (VKA-ICH: 32.8% vs. non-OAC ICH: 22.4%; OR 1.83, 95%CI 1.61-2.07, p < 0.00001, I2 = 20%, p = 0.27) and 3-month mortality (VKA-ICH: 47.1% vs. non-OAC ICH: 25.5%; OR 2.24, 95%CI 1.52-3.31, p < 0.00001, I2 = 71%, p = 0.001). We did not find sufficient data for a meta-analysis comparing NOAC-ICH and non-OAC-ICH. CONCLUSION This meta-analysis confirms, refines and expands findings from prior studies. We provide precise estimates of key prognostic factors and outcomes for VKA-ICH, which has larger haematoma volume, increased rate of HE and higher mortality compared to non-OAC ICH. There are insufficient data on NOACs.
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Affiliation(s)
- David J Seiffge
- Stroke Research Centre, Institute of Neurology, University College London, Russell Square House, 10 Russell Square, London, UK. .,Stroke Center and Neurology, Department of Clinical Research, University Hospital and University, Basel, Switzerland. .,Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
| | - Martina B Goeldlin
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.,University Institute for Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Turgut Tatlisumak
- Department of Clinical Neuroscience/Neurology, Institute of Neurosciences and Physiology, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden.,Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Philippe Lyrer
- Stroke Center and Neurology, Department of Clinical Research, University Hospital and University, Basel, Switzerland
| | - Urs Fischer
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Stefan T Engelter
- Stroke Center and Neurology, Department of Clinical Research, University Hospital and University, Basel, Switzerland.,Neurorehabilitation Unit, University Center for Medicine of Aging and Rehabilitation Basel, Felix Platter Hospital, University of Basel, Basel, Switzerland
| | - David J Werring
- Stroke Research Centre, Institute of Neurology, University College London, Russell Square House, 10 Russell Square, London, UK.
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11
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Intake of NOAC is associated with hematoma expansion of intracerebral hematomas after traumatic brain injury. Eur J Trauma Emerg Surg 2019; 47:565-571. [PMID: 31529164 DOI: 10.1007/s00068-019-01228-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Accepted: 09/03/2019] [Indexed: 02/05/2023]
Abstract
PURPOSE Novel oral anticoagulants are increasingly replacing vitamin K antagonists in the prophylaxis of thromboembolism as they are associated with lower incidence of spontaneous intracerebral hematomas and they do not require drug level monitoring. However, management dilemmas are apparent in patients on novel oral anticoagulants who have developed intracerebral hematomas after traumatic brain injury, since clinical experience with their reversal strategies is limited. METHODS We retrospectively studied 90 patients with traumatic intracerebral hematomas undergoing treatment at the surgical intensive care unit of the BG University Clinic Bergmannsheil in Bochum between 2015 and 2018. We analyzed potential prognostic factors for their radiological (expansion of intracerebral hematoma) and clinical (patients' outcome) course, in particular the role of novel oral anticoagulants. RESULTS 71.1% of patients were male; mean age was 67.3 years. Hematoma's expansion occurred in 35.9% of our patients, whereas 62.2% of our cohort showed a favorable outcome, defined as Glasgow Outcome Scale 4 and 5. Intake of novel oral anticoagulants was associated with a higher rate of hematoma's expansion compared to patients on vitamin K antagonists (p = 0.05) or to patients with normal coagulation status (p = 0.002). A younger age (p < 0.001) was identified as the sole independent prognostic factor for a more favorable outcome, after excluding our cases, who underwent a cardiopulmonary resuscitation. CONCLUSIONS Our data showed a higher rate of hematoma's expansion in patients with traumatic intracerebral hematomas on novel oral anticoagulants vs. vitamin K antagonists and recommend the consideration of prophylactic reversal of the novel oral anticoagulants at admission. Larger prospective trials are warranted to conclude whether the current specific reversal protocols are safe and effective.
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12
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Foerch C, Lo EH, van Leyen K, Lauer A, Schaefer JH. Intracerebral Hemorrhage Formation Under Direct Oral Anticoagulants. Stroke 2019; 50:1034-1042. [PMID: 30869572 DOI: 10.1161/strokeaha.118.023722] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Affiliation(s)
- Christian Foerch
- From the Department of Neurology (C.F., J.H.S.), Goethe University, Frankfurt am Main, Germany
| | - Eng H Lo
- Neuroprotection Research Laboratory, Massachusetts General Hospital, Harvard Medical School, Charlestown (E.H.L., K.v.L.)
| | - Klaus van Leyen
- Neuroprotection Research Laboratory, Massachusetts General Hospital, Harvard Medical School, Charlestown (E.H.L., K.v.L.)
| | - Arne Lauer
- Institute of Neuroradiology (A.L.), Goethe University, Frankfurt am Main, Germany
| | - Jan Hendrik Schaefer
- From the Department of Neurology (C.F., J.H.S.), Goethe University, Frankfurt am Main, Germany
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13
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Chen SJ, Yeh SJ, Tang SC, Lin SY, Tsai LK, Jeng JS. Similar outcomes between vitamin K and non-vitamin K antagonist oral anticoagulants associated intracerebral hemorrhage. J Formos Med Assoc 2019; 119:106-112. [PMID: 30876786 DOI: 10.1016/j.jfma.2019.02.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2018] [Revised: 10/13/2018] [Accepted: 02/22/2019] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND The application of non-vitamin K antagonist oral anticoagulant (NOAC) reduces the risk of intracerebral hemorrhage (ICH) in comparison with vitamin K antagonist (VKA). However, the features and outcomes of NOAC-associated ICH are still unclear, especially for Asian populations. METHODS We retrospectively analyzed 49 consecutive patients who had spontaneous ICH while using NOAC or VKA. We compared the clinical characteristics, ICH volume, 7-day and 3-month mortality, and functional outcomes at discharge and 3 months post-stroke using the modified Rankin Scale (mRS) between NOAC- and VKA-associated ICH. The clinical features, ICH volume, ICH location, and/or treatment methods were statistically adjusted. RESULTS Among the 49 ICH patients, 15 (30.6%) were using NOAC and 34 (69.4%) were taking VKA. There were no significant differences in the initial ICH volume between groups (mean volume 34.2 ± 43.8 vs. 59.4 ± 46.5 mL, p = 0.061). The percentage of early mortality (within 7 days post-ICH) was significantly lower in the NOAC group (13.3% vs. 44.1%; p = 0.047), but the 3-month mortality was similar (33.3% vs. 47.1%; p = 0.294). The functional outcome was equally poor in both groups at discharge (p = 0.670) and 3 months post-ICH (mean mRS score 4.7 ± 1.3 vs. 4.6 ± 1.7, p = 0.766). CONCLUSION There were no significant differences in initial ICH volume, 90-day mortality, or functional outcomes between NOAC and VKA-associated ICH in Asians.
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Affiliation(s)
- Szu-Ju Chen
- Department of Neurology and Stroke Center, National Taiwan University Hospital, Taipei, Taiwan; Department of Neurology, En Chu Kong Hospital, New Taipei City, Taiwan.
| | - Shin-Joe Yeh
- Department of Neurology and Stroke Center, National Taiwan University Hospital, Taipei, Taiwan.
| | - Sung-Chun Tang
- Department of Neurology and Stroke Center, National Taiwan University Hospital, Taipei, Taiwan.
| | - Shin-Yi Lin
- Department of Pharmacy, National Taiwan University Hospital, Taiwan.
| | - Li-Kai Tsai
- Department of Neurology and Stroke Center, National Taiwan University Hospital, Taipei, Taiwan.
| | - Jiann-Shing Jeng
- Department of Neurology and Stroke Center, National Taiwan University Hospital, Taipei, Taiwan.
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14
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Seiffge DJ, Curtze S, Dequatre-Ponchelle N, Pezzini A, Tatlisumak T, Cordonnier C, Werring D. Hematoma location and morphology of anticoagulation-associated intracerebral hemorrhage. Neurology 2019; 92:e782-e791. [PMID: 30674603 DOI: 10.1212/wnl.0000000000006958] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2018] [Accepted: 10/15/2018] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To study hematoma location and morphology of intracerebral hemorrhage (ICH) associated with oral anticoagulants (OAC) and delineate causes and mechanism. METHODS We performed a systematic literature research and meta-analysis of studies comparing neuroimaging findings in patients with OAC-ICH compared to those with ICH not associated with OAC (non-OAC ICH). We calculated pooled risk ratios (RRs) for ICH location using the Mantel-Haenszel random-effects method and corresponding 95% confidence intervals (95% CI). RESULTS We identified 8 studies including 6,259 patients (OAC-ICH n = 1,107, pooled OAC-ICH population 17.7%). There was some evidence for deep ICH location (defined as ICH in the thalamus, basal ganglia, internal capsule, or brainstem) being less frequent in patients with OAC-ICH (OAC-ICH: 450 of 1,102/40.8% vs non-OAC ICH: 2,656 of 4,819/55.1%; RR 0.94, 95% CI 0.88-1.00, p = 0.05, I 2 = 0%) while cerebellar ICH location was significantly more common in OAC-ICH (OAC-ICH: 111 of 1,069/10.4% vs non-OAC ICH: 326 of 4,787/6.8%; RR 1.45, 95% CI 1.12-1.89, p = 0.005, I 2 = 21%) compared to non-OAC ICH. There was no statistically significant relationship to OAC use for lobar (OAC-ICH: 423 of 1,107/38.2% vs non-OAC ICH: 1,884 of 5,152/36.6%; RR 1.02, 95% CI 0.89-1.17, p = 0.75, I 2 = 53%, p for heterogeneity = 0.04) or brainstem ICH (OAC-ICH: 36 of 546/6.6% vs non-OAC ICH: 172 of 2,626/6.5%; RR 1.04, 95% CI 0.58-1.87, p = 0.89, I 2 = 59%, p for heterogeneity = 0.04). The risk for intraventricular extension (OAC-ICH: 436 of 840/51.9% vs non-OAC ICH: 1,429 of 3,508/40.7%; RR 1.26, 95% CI 1.16-1.36, p < 0.001, I 2 = 0%) was significantly increased in patients with OAC-ICH. We found few data on ICH morphology in OAC-ICH vs non-OAC ICH. CONCLUSION The overrepresentation of cerebellar ICH location and intraventricular extension in OAC-ICH might have mechanistic relevance for the underlying arteriopathy, pathophysiology, or bleeding pattern of OAC-ICH, and should be investigated further.
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Affiliation(s)
- David J Seiffge
- From the Stroke Research Group (D.J.S., D.W.), UCL Queen Square Institute of Neurology, University College London and the National Hospital for Neurology and Neurosurgery, Queen Square, London, UK; Stroke Centre and Neurology (D.J.S.), University Hospital and University Basel, Switzerland; Department of Neurology (S.C., T.T.), Helsinki University Hospital, Finland; Degenerative & Vascular Cognitive Disorders, Department of Neurology (N.D.-P., C.C.), INSERM U1171, CHU Lille, University of Lille, France; Department of Clinical and Experimental Sciences, Neurology Clinic (A.P.), University of Brescia, Italy; Department of Clinical Neuroscience/Neurology (T.T.), Institute of Neurosciences and Physiology, Sahlgrenska Academy at University of Gothenburg; and Department of Neurology (T.T.), Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Sami Curtze
- From the Stroke Research Group (D.J.S., D.W.), UCL Queen Square Institute of Neurology, University College London and the National Hospital for Neurology and Neurosurgery, Queen Square, London, UK; Stroke Centre and Neurology (D.J.S.), University Hospital and University Basel, Switzerland; Department of Neurology (S.C., T.T.), Helsinki University Hospital, Finland; Degenerative & Vascular Cognitive Disorders, Department of Neurology (N.D.-P., C.C.), INSERM U1171, CHU Lille, University of Lille, France; Department of Clinical and Experimental Sciences, Neurology Clinic (A.P.), University of Brescia, Italy; Department of Clinical Neuroscience/Neurology (T.T.), Institute of Neurosciences and Physiology, Sahlgrenska Academy at University of Gothenburg; and Department of Neurology (T.T.), Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Nelly Dequatre-Ponchelle
- From the Stroke Research Group (D.J.S., D.W.), UCL Queen Square Institute of Neurology, University College London and the National Hospital for Neurology and Neurosurgery, Queen Square, London, UK; Stroke Centre and Neurology (D.J.S.), University Hospital and University Basel, Switzerland; Department of Neurology (S.C., T.T.), Helsinki University Hospital, Finland; Degenerative & Vascular Cognitive Disorders, Department of Neurology (N.D.-P., C.C.), INSERM U1171, CHU Lille, University of Lille, France; Department of Clinical and Experimental Sciences, Neurology Clinic (A.P.), University of Brescia, Italy; Department of Clinical Neuroscience/Neurology (T.T.), Institute of Neurosciences and Physiology, Sahlgrenska Academy at University of Gothenburg; and Department of Neurology (T.T.), Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Alessandro Pezzini
- From the Stroke Research Group (D.J.S., D.W.), UCL Queen Square Institute of Neurology, University College London and the National Hospital for Neurology and Neurosurgery, Queen Square, London, UK; Stroke Centre and Neurology (D.J.S.), University Hospital and University Basel, Switzerland; Department of Neurology (S.C., T.T.), Helsinki University Hospital, Finland; Degenerative & Vascular Cognitive Disorders, Department of Neurology (N.D.-P., C.C.), INSERM U1171, CHU Lille, University of Lille, France; Department of Clinical and Experimental Sciences, Neurology Clinic (A.P.), University of Brescia, Italy; Department of Clinical Neuroscience/Neurology (T.T.), Institute of Neurosciences and Physiology, Sahlgrenska Academy at University of Gothenburg; and Department of Neurology (T.T.), Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Turgut Tatlisumak
- From the Stroke Research Group (D.J.S., D.W.), UCL Queen Square Institute of Neurology, University College London and the National Hospital for Neurology and Neurosurgery, Queen Square, London, UK; Stroke Centre and Neurology (D.J.S.), University Hospital and University Basel, Switzerland; Department of Neurology (S.C., T.T.), Helsinki University Hospital, Finland; Degenerative & Vascular Cognitive Disorders, Department of Neurology (N.D.-P., C.C.), INSERM U1171, CHU Lille, University of Lille, France; Department of Clinical and Experimental Sciences, Neurology Clinic (A.P.), University of Brescia, Italy; Department of Clinical Neuroscience/Neurology (T.T.), Institute of Neurosciences and Physiology, Sahlgrenska Academy at University of Gothenburg; and Department of Neurology (T.T.), Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Charlotte Cordonnier
- From the Stroke Research Group (D.J.S., D.W.), UCL Queen Square Institute of Neurology, University College London and the National Hospital for Neurology and Neurosurgery, Queen Square, London, UK; Stroke Centre and Neurology (D.J.S.), University Hospital and University Basel, Switzerland; Department of Neurology (S.C., T.T.), Helsinki University Hospital, Finland; Degenerative & Vascular Cognitive Disorders, Department of Neurology (N.D.-P., C.C.), INSERM U1171, CHU Lille, University of Lille, France; Department of Clinical and Experimental Sciences, Neurology Clinic (A.P.), University of Brescia, Italy; Department of Clinical Neuroscience/Neurology (T.T.), Institute of Neurosciences and Physiology, Sahlgrenska Academy at University of Gothenburg; and Department of Neurology (T.T.), Sahlgrenska University Hospital, Gothenburg, Sweden
| | - David Werring
- From the Stroke Research Group (D.J.S., D.W.), UCL Queen Square Institute of Neurology, University College London and the National Hospital for Neurology and Neurosurgery, Queen Square, London, UK; Stroke Centre and Neurology (D.J.S.), University Hospital and University Basel, Switzerland; Department of Neurology (S.C., T.T.), Helsinki University Hospital, Finland; Degenerative & Vascular Cognitive Disorders, Department of Neurology (N.D.-P., C.C.), INSERM U1171, CHU Lille, University of Lille, France; Department of Clinical and Experimental Sciences, Neurology Clinic (A.P.), University of Brescia, Italy; Department of Clinical Neuroscience/Neurology (T.T.), Institute of Neurosciences and Physiology, Sahlgrenska Academy at University of Gothenburg; and Department of Neurology (T.T.), Sahlgrenska University Hospital, Gothenburg, Sweden.
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15
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Woo HG, Chung I, Gwak DS, Kim BK, Kang JH, Kim BJ, Bae HJ, Han MK. Intracerebral hemorrhage associated with warfarin versus non-vitamin K antagonist oral anticoagulants in Asian patients. J Clin Neurosci 2018; 61:160-165. [PMID: 30587420 DOI: 10.1016/j.jocn.2018.10.102] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2018] [Accepted: 10/24/2018] [Indexed: 01/14/2023]
Abstract
Non-valvular atrial fibrillation patients receiving non-vitamin K antagonist oral anticoagulants (NOACs) have half the incidence of intracerebral hemorrhage (ICH) compared to those receiving warfarin. However, the differences in outcomes of NOAC-associated ICH (NICH) and warfarin-associated ICH (WICH) remain controversial. In this study, we investigated the clinical outcome and radiologic findings of ICH in Asian patients receiving NOACs or warfarin. We retrospectively reviewed the medical records of 544 ICH patients admitted to our hospital from January 2013 through December 2017, and compared the baseline demographics, clinical characteristics, ICH-related radiologic findings, and clinical outcome between the WICH and NICH groups. WICH and NICH were diagnosed in 46 and 13 patients, respectively. Lesions were located more frequently in the supratentorial deep area (45.7% and 46.2%) than the lobar area (30.4% and 30.8%) or brainstem and cerebellum (23.9% and 23.1%) in the WICH and NICH groups, respectively. The hematoma expansion and concomitant intraventricular hemorrhage (IVH) rate was significantly higher in the WICH group than in the NICH group (58.7% versus 7.7%, P = 0.001 and 50.0% versus 15.4%, P = 0.030, respectively). Hematoma expansion (odds ratio [OR]: 50.546; 95% confidence interval [CI]: 2.763-924.748; P = 0.008) and concomitant IVH (OR: 9.240; 95% CI: 1.450-58.892; P = 0.019) were independently associated with mortality at three months, after adjustment for confounding variables. Our results indicate that the radiological findings and clinical outcome at three months in patients with ICH are more favorable in those receiving NOAC therapy than in those receiving warfarin treatment.
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Affiliation(s)
- Ho Geol Woo
- Department of Neurology, Soonchunhyang University Cheonan Hospital, Soonchunhyang University College of Medicine, Cheonan, Republic of Korea
| | - Inyoung Chung
- Department of Neurology, Seoul National University Bundang Hospital, Republic of Korea
| | - Dong Seok Gwak
- Department of Neurology, Seoul National University Bundang Hospital, Republic of Korea
| | - Baik Kyun Kim
- Department of Critical Care Medicine, Seoul National University Bundang Hospital, Republic of Korea
| | - Ji Hoon Kang
- Department of Neurology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Republic of Korea
| | - Beom Joon Kim
- Department of Neurology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Republic of Korea
| | - Hee-Joon Bae
- Department of Neurology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Republic of Korea
| | - Moon-Ku Han
- Department of Neurology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Republic of Korea.
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16
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DiRisio AC, Harary M, Muskens IS, Yunusa I, Gormley WB, Aglio LS, Smith TR, Connors JM, Mekary RA, Broekman MLD. Outcomes of intraparenchymal hemorrhage after direct oral anticoagulant or vitamin K antagonist therapy: A systematic review and meta-analysis. J Clin Neurosci 2018; 62:188-194. [PMID: 30472344 DOI: 10.1016/j.jocn.2018.11.032] [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: 10/14/2018] [Accepted: 11/12/2018] [Indexed: 10/27/2022]
Abstract
Direct Oral Anticoagulants (DOAC) are increasingly used as an alternative to vitamin-K antagonists (VKA) for anticoagulation and have shown lower rates of intracranial hemorrhage; however, there is disagreement in the literature over the outcomes of the intraparenchymal hemorrhages (IPH) associated with DOACs, and clinical concern regarding the lack of standardized reversal strategies for DOACs. Thus, the aim of this meta-analysis was to compare mortality, hematoma volume, and risk of hematoma expansion in patients who developed an IPH on DOACs versus VKA. A systematic review of the literature was conducted in accordance with the PRISMA guidelines. Studies were selected that reported on mortality, hematoma expansion, and hematoma volume in DOAC-associated IPH. Pooled risk ratios (RR) were calculated for mortality and hematoma expansion and pooled mean difference (MD) was calculated for hematoma volume (ml) using random-effect models. 15 studies reporting on 1238 patients were included in the systematic review. Eleven of these compared DOAC-IPH to VKA-IPH and were pooled quantitatively. DOAC-IPH was not associated with increased mortality risk (RR: 0.95, 95%-CI: 0.72 -1.27) or increased hematoma expansion risk (RR: 0.92; 95%-CI: 0.75-1.12) compared to VKA-IPH. The hematoma volume of DOAC- IPH was statistically significantly smaller than VKA-IPH (MD: -12.14 ml; 95%-CI: -15.38; -8.89). In conclusion, DOAC-IPH was not associated with increased mortality or hematoma expansion compared to VKA-IPH and may be associated with a smaller hematoma volume.
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Affiliation(s)
- Aislyn C DiRisio
- Computational Neuroscience Outcomes Center, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Maya Harary
- Computational Neuroscience Outcomes Center, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Ivo S Muskens
- Computational Neuroscience Outcomes Center, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Department of Neurosurgery, Brain Center Rudolf Magnus University Medical Center Utrecht, Utrecht, the Netherlands
| | - Ismaeel Yunusa
- Computational Neuroscience Outcomes Center, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Department of Pharmaceutical Business and Administrative Sciences, School of Pharmacy, MCPHS University, Boston, MA, USA
| | - William B Gormley
- Computational Neuroscience Outcomes Center, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Linda S Aglio
- Computational Neuroscience Outcomes Center, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Timothy R Smith
- Computational Neuroscience Outcomes Center, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Jean M Connors
- Division of Hematology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Rania A Mekary
- Computational Neuroscience Outcomes Center, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Department of Pharmaceutical Business and Administrative Sciences, School of Pharmacy, MCPHS University, Boston, MA, USA
| | - Marike L D Broekman
- Computational Neuroscience Outcomes Center, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Department of Neurosurgery, Brain Center Rudolf Magnus University Medical Center Utrecht, Utrecht, the Netherlands; Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
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17
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Tsivgoulis G, Wilson D, Katsanos AH, Sargento-Freitas J, Marques-Matos C, Azevedo E, Adachi T, von der Brelie C, Aizawa Y, Abe H, Tomita H, Okumura K, Hagii J, Seiffge DJ, Lioutas VA, Traenka C, Varelas P, Basir G, Krogias C, Purrucker JC, Sharma VK, Rizos T, Mikulik R, Sobowale OA, Barlinn K, Sallinen H, Goyal N, Yeh SJ, Karapanayiotides T, Wu TY, Vadikolias K, Ferrigno M, Hadjigeorgiou G, Houben R, Giannopoulos S, Schreuder FHBM, Chang JJ, Perry LA, Mehdorn M, Marto JP, Pinho J, Tanaka J, Boulanger M, Al-Shahi Salman R, Jäger HR, Shakeshaft C, Yakushiji Y, Choi PMC, Staals J, Cordonnier C, Jeng JS, Veltkamp R, Dowlatshahi D, Engelter ST, Parry-Jones AR, Meretoja A, Mitsias PD, Alexandrov AV, Ambler G, Werring DJ. Neuroimaging and clinical outcomes of oral anticoagulant-associated intracerebral hemorrhage. Ann Neurol 2018; 84:694-704. [PMID: 30255970 DOI: 10.1002/ana.25342] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Revised: 09/13/2018] [Accepted: 09/14/2018] [Indexed: 01/11/2023]
Abstract
OBJECTIVE Whether intracerebral hemorrhage (ICH) associated with non-vitamin K antagonist oral anticoagulants (NOAC-ICH) has a better outcome compared to ICH associated with vitamin K antagonists (VKA-ICH) is uncertain. METHODS We performed a systematic review and individual patient data meta-analysis of cohort studies comparing clinical and radiological outcomes between NOAC-ICH and VKA-ICH patients. The primary outcome measure was 30-day all-cause mortality. All outcomes were assessed in multivariate regression analyses adjusted for age, sex, ICH location, and intraventricular hemorrhage extension. RESULTS We included 7 eligible studies comprising 219 NOAC-ICH and 831 VKA-ICH patients (mean age = 77 years, 52.5% females). The 30-day mortality was similar between NOAC-ICH and VKA-ICH (24.3% vs 26.5%; hazard ratio = 0.94, 95% confidence interval [CI] = 0.67-1.31). However, in multivariate analyses adjusting for potential confounders, NOAC-ICH was associated with lower admission National Institutes of Health Stroke Scale (NIHSS) score (linear regression coefficient = -2.83, 95% CI = -5.28 to -0.38), lower likelihood of severe stroke (NIHSS > 10 points) on admission (odds ratio [OR] = 0.50, 95% CI = 0.30-0.84), and smaller baseline hematoma volume (linear regression coefficient = -0.24, 95% CI = -0.47 to -0.16). The two groups did not differ in the likelihood of baseline hematoma volume < 30cm3 (OR = 1.14, 95% CI = 0.81-1.62), hematoma expansion (OR = 0.97, 95% CI = 0.63-1.48), in-hospital mortality (OR = 0.73, 95% CI = 0.49-1.11), functional status at discharge (common OR = 0.78, 95% CI = 0.57-1.07), or functional status at 3 months (common OR = 1.03, 95% CI = 0.75-1.43). INTERPRETATION Although functional outcome at discharge, 1 month, or 3 months was comparable after NOAC-ICH and VKA-ICH, patients with NOAC-ICH had smaller baseline hematoma volumes and less severe acute stroke syndromes. Ann Neurol 2018;84:702-712.
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Affiliation(s)
- Georgios Tsivgoulis
- Second Department of Neurology, Attikon University Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece.,Department of Neurology, University of Tennessee Health Science Center, Memphis, TN
| | - Duncan Wilson
- Stroke Research Centre, Department of Brain Repair and Rehabilitation, University College London Institute of Neurology and National Hospital for Neurology and Neurosurgery, London, United Kingdom, New Zealand Brain Research Institute, Christchurch, New Zealand
| | - Aristeidis H Katsanos
- Second Department of Neurology, Attikon University Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece.,Department of Neurology, University of Ioannina School of Medicine, Ioannina, Greece
| | - João Sargento-Freitas
- Department of Neurology, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal.,Faculty of Medicine, University of Coimbra, Coimbra, Portugal
| | - Cláudia Marques-Matos
- Department of Neurology, São João University Hospital Center, Porto, Portugal.,Department of Clinical Neurosciences and Mental Health, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Elsa Azevedo
- Department of Neurology, São João University Hospital Center, Porto, Portugal.,Department of Clinical Neurosciences and Mental Health, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Tomohide Adachi
- Department of Neurology and General Internal Medicine, Tokyo Saiseikai Central Hospital, Tokyo, Japan
| | | | - Yoshifusa Aizawa
- Department of Research and Development, Tachikawa Medical Center, Nagaoka, Japan
| | - Hiroshi Abe
- Department of Research and Development, Tachikawa Medical Center, Nagaoka, Japan
| | - Hirofumi Tomita
- Department of Cardiology and Department of Hypertension and Stroke Medicine, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Ken Okumura
- Advanced Arrhythmia Therapeutic Branch, Division of Cardiology, Saiseikai Kumamoto Hospital Cardiovascular Center, Kumamoto, Japan
| | - Joji Hagii
- Hirosaki Stroke and Rehabilitation Center, Hirosaki, Japan
| | - David J Seiffge
- Stroke Center and Neurology, University Hospital and University of Basel, Basel, Switzerland
| | | | - Christopher Traenka
- Stroke Center and Neurology, University Hospital and University of Basel, Basel, Switzerland
| | | | - Ghazala Basir
- Ottawa Hospital Research Institute and University of Ottawa, Ottawa, Ontario, Canada
| | - Christos Krogias
- Department of Neurology, St Josef Hospital, Ruhr University Bochum, Bochum, Germany
| | - Jan C Purrucker
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Vijay K Sharma
- Division of Neurology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Timolaos Rizos
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Robert Mikulik
- International Clinical Research Center and Neurology Department, St Anne's Hospital and Masaryk University, Brno, Czech Republic
| | - Oluwaseun A Sobowale
- Division of Cardiovascular Sciences, School of Medical Sciences, University of Manchester, Manchester Academic Health Science Centre, Manchester, United Kingdom
| | - Kristian Barlinn
- Department of Neurology, Dresden Neurovascular Center, Dresden, Germany
| | - Hanne Sallinen
- Department of Neurology, Helsinki University Hospital, Helsinki, Finland
| | - Nitin Goyal
- Department of Neurology, University of Tennessee Health Science Center, Memphis, TN
| | - Shin-Joe Yeh
- Stroke Center and Department of Neurology, National Taiwan University Hospital, Taiwan
| | - Theodore Karapanayiotides
- Second Department of Neurology, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Teddy Y Wu
- Department of Neurology, Christchurch Hospital, Christchurch, New Zealand
| | | | - Marc Ferrigno
- Department of Neurology, Lille University, INSERM U1171, Degenerative and Vascular Cognitive Disorders, CHU Lille, Lille, France
| | | | - Rik Houben
- Department of Neurology, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Sotirios Giannopoulos
- Department of Neurology, University of Ioannina School of Medicine, Ioannina, Greece
| | - Floris H B M Schreuder
- Department of Neurology, Maastricht University Medical Center, Maastricht, the Netherlands.,Department of Neurology, Donders Institute for Brain, Cognition, and Behavior, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Jason J Chang
- Department of Neurology, University of Tennessee Health Science Center, Memphis, TN
| | - Luke A Perry
- Department of Neurosciences, Eastern Health, Melbourne, Victoria, Australia
| | - Maximilian Mehdorn
- Department of Neurosurgery, Georg August University of Göttingen, Göttingen, Germany
| | - João-Pedro Marto
- Neurology Department, Egas Moniz Hospital, West Lisbon Hospital Center, Lisbon, Portugal.,CEDOC, Nova Medical School, New University of Lisbon, Lisbon, Portugal
| | - João Pinho
- Department of Neurology, Braga Hospital, Braga, Portugal
| | - Jun Tanaka
- Division of Neurology, Department of Internal Medicine, Faculty of Medicine, Saga University, Saga, Japan
| | - Marion Boulanger
- Centre for Clinical Brain Sciences, School of Clinical Sciences, University of Edinburgh, Edinburgh, United Kingdom
| | - Rustam Al-Shahi Salman
- Centre for Clinical Brain Sciences, School of Clinical Sciences, University of Edinburgh, Edinburgh, United Kingdom
| | - Hans R Jäger
- Neuroradiological Academic Unit, Department of Brain Repair and Rehabilitation, Institute of Neurology, University College London, London, United Kingdom
| | - Clare Shakeshaft
- Stroke Research Centre, Department of Brain Repair and Rehabilitation, University College London Institute of Neurology and National Hospital for Neurology and Neurosurgery, London, United Kingdom, New Zealand Brain Research Institute, Christchurch, New Zealand
| | - Yusuke Yakushiji
- Division of Neurology, Department of Internal Medicine, Faculty of Medicine, Saga University, Saga, Japan
| | - Philip M C Choi
- Department of Neurosciences, Eastern Health, Melbourne, Victoria, Australia
| | - Julie Staals
- Department of Neurology, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Charlotte Cordonnier
- Department of Neurology, Lille University, INSERM U1171, Degenerative and Vascular Cognitive Disorders, CHU Lille, Lille, France
| | - Jiann-Shing Jeng
- Stroke Center and Department of Neurology, National Taiwan University Hospital, Taiwan
| | - Roland Veltkamp
- Division of Brain Sciences, Department of Stroke Medicine, Imperial College London, United Kingdom
| | - Dar Dowlatshahi
- Ottawa Hospital Research Institute and University of Ottawa, Ottawa, Ontario, Canada
| | - Stefan T Engelter
- Stroke Center and Neurology, University Hospital and University of Basel, Basel, Switzerland.,Neurorehabilitation Unit, University of Basel and University Center for Medicine of Aging, Felix Platter Hospital, Basel, Switzerland
| | - Adrian R Parry-Jones
- Division of Cardiovascular Sciences, School of Medical Sciences, University of Manchester, Manchester Academic Health Science Centre, Manchester, United Kingdom
| | - Atte Meretoja
- Department of Neurology, Helsinki University Hospital, Helsinki, Finland.,Department of Medicine and Neurology at Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia
| | - Panayiotis D Mitsias
- Department of Neurology, Henry Ford Hospital, Detroit, MI.,Department of Neurology, School of Medicine, University of Crete, Crete, Greece
| | - Andrei V Alexandrov
- Department of Neurology, University of Tennessee Health Science Center, Memphis, TN
| | - Gareth Ambler
- Department of Statistical Science, University College London, London, United Kingdom
| | - David J Werring
- Stroke Research Centre, Department of Brain Repair and Rehabilitation, University College London Institute of Neurology and National Hospital for Neurology and Neurosurgery, London, United Kingdom, New Zealand Brain Research Institute, Christchurch, New Zealand
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18
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Ovesen C, Purrucker J, Gluud C, Jakobsen JC, Christensen H, Steiner T. Prothrombin complex concentrate versus placebo, no intervention, or other interventions in critically bleeding patients associated with oral anticoagulant administration: a protocol for a systematic review of randomised clinical trials with meta-analysis and trial sequential analysis. Syst Rev 2018; 7:169. [PMID: 30342540 PMCID: PMC6195723 DOI: 10.1186/s13643-018-0838-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2018] [Accepted: 10/05/2018] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Acute critical bleeding is one of the most feared complications during treatment with oral anticoagulating agents. As more patients undergo treatment with anticoagulating agents, critically bleeding episodes in patients with vitamin K antagonists, thrombin inhibitor, or factor Xa inhibitor-inducted coagulopathy will be encountered frequently by physicians. Hence, an effective treatment capable of reversing the iatrogenic coagulopathy in the acute setting is needed. In randomised clinical trials and observational studies, prothrombin complex concentrate has been reported to be superior to other acute interventions, and many guidelines recommend prothrombin complex concentrate in treatment of critically bleeding patients. The aim of this systematic review is to synthesise the evidence of the effects of prothrombin complex concentrate compared with placebo, no intervention, or other treatment options in critically bleeding patients treated with oral anticoagulants. METHODS/DESIGN A comprehensive search for relevant published literature will be undertaken in Cochrane Central Register of Controlled Trials, MEDLINE, Embase, WHO International Clinical Trials Registry Platform, Science Citation Index, regulatory databases, and trial registers. We will include randomised clinical trials comparing prothrombin complex concentrate versus placebo, no intervention, or other interventions in critically bleeding patients with oral anticoagulant-induced coagulopathy. Data extraction and risk of bias assessment will be handled by two independent review authors. Meta-analysis will be performed as recommended by Cochrane Handbook for Systematic Reviews of Interventions, bias will be assessed with domains, and trial sequential analysis will be conducted to control random errors. Certainty will be assessed by GRADE. DISCUSSION As critical bleeding in patients treated with oral anticoagulants is an increasing problem, an up-to-date systematic review evaluating the benefits and harms of prothrombin complex concentrate is urgently needed. It is the hope that this review will be able to guide best practice in treatment and clinical research of these critically bleeding patients. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42018084371.
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Affiliation(s)
- Christian Ovesen
- Department of Neurology, Bispebjerg Hospital, University of Copenhagen, Nielsine Nielsensvej 6A & B, DK-2400, Copenhagen, Denmark. .,Copenhagen Trial Unit, Centre for Clinical Intervention Research, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark.
| | - Jan Purrucker
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Christian Gluud
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Janus Christian Jakobsen
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark.,Department of Cardiology, Holbæk Hospital, Holbæk, Denmark
| | - Hanne Christensen
- Department of Neurology, Bispebjerg Hospital, University of Copenhagen, Nielsine Nielsensvej 6A & B, DK-2400, Copenhagen, Denmark
| | - Thorsten Steiner
- Department of Neurology, Klinikum Frankfurt Höchst, Frankfurt, Germany
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19
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Bernhardt J, Zorowitz RD, Becker KJ, Keller E, Saposnik G, Strbian D, Dichgans M, Woo D, Reeves M, Thrift A, Kidwell CS, Olivot JM, Goyal M, Pierot L, Bennett DA, Howard G, Ford GA, Goldstein LB, Planas AM, Yenari MA, Greenberg SM, Pantoni L, Amin-Hanjani S, Tymianski M. Advances in Stroke 2017. Stroke 2018; 49:e174-e199. [DOI: 10.1161/strokeaha.118.021380] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Revised: 03/02/2018] [Accepted: 03/12/2018] [Indexed: 12/11/2022]
Affiliation(s)
- Julie Bernhardt
- From the Florey Institute of Neuroscience and Mental Health, University of Melbourne, Australia (J.B.)
| | - Richard D. Zorowitz
- MedStar National Rehabilitation Network and Department of Rehabilitation Medicine, Georgetown University School of Medicine, Washington, DC (R.D.Z.)
| | - Kyra J. Becker
- Department of Neurology, University of Washington, Seattle (K.J.B.)
| | - Emanuela Keller
- Division of Internal Medicine, University Hospital of Zurich, Switzerland (E.K.)
| | | | - Daniel Strbian
- Department of Neurology, Helsinki University Central Hospital, Finland (D.S.)
| | - Martin Dichgans
- Institute for Stroke and Dementia Research, Klinikum der Universität München, Ludwig-Maximilians-Universität LMU, Germany (M.D.)
- Munich Cluster for Systems Neurology (SyNergy), Germany (M.D.)
| | - Daniel Woo
- Department of Neurology, University of Cincinnati College of Medicine, OH (D.W.)
| | - Mathew Reeves
- Department of Epidemiology and Biostatistics, Michigan State University, East Lansing (M.R.)
| | - Amanda Thrift
- Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, Victoria, Australia (A.T.)
| | - Chelsea S. Kidwell
- Departments of Neurology and Medical Imaging, University of Arizona, Tucson (C.S.K.)
| | - Jean Marc Olivot
- Acute Stroke Unit, Toulouse Neuroimaging Center and Clinical Investigation Center, Toulouse University Hospital, France (J.M.O.)
| | - Mayank Goyal
- Department of Diagnostic and Interventional Neuroradiology, University of Calgary, AB, Canada (M.G.)
| | - Laurent Pierot
- Department of Neuroradiology, Hôpital Maison Blanche, CHU Reims, Reims Champagne-Ardenne University, France (L.P.)
| | - Derrick A. Bennett
- Clinical Trial Service Unit and Epidemiological Studies Unit (CTSU), Nuffield Department of Population Health, University of Oxford, United Kingdom (D.A.B.)
| | - George Howard
- Department of Biostatistics, Ryals School of Public Health, University of Alabama at Birmingham (G.H.)
| | - Gary A. Ford
- Oxford Academic Health Science Network, United Kingdom (G.A.F.)
| | | | - Anna M. Planas
- Department of Brain Ischemia and Neurodegeneration, Institute for Biomedical Research of Barcelona (IIBB), Consejo Superior de Investigaciones CIentíficas (CSIC), Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain (A.M.P.)
| | - Midori A. Yenari
- Department of Neurology, University of California, San Francisco (M.A.Y.)
- San Francisco Veterans Affairs Medical Center, CA (M.A.Y.)
| | - Steven M. Greenberg
- Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston (S.M.G.)
| | - Leonardo Pantoni
- ‘L. Sacco’ Department of Biomedical and Clinical Sciences, University of Milan, Italy (L.P.)
| | | | - Michael Tymianski
- Departments of Surgery and Physiology, University of Toronto, ON, Canada (M.T.)
- Department of Surgery, University Health Network (Neurosurgery), Toronto, ON, Canada (M.T.)
- Krembil Research Institute, Toronto Western Hospital, ON, Canada (M.T.)
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20
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Boulouis G, Morotti A, Pasi M, Goldstein JN, Gurol ME, Charidimou A. Outcome of intracerebral haemorrhage related to non-vitamin K antagonists oral anticoagulants versus vitamin K antagonists: a comprehensive systematic review and meta-analysis. J Neurol Neurosurg Psychiatry 2018; 89:263-270. [PMID: 29030422 DOI: 10.1136/jnnp-2017-316631] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2017] [Revised: 08/25/2017] [Accepted: 09/25/2017] [Indexed: 12/29/2022]
Abstract
INTRODUCTION The characteristics and natural history of acute non-vitamin K antagonists oral anticoagulants (NOAC)-associated intracerebral haemorrhage (ICH) are largely unknown. We performed a comprehensive systematic review and meta-analysis to compare baseline ICH volume, haematoma expansion and clinical outcomes between NOAC-ICH versus vitamin K antagonists-ICH (VKA-ICH). METHODS We searched PubMed and conference abstracts for observational studies comparing baseline characteristics and outcomes in patients with NOAC-ICH versus VKA-ICH using an appropriate keyword/MeSH term search strategy. Data were extracted following PRISMA and MOOSE guidelines. The main outcome measures were mortality and unfavourable functional outcome (modified Rankin Score: 4-6) at discharge and at 3 months, as well as ICH volumes and haematoma expansion rates in the two groups. Random-effects models with DerSimonian-Laird weights were used for pooled estimates calculation. RESULTS Twelve studies including 393 NOAC-ICH and 3482 VKA-ICH were pooled in meta-analysis. There was no difference in mean ICH-volume between the two groups (standard mean difference: -0.24; 95% CI -0.52 to 0.04, p=0.093). The rates of haematoma expansion were comparable in NOAC-ICH versus VKA-ICH (OR: 0.76; 95% CI 0.49 to 1.19, p=0.236). We did not find any difference between patients with NOAC-ICH versus VKA-ICH in all-cause mortality at discharge (OR: 0.66; 95% CI 0.42 to 1.05, p=0.077) and unfavourable functional outcome at discharge (OR: 0.77; 95% CI 0.41 to 1.44, p=0.413). The 3-month outcome was also comparable between the two ICH groups. Moderate-to-substantial statistical heterogeneity was noted. CONCLUSION Our results confirm that ICH volume, haematoma expansion, mortality and functional outcome appear to be similar for NOAC-ICH versus VKA-ICH. Large prospective cohorts and updated meta-analyses are needed to provide more precise estimates.
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Affiliation(s)
- Gregoire Boulouis
- Department of Neuroradiology, Université Paris-Descartes, Centre Hospitalier Sainte Anne, Paris, Ile de France, France
| | - Andrea Morotti
- Department of Emergency Neurology, Stroke Unit, C. Mondino National Neurological Institute, Pavia, Italy
| | - Marco Pasi
- Department of Hemorrhagic Stroke Research Group, Massachusetts General Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Joshua N Goldstein
- Department of Hemorrhagic Stroke Research Group, Massachusetts General Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts, USA.,Division of Neurocritical Care and Emergency Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - M Edip Gurol
- Department of Hemorrhagic Stroke Research Group, Massachusetts General Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Andreas Charidimou
- Department of Hemorrhagic Stroke Research Group, Massachusetts General Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts, USA
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21
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Kurogi R, Nishimura K, Nakai M, Kada A, Kamitani S, Nakagawara J, Toyoda K, Ogasawara K, Ono J, Shiokawa Y, Aruga T, Miyachi S, Nagata I, Matsuda S, Yoshimura S, Okuchi K, Suzuki A, Nakamura F, Onozuka D, Ido K, Kurogi A, Mukae N, Nishimura A, Arimura K, Kitazono T, Hagihara A, Iihara K. Comparing intracerebral hemorrhages associated with direct oral anticoagulants or warfarin. Neurology 2018; 90:e1143-e1149. [PMID: 29490916 PMCID: PMC5880631 DOI: 10.1212/wnl.0000000000005207] [Citation(s) in RCA: 57] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2017] [Accepted: 12/27/2017] [Indexed: 01/16/2023] Open
Abstract
OBJECTIVES This cross-sectional survey explored the characteristics and outcomes of direct oral anticoagulant (DOAC)-associated nontraumatic intracerebral hemorrhages (ICHs) by analyzing a large nationwide Japanese discharge database. METHODS We analyzed data from 2,245 patients who experienced ICHs while taking anticoagulants (DOAC: 227; warfarin: 2,018) and were urgently hospitalized at 621 institutions in Japan between April 2010 and March 2015. We compared the DOAC- and warfarin-treated patients based on their backgrounds, ICH severities, antiplatelet therapies at admission, hematoma removal surgeries, reversal agents, mortality rates, and modified Rankin Scale scores at discharge. RESULTS DOAC-associated ICHs were less likely to cause moderately or severely impaired consciousness (DOAC-associated ICHs: 31.3%; warfarin-associated ICHs: 39.4%; p = 0.002) or require surgical removal (DOAC-associated ICHs: 5.3%; warfarin-associated ICHs: 9.9%; p = 0.024) in the univariate analysis. Propensity score analysis revealed that patients with DOAC-associated ICHs also exhibited lower mortality rates within 1 day (odds ratio [OR] 4.96, p = 0.005), within 7 days (OR 2.29, p = 0.037), and during hospitalization (OR 1.96, p = 0.039). CONCLUSIONS This nationwide study revealed that DOAC-treated patients had less severe ICHs and lower mortality rates than did warfarin-treated patients, probably due to milder hemorrhages at admission and lower hematoma expansion frequencies.
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Affiliation(s)
- Ryota Kurogi
- From the Departments of Neurosurgery (R.K., K. Ido, A. Kurogi, N.M., A.N., K.A., K. Iihara), Health Communication (D.O., A.H.), and Medicine and Clinical Science (T.K.), Graduate School of Medical Sciences, Kyushu University; Department of Neuroendovascular Surgery (R.K.), National Hospital Organization, Clinical Research Institute, Kyushu Medical Center, Fukuoka; Department of Statistics and Data Analysis, Center for Cerebral and Cardiovascular Disease Information (K.N., M.N.), Integrative Stroke Imaging Centre (J.N.), and Department of Cerebrovascular Medicine (K.T.), National Cerebral and Cardiovascular Center, Suita; Department of Clinical Trials and Research (A. Kada), National Hospital Organization, Nagoya Medical Center; Division of Health Services Research (S.K.), Center for Cancer Control and Information Services, National Cancer Center, Tokyo; Department of Neurosurgery (K. Ogasawara), Iwate Medical University, Morioka; Department of Neurosurgery (J.O.), Sanmu Medical Center; Department of Neurosurgery (Y.S.), Kyorin University, Mitaka; Department of Emergency and Critical Care Medicine (T.A.), Showa University Hospital, Shinagawa; Department of Neurosurgery (S. Miyachi), Osaka Medical College, Takatsuki; Department of Neurosurgery (I.N.), Kokura Memorial Hospital; Department of Preventive Medicine and Community Health (S. Matsuda), School of Medicine, University of Occupational and Environmental Health, Kitakyushu; Department of Neurosurgery (S.Y.), Hyogo College of Medicine, Nishinomiya; Department of Emergency and Critical Care Medicine (K. Okuchi), Nara Medical University, Kashihara; Department of Surgical Neurology (A.S.), Research Institute for Brain and Blood Vessels, Akita; and Division of Data Management Center for Cardiovascular Disease Information (F.N.), National Cerebral Cardiovascular Disease Information, Suita, Japan
| | - Kunihiro Nishimura
- From the Departments of Neurosurgery (R.K., K. Ido, A. Kurogi, N.M., A.N., K.A., K. Iihara), Health Communication (D.O., A.H.), and Medicine and Clinical Science (T.K.), Graduate School of Medical Sciences, Kyushu University; Department of Neuroendovascular Surgery (R.K.), National Hospital Organization, Clinical Research Institute, Kyushu Medical Center, Fukuoka; Department of Statistics and Data Analysis, Center for Cerebral and Cardiovascular Disease Information (K.N., M.N.), Integrative Stroke Imaging Centre (J.N.), and Department of Cerebrovascular Medicine (K.T.), National Cerebral and Cardiovascular Center, Suita; Department of Clinical Trials and Research (A. Kada), National Hospital Organization, Nagoya Medical Center; Division of Health Services Research (S.K.), Center for Cancer Control and Information Services, National Cancer Center, Tokyo; Department of Neurosurgery (K. Ogasawara), Iwate Medical University, Morioka; Department of Neurosurgery (J.O.), Sanmu Medical Center; Department of Neurosurgery (Y.S.), Kyorin University, Mitaka; Department of Emergency and Critical Care Medicine (T.A.), Showa University Hospital, Shinagawa; Department of Neurosurgery (S. Miyachi), Osaka Medical College, Takatsuki; Department of Neurosurgery (I.N.), Kokura Memorial Hospital; Department of Preventive Medicine and Community Health (S. Matsuda), School of Medicine, University of Occupational and Environmental Health, Kitakyushu; Department of Neurosurgery (S.Y.), Hyogo College of Medicine, Nishinomiya; Department of Emergency and Critical Care Medicine (K. Okuchi), Nara Medical University, Kashihara; Department of Surgical Neurology (A.S.), Research Institute for Brain and Blood Vessels, Akita; and Division of Data Management Center for Cardiovascular Disease Information (F.N.), National Cerebral Cardiovascular Disease Information, Suita, Japan
| | - Michikazu Nakai
- From the Departments of Neurosurgery (R.K., K. Ido, A. Kurogi, N.M., A.N., K.A., K. Iihara), Health Communication (D.O., A.H.), and Medicine and Clinical Science (T.K.), Graduate School of Medical Sciences, Kyushu University; Department of Neuroendovascular Surgery (R.K.), National Hospital Organization, Clinical Research Institute, Kyushu Medical Center, Fukuoka; Department of Statistics and Data Analysis, Center for Cerebral and Cardiovascular Disease Information (K.N., M.N.), Integrative Stroke Imaging Centre (J.N.), and Department of Cerebrovascular Medicine (K.T.), National Cerebral and Cardiovascular Center, Suita; Department of Clinical Trials and Research (A. Kada), National Hospital Organization, Nagoya Medical Center; Division of Health Services Research (S.K.), Center for Cancer Control and Information Services, National Cancer Center, Tokyo; Department of Neurosurgery (K. Ogasawara), Iwate Medical University, Morioka; Department of Neurosurgery (J.O.), Sanmu Medical Center; Department of Neurosurgery (Y.S.), Kyorin University, Mitaka; Department of Emergency and Critical Care Medicine (T.A.), Showa University Hospital, Shinagawa; Department of Neurosurgery (S. Miyachi), Osaka Medical College, Takatsuki; Department of Neurosurgery (I.N.), Kokura Memorial Hospital; Department of Preventive Medicine and Community Health (S. Matsuda), School of Medicine, University of Occupational and Environmental Health, Kitakyushu; Department of Neurosurgery (S.Y.), Hyogo College of Medicine, Nishinomiya; Department of Emergency and Critical Care Medicine (K. Okuchi), Nara Medical University, Kashihara; Department of Surgical Neurology (A.S.), Research Institute for Brain and Blood Vessels, Akita; and Division of Data Management Center for Cardiovascular Disease Information (F.N.), National Cerebral Cardiovascular Disease Information, Suita, Japan
| | - Akiko Kada
- From the Departments of Neurosurgery (R.K., K. Ido, A. Kurogi, N.M., A.N., K.A., K. Iihara), Health Communication (D.O., A.H.), and Medicine and Clinical Science (T.K.), Graduate School of Medical Sciences, Kyushu University; Department of Neuroendovascular Surgery (R.K.), National Hospital Organization, Clinical Research Institute, Kyushu Medical Center, Fukuoka; Department of Statistics and Data Analysis, Center for Cerebral and Cardiovascular Disease Information (K.N., M.N.), Integrative Stroke Imaging Centre (J.N.), and Department of Cerebrovascular Medicine (K.T.), National Cerebral and Cardiovascular Center, Suita; Department of Clinical Trials and Research (A. Kada), National Hospital Organization, Nagoya Medical Center; Division of Health Services Research (S.K.), Center for Cancer Control and Information Services, National Cancer Center, Tokyo; Department of Neurosurgery (K. Ogasawara), Iwate Medical University, Morioka; Department of Neurosurgery (J.O.), Sanmu Medical Center; Department of Neurosurgery (Y.S.), Kyorin University, Mitaka; Department of Emergency and Critical Care Medicine (T.A.), Showa University Hospital, Shinagawa; Department of Neurosurgery (S. Miyachi), Osaka Medical College, Takatsuki; Department of Neurosurgery (I.N.), Kokura Memorial Hospital; Department of Preventive Medicine and Community Health (S. Matsuda), School of Medicine, University of Occupational and Environmental Health, Kitakyushu; Department of Neurosurgery (S.Y.), Hyogo College of Medicine, Nishinomiya; Department of Emergency and Critical Care Medicine (K. Okuchi), Nara Medical University, Kashihara; Department of Surgical Neurology (A.S.), Research Institute for Brain and Blood Vessels, Akita; and Division of Data Management Center for Cardiovascular Disease Information (F.N.), National Cerebral Cardiovascular Disease Information, Suita, Japan
| | - Satoru Kamitani
- From the Departments of Neurosurgery (R.K., K. Ido, A. Kurogi, N.M., A.N., K.A., K. Iihara), Health Communication (D.O., A.H.), and Medicine and Clinical Science (T.K.), Graduate School of Medical Sciences, Kyushu University; Department of Neuroendovascular Surgery (R.K.), National Hospital Organization, Clinical Research Institute, Kyushu Medical Center, Fukuoka; Department of Statistics and Data Analysis, Center for Cerebral and Cardiovascular Disease Information (K.N., M.N.), Integrative Stroke Imaging Centre (J.N.), and Department of Cerebrovascular Medicine (K.T.), National Cerebral and Cardiovascular Center, Suita; Department of Clinical Trials and Research (A. Kada), National Hospital Organization, Nagoya Medical Center; Division of Health Services Research (S.K.), Center for Cancer Control and Information Services, National Cancer Center, Tokyo; Department of Neurosurgery (K. Ogasawara), Iwate Medical University, Morioka; Department of Neurosurgery (J.O.), Sanmu Medical Center; Department of Neurosurgery (Y.S.), Kyorin University, Mitaka; Department of Emergency and Critical Care Medicine (T.A.), Showa University Hospital, Shinagawa; Department of Neurosurgery (S. Miyachi), Osaka Medical College, Takatsuki; Department of Neurosurgery (I.N.), Kokura Memorial Hospital; Department of Preventive Medicine and Community Health (S. Matsuda), School of Medicine, University of Occupational and Environmental Health, Kitakyushu; Department of Neurosurgery (S.Y.), Hyogo College of Medicine, Nishinomiya; Department of Emergency and Critical Care Medicine (K. Okuchi), Nara Medical University, Kashihara; Department of Surgical Neurology (A.S.), Research Institute for Brain and Blood Vessels, Akita; and Division of Data Management Center for Cardiovascular Disease Information (F.N.), National Cerebral Cardiovascular Disease Information, Suita, Japan
| | - Jyoji Nakagawara
- From the Departments of Neurosurgery (R.K., K. Ido, A. Kurogi, N.M., A.N., K.A., K. Iihara), Health Communication (D.O., A.H.), and Medicine and Clinical Science (T.K.), Graduate School of Medical Sciences, Kyushu University; Department of Neuroendovascular Surgery (R.K.), National Hospital Organization, Clinical Research Institute, Kyushu Medical Center, Fukuoka; Department of Statistics and Data Analysis, Center for Cerebral and Cardiovascular Disease Information (K.N., M.N.), Integrative Stroke Imaging Centre (J.N.), and Department of Cerebrovascular Medicine (K.T.), National Cerebral and Cardiovascular Center, Suita; Department of Clinical Trials and Research (A. Kada), National Hospital Organization, Nagoya Medical Center; Division of Health Services Research (S.K.), Center for Cancer Control and Information Services, National Cancer Center, Tokyo; Department of Neurosurgery (K. Ogasawara), Iwate Medical University, Morioka; Department of Neurosurgery (J.O.), Sanmu Medical Center; Department of Neurosurgery (Y.S.), Kyorin University, Mitaka; Department of Emergency and Critical Care Medicine (T.A.), Showa University Hospital, Shinagawa; Department of Neurosurgery (S. Miyachi), Osaka Medical College, Takatsuki; Department of Neurosurgery (I.N.), Kokura Memorial Hospital; Department of Preventive Medicine and Community Health (S. Matsuda), School of Medicine, University of Occupational and Environmental Health, Kitakyushu; Department of Neurosurgery (S.Y.), Hyogo College of Medicine, Nishinomiya; Department of Emergency and Critical Care Medicine (K. Okuchi), Nara Medical University, Kashihara; Department of Surgical Neurology (A.S.), Research Institute for Brain and Blood Vessels, Akita; and Division of Data Management Center for Cardiovascular Disease Information (F.N.), National Cerebral Cardiovascular Disease Information, Suita, Japan
| | - Kazunori Toyoda
- From the Departments of Neurosurgery (R.K., K. Ido, A. Kurogi, N.M., A.N., K.A., K. Iihara), Health Communication (D.O., A.H.), and Medicine and Clinical Science (T.K.), Graduate School of Medical Sciences, Kyushu University; Department of Neuroendovascular Surgery (R.K.), National Hospital Organization, Clinical Research Institute, Kyushu Medical Center, Fukuoka; Department of Statistics and Data Analysis, Center for Cerebral and Cardiovascular Disease Information (K.N., M.N.), Integrative Stroke Imaging Centre (J.N.), and Department of Cerebrovascular Medicine (K.T.), National Cerebral and Cardiovascular Center, Suita; Department of Clinical Trials and Research (A. Kada), National Hospital Organization, Nagoya Medical Center; Division of Health Services Research (S.K.), Center for Cancer Control and Information Services, National Cancer Center, Tokyo; Department of Neurosurgery (K. Ogasawara), Iwate Medical University, Morioka; Department of Neurosurgery (J.O.), Sanmu Medical Center; Department of Neurosurgery (Y.S.), Kyorin University, Mitaka; Department of Emergency and Critical Care Medicine (T.A.), Showa University Hospital, Shinagawa; Department of Neurosurgery (S. Miyachi), Osaka Medical College, Takatsuki; Department of Neurosurgery (I.N.), Kokura Memorial Hospital; Department of Preventive Medicine and Community Health (S. Matsuda), School of Medicine, University of Occupational and Environmental Health, Kitakyushu; Department of Neurosurgery (S.Y.), Hyogo College of Medicine, Nishinomiya; Department of Emergency and Critical Care Medicine (K. Okuchi), Nara Medical University, Kashihara; Department of Surgical Neurology (A.S.), Research Institute for Brain and Blood Vessels, Akita; and Division of Data Management Center for Cardiovascular Disease Information (F.N.), National Cerebral Cardiovascular Disease Information, Suita, Japan
| | - Kuniaki Ogasawara
- From the Departments of Neurosurgery (R.K., K. Ido, A. Kurogi, N.M., A.N., K.A., K. Iihara), Health Communication (D.O., A.H.), and Medicine and Clinical Science (T.K.), Graduate School of Medical Sciences, Kyushu University; Department of Neuroendovascular Surgery (R.K.), National Hospital Organization, Clinical Research Institute, Kyushu Medical Center, Fukuoka; Department of Statistics and Data Analysis, Center for Cerebral and Cardiovascular Disease Information (K.N., M.N.), Integrative Stroke Imaging Centre (J.N.), and Department of Cerebrovascular Medicine (K.T.), National Cerebral and Cardiovascular Center, Suita; Department of Clinical Trials and Research (A. Kada), National Hospital Organization, Nagoya Medical Center; Division of Health Services Research (S.K.), Center for Cancer Control and Information Services, National Cancer Center, Tokyo; Department of Neurosurgery (K. Ogasawara), Iwate Medical University, Morioka; Department of Neurosurgery (J.O.), Sanmu Medical Center; Department of Neurosurgery (Y.S.), Kyorin University, Mitaka; Department of Emergency and Critical Care Medicine (T.A.), Showa University Hospital, Shinagawa; Department of Neurosurgery (S. Miyachi), Osaka Medical College, Takatsuki; Department of Neurosurgery (I.N.), Kokura Memorial Hospital; Department of Preventive Medicine and Community Health (S. Matsuda), School of Medicine, University of Occupational and Environmental Health, Kitakyushu; Department of Neurosurgery (S.Y.), Hyogo College of Medicine, Nishinomiya; Department of Emergency and Critical Care Medicine (K. Okuchi), Nara Medical University, Kashihara; Department of Surgical Neurology (A.S.), Research Institute for Brain and Blood Vessels, Akita; and Division of Data Management Center for Cardiovascular Disease Information (F.N.), National Cerebral Cardiovascular Disease Information, Suita, Japan
| | - Junichi Ono
- From the Departments of Neurosurgery (R.K., K. Ido, A. Kurogi, N.M., A.N., K.A., K. Iihara), Health Communication (D.O., A.H.), and Medicine and Clinical Science (T.K.), Graduate School of Medical Sciences, Kyushu University; Department of Neuroendovascular Surgery (R.K.), National Hospital Organization, Clinical Research Institute, Kyushu Medical Center, Fukuoka; Department of Statistics and Data Analysis, Center for Cerebral and Cardiovascular Disease Information (K.N., M.N.), Integrative Stroke Imaging Centre (J.N.), and Department of Cerebrovascular Medicine (K.T.), National Cerebral and Cardiovascular Center, Suita; Department of Clinical Trials and Research (A. Kada), National Hospital Organization, Nagoya Medical Center; Division of Health Services Research (S.K.), Center for Cancer Control and Information Services, National Cancer Center, Tokyo; Department of Neurosurgery (K. Ogasawara), Iwate Medical University, Morioka; Department of Neurosurgery (J.O.), Sanmu Medical Center; Department of Neurosurgery (Y.S.), Kyorin University, Mitaka; Department of Emergency and Critical Care Medicine (T.A.), Showa University Hospital, Shinagawa; Department of Neurosurgery (S. Miyachi), Osaka Medical College, Takatsuki; Department of Neurosurgery (I.N.), Kokura Memorial Hospital; Department of Preventive Medicine and Community Health (S. Matsuda), School of Medicine, University of Occupational and Environmental Health, Kitakyushu; Department of Neurosurgery (S.Y.), Hyogo College of Medicine, Nishinomiya; Department of Emergency and Critical Care Medicine (K. Okuchi), Nara Medical University, Kashihara; Department of Surgical Neurology (A.S.), Research Institute for Brain and Blood Vessels, Akita; and Division of Data Management Center for Cardiovascular Disease Information (F.N.), National Cerebral Cardiovascular Disease Information, Suita, Japan
| | - Yoshiaki Shiokawa
- From the Departments of Neurosurgery (R.K., K. Ido, A. Kurogi, N.M., A.N., K.A., K. Iihara), Health Communication (D.O., A.H.), and Medicine and Clinical Science (T.K.), Graduate School of Medical Sciences, Kyushu University; Department of Neuroendovascular Surgery (R.K.), National Hospital Organization, Clinical Research Institute, Kyushu Medical Center, Fukuoka; Department of Statistics and Data Analysis, Center for Cerebral and Cardiovascular Disease Information (K.N., M.N.), Integrative Stroke Imaging Centre (J.N.), and Department of Cerebrovascular Medicine (K.T.), National Cerebral and Cardiovascular Center, Suita; Department of Clinical Trials and Research (A. Kada), National Hospital Organization, Nagoya Medical Center; Division of Health Services Research (S.K.), Center for Cancer Control and Information Services, National Cancer Center, Tokyo; Department of Neurosurgery (K. Ogasawara), Iwate Medical University, Morioka; Department of Neurosurgery (J.O.), Sanmu Medical Center; Department of Neurosurgery (Y.S.), Kyorin University, Mitaka; Department of Emergency and Critical Care Medicine (T.A.), Showa University Hospital, Shinagawa; Department of Neurosurgery (S. Miyachi), Osaka Medical College, Takatsuki; Department of Neurosurgery (I.N.), Kokura Memorial Hospital; Department of Preventive Medicine and Community Health (S. Matsuda), School of Medicine, University of Occupational and Environmental Health, Kitakyushu; Department of Neurosurgery (S.Y.), Hyogo College of Medicine, Nishinomiya; Department of Emergency and Critical Care Medicine (K. Okuchi), Nara Medical University, Kashihara; Department of Surgical Neurology (A.S.), Research Institute for Brain and Blood Vessels, Akita; and Division of Data Management Center for Cardiovascular Disease Information (F.N.), National Cerebral Cardiovascular Disease Information, Suita, Japan
| | - Toru Aruga
- From the Departments of Neurosurgery (R.K., K. Ido, A. Kurogi, N.M., A.N., K.A., K. Iihara), Health Communication (D.O., A.H.), and Medicine and Clinical Science (T.K.), Graduate School of Medical Sciences, Kyushu University; Department of Neuroendovascular Surgery (R.K.), National Hospital Organization, Clinical Research Institute, Kyushu Medical Center, Fukuoka; Department of Statistics and Data Analysis, Center for Cerebral and Cardiovascular Disease Information (K.N., M.N.), Integrative Stroke Imaging Centre (J.N.), and Department of Cerebrovascular Medicine (K.T.), National Cerebral and Cardiovascular Center, Suita; Department of Clinical Trials and Research (A. Kada), National Hospital Organization, Nagoya Medical Center; Division of Health Services Research (S.K.), Center for Cancer Control and Information Services, National Cancer Center, Tokyo; Department of Neurosurgery (K. Ogasawara), Iwate Medical University, Morioka; Department of Neurosurgery (J.O.), Sanmu Medical Center; Department of Neurosurgery (Y.S.), Kyorin University, Mitaka; Department of Emergency and Critical Care Medicine (T.A.), Showa University Hospital, Shinagawa; Department of Neurosurgery (S. Miyachi), Osaka Medical College, Takatsuki; Department of Neurosurgery (I.N.), Kokura Memorial Hospital; Department of Preventive Medicine and Community Health (S. Matsuda), School of Medicine, University of Occupational and Environmental Health, Kitakyushu; Department of Neurosurgery (S.Y.), Hyogo College of Medicine, Nishinomiya; Department of Emergency and Critical Care Medicine (K. Okuchi), Nara Medical University, Kashihara; Department of Surgical Neurology (A.S.), Research Institute for Brain and Blood Vessels, Akita; and Division of Data Management Center for Cardiovascular Disease Information (F.N.), National Cerebral Cardiovascular Disease Information, Suita, Japan
| | - Shigeru Miyachi
- From the Departments of Neurosurgery (R.K., K. Ido, A. Kurogi, N.M., A.N., K.A., K. Iihara), Health Communication (D.O., A.H.), and Medicine and Clinical Science (T.K.), Graduate School of Medical Sciences, Kyushu University; Department of Neuroendovascular Surgery (R.K.), National Hospital Organization, Clinical Research Institute, Kyushu Medical Center, Fukuoka; Department of Statistics and Data Analysis, Center for Cerebral and Cardiovascular Disease Information (K.N., M.N.), Integrative Stroke Imaging Centre (J.N.), and Department of Cerebrovascular Medicine (K.T.), National Cerebral and Cardiovascular Center, Suita; Department of Clinical Trials and Research (A. Kada), National Hospital Organization, Nagoya Medical Center; Division of Health Services Research (S.K.), Center for Cancer Control and Information Services, National Cancer Center, Tokyo; Department of Neurosurgery (K. Ogasawara), Iwate Medical University, Morioka; Department of Neurosurgery (J.O.), Sanmu Medical Center; Department of Neurosurgery (Y.S.), Kyorin University, Mitaka; Department of Emergency and Critical Care Medicine (T.A.), Showa University Hospital, Shinagawa; Department of Neurosurgery (S. Miyachi), Osaka Medical College, Takatsuki; Department of Neurosurgery (I.N.), Kokura Memorial Hospital; Department of Preventive Medicine and Community Health (S. Matsuda), School of Medicine, University of Occupational and Environmental Health, Kitakyushu; Department of Neurosurgery (S.Y.), Hyogo College of Medicine, Nishinomiya; Department of Emergency and Critical Care Medicine (K. Okuchi), Nara Medical University, Kashihara; Department of Surgical Neurology (A.S.), Research Institute for Brain and Blood Vessels, Akita; and Division of Data Management Center for Cardiovascular Disease Information (F.N.), National Cerebral Cardiovascular Disease Information, Suita, Japan
| | - Izumi Nagata
- From the Departments of Neurosurgery (R.K., K. Ido, A. Kurogi, N.M., A.N., K.A., K. Iihara), Health Communication (D.O., A.H.), and Medicine and Clinical Science (T.K.), Graduate School of Medical Sciences, Kyushu University; Department of Neuroendovascular Surgery (R.K.), National Hospital Organization, Clinical Research Institute, Kyushu Medical Center, Fukuoka; Department of Statistics and Data Analysis, Center for Cerebral and Cardiovascular Disease Information (K.N., M.N.), Integrative Stroke Imaging Centre (J.N.), and Department of Cerebrovascular Medicine (K.T.), National Cerebral and Cardiovascular Center, Suita; Department of Clinical Trials and Research (A. Kada), National Hospital Organization, Nagoya Medical Center; Division of Health Services Research (S.K.), Center for Cancer Control and Information Services, National Cancer Center, Tokyo; Department of Neurosurgery (K. Ogasawara), Iwate Medical University, Morioka; Department of Neurosurgery (J.O.), Sanmu Medical Center; Department of Neurosurgery (Y.S.), Kyorin University, Mitaka; Department of Emergency and Critical Care Medicine (T.A.), Showa University Hospital, Shinagawa; Department of Neurosurgery (S. Miyachi), Osaka Medical College, Takatsuki; Department of Neurosurgery (I.N.), Kokura Memorial Hospital; Department of Preventive Medicine and Community Health (S. Matsuda), School of Medicine, University of Occupational and Environmental Health, Kitakyushu; Department of Neurosurgery (S.Y.), Hyogo College of Medicine, Nishinomiya; Department of Emergency and Critical Care Medicine (K. Okuchi), Nara Medical University, Kashihara; Department of Surgical Neurology (A.S.), Research Institute for Brain and Blood Vessels, Akita; and Division of Data Management Center for Cardiovascular Disease Information (F.N.), National Cerebral Cardiovascular Disease Information, Suita, Japan
| | - Shinya Matsuda
- From the Departments of Neurosurgery (R.K., K. Ido, A. Kurogi, N.M., A.N., K.A., K. Iihara), Health Communication (D.O., A.H.), and Medicine and Clinical Science (T.K.), Graduate School of Medical Sciences, Kyushu University; Department of Neuroendovascular Surgery (R.K.), National Hospital Organization, Clinical Research Institute, Kyushu Medical Center, Fukuoka; Department of Statistics and Data Analysis, Center for Cerebral and Cardiovascular Disease Information (K.N., M.N.), Integrative Stroke Imaging Centre (J.N.), and Department of Cerebrovascular Medicine (K.T.), National Cerebral and Cardiovascular Center, Suita; Department of Clinical Trials and Research (A. Kada), National Hospital Organization, Nagoya Medical Center; Division of Health Services Research (S.K.), Center for Cancer Control and Information Services, National Cancer Center, Tokyo; Department of Neurosurgery (K. Ogasawara), Iwate Medical University, Morioka; Department of Neurosurgery (J.O.), Sanmu Medical Center; Department of Neurosurgery (Y.S.), Kyorin University, Mitaka; Department of Emergency and Critical Care Medicine (T.A.), Showa University Hospital, Shinagawa; Department of Neurosurgery (S. Miyachi), Osaka Medical College, Takatsuki; Department of Neurosurgery (I.N.), Kokura Memorial Hospital; Department of Preventive Medicine and Community Health (S. Matsuda), School of Medicine, University of Occupational and Environmental Health, Kitakyushu; Department of Neurosurgery (S.Y.), Hyogo College of Medicine, Nishinomiya; Department of Emergency and Critical Care Medicine (K. Okuchi), Nara Medical University, Kashihara; Department of Surgical Neurology (A.S.), Research Institute for Brain and Blood Vessels, Akita; and Division of Data Management Center for Cardiovascular Disease Information (F.N.), National Cerebral Cardiovascular Disease Information, Suita, Japan
| | - Shinichi Yoshimura
- From the Departments of Neurosurgery (R.K., K. Ido, A. Kurogi, N.M., A.N., K.A., K. Iihara), Health Communication (D.O., A.H.), and Medicine and Clinical Science (T.K.), Graduate School of Medical Sciences, Kyushu University; Department of Neuroendovascular Surgery (R.K.), National Hospital Organization, Clinical Research Institute, Kyushu Medical Center, Fukuoka; Department of Statistics and Data Analysis, Center for Cerebral and Cardiovascular Disease Information (K.N., M.N.), Integrative Stroke Imaging Centre (J.N.), and Department of Cerebrovascular Medicine (K.T.), National Cerebral and Cardiovascular Center, Suita; Department of Clinical Trials and Research (A. Kada), National Hospital Organization, Nagoya Medical Center; Division of Health Services Research (S.K.), Center for Cancer Control and Information Services, National Cancer Center, Tokyo; Department of Neurosurgery (K. Ogasawara), Iwate Medical University, Morioka; Department of Neurosurgery (J.O.), Sanmu Medical Center; Department of Neurosurgery (Y.S.), Kyorin University, Mitaka; Department of Emergency and Critical Care Medicine (T.A.), Showa University Hospital, Shinagawa; Department of Neurosurgery (S. Miyachi), Osaka Medical College, Takatsuki; Department of Neurosurgery (I.N.), Kokura Memorial Hospital; Department of Preventive Medicine and Community Health (S. Matsuda), School of Medicine, University of Occupational and Environmental Health, Kitakyushu; Department of Neurosurgery (S.Y.), Hyogo College of Medicine, Nishinomiya; Department of Emergency and Critical Care Medicine (K. Okuchi), Nara Medical University, Kashihara; Department of Surgical Neurology (A.S.), Research Institute for Brain and Blood Vessels, Akita; and Division of Data Management Center for Cardiovascular Disease Information (F.N.), National Cerebral Cardiovascular Disease Information, Suita, Japan
| | - Kazuo Okuchi
- From the Departments of Neurosurgery (R.K., K. Ido, A. Kurogi, N.M., A.N., K.A., K. Iihara), Health Communication (D.O., A.H.), and Medicine and Clinical Science (T.K.), Graduate School of Medical Sciences, Kyushu University; Department of Neuroendovascular Surgery (R.K.), National Hospital Organization, Clinical Research Institute, Kyushu Medical Center, Fukuoka; Department of Statistics and Data Analysis, Center for Cerebral and Cardiovascular Disease Information (K.N., M.N.), Integrative Stroke Imaging Centre (J.N.), and Department of Cerebrovascular Medicine (K.T.), National Cerebral and Cardiovascular Center, Suita; Department of Clinical Trials and Research (A. Kada), National Hospital Organization, Nagoya Medical Center; Division of Health Services Research (S.K.), Center for Cancer Control and Information Services, National Cancer Center, Tokyo; Department of Neurosurgery (K. Ogasawara), Iwate Medical University, Morioka; Department of Neurosurgery (J.O.), Sanmu Medical Center; Department of Neurosurgery (Y.S.), Kyorin University, Mitaka; Department of Emergency and Critical Care Medicine (T.A.), Showa University Hospital, Shinagawa; Department of Neurosurgery (S. Miyachi), Osaka Medical College, Takatsuki; Department of Neurosurgery (I.N.), Kokura Memorial Hospital; Department of Preventive Medicine and Community Health (S. Matsuda), School of Medicine, University of Occupational and Environmental Health, Kitakyushu; Department of Neurosurgery (S.Y.), Hyogo College of Medicine, Nishinomiya; Department of Emergency and Critical Care Medicine (K. Okuchi), Nara Medical University, Kashihara; Department of Surgical Neurology (A.S.), Research Institute for Brain and Blood Vessels, Akita; and Division of Data Management Center for Cardiovascular Disease Information (F.N.), National Cerebral Cardiovascular Disease Information, Suita, Japan
| | - Akifumi Suzuki
- From the Departments of Neurosurgery (R.K., K. Ido, A. Kurogi, N.M., A.N., K.A., K. Iihara), Health Communication (D.O., A.H.), and Medicine and Clinical Science (T.K.), Graduate School of Medical Sciences, Kyushu University; Department of Neuroendovascular Surgery (R.K.), National Hospital Organization, Clinical Research Institute, Kyushu Medical Center, Fukuoka; Department of Statistics and Data Analysis, Center for Cerebral and Cardiovascular Disease Information (K.N., M.N.), Integrative Stroke Imaging Centre (J.N.), and Department of Cerebrovascular Medicine (K.T.), National Cerebral and Cardiovascular Center, Suita; Department of Clinical Trials and Research (A. Kada), National Hospital Organization, Nagoya Medical Center; Division of Health Services Research (S.K.), Center for Cancer Control and Information Services, National Cancer Center, Tokyo; Department of Neurosurgery (K. Ogasawara), Iwate Medical University, Morioka; Department of Neurosurgery (J.O.), Sanmu Medical Center; Department of Neurosurgery (Y.S.), Kyorin University, Mitaka; Department of Emergency and Critical Care Medicine (T.A.), Showa University Hospital, Shinagawa; Department of Neurosurgery (S. Miyachi), Osaka Medical College, Takatsuki; Department of Neurosurgery (I.N.), Kokura Memorial Hospital; Department of Preventive Medicine and Community Health (S. Matsuda), School of Medicine, University of Occupational and Environmental Health, Kitakyushu; Department of Neurosurgery (S.Y.), Hyogo College of Medicine, Nishinomiya; Department of Emergency and Critical Care Medicine (K. Okuchi), Nara Medical University, Kashihara; Department of Surgical Neurology (A.S.), Research Institute for Brain and Blood Vessels, Akita; and Division of Data Management Center for Cardiovascular Disease Information (F.N.), National Cerebral Cardiovascular Disease Information, Suita, Japan
| | - Fumiaki Nakamura
- From the Departments of Neurosurgery (R.K., K. Ido, A. Kurogi, N.M., A.N., K.A., K. Iihara), Health Communication (D.O., A.H.), and Medicine and Clinical Science (T.K.), Graduate School of Medical Sciences, Kyushu University; Department of Neuroendovascular Surgery (R.K.), National Hospital Organization, Clinical Research Institute, Kyushu Medical Center, Fukuoka; Department of Statistics and Data Analysis, Center for Cerebral and Cardiovascular Disease Information (K.N., M.N.), Integrative Stroke Imaging Centre (J.N.), and Department of Cerebrovascular Medicine (K.T.), National Cerebral and Cardiovascular Center, Suita; Department of Clinical Trials and Research (A. Kada), National Hospital Organization, Nagoya Medical Center; Division of Health Services Research (S.K.), Center for Cancer Control and Information Services, National Cancer Center, Tokyo; Department of Neurosurgery (K. Ogasawara), Iwate Medical University, Morioka; Department of Neurosurgery (J.O.), Sanmu Medical Center; Department of Neurosurgery (Y.S.), Kyorin University, Mitaka; Department of Emergency and Critical Care Medicine (T.A.), Showa University Hospital, Shinagawa; Department of Neurosurgery (S. Miyachi), Osaka Medical College, Takatsuki; Department of Neurosurgery (I.N.), Kokura Memorial Hospital; Department of Preventive Medicine and Community Health (S. Matsuda), School of Medicine, University of Occupational and Environmental Health, Kitakyushu; Department of Neurosurgery (S.Y.), Hyogo College of Medicine, Nishinomiya; Department of Emergency and Critical Care Medicine (K. Okuchi), Nara Medical University, Kashihara; Department of Surgical Neurology (A.S.), Research Institute for Brain and Blood Vessels, Akita; and Division of Data Management Center for Cardiovascular Disease Information (F.N.), National Cerebral Cardiovascular Disease Information, Suita, Japan
| | - Daisuke Onozuka
- From the Departments of Neurosurgery (R.K., K. Ido, A. Kurogi, N.M., A.N., K.A., K. Iihara), Health Communication (D.O., A.H.), and Medicine and Clinical Science (T.K.), Graduate School of Medical Sciences, Kyushu University; Department of Neuroendovascular Surgery (R.K.), National Hospital Organization, Clinical Research Institute, Kyushu Medical Center, Fukuoka; Department of Statistics and Data Analysis, Center for Cerebral and Cardiovascular Disease Information (K.N., M.N.), Integrative Stroke Imaging Centre (J.N.), and Department of Cerebrovascular Medicine (K.T.), National Cerebral and Cardiovascular Center, Suita; Department of Clinical Trials and Research (A. Kada), National Hospital Organization, Nagoya Medical Center; Division of Health Services Research (S.K.), Center for Cancer Control and Information Services, National Cancer Center, Tokyo; Department of Neurosurgery (K. Ogasawara), Iwate Medical University, Morioka; Department of Neurosurgery (J.O.), Sanmu Medical Center; Department of Neurosurgery (Y.S.), Kyorin University, Mitaka; Department of Emergency and Critical Care Medicine (T.A.), Showa University Hospital, Shinagawa; Department of Neurosurgery (S. Miyachi), Osaka Medical College, Takatsuki; Department of Neurosurgery (I.N.), Kokura Memorial Hospital; Department of Preventive Medicine and Community Health (S. Matsuda), School of Medicine, University of Occupational and Environmental Health, Kitakyushu; Department of Neurosurgery (S.Y.), Hyogo College of Medicine, Nishinomiya; Department of Emergency and Critical Care Medicine (K. Okuchi), Nara Medical University, Kashihara; Department of Surgical Neurology (A.S.), Research Institute for Brain and Blood Vessels, Akita; and Division of Data Management Center for Cardiovascular Disease Information (F.N.), National Cerebral Cardiovascular Disease Information, Suita, Japan
| | - Keisuke Ido
- From the Departments of Neurosurgery (R.K., K. Ido, A. Kurogi, N.M., A.N., K.A., K. Iihara), Health Communication (D.O., A.H.), and Medicine and Clinical Science (T.K.), Graduate School of Medical Sciences, Kyushu University; Department of Neuroendovascular Surgery (R.K.), National Hospital Organization, Clinical Research Institute, Kyushu Medical Center, Fukuoka; Department of Statistics and Data Analysis, Center for Cerebral and Cardiovascular Disease Information (K.N., M.N.), Integrative Stroke Imaging Centre (J.N.), and Department of Cerebrovascular Medicine (K.T.), National Cerebral and Cardiovascular Center, Suita; Department of Clinical Trials and Research (A. Kada), National Hospital Organization, Nagoya Medical Center; Division of Health Services Research (S.K.), Center for Cancer Control and Information Services, National Cancer Center, Tokyo; Department of Neurosurgery (K. Ogasawara), Iwate Medical University, Morioka; Department of Neurosurgery (J.O.), Sanmu Medical Center; Department of Neurosurgery (Y.S.), Kyorin University, Mitaka; Department of Emergency and Critical Care Medicine (T.A.), Showa University Hospital, Shinagawa; Department of Neurosurgery (S. Miyachi), Osaka Medical College, Takatsuki; Department of Neurosurgery (I.N.), Kokura Memorial Hospital; Department of Preventive Medicine and Community Health (S. Matsuda), School of Medicine, University of Occupational and Environmental Health, Kitakyushu; Department of Neurosurgery (S.Y.), Hyogo College of Medicine, Nishinomiya; Department of Emergency and Critical Care Medicine (K. Okuchi), Nara Medical University, Kashihara; Department of Surgical Neurology (A.S.), Research Institute for Brain and Blood Vessels, Akita; and Division of Data Management Center for Cardiovascular Disease Information (F.N.), National Cerebral Cardiovascular Disease Information, Suita, Japan
| | - Ai Kurogi
- From the Departments of Neurosurgery (R.K., K. Ido, A. Kurogi, N.M., A.N., K.A., K. Iihara), Health Communication (D.O., A.H.), and Medicine and Clinical Science (T.K.), Graduate School of Medical Sciences, Kyushu University; Department of Neuroendovascular Surgery (R.K.), National Hospital Organization, Clinical Research Institute, Kyushu Medical Center, Fukuoka; Department of Statistics and Data Analysis, Center for Cerebral and Cardiovascular Disease Information (K.N., M.N.), Integrative Stroke Imaging Centre (J.N.), and Department of Cerebrovascular Medicine (K.T.), National Cerebral and Cardiovascular Center, Suita; Department of Clinical Trials and Research (A. Kada), National Hospital Organization, Nagoya Medical Center; Division of Health Services Research (S.K.), Center for Cancer Control and Information Services, National Cancer Center, Tokyo; Department of Neurosurgery (K. Ogasawara), Iwate Medical University, Morioka; Department of Neurosurgery (J.O.), Sanmu Medical Center; Department of Neurosurgery (Y.S.), Kyorin University, Mitaka; Department of Emergency and Critical Care Medicine (T.A.), Showa University Hospital, Shinagawa; Department of Neurosurgery (S. Miyachi), Osaka Medical College, Takatsuki; Department of Neurosurgery (I.N.), Kokura Memorial Hospital; Department of Preventive Medicine and Community Health (S. Matsuda), School of Medicine, University of Occupational and Environmental Health, Kitakyushu; Department of Neurosurgery (S.Y.), Hyogo College of Medicine, Nishinomiya; Department of Emergency and Critical Care Medicine (K. Okuchi), Nara Medical University, Kashihara; Department of Surgical Neurology (A.S.), Research Institute for Brain and Blood Vessels, Akita; and Division of Data Management Center for Cardiovascular Disease Information (F.N.), National Cerebral Cardiovascular Disease Information, Suita, Japan
| | - Nobutaka Mukae
- From the Departments of Neurosurgery (R.K., K. Ido, A. Kurogi, N.M., A.N., K.A., K. Iihara), Health Communication (D.O., A.H.), and Medicine and Clinical Science (T.K.), Graduate School of Medical Sciences, Kyushu University; Department of Neuroendovascular Surgery (R.K.), National Hospital Organization, Clinical Research Institute, Kyushu Medical Center, Fukuoka; Department of Statistics and Data Analysis, Center for Cerebral and Cardiovascular Disease Information (K.N., M.N.), Integrative Stroke Imaging Centre (J.N.), and Department of Cerebrovascular Medicine (K.T.), National Cerebral and Cardiovascular Center, Suita; Department of Clinical Trials and Research (A. Kada), National Hospital Organization, Nagoya Medical Center; Division of Health Services Research (S.K.), Center for Cancer Control and Information Services, National Cancer Center, Tokyo; Department of Neurosurgery (K. Ogasawara), Iwate Medical University, Morioka; Department of Neurosurgery (J.O.), Sanmu Medical Center; Department of Neurosurgery (Y.S.), Kyorin University, Mitaka; Department of Emergency and Critical Care Medicine (T.A.), Showa University Hospital, Shinagawa; Department of Neurosurgery (S. Miyachi), Osaka Medical College, Takatsuki; Department of Neurosurgery (I.N.), Kokura Memorial Hospital; Department of Preventive Medicine and Community Health (S. Matsuda), School of Medicine, University of Occupational and Environmental Health, Kitakyushu; Department of Neurosurgery (S.Y.), Hyogo College of Medicine, Nishinomiya; Department of Emergency and Critical Care Medicine (K. Okuchi), Nara Medical University, Kashihara; Department of Surgical Neurology (A.S.), Research Institute for Brain and Blood Vessels, Akita; and Division of Data Management Center for Cardiovascular Disease Information (F.N.), National Cerebral Cardiovascular Disease Information, Suita, Japan
| | - Ataru Nishimura
- From the Departments of Neurosurgery (R.K., K. Ido, A. Kurogi, N.M., A.N., K.A., K. Iihara), Health Communication (D.O., A.H.), and Medicine and Clinical Science (T.K.), Graduate School of Medical Sciences, Kyushu University; Department of Neuroendovascular Surgery (R.K.), National Hospital Organization, Clinical Research Institute, Kyushu Medical Center, Fukuoka; Department of Statistics and Data Analysis, Center for Cerebral and Cardiovascular Disease Information (K.N., M.N.), Integrative Stroke Imaging Centre (J.N.), and Department of Cerebrovascular Medicine (K.T.), National Cerebral and Cardiovascular Center, Suita; Department of Clinical Trials and Research (A. Kada), National Hospital Organization, Nagoya Medical Center; Division of Health Services Research (S.K.), Center for Cancer Control and Information Services, National Cancer Center, Tokyo; Department of Neurosurgery (K. Ogasawara), Iwate Medical University, Morioka; Department of Neurosurgery (J.O.), Sanmu Medical Center; Department of Neurosurgery (Y.S.), Kyorin University, Mitaka; Department of Emergency and Critical Care Medicine (T.A.), Showa University Hospital, Shinagawa; Department of Neurosurgery (S. Miyachi), Osaka Medical College, Takatsuki; Department of Neurosurgery (I.N.), Kokura Memorial Hospital; Department of Preventive Medicine and Community Health (S. Matsuda), School of Medicine, University of Occupational and Environmental Health, Kitakyushu; Department of Neurosurgery (S.Y.), Hyogo College of Medicine, Nishinomiya; Department of Emergency and Critical Care Medicine (K. Okuchi), Nara Medical University, Kashihara; Department of Surgical Neurology (A.S.), Research Institute for Brain and Blood Vessels, Akita; and Division of Data Management Center for Cardiovascular Disease Information (F.N.), National Cerebral Cardiovascular Disease Information, Suita, Japan
| | - Koichi Arimura
- From the Departments of Neurosurgery (R.K., K. Ido, A. Kurogi, N.M., A.N., K.A., K. Iihara), Health Communication (D.O., A.H.), and Medicine and Clinical Science (T.K.), Graduate School of Medical Sciences, Kyushu University; Department of Neuroendovascular Surgery (R.K.), National Hospital Organization, Clinical Research Institute, Kyushu Medical Center, Fukuoka; Department of Statistics and Data Analysis, Center for Cerebral and Cardiovascular Disease Information (K.N., M.N.), Integrative Stroke Imaging Centre (J.N.), and Department of Cerebrovascular Medicine (K.T.), National Cerebral and Cardiovascular Center, Suita; Department of Clinical Trials and Research (A. Kada), National Hospital Organization, Nagoya Medical Center; Division of Health Services Research (S.K.), Center for Cancer Control and Information Services, National Cancer Center, Tokyo; Department of Neurosurgery (K. Ogasawara), Iwate Medical University, Morioka; Department of Neurosurgery (J.O.), Sanmu Medical Center; Department of Neurosurgery (Y.S.), Kyorin University, Mitaka; Department of Emergency and Critical Care Medicine (T.A.), Showa University Hospital, Shinagawa; Department of Neurosurgery (S. Miyachi), Osaka Medical College, Takatsuki; Department of Neurosurgery (I.N.), Kokura Memorial Hospital; Department of Preventive Medicine and Community Health (S. Matsuda), School of Medicine, University of Occupational and Environmental Health, Kitakyushu; Department of Neurosurgery (S.Y.), Hyogo College of Medicine, Nishinomiya; Department of Emergency and Critical Care Medicine (K. Okuchi), Nara Medical University, Kashihara; Department of Surgical Neurology (A.S.), Research Institute for Brain and Blood Vessels, Akita; and Division of Data Management Center for Cardiovascular Disease Information (F.N.), National Cerebral Cardiovascular Disease Information, Suita, Japan
| | - Takanari Kitazono
- From the Departments of Neurosurgery (R.K., K. Ido, A. Kurogi, N.M., A.N., K.A., K. Iihara), Health Communication (D.O., A.H.), and Medicine and Clinical Science (T.K.), Graduate School of Medical Sciences, Kyushu University; Department of Neuroendovascular Surgery (R.K.), National Hospital Organization, Clinical Research Institute, Kyushu Medical Center, Fukuoka; Department of Statistics and Data Analysis, Center for Cerebral and Cardiovascular Disease Information (K.N., M.N.), Integrative Stroke Imaging Centre (J.N.), and Department of Cerebrovascular Medicine (K.T.), National Cerebral and Cardiovascular Center, Suita; Department of Clinical Trials and Research (A. Kada), National Hospital Organization, Nagoya Medical Center; Division of Health Services Research (S.K.), Center for Cancer Control and Information Services, National Cancer Center, Tokyo; Department of Neurosurgery (K. Ogasawara), Iwate Medical University, Morioka; Department of Neurosurgery (J.O.), Sanmu Medical Center; Department of Neurosurgery (Y.S.), Kyorin University, Mitaka; Department of Emergency and Critical Care Medicine (T.A.), Showa University Hospital, Shinagawa; Department of Neurosurgery (S. Miyachi), Osaka Medical College, Takatsuki; Department of Neurosurgery (I.N.), Kokura Memorial Hospital; Department of Preventive Medicine and Community Health (S. Matsuda), School of Medicine, University of Occupational and Environmental Health, Kitakyushu; Department of Neurosurgery (S.Y.), Hyogo College of Medicine, Nishinomiya; Department of Emergency and Critical Care Medicine (K. Okuchi), Nara Medical University, Kashihara; Department of Surgical Neurology (A.S.), Research Institute for Brain and Blood Vessels, Akita; and Division of Data Management Center for Cardiovascular Disease Information (F.N.), National Cerebral Cardiovascular Disease Information, Suita, Japan
| | - Akihito Hagihara
- From the Departments of Neurosurgery (R.K., K. Ido, A. Kurogi, N.M., A.N., K.A., K. Iihara), Health Communication (D.O., A.H.), and Medicine and Clinical Science (T.K.), Graduate School of Medical Sciences, Kyushu University; Department of Neuroendovascular Surgery (R.K.), National Hospital Organization, Clinical Research Institute, Kyushu Medical Center, Fukuoka; Department of Statistics and Data Analysis, Center for Cerebral and Cardiovascular Disease Information (K.N., M.N.), Integrative Stroke Imaging Centre (J.N.), and Department of Cerebrovascular Medicine (K.T.), National Cerebral and Cardiovascular Center, Suita; Department of Clinical Trials and Research (A. Kada), National Hospital Organization, Nagoya Medical Center; Division of Health Services Research (S.K.), Center for Cancer Control and Information Services, National Cancer Center, Tokyo; Department of Neurosurgery (K. Ogasawara), Iwate Medical University, Morioka; Department of Neurosurgery (J.O.), Sanmu Medical Center; Department of Neurosurgery (Y.S.), Kyorin University, Mitaka; Department of Emergency and Critical Care Medicine (T.A.), Showa University Hospital, Shinagawa; Department of Neurosurgery (S. Miyachi), Osaka Medical College, Takatsuki; Department of Neurosurgery (I.N.), Kokura Memorial Hospital; Department of Preventive Medicine and Community Health (S. Matsuda), School of Medicine, University of Occupational and Environmental Health, Kitakyushu; Department of Neurosurgery (S.Y.), Hyogo College of Medicine, Nishinomiya; Department of Emergency and Critical Care Medicine (K. Okuchi), Nara Medical University, Kashihara; Department of Surgical Neurology (A.S.), Research Institute for Brain and Blood Vessels, Akita; and Division of Data Management Center for Cardiovascular Disease Information (F.N.), National Cerebral Cardiovascular Disease Information, Suita, Japan
| | - Koji Iihara
- From the Departments of Neurosurgery (R.K., K. Ido, A. Kurogi, N.M., A.N., K.A., K. Iihara), Health Communication (D.O., A.H.), and Medicine and Clinical Science (T.K.), Graduate School of Medical Sciences, Kyushu University; Department of Neuroendovascular Surgery (R.K.), National Hospital Organization, Clinical Research Institute, Kyushu Medical Center, Fukuoka; Department of Statistics and Data Analysis, Center for Cerebral and Cardiovascular Disease Information (K.N., M.N.), Integrative Stroke Imaging Centre (J.N.), and Department of Cerebrovascular Medicine (K.T.), National Cerebral and Cardiovascular Center, Suita; Department of Clinical Trials and Research (A. Kada), National Hospital Organization, Nagoya Medical Center; Division of Health Services Research (S.K.), Center for Cancer Control and Information Services, National Cancer Center, Tokyo; Department of Neurosurgery (K. Ogasawara), Iwate Medical University, Morioka; Department of Neurosurgery (J.O.), Sanmu Medical Center; Department of Neurosurgery (Y.S.), Kyorin University, Mitaka; Department of Emergency and Critical Care Medicine (T.A.), Showa University Hospital, Shinagawa; Department of Neurosurgery (S. Miyachi), Osaka Medical College, Takatsuki; Department of Neurosurgery (I.N.), Kokura Memorial Hospital; Department of Preventive Medicine and Community Health (S. Matsuda), School of Medicine, University of Occupational and Environmental Health, Kitakyushu; Department of Neurosurgery (S.Y.), Hyogo College of Medicine, Nishinomiya; Department of Emergency and Critical Care Medicine (K. Okuchi), Nara Medical University, Kashihara; Department of Surgical Neurology (A.S.), Research Institute for Brain and Blood Vessels, Akita; and Division of Data Management Center for Cardiovascular Disease Information (F.N.), National Cerebral Cardiovascular Disease Information, Suita, Japan.
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Canavero I, Micieli G, Paciaroni M. Decision Algorithms for Direct Oral Anticoagulant Use in Patients With Nonvalvular Atrial Fibrillation: A Practical Guide for Neurologists. Clin Appl Thromb Hemost 2017; 24:396-404. [PMID: 28914077 DOI: 10.1177/1076029617720068] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Direct oral anticoagulants (DOACs) are valid alternative options to vitamin K antagonists due to their limited interactions with drugs or food and the fact that they do not require regular coagulation monitoring. To this regard, recent practice guidelines recommend that DOACs should be considered as first-line anticoagulant therapy for stroke prevention in patients with nonvalvular atrial fibrillation (NVAF). This review (1) outlines current international guidelines for the management of DOACs to prevent stroke in patients with NVAF, (2) outlines indications for elderly patients as well as specific settings including acute coronary syndromes and intracranial hemorrhage, and (3) offers a practical guide for the use of DOACs in neurological settings.
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Affiliation(s)
- Isabella Canavero
- 1 Department of Emergency Neurology, IRCCS National Neurological Institute "Casimiro Mondino," Pavia, Italy
| | - Giuseppe Micieli
- 1 Department of Emergency Neurology, IRCCS National Neurological Institute "Casimiro Mondino," Pavia, Italy
| | - Maurizio Paciaroni
- 2 Stroke Unit and Division of Cardiovascular Medicine, University of Perugia, "Santa Maria della Misericordia" Hospital, Perugia, Italy
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