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Ghannam M, Al-Qudah AM, Alshaer QN, Kronmal R, Ntaios G, Childs CA, Longstreth WT, Alsawareah A, Keller T, Serna-Higuita LM, Geisler T, Furie K, Saver JL, Kasner SE, Elkind MSV, Tirschwell D, Poli S, Kamel H, Yaghi S. Anticoagulation vs Antiplatelets Across Subgroups of Embolic Stroke of Undetermined Source: A Meta-Analysis of Randomized Controlled Trials. Neurology 2024; 103:e209949. [PMID: 39365971 DOI: 10.1212/wnl.0000000000209949] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/06/2024] Open
Abstract
BACKGROUND AND OBJECTIVES The term "embolic stroke of undetermined source" (ESUS) encompasses a substantial but heterogeneous population of patients with ischemic stroke, underscoring the importance of identifying personalized treatment strategies. In subgroups of patients randomized in ESUS trials, we evaluated the effectiveness of anticoagulation compared with antiplatelet therapy in secondary ischemic stroke prevention. METHODS A study-level meta-analysis was conducted on randomized controlled trials of patients with ESUS, comparing anticoagulation with antiplatelet therapy. The primary efficacy outcome was recurrent ischemic stroke, and safety outcomes were major bleeding and death. Subgroups assessed were age, sex, presence of patent foramen ovale (PFO), left atrial enlargement (LAE), and atrial cardiopathy. Pooled risk ratios (RRs) were meta-analyzed. Cochrane Risk of Bias Tool 2.0 was used for risk-of-bias assessment. RESULTS A total of 7 randomized controlled trials involving 14,804 patients were analyzed, with 7,406 patients treated with anticoagulation and 7,398 treated with antiplatelet therapy. Compared with antiplatelet therapy, anticoagulation was associated with a similar rate of recurrent ischemic stroke (RR 0.91, 95% CI 0.80-1.05; I2 = 0%). In ESUS with PFO, anticoagulation was associated with significantly lower risk of ischemic stroke (RR 0.59, 95% CI 0.35-0.98; I2 = 0%). Heterogeneity was present in those with LAE: antiplatelet therapy was superior in trials allowing cardiac monitoring after randomization (RR 6.65, 95% CI 1.26-35.08; I2 = 0%), but anticoagulation was superior in trials prohibiting cardiac monitoring after randomization (RR 0.25 95% CI 0.07-0.89). Subgroups based on age, sex, or presence of atrial cardiopathy did not benefit from anticoagulation over antiplatelet therapy. DISCUSSION In this meta-analysis, an empiric anticoagulation approach is not beneficial for patients with ESUS. This finding highlights the importance of an individualized treatment strategy. Such a strategy should include prolonged cardiac monitoring for atrial fibrillation, particularly in patients with moderate-to-severe LAE. Anticoagulation treatment showed promise in patients with medically treated PFO. Other subgroups did not benefit from anticoagulation therapy. Large prospective studies within ESUS subgroups are needed to validate our findings.
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Affiliation(s)
- Malik Ghannam
- From the Department of Neurology (M.G., Q.N.A., A.A.), University of Iowa Hospitals & Clinics, Iowa City; Department of Neurology (A.M.A.-Q.), University of Pittsburgh Medical Center, PA; Departments of Biostatistics (R.K.), Neurology (W.T.L., D.T.) and Epidemiology (W.T.L.), University of Washington, Seattle; Department of Internal Medicine (G.N.), Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece; Hardin Library for the Health Sciences (C.A.C.), The University of Iowa, Iowa City; Department of Cardiology and Angiology (T.K., T.G.), and Institute for Clinical Epidemiology and Applied Biometry (L.M.S.-H.), Faculty of Medicine, Eberhard Karls University Tübingen, Germany; Department of Neurology (K.F., S.Y.), Brown University, Providence, RI; Department of Neurology (J.L.S.), University of California at Los Angeles (UCLA); Department of Neurology (S.E.K.), University of Pennsylvania, PA; Department of Neurology (M.S.V.E.), Vagelos College of Physicians and Surgeons; Department of Epidemiology (M.S.V.E.), Mailman School of Public Health, Columbia University, New York, NY; Department of Neurology & Stroke (S.P.), and Hertie Institute for Clinical Brain Research (S.P.), Eberhard Karls University Tübingen, Germany; and Department of Neurology (H.K.), Weill Cornell Medicine, New York, NY
| | - Abdullah M Al-Qudah
- From the Department of Neurology (M.G., Q.N.A., A.A.), University of Iowa Hospitals & Clinics, Iowa City; Department of Neurology (A.M.A.-Q.), University of Pittsburgh Medical Center, PA; Departments of Biostatistics (R.K.), Neurology (W.T.L., D.T.) and Epidemiology (W.T.L.), University of Washington, Seattle; Department of Internal Medicine (G.N.), Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece; Hardin Library for the Health Sciences (C.A.C.), The University of Iowa, Iowa City; Department of Cardiology and Angiology (T.K., T.G.), and Institute for Clinical Epidemiology and Applied Biometry (L.M.S.-H.), Faculty of Medicine, Eberhard Karls University Tübingen, Germany; Department of Neurology (K.F., S.Y.), Brown University, Providence, RI; Department of Neurology (J.L.S.), University of California at Los Angeles (UCLA); Department of Neurology (S.E.K.), University of Pennsylvania, PA; Department of Neurology (M.S.V.E.), Vagelos College of Physicians and Surgeons; Department of Epidemiology (M.S.V.E.), Mailman School of Public Health, Columbia University, New York, NY; Department of Neurology & Stroke (S.P.), and Hertie Institute for Clinical Brain Research (S.P.), Eberhard Karls University Tübingen, Germany; and Department of Neurology (H.K.), Weill Cornell Medicine, New York, NY
| | - Qasem N Alshaer
- From the Department of Neurology (M.G., Q.N.A., A.A.), University of Iowa Hospitals & Clinics, Iowa City; Department of Neurology (A.M.A.-Q.), University of Pittsburgh Medical Center, PA; Departments of Biostatistics (R.K.), Neurology (W.T.L., D.T.) and Epidemiology (W.T.L.), University of Washington, Seattle; Department of Internal Medicine (G.N.), Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece; Hardin Library for the Health Sciences (C.A.C.), The University of Iowa, Iowa City; Department of Cardiology and Angiology (T.K., T.G.), and Institute for Clinical Epidemiology and Applied Biometry (L.M.S.-H.), Faculty of Medicine, Eberhard Karls University Tübingen, Germany; Department of Neurology (K.F., S.Y.), Brown University, Providence, RI; Department of Neurology (J.L.S.), University of California at Los Angeles (UCLA); Department of Neurology (S.E.K.), University of Pennsylvania, PA; Department of Neurology (M.S.V.E.), Vagelos College of Physicians and Surgeons; Department of Epidemiology (M.S.V.E.), Mailman School of Public Health, Columbia University, New York, NY; Department of Neurology & Stroke (S.P.), and Hertie Institute for Clinical Brain Research (S.P.), Eberhard Karls University Tübingen, Germany; and Department of Neurology (H.K.), Weill Cornell Medicine, New York, NY
| | - Richard Kronmal
- From the Department of Neurology (M.G., Q.N.A., A.A.), University of Iowa Hospitals & Clinics, Iowa City; Department of Neurology (A.M.A.-Q.), University of Pittsburgh Medical Center, PA; Departments of Biostatistics (R.K.), Neurology (W.T.L., D.T.) and Epidemiology (W.T.L.), University of Washington, Seattle; Department of Internal Medicine (G.N.), Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece; Hardin Library for the Health Sciences (C.A.C.), The University of Iowa, Iowa City; Department of Cardiology and Angiology (T.K., T.G.), and Institute for Clinical Epidemiology and Applied Biometry (L.M.S.-H.), Faculty of Medicine, Eberhard Karls University Tübingen, Germany; Department of Neurology (K.F., S.Y.), Brown University, Providence, RI; Department of Neurology (J.L.S.), University of California at Los Angeles (UCLA); Department of Neurology (S.E.K.), University of Pennsylvania, PA; Department of Neurology (M.S.V.E.), Vagelos College of Physicians and Surgeons; Department of Epidemiology (M.S.V.E.), Mailman School of Public Health, Columbia University, New York, NY; Department of Neurology & Stroke (S.P.), and Hertie Institute for Clinical Brain Research (S.P.), Eberhard Karls University Tübingen, Germany; and Department of Neurology (H.K.), Weill Cornell Medicine, New York, NY
| | - George Ntaios
- From the Department of Neurology (M.G., Q.N.A., A.A.), University of Iowa Hospitals & Clinics, Iowa City; Department of Neurology (A.M.A.-Q.), University of Pittsburgh Medical Center, PA; Departments of Biostatistics (R.K.), Neurology (W.T.L., D.T.) and Epidemiology (W.T.L.), University of Washington, Seattle; Department of Internal Medicine (G.N.), Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece; Hardin Library for the Health Sciences (C.A.C.), The University of Iowa, Iowa City; Department of Cardiology and Angiology (T.K., T.G.), and Institute for Clinical Epidemiology and Applied Biometry (L.M.S.-H.), Faculty of Medicine, Eberhard Karls University Tübingen, Germany; Department of Neurology (K.F., S.Y.), Brown University, Providence, RI; Department of Neurology (J.L.S.), University of California at Los Angeles (UCLA); Department of Neurology (S.E.K.), University of Pennsylvania, PA; Department of Neurology (M.S.V.E.), Vagelos College of Physicians and Surgeons; Department of Epidemiology (M.S.V.E.), Mailman School of Public Health, Columbia University, New York, NY; Department of Neurology & Stroke (S.P.), and Hertie Institute for Clinical Brain Research (S.P.), Eberhard Karls University Tübingen, Germany; and Department of Neurology (H.K.), Weill Cornell Medicine, New York, NY
| | - Christopher A Childs
- From the Department of Neurology (M.G., Q.N.A., A.A.), University of Iowa Hospitals & Clinics, Iowa City; Department of Neurology (A.M.A.-Q.), University of Pittsburgh Medical Center, PA; Departments of Biostatistics (R.K.), Neurology (W.T.L., D.T.) and Epidemiology (W.T.L.), University of Washington, Seattle; Department of Internal Medicine (G.N.), Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece; Hardin Library for the Health Sciences (C.A.C.), The University of Iowa, Iowa City; Department of Cardiology and Angiology (T.K., T.G.), and Institute for Clinical Epidemiology and Applied Biometry (L.M.S.-H.), Faculty of Medicine, Eberhard Karls University Tübingen, Germany; Department of Neurology (K.F., S.Y.), Brown University, Providence, RI; Department of Neurology (J.L.S.), University of California at Los Angeles (UCLA); Department of Neurology (S.E.K.), University of Pennsylvania, PA; Department of Neurology (M.S.V.E.), Vagelos College of Physicians and Surgeons; Department of Epidemiology (M.S.V.E.), Mailman School of Public Health, Columbia University, New York, NY; Department of Neurology & Stroke (S.P.), and Hertie Institute for Clinical Brain Research (S.P.), Eberhard Karls University Tübingen, Germany; and Department of Neurology (H.K.), Weill Cornell Medicine, New York, NY
| | - W T Longstreth
- From the Department of Neurology (M.G., Q.N.A., A.A.), University of Iowa Hospitals & Clinics, Iowa City; Department of Neurology (A.M.A.-Q.), University of Pittsburgh Medical Center, PA; Departments of Biostatistics (R.K.), Neurology (W.T.L., D.T.) and Epidemiology (W.T.L.), University of Washington, Seattle; Department of Internal Medicine (G.N.), Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece; Hardin Library for the Health Sciences (C.A.C.), The University of Iowa, Iowa City; Department of Cardiology and Angiology (T.K., T.G.), and Institute for Clinical Epidemiology and Applied Biometry (L.M.S.-H.), Faculty of Medicine, Eberhard Karls University Tübingen, Germany; Department of Neurology (K.F., S.Y.), Brown University, Providence, RI; Department of Neurology (J.L.S.), University of California at Los Angeles (UCLA); Department of Neurology (S.E.K.), University of Pennsylvania, PA; Department of Neurology (M.S.V.E.), Vagelos College of Physicians and Surgeons; Department of Epidemiology (M.S.V.E.), Mailman School of Public Health, Columbia University, New York, NY; Department of Neurology & Stroke (S.P.), and Hertie Institute for Clinical Brain Research (S.P.), Eberhard Karls University Tübingen, Germany; and Department of Neurology (H.K.), Weill Cornell Medicine, New York, NY
| | - Ashraf Alsawareah
- From the Department of Neurology (M.G., Q.N.A., A.A.), University of Iowa Hospitals & Clinics, Iowa City; Department of Neurology (A.M.A.-Q.), University of Pittsburgh Medical Center, PA; Departments of Biostatistics (R.K.), Neurology (W.T.L., D.T.) and Epidemiology (W.T.L.), University of Washington, Seattle; Department of Internal Medicine (G.N.), Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece; Hardin Library for the Health Sciences (C.A.C.), The University of Iowa, Iowa City; Department of Cardiology and Angiology (T.K., T.G.), and Institute for Clinical Epidemiology and Applied Biometry (L.M.S.-H.), Faculty of Medicine, Eberhard Karls University Tübingen, Germany; Department of Neurology (K.F., S.Y.), Brown University, Providence, RI; Department of Neurology (J.L.S.), University of California at Los Angeles (UCLA); Department of Neurology (S.E.K.), University of Pennsylvania, PA; Department of Neurology (M.S.V.E.), Vagelos College of Physicians and Surgeons; Department of Epidemiology (M.S.V.E.), Mailman School of Public Health, Columbia University, New York, NY; Department of Neurology & Stroke (S.P.), and Hertie Institute for Clinical Brain Research (S.P.), Eberhard Karls University Tübingen, Germany; and Department of Neurology (H.K.), Weill Cornell Medicine, New York, NY
| | - Timea Keller
- From the Department of Neurology (M.G., Q.N.A., A.A.), University of Iowa Hospitals & Clinics, Iowa City; Department of Neurology (A.M.A.-Q.), University of Pittsburgh Medical Center, PA; Departments of Biostatistics (R.K.), Neurology (W.T.L., D.T.) and Epidemiology (W.T.L.), University of Washington, Seattle; Department of Internal Medicine (G.N.), Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece; Hardin Library for the Health Sciences (C.A.C.), The University of Iowa, Iowa City; Department of Cardiology and Angiology (T.K., T.G.), and Institute for Clinical Epidemiology and Applied Biometry (L.M.S.-H.), Faculty of Medicine, Eberhard Karls University Tübingen, Germany; Department of Neurology (K.F., S.Y.), Brown University, Providence, RI; Department of Neurology (J.L.S.), University of California at Los Angeles (UCLA); Department of Neurology (S.E.K.), University of Pennsylvania, PA; Department of Neurology (M.S.V.E.), Vagelos College of Physicians and Surgeons; Department of Epidemiology (M.S.V.E.), Mailman School of Public Health, Columbia University, New York, NY; Department of Neurology & Stroke (S.P.), and Hertie Institute for Clinical Brain Research (S.P.), Eberhard Karls University Tübingen, Germany; and Department of Neurology (H.K.), Weill Cornell Medicine, New York, NY
| | - Lina M Serna-Higuita
- From the Department of Neurology (M.G., Q.N.A., A.A.), University of Iowa Hospitals & Clinics, Iowa City; Department of Neurology (A.M.A.-Q.), University of Pittsburgh Medical Center, PA; Departments of Biostatistics (R.K.), Neurology (W.T.L., D.T.) and Epidemiology (W.T.L.), University of Washington, Seattle; Department of Internal Medicine (G.N.), Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece; Hardin Library for the Health Sciences (C.A.C.), The University of Iowa, Iowa City; Department of Cardiology and Angiology (T.K., T.G.), and Institute for Clinical Epidemiology and Applied Biometry (L.M.S.-H.), Faculty of Medicine, Eberhard Karls University Tübingen, Germany; Department of Neurology (K.F., S.Y.), Brown University, Providence, RI; Department of Neurology (J.L.S.), University of California at Los Angeles (UCLA); Department of Neurology (S.E.K.), University of Pennsylvania, PA; Department of Neurology (M.S.V.E.), Vagelos College of Physicians and Surgeons; Department of Epidemiology (M.S.V.E.), Mailman School of Public Health, Columbia University, New York, NY; Department of Neurology & Stroke (S.P.), and Hertie Institute for Clinical Brain Research (S.P.), Eberhard Karls University Tübingen, Germany; and Department of Neurology (H.K.), Weill Cornell Medicine, New York, NY
| | - Tobias Geisler
- From the Department of Neurology (M.G., Q.N.A., A.A.), University of Iowa Hospitals & Clinics, Iowa City; Department of Neurology (A.M.A.-Q.), University of Pittsburgh Medical Center, PA; Departments of Biostatistics (R.K.), Neurology (W.T.L., D.T.) and Epidemiology (W.T.L.), University of Washington, Seattle; Department of Internal Medicine (G.N.), Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece; Hardin Library for the Health Sciences (C.A.C.), The University of Iowa, Iowa City; Department of Cardiology and Angiology (T.K., T.G.), and Institute for Clinical Epidemiology and Applied Biometry (L.M.S.-H.), Faculty of Medicine, Eberhard Karls University Tübingen, Germany; Department of Neurology (K.F., S.Y.), Brown University, Providence, RI; Department of Neurology (J.L.S.), University of California at Los Angeles (UCLA); Department of Neurology (S.E.K.), University of Pennsylvania, PA; Department of Neurology (M.S.V.E.), Vagelos College of Physicians and Surgeons; Department of Epidemiology (M.S.V.E.), Mailman School of Public Health, Columbia University, New York, NY; Department of Neurology & Stroke (S.P.), and Hertie Institute for Clinical Brain Research (S.P.), Eberhard Karls University Tübingen, Germany; and Department of Neurology (H.K.), Weill Cornell Medicine, New York, NY
| | - Karen Furie
- From the Department of Neurology (M.G., Q.N.A., A.A.), University of Iowa Hospitals & Clinics, Iowa City; Department of Neurology (A.M.A.-Q.), University of Pittsburgh Medical Center, PA; Departments of Biostatistics (R.K.), Neurology (W.T.L., D.T.) and Epidemiology (W.T.L.), University of Washington, Seattle; Department of Internal Medicine (G.N.), Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece; Hardin Library for the Health Sciences (C.A.C.), The University of Iowa, Iowa City; Department of Cardiology and Angiology (T.K., T.G.), and Institute for Clinical Epidemiology and Applied Biometry (L.M.S.-H.), Faculty of Medicine, Eberhard Karls University Tübingen, Germany; Department of Neurology (K.F., S.Y.), Brown University, Providence, RI; Department of Neurology (J.L.S.), University of California at Los Angeles (UCLA); Department of Neurology (S.E.K.), University of Pennsylvania, PA; Department of Neurology (M.S.V.E.), Vagelos College of Physicians and Surgeons; Department of Epidemiology (M.S.V.E.), Mailman School of Public Health, Columbia University, New York, NY; Department of Neurology & Stroke (S.P.), and Hertie Institute for Clinical Brain Research (S.P.), Eberhard Karls University Tübingen, Germany; and Department of Neurology (H.K.), Weill Cornell Medicine, New York, NY
| | - Jeffrey L Saver
- From the Department of Neurology (M.G., Q.N.A., A.A.), University of Iowa Hospitals & Clinics, Iowa City; Department of Neurology (A.M.A.-Q.), University of Pittsburgh Medical Center, PA; Departments of Biostatistics (R.K.), Neurology (W.T.L., D.T.) and Epidemiology (W.T.L.), University of Washington, Seattle; Department of Internal Medicine (G.N.), Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece; Hardin Library for the Health Sciences (C.A.C.), The University of Iowa, Iowa City; Department of Cardiology and Angiology (T.K., T.G.), and Institute for Clinical Epidemiology and Applied Biometry (L.M.S.-H.), Faculty of Medicine, Eberhard Karls University Tübingen, Germany; Department of Neurology (K.F., S.Y.), Brown University, Providence, RI; Department of Neurology (J.L.S.), University of California at Los Angeles (UCLA); Department of Neurology (S.E.K.), University of Pennsylvania, PA; Department of Neurology (M.S.V.E.), Vagelos College of Physicians and Surgeons; Department of Epidemiology (M.S.V.E.), Mailman School of Public Health, Columbia University, New York, NY; Department of Neurology & Stroke (S.P.), and Hertie Institute for Clinical Brain Research (S.P.), Eberhard Karls University Tübingen, Germany; and Department of Neurology (H.K.), Weill Cornell Medicine, New York, NY
| | - Scott E Kasner
- From the Department of Neurology (M.G., Q.N.A., A.A.), University of Iowa Hospitals & Clinics, Iowa City; Department of Neurology (A.M.A.-Q.), University of Pittsburgh Medical Center, PA; Departments of Biostatistics (R.K.), Neurology (W.T.L., D.T.) and Epidemiology (W.T.L.), University of Washington, Seattle; Department of Internal Medicine (G.N.), Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece; Hardin Library for the Health Sciences (C.A.C.), The University of Iowa, Iowa City; Department of Cardiology and Angiology (T.K., T.G.), and Institute for Clinical Epidemiology and Applied Biometry (L.M.S.-H.), Faculty of Medicine, Eberhard Karls University Tübingen, Germany; Department of Neurology (K.F., S.Y.), Brown University, Providence, RI; Department of Neurology (J.L.S.), University of California at Los Angeles (UCLA); Department of Neurology (S.E.K.), University of Pennsylvania, PA; Department of Neurology (M.S.V.E.), Vagelos College of Physicians and Surgeons; Department of Epidemiology (M.S.V.E.), Mailman School of Public Health, Columbia University, New York, NY; Department of Neurology & Stroke (S.P.), and Hertie Institute for Clinical Brain Research (S.P.), Eberhard Karls University Tübingen, Germany; and Department of Neurology (H.K.), Weill Cornell Medicine, New York, NY
| | - Mitchell S V Elkind
- From the Department of Neurology (M.G., Q.N.A., A.A.), University of Iowa Hospitals & Clinics, Iowa City; Department of Neurology (A.M.A.-Q.), University of Pittsburgh Medical Center, PA; Departments of Biostatistics (R.K.), Neurology (W.T.L., D.T.) and Epidemiology (W.T.L.), University of Washington, Seattle; Department of Internal Medicine (G.N.), Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece; Hardin Library for the Health Sciences (C.A.C.), The University of Iowa, Iowa City; Department of Cardiology and Angiology (T.K., T.G.), and Institute for Clinical Epidemiology and Applied Biometry (L.M.S.-H.), Faculty of Medicine, Eberhard Karls University Tübingen, Germany; Department of Neurology (K.F., S.Y.), Brown University, Providence, RI; Department of Neurology (J.L.S.), University of California at Los Angeles (UCLA); Department of Neurology (S.E.K.), University of Pennsylvania, PA; Department of Neurology (M.S.V.E.), Vagelos College of Physicians and Surgeons; Department of Epidemiology (M.S.V.E.), Mailman School of Public Health, Columbia University, New York, NY; Department of Neurology & Stroke (S.P.), and Hertie Institute for Clinical Brain Research (S.P.), Eberhard Karls University Tübingen, Germany; and Department of Neurology (H.K.), Weill Cornell Medicine, New York, NY
| | - David Tirschwell
- From the Department of Neurology (M.G., Q.N.A., A.A.), University of Iowa Hospitals & Clinics, Iowa City; Department of Neurology (A.M.A.-Q.), University of Pittsburgh Medical Center, PA; Departments of Biostatistics (R.K.), Neurology (W.T.L., D.T.) and Epidemiology (W.T.L.), University of Washington, Seattle; Department of Internal Medicine (G.N.), Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece; Hardin Library for the Health Sciences (C.A.C.), The University of Iowa, Iowa City; Department of Cardiology and Angiology (T.K., T.G.), and Institute for Clinical Epidemiology and Applied Biometry (L.M.S.-H.), Faculty of Medicine, Eberhard Karls University Tübingen, Germany; Department of Neurology (K.F., S.Y.), Brown University, Providence, RI; Department of Neurology (J.L.S.), University of California at Los Angeles (UCLA); Department of Neurology (S.E.K.), University of Pennsylvania, PA; Department of Neurology (M.S.V.E.), Vagelos College of Physicians and Surgeons; Department of Epidemiology (M.S.V.E.), Mailman School of Public Health, Columbia University, New York, NY; Department of Neurology & Stroke (S.P.), and Hertie Institute for Clinical Brain Research (S.P.), Eberhard Karls University Tübingen, Germany; and Department of Neurology (H.K.), Weill Cornell Medicine, New York, NY
| | - Sven Poli
- From the Department of Neurology (M.G., Q.N.A., A.A.), University of Iowa Hospitals & Clinics, Iowa City; Department of Neurology (A.M.A.-Q.), University of Pittsburgh Medical Center, PA; Departments of Biostatistics (R.K.), Neurology (W.T.L., D.T.) and Epidemiology (W.T.L.), University of Washington, Seattle; Department of Internal Medicine (G.N.), Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece; Hardin Library for the Health Sciences (C.A.C.), The University of Iowa, Iowa City; Department of Cardiology and Angiology (T.K., T.G.), and Institute for Clinical Epidemiology and Applied Biometry (L.M.S.-H.), Faculty of Medicine, Eberhard Karls University Tübingen, Germany; Department of Neurology (K.F., S.Y.), Brown University, Providence, RI; Department of Neurology (J.L.S.), University of California at Los Angeles (UCLA); Department of Neurology (S.E.K.), University of Pennsylvania, PA; Department of Neurology (M.S.V.E.), Vagelos College of Physicians and Surgeons; Department of Epidemiology (M.S.V.E.), Mailman School of Public Health, Columbia University, New York, NY; Department of Neurology & Stroke (S.P.), and Hertie Institute for Clinical Brain Research (S.P.), Eberhard Karls University Tübingen, Germany; and Department of Neurology (H.K.), Weill Cornell Medicine, New York, NY
| | - Hooman Kamel
- From the Department of Neurology (M.G., Q.N.A., A.A.), University of Iowa Hospitals & Clinics, Iowa City; Department of Neurology (A.M.A.-Q.), University of Pittsburgh Medical Center, PA; Departments of Biostatistics (R.K.), Neurology (W.T.L., D.T.) and Epidemiology (W.T.L.), University of Washington, Seattle; Department of Internal Medicine (G.N.), Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece; Hardin Library for the Health Sciences (C.A.C.), The University of Iowa, Iowa City; Department of Cardiology and Angiology (T.K., T.G.), and Institute for Clinical Epidemiology and Applied Biometry (L.M.S.-H.), Faculty of Medicine, Eberhard Karls University Tübingen, Germany; Department of Neurology (K.F., S.Y.), Brown University, Providence, RI; Department of Neurology (J.L.S.), University of California at Los Angeles (UCLA); Department of Neurology (S.E.K.), University of Pennsylvania, PA; Department of Neurology (M.S.V.E.), Vagelos College of Physicians and Surgeons; Department of Epidemiology (M.S.V.E.), Mailman School of Public Health, Columbia University, New York, NY; Department of Neurology & Stroke (S.P.), and Hertie Institute for Clinical Brain Research (S.P.), Eberhard Karls University Tübingen, Germany; and Department of Neurology (H.K.), Weill Cornell Medicine, New York, NY
| | - Shadi Yaghi
- From the Department of Neurology (M.G., Q.N.A., A.A.), University of Iowa Hospitals & Clinics, Iowa City; Department of Neurology (A.M.A.-Q.), University of Pittsburgh Medical Center, PA; Departments of Biostatistics (R.K.), Neurology (W.T.L., D.T.) and Epidemiology (W.T.L.), University of Washington, Seattle; Department of Internal Medicine (G.N.), Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece; Hardin Library for the Health Sciences (C.A.C.), The University of Iowa, Iowa City; Department of Cardiology and Angiology (T.K., T.G.), and Institute for Clinical Epidemiology and Applied Biometry (L.M.S.-H.), Faculty of Medicine, Eberhard Karls University Tübingen, Germany; Department of Neurology (K.F., S.Y.), Brown University, Providence, RI; Department of Neurology (J.L.S.), University of California at Los Angeles (UCLA); Department of Neurology (S.E.K.), University of Pennsylvania, PA; Department of Neurology (M.S.V.E.), Vagelos College of Physicians and Surgeons; Department of Epidemiology (M.S.V.E.), Mailman School of Public Health, Columbia University, New York, NY; Department of Neurology & Stroke (S.P.), and Hertie Institute for Clinical Brain Research (S.P.), Eberhard Karls University Tübingen, Germany; and Department of Neurology (H.K.), Weill Cornell Medicine, New York, NY
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