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Zhao B, Yuan Y, Li Z, Chen Y, Gao Y, Yang B, Wu J, Jia W. Risk of intracranial hemorrhage in patients using anticoagulant therapy for atrial fibrillation after cerebral microbleeds combined with acute ischemic stroke: a meta-analysis. Front Neurol 2024; 15:1372231. [PMID: 38560733 PMCID: PMC10978779 DOI: 10.3389/fneur.2024.1372231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Accepted: 03/05/2024] [Indexed: 04/04/2024] Open
Abstract
Objective To evaluate intracerebral hemorrhage (ICH) risk in patients with ischemic stroke (IS) and cerebral microbleeds (CMBs) undergoing anticoagulation therapy for non-valvular atrial fibrillation (AF). Methods We conducted a comprehensive search across multiple databases, including Embase, PubMed, Cochrane, UpToDate, Scopus, WOS, and SinoMed. The search covered observational literature published from each database inception until February 1, 2023. We analyzed the prevalence of CMBs during the follow-up period, compared future ICH risk between patients with and without baseline CMBs (CMBs presence/absence, ≧5 CMBs), and examined factors influencing ICH occurrence in patients with CMBs. Also studied recurrent stroke during anticoagulation therapy, the risk of future ICH when white matter hyperintensity (WMH) and CMBs coexist, and the effects of anticoagulants vitamin K antagonists (VKAs) and direct oral anticoagulants (DOACs) on future ICH. Results We included 7 articles involving 5,134 participants. The incidence of CMBs was 24%; baseline CMBs were associated with an increased ICH risk compared to patients without CMBs. ICH-risk was more significant in patients with baseline ≥5 CMBs. After anticoagulant therapy, ICH risk was higher than that of recurrent IS. The risk of future ICH was significantly increased with anticoagulant VKAs compared with NOAC. Conclusion Anticoagulant therapy for ischemic stroke patients with non-valvular AF and CMBs increases future ICH risk. Discontinuing anticoagulation due to ICH risk should be avoided. NOACs are safe and effective for patients with CMBs and IS.
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Affiliation(s)
- Bingqing Zhao
- Department of Neurology, Beijing Shijingshan Hospital, Shijingshan Teaching Hospital of Capital Medical University, Beijing, China
| | - Ye Yuan
- Department of Neurology, Beijing Shijingshan Hospital, Shijingshan Teaching Hospital of Capital Medical University, Beijing, China
| | - Zheng Li
- Department of Neurology, Beijing Shijingshan Hospital, Shijingshan Teaching Hospital of Capital Medical University, Beijing, China
| | - Ying Chen
- Department of Neurology, Beijing Shijingshan Hospital, Shijingshan Teaching Hospital of Capital Medical University, Beijing, China
| | - Yali Gao
- Department of Neurology, Beijing Shijingshan Hospital, Shijingshan Teaching Hospital of Capital Medical University, Beijing, China
| | - Baoling Yang
- Department of Neurology, Beijing Shijingshan Hospital, Shijingshan Teaching Hospital of Capital Medical University, Beijing, China
| | - Jingyi Wu
- University of Glasgow, Glasgow, United Kingdom
| | - Weihua Jia
- Department of Neurology, Beijing Shijingshan Hospital, Shijingshan Teaching Hospital of Capital Medical University, Beijing, China
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2
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Corica B, Romiti GF, Raparelli V, Cangemi R, Basili S, Proietti M. Epidemiology of cerebral microbleeds and risk of adverse outcomes in atrial fibrillation: a systematic review and meta-analysis. Europace 2022; 24:1395-1403. [PMID: 35244694 DOI: 10.1093/europace/euac028] [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: 08/02/2021] [Accepted: 02/18/2022] [Indexed: 11/12/2022] Open
Abstract
AIMS The aim of this study is to perform a systematic review and meta-analysis on the epidemiology of cerebral microbleeds (CMBs) and the risk of intracranial haemorrhage (ICH) and ischaemic stroke (IS) in patients with atrial fibrillation (AF). METHODS AND RESULTS PubMed and EMBASE databases were systematically searched from inception to 6 March 2021. All studies reporting the prevalence of CMBs and incidence of ICH and IS in AF patients with and without CMBs were included. Meta-analysis was conducted using random-effect models; odds ratios (ORs), 95% confidence intervals (CIs), and prediction intervals (PIs) were calculated for each outcome. Subgroup analyses were performed according to the number and localization of CMBs. A total of 562 studies were retrieved, with 17 studies finally included in the meta-analysis. Prevalence of CMBs in AF population was estimated at 28.3% (95% CI: 23.8-33.4%). Individuals with CMBs showed a higher risk of ICH (OR: 3.04, 95% CI: 1.83-5.06, 95% PI 1.23-7.49) and IS (OR: 1.78, 95% CI: 1.26-2.49, 95% PI 1.10-2.87). Patients with ≥5 CMBs showed a higher risk of ICH. Metaregression showed how higher of prevalence of diabetes mellitus in AF cohort is associated with higher prevalence of CMBs. CONCLUSIONS Cerebral microbleeds are common in patients with AF, found in almost one out of four subjects. Cerebral microbleeds were associated with both haemorrhagic and thromboembolic events in AF patients. Moreover, the risk of ICH increased consistently with the burden of CMBs. Cerebral microbleeds may represent an important overlooked risk factor for both ICH and IS in adults with AF.
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Affiliation(s)
- Bernadette Corica
- Department of Translational and Precision Medicine, Sapienza-University of Rome, Rome, Italy
| | - Giulio Francesco Romiti
- Department of Translational and Precision Medicine, Sapienza-University of Rome, Rome, Italy
| | - Valeria Raparelli
- Department of Translational Medicine, University of Ferrara, Ferrara, Italy
| | - Roberto Cangemi
- Department of Translational and Precision Medicine, Sapienza-University of Rome, Rome, Italy
| | - Stefania Basili
- Department of Translational and Precision Medicine, Sapienza-University of Rome, Rome, Italy
| | - Marco Proietti
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy.,Geriatric Unit, IRCCS Istituti Clinici Scientifici Maugeri, Via Camaldoli, 64, 20138 Milan, Italy.,Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK
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3
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Nam KW, Kwon HM, Lee YS, Kim JM, Ko SB. Effects of cerebral small vessel disease on the outcomes in cryptogenic stroke with active cancer. Sci Rep 2021; 11:17510. [PMID: 34471193 PMCID: PMC8410810 DOI: 10.1038/s41598-021-97154-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2021] [Accepted: 08/20/2021] [Indexed: 11/09/2022] Open
Abstract
Cerebral small vessel diseases (cSVDs) affect the prognosis of various types of ischemic stroke. Therefore, we evaluated the association between cSVD and the prognosis of cryptogenic stroke patients with active cancer. We enrolled patients diagnosed with cryptogenic stroke and active cancer from 2010 to 2016. Early neurological deterioration (END) was defined as a ≥ 2-point increase in the total NIHSS score or a ≥ 1-point increase in the motor NIHSS score within the first 72 h. We defined an unfavorable outcome as the modified Rankin Scale (mRS) score ≥ 3 points. We analyzed cSVD separately for each subtype including white matter hyperintensity (WMH), silent brain infarct (SBI), and cerebral microbleed (CMB). A total of 179 cryptogenic stroke patients with active cancer were evaluated. In the multivariable analysis, SBI was significantly associated with END (adjusted odds ratio = 3.97, 95% confidence interval: 1.53–10.33). This close relationship between SBI and END increased proportionally with an increase in SBI burden. However, WMH and CMB showed no significant association with END. None of the cSVD subtypes showed a statistically significant relationship with the 3-month unfavorable outcome. SBI was the only parameter closely associated with END in cryptogenic stroke patients with active cancer.
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Affiliation(s)
- Ki-Woong Nam
- Department of Neurology, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul, South Korea.,Department of Neurology, Seoul National University College of Medicine, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, 20 Boramae-ro 5-gil, Dongjak-Gu, Seoul, 07061, South Korea
| | - Hyung-Min Kwon
- Department of Neurology, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul, South Korea. .,Department of Neurology, Seoul National University College of Medicine, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, 20 Boramae-ro 5-gil, Dongjak-Gu, Seoul, 07061, South Korea.
| | - Yong-Seok Lee
- Department of Neurology, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul, South Korea.,Department of Neurology, Seoul National University College of Medicine, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, 20 Boramae-ro 5-gil, Dongjak-Gu, Seoul, 07061, South Korea
| | - Jeong-Min Kim
- Department of Neurology, Seoul National University College of Medicine, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, 20 Boramae-ro 5-gil, Dongjak-Gu, Seoul, 07061, South Korea. .,Department of Neurology, Seoul National University College of Medicine, Seoul National University Hospital, 101 Daehakno, Jongno-Gu, Seoul, 03080, South Korea.
| | - Sang-Bae Ko
- Department of Neurology, Seoul National University College of Medicine, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, 20 Boramae-ro 5-gil, Dongjak-Gu, Seoul, 07061, South Korea.,Department of Neurology, Seoul National University College of Medicine, Seoul National University Hospital, 101 Daehakno, Jongno-Gu, Seoul, 03080, South Korea
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4
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Shoamanesh A, Hart RG, Connolly SJ, Kasner SE, Smith EE, Martí-Fàbregas J, Liu YY, Uchiyama S, Mikulik R, Veltkamp R, O'Donnell MJ, Ntaios G, Muir KW, Field TS, Santo GC, Olavarria V, Mundl H, Lutsep H, Berkowitz SD, Sharma M. Microbleeds and the Effect of Anticoagulation in Patients With Embolic Stroke of Undetermined Source: An Exploratory Analysis of the NAVIGATE ESUS Randomized Clinical Trial. JAMA Neurol 2021; 78:11-20. [PMID: 33074284 DOI: 10.1001/jamaneurol.2020.3836] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Importance The reported associations of cerebral microbleeds with recurrent stroke and intracerebral hemorrhage have raised concerns regarding antithrombotic treatment in patients with a history of stroke and microbleeds on magnetic resonance imaging. Objective To characterize microbleeds in embolic strokes of undetermined source (ESUS) and report interactions between microbleeds and the effects of random assignment to anticoagulant vs antiplatelet therapy. Design, Setting, and Participants Subgroup analyses of the New Approach Rivaroxaban Inhibition of Factor Xa in a Global Trial vs Aspirin to Prevent Embolism in ESUS (NAVIGATE ESUS) international, double-blind, randomized, event-driven phase 3 clinical trial. Participants were enrolled between December 2014 and September 2017 and followed up for a median of 11 months. The study setting included 459 stroke recruitment centers in 31 countries. Patients aged 50 years or older who had neuroimaging-confirmed ESUS between 7 days and 6 months before screening were eligible. Of these 7213 NAVIGATE ESUS participants, 3699 (51%) had information on cerebral microbleeds reported on their baseline clinical magnetic resonance imaging and were eligible for these analyses. Patients with a prior history of symptomatic intracerebral hemorrhage were excluded from the NAVIGATE ESUS trial. Interventions Rivaroxaban, 15 mg, compared with aspirin, 100 mg, daily. Main Outcomes and Measures The primary outcome was recurrent stroke. Secondary outcomes were ischemic stroke, intracerebral hemorrhage, and all-cause mortality. Results Microbleeds were present in 395 of 3699 participants (11%). Of patients with cerebral microbleeds, mean (SD) age was 69.5 (9.4) years, 241 were men (61%), and 201 were White (51%). Advancing age (odds ratio [OR] per year, 1.03; 95% CI, 1.01-1.04), East Asian race/ethnicity (OR, 1.57; 95% CI, 1.04-2.37), hypertension (OR, 2.20; 95% CI, 1.54-3.15), multiterritorial infarcts (OR, 1.95; 95% CI, 1.42-2.67), chronic infarcts (OR, 1.78; 95% CI, 1.42-2.23), and occult intracerebral hemorrhage (OR, 5.23; 95% CI, 2.76-9.90) were independently associated with microbleeds. The presence of microbleeds was associated with a 1.5-fold increased risk of recurrent stroke (hazard ratio [HR], 1.5; 95% CI, 1.0-2.3), a 4-fold risk of intracerebral hemorrhage (HR, 4.2; 95% CI, 1.3-13.9), a 2-fold risk of all-cause mortality (HR, 2.1; 95% CI, 1.1-4.3), and strictly lobar microbleeds with an approximately 2.5-fold risk of ischemic stroke (HR, 2.3; 95% CI, 1.3-4.3). There were no interactions between microbleeds and treatment assignments for recurrent stroke, ischemic stroke, or all-cause mortality. The HR of intracerebral hemorrhage on rivaroxaban was similar between persons with microbleeds (HR, 3.1; 95% CI, 0.3-30.0) and persons without microbleeds (HR, 3.0; 95% CI, 0.6-14.7; interaction P = .97). Conclusions and Relevance Microbleeds mark an increased risk of recurrent stroke, ischemic stroke, intracerebral hemorrhage, and mortality in ESUS but do not appear to influence effects of rivaroxaban on clinical outcomes. Trial Registration ClinicalTrials.gov Identifier: NCT02313909.
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Affiliation(s)
- Ashkan Shoamanesh
- Division of Neurology, McMaster University / Population Health Research Institute, Hamilton, Ontario, Canada
| | - Robert G Hart
- Division of Neurology, McMaster University / Population Health Research Institute, Hamilton, Ontario, Canada
| | - Stuart J Connolly
- Division of Neurology, McMaster University / Population Health Research Institute, Hamilton, Ontario, Canada
| | - Scott E Kasner
- Department of Neurology, University of Pennsylvania, Philadelphia
| | - Eric E Smith
- Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
| | | | - Yan Yun Liu
- Department of Statistics, Population Health Research Institute, Hamilton, Ontario, Canada
| | - Shinichiro Uchiyama
- Department of Neurology, Clinical Research Center for Medicine, International University of Health and Welfare, Tokyo, Japan
| | - Robert Mikulik
- International Clinical Research Center and Department of Neurology, St. Anne's University Hospital and Masaryk University, Brno, Czech Republic
| | - Roland Veltkamp
- Department of Neurology, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Martin J O'Donnell
- Division of Neurology, McMaster University / Population Health Research Institute, Hamilton, Ontario, Canada.,Department of Medicine, National University of Ireland Galway, Galway, Ireland
| | - George Ntaios
- Department of Internal Medicine, University of Thessaly, Larissa, Greece
| | - Keith W Muir
- Institute of Neuroscience & Psychology, University of Glasgow, Glasgow, Scotland
| | - Thalia S Field
- Division of Neurology, University of British Columbia, Vancouver, Canada
| | - Gustavo C Santo
- Department of Neurology, Hospitais da Universidade de Coimbra, Coimbra, Portugal
| | - Veronica Olavarria
- Department of Neurology and Psychiatry, Clínica Alemana de Santiago, Facultad de Medicina, Clínica Alemana Universidad del Desarrollo, Santiago, Chile
| | - Hardi Mundl
- Pharmaceuticals Development, TA Cardiovascular, Bayer Pharma AG, Wuppertal, Germany
| | - Helmi Lutsep
- Department of Neurology, Oregon Health and Science University, Portland
| | - Scott D Berkowitz
- Thrombosis Group, Pharmaceuticals Research and Development, Bayer, Whippany, New Jersey
| | - Mukul Sharma
- Division of Neurology, McMaster University / Population Health Research Institute, Hamilton, Ontario, Canada
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5
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Zhang Y, Huang L, Wang D, Ren P, Hong Q, Kang D. The ROBINS-I and the NOS had similar reliability but differed in applicability: A random sampling observational studies of systematic reviews/meta-analysis. J Evid Based Med 2021; 14:112-122. [PMID: 34002466 DOI: 10.1111/jebm.12427] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Accepted: 02/07/2021] [Indexed: 02/05/2023]
Abstract
OBJECTIVE There is a lack of evidence on the usage of the quality assessment tool-the Risk Of Bias In Nonrandomized Studies-of Interventions (ROBINS-I). This article aimed to measure the reliability, criterion validity, and feasibility of the ROBINS-I and the Newcastle-Ottawa Scale (NOS). METHODS A sample of systematic reviews or meta-analyses of observational studies were selected from Medline (2013-2017) and assessed by two reviewers using ROBINS-I and the NOS. We reported on reliability in terms of the first-order agreement coefficient (AC1) statistic. Correlation coefficient statistic was used to explore the criterion validity of the ROBINS-I. We compared the feasibility of the ROBINS-I and NOS by recording the time to complete an assessment and the instances where assessing was difficult. RESULTS Five systematic reviews containing 41 cohort studies were finally included. Interobserver agreement on the individual domain of the ROBINS-I as well as the NOS was substantial with a mean AC1 statistic of 0.67 (95% CI: 0.50-0.83) and 0.73 (95% CI: 0.65-0.81), respectively. The criterion validity of the ROBNS-I was moderate (K = 0.52) against NOS. The time in assessing a single study by ROBINS-I varied from 7 hours initially to 3 hours compared with 30 minutes for the NOS. Both reviewers rated "bias due to departure from the intended interventions" the most time-consuming domain in the ROBINS-I, items in the NOS were equal. CONCLUSIONS The ROBINS-I and the NOS seem to provide the same reliability but vary in applicability. The over-complicated feature of ROBINS-I may limit its usage and a simplified version is needed.
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Affiliation(s)
- Yuhui Zhang
- Department of Evidence-based Medicine and Clinical Epidemiology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Litao Huang
- Department of Evidence-based Medicine and Clinical Epidemiology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Dandan Wang
- The First School of Clinical Medicine, Lanzhou University, Lanzhou, Gansu, China
| | - Pengwei Ren
- Clinical Research Center for Respiratory Diseases, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Qi Hong
- Department of Evidence-based Medicine and Clinical Epidemiology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Deying Kang
- Department of Evidence-based Medicine and Clinical Epidemiology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
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6
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Choi KH, Kim JH, Lee C, Kim JM, Kang KW, Kim JT, Choi SM, Park MS, Cho KH. Microbleeds and Outcome in Patients With Acute Ischemic Stroke and Atrial Fibrillation Taking Anticoagulants. Stroke 2020; 51:3514-3522. [DOI: 10.1161/strokeaha.120.030300] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Background and Purpose:
We investigated the impact of the presence, burden, and location of cerebral microbleeds (CMBs) on the risk of major adverse cerebrovascular and cardiovascular events (MACCE) in patients with acute ischemic stroke and atrial fibrillation treated with oral anticoagulants (OACs). We also examined whether the clinical effect of CMBs differs according to the type of OACs.
Methods:
A total of 1742 patients with acute ischemic stroke and atrial fibrillation treated with OACs were enrolled in this cohort study. The primary composite outcome was the occurrence of MACCE (a composite of stroke, acute myocardial infarction, or vascular death) over a 2-year period according to CMB status.
Results:
CMB presence was significantly associated with the risk of future MACCE (hazard ratio, 1.89 [95% CI, 1.23–2.88];
P
=0.003) after adjustment for confounders in patients with acute ischemic stroke and atrial fibrillation taking OACs. Patients with exactly 1 CMB had a similar rate of MACCE compared with those without CMBs (
P
=0.461). However, patients with multiple CMBs (≥2), particularly high burden CMBs (≥5), had a significantly higher proportion of MACCE. Both CMB-positive groups with lobar and deep CMB had more frequent MACCE than the CMB-negative group, and the rate of MACCE was not different according to CMB location. In patients treated with warfarin, CMB was significantly associated with a risk of MACCE (
P
=0.002), but not in patients treated with direct OACs (
P
=0.517).
Conclusions:
The study results indicate that the risk of future MACCE increased with increasing CMB burden in patients with AIS and atrial fibrillation taking OACs, while the anatomic location of CMBs did not influence the risk of future MACCE. This risk seemed to be more apparent in patients taking warfarin.
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Affiliation(s)
- Kang-Ho Choi
- Department of Neurology (K.-H. Choi, J.-M.K., K.-W.K., J.-T.K., S.-M.C., M.-S.P., K.-H. Cho), Chonnam National University Medical School and Hospital, Gwangju, Korea
- Department of Neurology, Chonnam National University Hwasun Hospital, Korea (K.-H. Choi, J.-M.K., K.-W.K.)
| | - Ja-Hae Kim
- Department of Nuclear Medicine, Molecular Imaging Center (J.-H.K.), Chonnam National University Medical School and Hospital, Gwangju, Korea
| | - Changho Lee
- Department of Nuclear Medicine, Chonnam National University Medical School and Hwasun Hospital, Korea (C.L.)
| | - Jae-Myung Kim
- Department of Neurology (K.-H. Choi, J.-M.K., K.-W.K., J.-T.K., S.-M.C., M.-S.P., K.-H. Cho), Chonnam National University Medical School and Hospital, Gwangju, Korea
- Department of Neurology, Chonnam National University Hwasun Hospital, Korea (K.-H. Choi, J.-M.K., K.-W.K.)
| | - Kyung-Wook Kang
- Department of Neurology (K.-H. Choi, J.-M.K., K.-W.K., J.-T.K., S.-M.C., M.-S.P., K.-H. Cho), Chonnam National University Medical School and Hospital, Gwangju, Korea
- Department of Neurology, Chonnam National University Hwasun Hospital, Korea (K.-H. Choi, J.-M.K., K.-W.K.)
| | - Joon-Tae Kim
- Department of Neurology (K.-H. Choi, J.-M.K., K.-W.K., J.-T.K., S.-M.C., M.-S.P., K.-H. Cho), Chonnam National University Medical School and Hospital, Gwangju, Korea
| | - Seong-Min Choi
- Department of Neurology (K.-H. Choi, J.-M.K., K.-W.K., J.-T.K., S.-M.C., M.-S.P., K.-H. Cho), Chonnam National University Medical School and Hospital, Gwangju, Korea
| | - Man-Seok Park
- Department of Neurology (K.-H. Choi, J.-M.K., K.-W.K., J.-T.K., S.-M.C., M.-S.P., K.-H. Cho), Chonnam National University Medical School and Hospital, Gwangju, Korea
| | - Ki-Hyun Cho
- Department of Neurology (K.-H. Choi, J.-M.K., K.-W.K., J.-T.K., S.-M.C., M.-S.P., K.-H. Cho), Chonnam National University Medical School and Hospital, Gwangju, Korea
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7
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Cerebral Microbleeds and Chronic Kidney Disease in Acute Ischemic Stroke Patients with Atrial Fibrillation. J Stroke Cerebrovasc Dis 2020; 29:104650. [PMID: 32024601 DOI: 10.1016/j.jstrokecerebrovasdis.2020.104650] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Revised: 12/27/2019] [Accepted: 01/06/2020] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Cerebral microbleeds (CMBs) are associated with the risk of intracerebral hemorrhage in stroke patients with atrial fibrillation (AF). We investigated the association between CMBs and chronic kidney disease (CKD) in patients with acute ischemic stroke and AF. METHODS We retrospectively examined consecutive patients with acute ischemic stroke and AF who underwent brain gradient-echo T2*-weighted magnetic resonance imaging. The number and distribution (lobar, deep or infratentorial, and mixed) of CMBs were assessed. Kidney function was assessed according to the estimated glomerular filtration rate (eGFR), which was calculated using a modified version of the Modification of Diet in Renal Disease equation. RESULTS Of the 357 included patients, 105 (29.4%) had CMBs. CKD (eGFR < 60 mL/min/1.73 m2) was found in 131 (36.7%) patients. Patients with CKD showed a higher prevalence of any form of CMB (41.2% versus 22.6%, P < .001), deep or infratentorial CMBs (19.9% versus 9.3%, P < .01), and mixed CMBs (14.5% versus 5.3%, P < .01) than those without CKD. After adjusting for age and other confounding factors, CKD was found to be independently associated with the presence of any form of CMB (odds ratio 1.89, P = .02) and mixed CMBs (odds ratio 3.10, P < .01). Moreover, moderate to severe CKD (eGFR < 45 mL/min/1.73 m2) was independently associated with the presence of multiple CMBs (odds ratio 2.31, P = .04). CONCLUSIONS CMBs and CKD are common in acute ischemic stroke patients with AF, and CKD may be a risk factor for CMBs. Further longitudinal studies are needed to evaluate whether maintaining kidney function can prevent the development of CMBs.
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8
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Circulating Levels of Biomarkers of Cerebral Injury in Patients with Atrial Fibrillation. Am J Cardiol 2019; 124:1697-1700. [PMID: 31575426 DOI: 10.1016/j.amjcard.2019.08.027] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Revised: 08/12/2019] [Accepted: 08/19/2019] [Indexed: 01/08/2023]
Abstract
Atrial fibrillation (AF) is a source of altered brain perfusion and ischemia, potentially leading to cerebral injury and blood brain barrier (BBB) disruption, which may result in the permeation of neurospecific molecules into the bloodstream. We retrospectively analyzed circulating levels of biomarkers of cerebral injury: Astrocyte-specific glial acidic fibrillary protein (GFAP), calcium-binding protein B (S100 b), stress response marker growth differential factor 15 (GDF15), and microtubule associated Tau protein, in patients with AF and non-AF controls. A total of 196 AF cases and 47 non-AF controls were enrolled in this study all without previous clinical stroke or cerebral injury. Plasma samples were obtained from the Intermountain INSPIRE biobank registry. AF status was determined at the time of the sample draw using clinical diagnosis. Assessment of circulating biomarkers was conducted with EIA. Multivariate linear modeling, using natural log, and square root transformation of the biomarkers, was done adjusting for (1) CHA2DS2-VASc and anticoagulation, and (2) age, gender, coronary artery disease and anticoagulation. Circulating Tau, GDF15, and GFAP were elevated in AF cases. After multivariate adjustment, GFAP and Tau remained significantly elevated in the AF, whereas the signal for GDF15 was confounded by age. In conclusion, circulating biomarkers of neuronal and glial injury Tau and GFAP are elevated in patients with AF that are consistent with subclinical cerebral injury and disruption of the BBB, which can predispose these patients to the development of cognitive dysfunction and/or dementia later in life.
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9
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Debette S, Schilling S, Duperron MG, Larsson SC, Markus HS. Clinical Significance of Magnetic Resonance Imaging Markers of Vascular Brain Injury: A Systematic Review and Meta-analysis. JAMA Neurol 2019; 76:81-94. [PMID: 30422209 DOI: 10.1001/jamaneurol.2018.3122] [Citation(s) in RCA: 361] [Impact Index Per Article: 72.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Importance Covert vascular brain injury (VBI) is highly prevalent in community-dwelling older persons, but its clinical and therapeutic implications are debated. Objective To better understand the clinical significance of VBI to optimize prevention strategies for the most common age-related neurological diseases, stroke and dementia. Data Source We searched for articles in PubMed between 1966 and December 22, 2017, studying the association of 4 magnetic resonance imaging (MRI) markers of covert VBI (white matter hyperintensities [WMHs] of presumed vascular origin, MRI-defined covert brain infarcts [BIs], cerebral microbleeds [CMBs], and perivascular spaces [PVSs]) with incident stroke, dementia, or death. Study Selection Data were taken from prospective, longitudinal cohort studies including 50 or more adults. Data Extraction and Synthesis We performed inverse variance-weighted meta-analyses with random effects and z score-based meta-analyses for WMH burden. The significance threshold was P < .003 (17 independent tests). We complied with the Meta-analyses of Observational Studies in Epidemiology guidelines. Main Outcomes and Measures Stroke (hemorrhagic and ischemic), dementia (all and Alzheimer disease), and death. Results Of 2846 articles identified, 94 studies were eligible, with up to 14 529 participants for WMH, 16 012 participants for BI, 15 693 participants for CMB, and 4587 participants for PVS. Extensive WMH burden was associated with higher risk of incident stroke (hazard ratio [HR], 2.45; 95% CI, 1.93-3.12; P < .001), ischemic stroke (HR, 2.39; 95% CI, 1.65-3.47; P < .001), intracerebral hemorrhage (HR, 3.17; 95% CI, 1.54-6.52; P = .002), dementia (HR, 1.84; 95% CI, 1.40-2.43; P < .001), Alzheimer disease (HR, 1.50; 95% CI, 1.22-1.84; P < .001), and death (HR, 2.00; 95% CI, 1.69-2.36; P < .001). Presence of MRI-defined BIs was associated with higher risk of incident stroke (HR, 2.38; 95% CI, 1.87-3.04; P < .001), ischemic stroke (HR, 2.18; 95% CI, 1.67-2.85; P < .001), intracerebral hemorrhage (HR, 3.81; 95% CI, 1.75-8.27; P < .001), and death (HR, 1.64; 95% CI, 1.40-1.91; P < .001). Presence of CMBs was associated with increased risk of stroke (HR, 1.98; 95% CI, 1.55-2.53; P < .001), ischemic stroke (HR, 1.92; 95% CI, 1.40-2.63; P < .001), intracerebral hemorrhage (HR, 3.82; 95% CI, 2.15-6.80; P < .001), and death (HR, 1.53; 95% CI, 1.31-1.80; P < .001). Data on PVS were limited and insufficient to conduct meta-analyses but suggested an association of high PVS burden with increased risk of stroke, dementia, and death; this requires confirmation. Conclusions and Relevance We report evidence that MRI markers of VBI have major clinical significance. This research prompts careful evaluation of the benefit-risk ratio for available prevention strategies in individuals with covert VBI.
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Affiliation(s)
- Stéphanie Debette
- University of Bordeaux, Inserm 1219, Bordeaux Population Health Research Center, Bordeaux, France.,Department of Neurology, Memory Clinic, Bordeaux University Hospital, Bordeaux, France
| | - Sabrina Schilling
- University of Bordeaux, Inserm 1219, Bordeaux Population Health Research Center, Bordeaux, France
| | - Marie-Gabrielle Duperron
- University of Bordeaux, Inserm 1219, Bordeaux Population Health Research Center, Bordeaux, France
| | - Susanna C Larsson
- Stroke Research Group, Department of Clinical Neurosciences, University of Cambridge, Cambridge Biomedical Campus, Cambridge, United Kingdom.,Unit of Nutritional Epidemiology, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Hugh S Markus
- Stroke Research Group, Department of Clinical Neurosciences, University of Cambridge, Cambridge Biomedical Campus, Cambridge, United Kingdom
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Cheng Y, Wang Y, Song Q, Qiu K, Liu M. Use of anticoagulant therapy and cerebral microbleeds: a systematic review and meta-analysis. J Neurol 2019; 268:1666-1679. [PMID: 31616992 DOI: 10.1007/s00415-019-09572-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Revised: 10/02/2019] [Accepted: 10/03/2019] [Indexed: 02/05/2023]
Abstract
BACKGROUND Anticoagulant therapy increases the risk that cerebral microbleeds (CMBs) progress to intracerebral hemorrhage, but whether the therapy increases risk of CMB occurrence is unclear. We performed a systematic review and meta-analysis to investigate the potential association between anticoagulant use and CMB occurrence in stroke and stroke-free individuals. METHODS We searched observational studies in PubMed, Ovid EMBASE, and Cochrane Library from their inception until September 2019. We calculated the pooled odds ratio (OR) and 95% confidence interval (CI) for the prevalence and incidence of CMBs in anticoagulant users relative to non-anticoagulant users. RESULTS Forty-seven studies with 25,245 participants were included. The pooled analysis showed that anticoagulant use was associated with CMB prevalence (OR 1.54, 95% CI 1.26-1.88). The association was observed in subgroups stratified by type of participants: stroke-free, OR 1.86, 95% CI 1.25-2.77; ischemic stroke/transient ischemic attack, OR 1.33, 95% CI 1.06-1.67; and intracerebral hemorrhage, OR 2.26, 95% CI 1.06-4.83. Anticoagulant use was associated with increased prevalence of strictly lobar CMBs (OR 1.68, 95% CI 1.22-2.32) but not deep/infratentorial CMBs. Warfarin was associated with increased CMB prevalence (OR 1.64, 95% CI 1.23-2.18), but novel oral anticoagulants were not. Anticoagulant users showed higher incidence of CMBs during long-term follow-up (OR 1.72, 95% CI 1.22-2.44). CONCLUSION Anticoagulant use is associated with higher prevalence and incidence of CMBs. This association appears to depend on location of CMBs and type of anticoagulants. More longitudinal investigations with adjustment for confounders are required to establish the causality.
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Affiliation(s)
- Yajun Cheng
- Department of Neurology, Center of Cerebrovascular Disease, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan, China
| | - Yanan Wang
- Department of Neurology, Center of Cerebrovascular Disease, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan, China
| | - Quhong Song
- Department of Neurology, Center of Cerebrovascular Disease, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan, China
| | - Ke Qiu
- West China School of Medicine, Sichuan University, Chengdu, 610041, Sichuan, China
| | - Ming Liu
- Department of Neurology, Center of Cerebrovascular Disease, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan, China.
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Abstract
PURPOSE OF REVIEW Atrial fibrillation is one of the most common clinically encountered arrhythmias exhibiting a strong association with a spectrum of cerebral injuries from the occurrence of clinical stroke, subclinical stroke, dementia, and cognitive decline. Dynamic noninvasive specific and sensitive diagnostic tests may allow a personalized approach to the atrial fibrillation patient's treatment based upon quantitative parameters, aiming to prevent or delay stroke, dementia, progressive cognitive decline, or to assess responses to these therapies. This review will explore molecular markers that have been shown to have an association with atrial fibrillation, and have a potential to be predictive for the risk for stroke, cognitive dysfunction, and dementia in these patients. RECENT FINDINGS Circulating biomarkers of vascular disease, fibrosis, thrombosis, and inflammation are associated with risk of stroke in patients with atrial fibrillation. These biomarkers are additive to the predictive utility of the CHADS2 and CHA2DS2-VASc scores, and in some cases allow for additional risk prognostication of the broad categories allocated by CHADS2 and CHA2DS2-VASc scores of low, medium, and high. SUMMARY Across the spectrum of cerebral injuries in patients with atrial fibrillation, biomarkers hold the promise of personalized risk stratification and management to minimize risks of disease.
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Vales-Montero M, García-Pastor A, Iglesias-Mohedano AM, Esteban-de Antonio E, Salgado-Cámara P, García-Domínguez JM, Vázquez-Alén P, Díaz-Otero F, Fernández-Bullido Y, Gil-Núñez A. Cerebral amyloid angiopathy-related transient focal neurological episodes: A transient ischemic attack mimic with an increased risk of intracranial hemorrhage. J Neurol Sci 2019; 406:116452. [PMID: 31525529 DOI: 10.1016/j.jns.2019.116452] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Revised: 08/05/2019] [Accepted: 09/06/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Transient focal neurological episodes (TFNEs) are a recently recognized clinical presentation of cerebral amyloid angiopathy (CAA). Our aim was to describe the clinical and radiological features of a series of patients with AS. METHODS We included 11 patients presenting with recurrent transient focal neurological symptoms and radiological features related to CAA. RESULTS Mean age was 76,6 and 5 patients were women. All patients reported transient, stereotyped, and recurrent episodes (6 patients had >10 episodes). Gradual spread of the symptoms was recorded in 9 patients. Initially, 3 patients were misdiagnosed as having recurrent transient ischemic attack (TIA), 6 as having seizures, and 2 as having both. Two patients were prescribed antiplatelet therapy. A cerebral MRI with T2* gradient-recalled echo sequence revealed cortical superficial siderosis (cSS) in 5 patients, cortical microbleeds in 1 patient, and both features in 5 cases. After a median follow-up of 36 months, intracranial hemorrhage (ICH) was recorded in 4 patients. All 4 had cSS in the previous cerebral MRI, and 1 was on antiplatelet therapy. CONCLUSION CAA-related TFNEs are an underdiagnosed entity, often mimicking TIA, seizures, or migraine aura. This misdiagnosis can lead to the prescription of antiplatelet or anticoagulant therapy, which increases the risk of ICH. Our results suggest that cSS might be a radiological marker that is closely related to an increased risk of bleeding. A T2* gradient-recalled echo MRI should be performed in elderly patients with transient focal neurological symptoms suggestive of CAA.
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Affiliation(s)
- Marta Vales-Montero
- Stroke Centre - Department of Vascular Neurology, Hospital General Universitario Gregorio Marañón, C/ Dr. Esquerdo 46, 28007 Madrid, Spain
| | - Andrés García-Pastor
- Stroke Centre - Department of Vascular Neurology, Hospital General Universitario Gregorio Marañón, C/ Dr. Esquerdo 46, 28007 Madrid, Spain.
| | - Ana María Iglesias-Mohedano
- Stroke Centre - Department of Vascular Neurology, Hospital General Universitario Gregorio Marañón, C/ Dr. Esquerdo 46, 28007 Madrid, Spain
| | - Ester Esteban-de Antonio
- Stroke Centre - Department of Vascular Neurology, Hospital General Universitario Gregorio Marañón, C/ Dr. Esquerdo 46, 28007 Madrid, Spain
| | - Paula Salgado-Cámara
- Stroke Centre - Department of Vascular Neurology, Hospital General Universitario Gregorio Marañón, C/ Dr. Esquerdo 46, 28007 Madrid, Spain
| | - José Manuel García-Domínguez
- Stroke Centre - Department of Vascular Neurology, Hospital General Universitario Gregorio Marañón, C/ Dr. Esquerdo 46, 28007 Madrid, Spain
| | - Pilar Vázquez-Alén
- Stroke Centre - Department of Vascular Neurology, Hospital General Universitario Gregorio Marañón, C/ Dr. Esquerdo 46, 28007 Madrid, Spain
| | - Fernando Díaz-Otero
- Stroke Centre - Department of Vascular Neurology, Hospital General Universitario Gregorio Marañón, C/ Dr. Esquerdo 46, 28007 Madrid, Spain
| | - Yolanda Fernández-Bullido
- Stroke Centre - Department of Vascular Neurology, Hospital General Universitario Gregorio Marañón, C/ Dr. Esquerdo 46, 28007 Madrid, Spain
| | - Antonio Gil-Núñez
- Stroke Centre - Department of Vascular Neurology, Hospital General Universitario Gregorio Marañón, C/ Dr. Esquerdo 46, 28007 Madrid, Spain
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Martí-Fàbregas J, Medrano-Martorell S, Merino E, Prats-Sánchez L, Marín R, Delgado-Mederos R, Martínez-Domeño A, Camps-Renom P, Jiménez-Xarrié E, Zedde M, Gómez-Choco M, Lara L, Boix A, Calleja A, De Arce-Borda AM, Bravo Y, Fuentes B, Hernández-Pérez M, Cánovas D, Llull L, Zandio B, Freijo M, Casado-Naranjo I, Sanahuja J, Cocho D, Krupinski J, Rodríguez-Campello A, Palomeras E, De Felipe A, Serrano M, Zapata-Arriaza E, Zaragoza-Brunet J, Díaz-Maroto I, Fernández-Domínguez J, Lago A, Maestre J, Rodríguez-Yáñez M, Gich I. MRI predicts intracranial hemorrhage in patients who receive long-term oral anticoagulation. Neurology 2019; 92:e2432-e2443. [PMID: 31004066 DOI: 10.1212/wnl.0000000000007532] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2018] [Accepted: 01/24/2019] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVE We tested the hypothesis that the risk of intracranial hemorrhage (ICH) in patients with cardioembolic ischemic stroke who are treated with oral anticoagulants (OAs) can be predicted by evaluating surrogate markers of hemorrhagic-prone cerebral angiopathies using a baseline MRI. METHODS Patients were participants in a multicenter and prospective observational study. They were older than 64 years, had a recent cardioembolic ischemic stroke, and were new users of OAs. They underwent a baseline MRI analysis to evaluate microbleeds, white matter hyperintensities, and cortical superficial siderosis. We collected demographic variables, clinical characteristics, risk scores, and therapeutic data. The primary endpoint was ICH that occurred during follow-up. We performed bivariate and multivariate Cox regression analyses. RESULTS We recruited 937 patients (aged 77.6 ± 6.5 years; 47.9% were men). Microbleeds were detected in 207 patients (22.5%), moderate/severe white matter hyperintensities in 419 (45.1%), and superficial siderosis in 28 patients (3%). After a mean follow-up of 23.1 ± 6.8 months, 18 patients (1.9%) experienced an ICH. In multivariable analysis, microbleeds (hazard ratio 2.7, 95% confidence interval [CI] 1.1-7, p = 0.034) and moderate/severe white matter hyperintensities (hazard ratio 5.7, 95% CI 1.6-20, p = 0.006) were associated with ICH (C index 0.76, 95% CI 0.66-0.85). Rate of ICH was highest in patients with both microbleed and moderate/severe WMH (3.76 per 100 patient-years, 95% CI 1.62-7.4). CONCLUSION Patients taking OAs who have advanced cerebral small vessel disease, evidenced by microbleeds and moderate to severe white matter hyperintensities, had an increased risk of ICH. Our results should help to determine the risk of prescribing OA for a patient with cardioembolic stroke. CLINICALTRIALSGOV IDENTIFIER NCT02238470.
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Affiliation(s)
- Joan Martí-Fàbregas
- From the Department of Neurology (J.M.-F., L.P.-S., R.M., R.D.-M., A.M.-D., P.C.-R., E.J.-X.) and Epidemiology (I.G.), Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute, Barcelona; Departments of Radiology (S.M.-M.) and Neurology (A.R.-C.), Hospital del Mar-Parc de Salut Mar, Barcelona; Unitat RM IDI (E.M.) and Department of Neurosciences (M.H.-P.), Hospital Germans Trias i Pujol, Badalona; Department of Neurology (M.Z.), Arcispedale Santa Maria Nuova IRCCS, Reggio Emilia, Italy; Department of Neurology (M.G.-C.), Hospital de Sant Joan Despí Moises Broggi, Sant Joan Despí, Spain; Department of Neurology (L. Lara), Hospital de León; Department of Neurology (A.B.), Hospital Universitari Son Espases, Palma de Mallorca; Department of Neurology (A.C.), Hospital de Valladolid; Department of Neurology (A.M.D.A.-B.), Hospital de Donostia; Department of Neurology (Y.B.), Hospital de Burgos; Department of Neurology (B.F.), Hospital Universitario La Paz, Universidad Autónoma de Madrid, Instituto de Investigación IdiPaz, Madrid; Department of Neurology (D. Cánovas), Hospital Parc Taulí, Sabadell; Department of Neurology (L. Llull), Hospital Clínic, Barcelona; Department of Neurology (B.Z.), Hospital de Navarra, Pamplona; Department of Neurology (M.F.), Hospital de Basurto, Bilbao; Department of Neurology (I.C.-N.), Hospital San Pedro de Alcántara, Cáceres; Department of Neurology (J.S.), Hospital Arnau de Vilanova, Lleida; Department of Neurology (D. Cocho), Hospital de Granollers; Department of Neurology (J.K.), F.Ass. Mutua Terrassa; Department of Neurology (E.P.), Hospital de Mataró; Department of Neurology (A.D.F.), Hospital Ramón y Cajal, Madrid; Department of Neurology (M.S.), Hospital La Rioja, Logroño; Department of Neurology (E.Z.-A.), Hospital Virgen del Rocío, Sevilla; Department of Neurology (J.Z.-B.), Hospital Verge de la Cinta, Tortosa; Department of Neurology (I.D.-M.), Hospital de Albacete; Department of Neurology (J.F.-D.), Centro Médico Asturias, Oviedo; Department of Neurology (A.L.), Hospital La Fe, Valencia; Department of Neurology (J.M.), Hospital Virgen de las Nieves, Granada; and Department of Neurology (M.R.-Y.), Hospital Santiago de Compostela, Santiago de Compostela, Spain.
| | - Santiago Medrano-Martorell
- From the Department of Neurology (J.M.-F., L.P.-S., R.M., R.D.-M., A.M.-D., P.C.-R., E.J.-X.) and Epidemiology (I.G.), Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute, Barcelona; Departments of Radiology (S.M.-M.) and Neurology (A.R.-C.), Hospital del Mar-Parc de Salut Mar, Barcelona; Unitat RM IDI (E.M.) and Department of Neurosciences (M.H.-P.), Hospital Germans Trias i Pujol, Badalona; Department of Neurology (M.Z.), Arcispedale Santa Maria Nuova IRCCS, Reggio Emilia, Italy; Department of Neurology (M.G.-C.), Hospital de Sant Joan Despí Moises Broggi, Sant Joan Despí, Spain; Department of Neurology (L. Lara), Hospital de León; Department of Neurology (A.B.), Hospital Universitari Son Espases, Palma de Mallorca; Department of Neurology (A.C.), Hospital de Valladolid; Department of Neurology (A.M.D.A.-B.), Hospital de Donostia; Department of Neurology (Y.B.), Hospital de Burgos; Department of Neurology (B.F.), Hospital Universitario La Paz, Universidad Autónoma de Madrid, Instituto de Investigación IdiPaz, Madrid; Department of Neurology (D. Cánovas), Hospital Parc Taulí, Sabadell; Department of Neurology (L. Llull), Hospital Clínic, Barcelona; Department of Neurology (B.Z.), Hospital de Navarra, Pamplona; Department of Neurology (M.F.), Hospital de Basurto, Bilbao; Department of Neurology (I.C.-N.), Hospital San Pedro de Alcántara, Cáceres; Department of Neurology (J.S.), Hospital Arnau de Vilanova, Lleida; Department of Neurology (D. Cocho), Hospital de Granollers; Department of Neurology (J.K.), F.Ass. Mutua Terrassa; Department of Neurology (E.P.), Hospital de Mataró; Department of Neurology (A.D.F.), Hospital Ramón y Cajal, Madrid; Department of Neurology (M.S.), Hospital La Rioja, Logroño; Department of Neurology (E.Z.-A.), Hospital Virgen del Rocío, Sevilla; Department of Neurology (J.Z.-B.), Hospital Verge de la Cinta, Tortosa; Department of Neurology (I.D.-M.), Hospital de Albacete; Department of Neurology (J.F.-D.), Centro Médico Asturias, Oviedo; Department of Neurology (A.L.), Hospital La Fe, Valencia; Department of Neurology (J.M.), Hospital Virgen de las Nieves, Granada; and Department of Neurology (M.R.-Y.), Hospital Santiago de Compostela, Santiago de Compostela, Spain
| | - Elisa Merino
- From the Department of Neurology (J.M.-F., L.P.-S., R.M., R.D.-M., A.M.-D., P.C.-R., E.J.-X.) and Epidemiology (I.G.), Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute, Barcelona; Departments of Radiology (S.M.-M.) and Neurology (A.R.-C.), Hospital del Mar-Parc de Salut Mar, Barcelona; Unitat RM IDI (E.M.) and Department of Neurosciences (M.H.-P.), Hospital Germans Trias i Pujol, Badalona; Department of Neurology (M.Z.), Arcispedale Santa Maria Nuova IRCCS, Reggio Emilia, Italy; Department of Neurology (M.G.-C.), Hospital de Sant Joan Despí Moises Broggi, Sant Joan Despí, Spain; Department of Neurology (L. Lara), Hospital de León; Department of Neurology (A.B.), Hospital Universitari Son Espases, Palma de Mallorca; Department of Neurology (A.C.), Hospital de Valladolid; Department of Neurology (A.M.D.A.-B.), Hospital de Donostia; Department of Neurology (Y.B.), Hospital de Burgos; Department of Neurology (B.F.), Hospital Universitario La Paz, Universidad Autónoma de Madrid, Instituto de Investigación IdiPaz, Madrid; Department of Neurology (D. Cánovas), Hospital Parc Taulí, Sabadell; Department of Neurology (L. Llull), Hospital Clínic, Barcelona; Department of Neurology (B.Z.), Hospital de Navarra, Pamplona; Department of Neurology (M.F.), Hospital de Basurto, Bilbao; Department of Neurology (I.C.-N.), Hospital San Pedro de Alcántara, Cáceres; Department of Neurology (J.S.), Hospital Arnau de Vilanova, Lleida; Department of Neurology (D. Cocho), Hospital de Granollers; Department of Neurology (J.K.), F.Ass. Mutua Terrassa; Department of Neurology (E.P.), Hospital de Mataró; Department of Neurology (A.D.F.), Hospital Ramón y Cajal, Madrid; Department of Neurology (M.S.), Hospital La Rioja, Logroño; Department of Neurology (E.Z.-A.), Hospital Virgen del Rocío, Sevilla; Department of Neurology (J.Z.-B.), Hospital Verge de la Cinta, Tortosa; Department of Neurology (I.D.-M.), Hospital de Albacete; Department of Neurology (J.F.-D.), Centro Médico Asturias, Oviedo; Department of Neurology (A.L.), Hospital La Fe, Valencia; Department of Neurology (J.M.), Hospital Virgen de las Nieves, Granada; and Department of Neurology (M.R.-Y.), Hospital Santiago de Compostela, Santiago de Compostela, Spain
| | - Luis Prats-Sánchez
- From the Department of Neurology (J.M.-F., L.P.-S., R.M., R.D.-M., A.M.-D., P.C.-R., E.J.-X.) and Epidemiology (I.G.), Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute, Barcelona; Departments of Radiology (S.M.-M.) and Neurology (A.R.-C.), Hospital del Mar-Parc de Salut Mar, Barcelona; Unitat RM IDI (E.M.) and Department of Neurosciences (M.H.-P.), Hospital Germans Trias i Pujol, Badalona; Department of Neurology (M.Z.), Arcispedale Santa Maria Nuova IRCCS, Reggio Emilia, Italy; Department of Neurology (M.G.-C.), Hospital de Sant Joan Despí Moises Broggi, Sant Joan Despí, Spain; Department of Neurology (L. Lara), Hospital de León; Department of Neurology (A.B.), Hospital Universitari Son Espases, Palma de Mallorca; Department of Neurology (A.C.), Hospital de Valladolid; Department of Neurology (A.M.D.A.-B.), Hospital de Donostia; Department of Neurology (Y.B.), Hospital de Burgos; Department of Neurology (B.F.), Hospital Universitario La Paz, Universidad Autónoma de Madrid, Instituto de Investigación IdiPaz, Madrid; Department of Neurology (D. Cánovas), Hospital Parc Taulí, Sabadell; Department of Neurology (L. Llull), Hospital Clínic, Barcelona; Department of Neurology (B.Z.), Hospital de Navarra, Pamplona; Department of Neurology (M.F.), Hospital de Basurto, Bilbao; Department of Neurology (I.C.-N.), Hospital San Pedro de Alcántara, Cáceres; Department of Neurology (J.S.), Hospital Arnau de Vilanova, Lleida; Department of Neurology (D. Cocho), Hospital de Granollers; Department of Neurology (J.K.), F.Ass. Mutua Terrassa; Department of Neurology (E.P.), Hospital de Mataró; Department of Neurology (A.D.F.), Hospital Ramón y Cajal, Madrid; Department of Neurology (M.S.), Hospital La Rioja, Logroño; Department of Neurology (E.Z.-A.), Hospital Virgen del Rocío, Sevilla; Department of Neurology (J.Z.-B.), Hospital Verge de la Cinta, Tortosa; Department of Neurology (I.D.-M.), Hospital de Albacete; Department of Neurology (J.F.-D.), Centro Médico Asturias, Oviedo; Department of Neurology (A.L.), Hospital La Fe, Valencia; Department of Neurology (J.M.), Hospital Virgen de las Nieves, Granada; and Department of Neurology (M.R.-Y.), Hospital Santiago de Compostela, Santiago de Compostela, Spain
| | - Rebeca Marín
- From the Department of Neurology (J.M.-F., L.P.-S., R.M., R.D.-M., A.M.-D., P.C.-R., E.J.-X.) and Epidemiology (I.G.), Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute, Barcelona; Departments of Radiology (S.M.-M.) and Neurology (A.R.-C.), Hospital del Mar-Parc de Salut Mar, Barcelona; Unitat RM IDI (E.M.) and Department of Neurosciences (M.H.-P.), Hospital Germans Trias i Pujol, Badalona; Department of Neurology (M.Z.), Arcispedale Santa Maria Nuova IRCCS, Reggio Emilia, Italy; Department of Neurology (M.G.-C.), Hospital de Sant Joan Despí Moises Broggi, Sant Joan Despí, Spain; Department of Neurology (L. Lara), Hospital de León; Department of Neurology (A.B.), Hospital Universitari Son Espases, Palma de Mallorca; Department of Neurology (A.C.), Hospital de Valladolid; Department of Neurology (A.M.D.A.-B.), Hospital de Donostia; Department of Neurology (Y.B.), Hospital de Burgos; Department of Neurology (B.F.), Hospital Universitario La Paz, Universidad Autónoma de Madrid, Instituto de Investigación IdiPaz, Madrid; Department of Neurology (D. Cánovas), Hospital Parc Taulí, Sabadell; Department of Neurology (L. Llull), Hospital Clínic, Barcelona; Department of Neurology (B.Z.), Hospital de Navarra, Pamplona; Department of Neurology (M.F.), Hospital de Basurto, Bilbao; Department of Neurology (I.C.-N.), Hospital San Pedro de Alcántara, Cáceres; Department of Neurology (J.S.), Hospital Arnau de Vilanova, Lleida; Department of Neurology (D. Cocho), Hospital de Granollers; Department of Neurology (J.K.), F.Ass. Mutua Terrassa; Department of Neurology (E.P.), Hospital de Mataró; Department of Neurology (A.D.F.), Hospital Ramón y Cajal, Madrid; Department of Neurology (M.S.), Hospital La Rioja, Logroño; Department of Neurology (E.Z.-A.), Hospital Virgen del Rocío, Sevilla; Department of Neurology (J.Z.-B.), Hospital Verge de la Cinta, Tortosa; Department of Neurology (I.D.-M.), Hospital de Albacete; Department of Neurology (J.F.-D.), Centro Médico Asturias, Oviedo; Department of Neurology (A.L.), Hospital La Fe, Valencia; Department of Neurology (J.M.), Hospital Virgen de las Nieves, Granada; and Department of Neurology (M.R.-Y.), Hospital Santiago de Compostela, Santiago de Compostela, Spain
| | - Raquel Delgado-Mederos
- From the Department of Neurology (J.M.-F., L.P.-S., R.M., R.D.-M., A.M.-D., P.C.-R., E.J.-X.) and Epidemiology (I.G.), Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute, Barcelona; Departments of Radiology (S.M.-M.) and Neurology (A.R.-C.), Hospital del Mar-Parc de Salut Mar, Barcelona; Unitat RM IDI (E.M.) and Department of Neurosciences (M.H.-P.), Hospital Germans Trias i Pujol, Badalona; Department of Neurology (M.Z.), Arcispedale Santa Maria Nuova IRCCS, Reggio Emilia, Italy; Department of Neurology (M.G.-C.), Hospital de Sant Joan Despí Moises Broggi, Sant Joan Despí, Spain; Department of Neurology (L. Lara), Hospital de León; Department of Neurology (A.B.), Hospital Universitari Son Espases, Palma de Mallorca; Department of Neurology (A.C.), Hospital de Valladolid; Department of Neurology (A.M.D.A.-B.), Hospital de Donostia; Department of Neurology (Y.B.), Hospital de Burgos; Department of Neurology (B.F.), Hospital Universitario La Paz, Universidad Autónoma de Madrid, Instituto de Investigación IdiPaz, Madrid; Department of Neurology (D. Cánovas), Hospital Parc Taulí, Sabadell; Department of Neurology (L. Llull), Hospital Clínic, Barcelona; Department of Neurology (B.Z.), Hospital de Navarra, Pamplona; Department of Neurology (M.F.), Hospital de Basurto, Bilbao; Department of Neurology (I.C.-N.), Hospital San Pedro de Alcántara, Cáceres; Department of Neurology (J.S.), Hospital Arnau de Vilanova, Lleida; Department of Neurology (D. Cocho), Hospital de Granollers; Department of Neurology (J.K.), F.Ass. Mutua Terrassa; Department of Neurology (E.P.), Hospital de Mataró; Department of Neurology (A.D.F.), Hospital Ramón y Cajal, Madrid; Department of Neurology (M.S.), Hospital La Rioja, Logroño; Department of Neurology (E.Z.-A.), Hospital Virgen del Rocío, Sevilla; Department of Neurology (J.Z.-B.), Hospital Verge de la Cinta, Tortosa; Department of Neurology (I.D.-M.), Hospital de Albacete; Department of Neurology (J.F.-D.), Centro Médico Asturias, Oviedo; Department of Neurology (A.L.), Hospital La Fe, Valencia; Department of Neurology (J.M.), Hospital Virgen de las Nieves, Granada; and Department of Neurology (M.R.-Y.), Hospital Santiago de Compostela, Santiago de Compostela, Spain
| | - Alejandro Martínez-Domeño
- From the Department of Neurology (J.M.-F., L.P.-S., R.M., R.D.-M., A.M.-D., P.C.-R., E.J.-X.) and Epidemiology (I.G.), Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute, Barcelona; Departments of Radiology (S.M.-M.) and Neurology (A.R.-C.), Hospital del Mar-Parc de Salut Mar, Barcelona; Unitat RM IDI (E.M.) and Department of Neurosciences (M.H.-P.), Hospital Germans Trias i Pujol, Badalona; Department of Neurology (M.Z.), Arcispedale Santa Maria Nuova IRCCS, Reggio Emilia, Italy; Department of Neurology (M.G.-C.), Hospital de Sant Joan Despí Moises Broggi, Sant Joan Despí, Spain; Department of Neurology (L. Lara), Hospital de León; Department of Neurology (A.B.), Hospital Universitari Son Espases, Palma de Mallorca; Department of Neurology (A.C.), Hospital de Valladolid; Department of Neurology (A.M.D.A.-B.), Hospital de Donostia; Department of Neurology (Y.B.), Hospital de Burgos; Department of Neurology (B.F.), Hospital Universitario La Paz, Universidad Autónoma de Madrid, Instituto de Investigación IdiPaz, Madrid; Department of Neurology (D. Cánovas), Hospital Parc Taulí, Sabadell; Department of Neurology (L. Llull), Hospital Clínic, Barcelona; Department of Neurology (B.Z.), Hospital de Navarra, Pamplona; Department of Neurology (M.F.), Hospital de Basurto, Bilbao; Department of Neurology (I.C.-N.), Hospital San Pedro de Alcántara, Cáceres; Department of Neurology (J.S.), Hospital Arnau de Vilanova, Lleida; Department of Neurology (D. Cocho), Hospital de Granollers; Department of Neurology (J.K.), F.Ass. Mutua Terrassa; Department of Neurology (E.P.), Hospital de Mataró; Department of Neurology (A.D.F.), Hospital Ramón y Cajal, Madrid; Department of Neurology (M.S.), Hospital La Rioja, Logroño; Department of Neurology (E.Z.-A.), Hospital Virgen del Rocío, Sevilla; Department of Neurology (J.Z.-B.), Hospital Verge de la Cinta, Tortosa; Department of Neurology (I.D.-M.), Hospital de Albacete; Department of Neurology (J.F.-D.), Centro Médico Asturias, Oviedo; Department of Neurology (A.L.), Hospital La Fe, Valencia; Department of Neurology (J.M.), Hospital Virgen de las Nieves, Granada; and Department of Neurology (M.R.-Y.), Hospital Santiago de Compostela, Santiago de Compostela, Spain
| | - Pol Camps-Renom
- From the Department of Neurology (J.M.-F., L.P.-S., R.M., R.D.-M., A.M.-D., P.C.-R., E.J.-X.) and Epidemiology (I.G.), Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute, Barcelona; Departments of Radiology (S.M.-M.) and Neurology (A.R.-C.), Hospital del Mar-Parc de Salut Mar, Barcelona; Unitat RM IDI (E.M.) and Department of Neurosciences (M.H.-P.), Hospital Germans Trias i Pujol, Badalona; Department of Neurology (M.Z.), Arcispedale Santa Maria Nuova IRCCS, Reggio Emilia, Italy; Department of Neurology (M.G.-C.), Hospital de Sant Joan Despí Moises Broggi, Sant Joan Despí, Spain; Department of Neurology (L. Lara), Hospital de León; Department of Neurology (A.B.), Hospital Universitari Son Espases, Palma de Mallorca; Department of Neurology (A.C.), Hospital de Valladolid; Department of Neurology (A.M.D.A.-B.), Hospital de Donostia; Department of Neurology (Y.B.), Hospital de Burgos; Department of Neurology (B.F.), Hospital Universitario La Paz, Universidad Autónoma de Madrid, Instituto de Investigación IdiPaz, Madrid; Department of Neurology (D. Cánovas), Hospital Parc Taulí, Sabadell; Department of Neurology (L. Llull), Hospital Clínic, Barcelona; Department of Neurology (B.Z.), Hospital de Navarra, Pamplona; Department of Neurology (M.F.), Hospital de Basurto, Bilbao; Department of Neurology (I.C.-N.), Hospital San Pedro de Alcántara, Cáceres; Department of Neurology (J.S.), Hospital Arnau de Vilanova, Lleida; Department of Neurology (D. Cocho), Hospital de Granollers; Department of Neurology (J.K.), F.Ass. Mutua Terrassa; Department of Neurology (E.P.), Hospital de Mataró; Department of Neurology (A.D.F.), Hospital Ramón y Cajal, Madrid; Department of Neurology (M.S.), Hospital La Rioja, Logroño; Department of Neurology (E.Z.-A.), Hospital Virgen del Rocío, Sevilla; Department of Neurology (J.Z.-B.), Hospital Verge de la Cinta, Tortosa; Department of Neurology (I.D.-M.), Hospital de Albacete; Department of Neurology (J.F.-D.), Centro Médico Asturias, Oviedo; Department of Neurology (A.L.), Hospital La Fe, Valencia; Department of Neurology (J.M.), Hospital Virgen de las Nieves, Granada; and Department of Neurology (M.R.-Y.), Hospital Santiago de Compostela, Santiago de Compostela, Spain
| | - Elena Jiménez-Xarrié
- From the Department of Neurology (J.M.-F., L.P.-S., R.M., R.D.-M., A.M.-D., P.C.-R., E.J.-X.) and Epidemiology (I.G.), Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute, Barcelona; Departments of Radiology (S.M.-M.) and Neurology (A.R.-C.), Hospital del Mar-Parc de Salut Mar, Barcelona; Unitat RM IDI (E.M.) and Department of Neurosciences (M.H.-P.), Hospital Germans Trias i Pujol, Badalona; Department of Neurology (M.Z.), Arcispedale Santa Maria Nuova IRCCS, Reggio Emilia, Italy; Department of Neurology (M.G.-C.), Hospital de Sant Joan Despí Moises Broggi, Sant Joan Despí, Spain; Department of Neurology (L. Lara), Hospital de León; Department of Neurology (A.B.), Hospital Universitari Son Espases, Palma de Mallorca; Department of Neurology (A.C.), Hospital de Valladolid; Department of Neurology (A.M.D.A.-B.), Hospital de Donostia; Department of Neurology (Y.B.), Hospital de Burgos; Department of Neurology (B.F.), Hospital Universitario La Paz, Universidad Autónoma de Madrid, Instituto de Investigación IdiPaz, Madrid; Department of Neurology (D. Cánovas), Hospital Parc Taulí, Sabadell; Department of Neurology (L. Llull), Hospital Clínic, Barcelona; Department of Neurology (B.Z.), Hospital de Navarra, Pamplona; Department of Neurology (M.F.), Hospital de Basurto, Bilbao; Department of Neurology (I.C.-N.), Hospital San Pedro de Alcántara, Cáceres; Department of Neurology (J.S.), Hospital Arnau de Vilanova, Lleida; Department of Neurology (D. Cocho), Hospital de Granollers; Department of Neurology (J.K.), F.Ass. Mutua Terrassa; Department of Neurology (E.P.), Hospital de Mataró; Department of Neurology (A.D.F.), Hospital Ramón y Cajal, Madrid; Department of Neurology (M.S.), Hospital La Rioja, Logroño; Department of Neurology (E.Z.-A.), Hospital Virgen del Rocío, Sevilla; Department of Neurology (J.Z.-B.), Hospital Verge de la Cinta, Tortosa; Department of Neurology (I.D.-M.), Hospital de Albacete; Department of Neurology (J.F.-D.), Centro Médico Asturias, Oviedo; Department of Neurology (A.L.), Hospital La Fe, Valencia; Department of Neurology (J.M.), Hospital Virgen de las Nieves, Granada; and Department of Neurology (M.R.-Y.), Hospital Santiago de Compostela, Santiago de Compostela, Spain
| | - Mariluisa Zedde
- From the Department of Neurology (J.M.-F., L.P.-S., R.M., R.D.-M., A.M.-D., P.C.-R., E.J.-X.) and Epidemiology (I.G.), Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute, Barcelona; Departments of Radiology (S.M.-M.) and Neurology (A.R.-C.), Hospital del Mar-Parc de Salut Mar, Barcelona; Unitat RM IDI (E.M.) and Department of Neurosciences (M.H.-P.), Hospital Germans Trias i Pujol, Badalona; Department of Neurology (M.Z.), Arcispedale Santa Maria Nuova IRCCS, Reggio Emilia, Italy; Department of Neurology (M.G.-C.), Hospital de Sant Joan Despí Moises Broggi, Sant Joan Despí, Spain; Department of Neurology (L. Lara), Hospital de León; Department of Neurology (A.B.), Hospital Universitari Son Espases, Palma de Mallorca; Department of Neurology (A.C.), Hospital de Valladolid; Department of Neurology (A.M.D.A.-B.), Hospital de Donostia; Department of Neurology (Y.B.), Hospital de Burgos; Department of Neurology (B.F.), Hospital Universitario La Paz, Universidad Autónoma de Madrid, Instituto de Investigación IdiPaz, Madrid; Department of Neurology (D. Cánovas), Hospital Parc Taulí, Sabadell; Department of Neurology (L. Llull), Hospital Clínic, Barcelona; Department of Neurology (B.Z.), Hospital de Navarra, Pamplona; Department of Neurology (M.F.), Hospital de Basurto, Bilbao; Department of Neurology (I.C.-N.), Hospital San Pedro de Alcántara, Cáceres; Department of Neurology (J.S.), Hospital Arnau de Vilanova, Lleida; Department of Neurology (D. Cocho), Hospital de Granollers; Department of Neurology (J.K.), F.Ass. Mutua Terrassa; Department of Neurology (E.P.), Hospital de Mataró; Department of Neurology (A.D.F.), Hospital Ramón y Cajal, Madrid; Department of Neurology (M.S.), Hospital La Rioja, Logroño; Department of Neurology (E.Z.-A.), Hospital Virgen del Rocío, Sevilla; Department of Neurology (J.Z.-B.), Hospital Verge de la Cinta, Tortosa; Department of Neurology (I.D.-M.), Hospital de Albacete; Department of Neurology (J.F.-D.), Centro Médico Asturias, Oviedo; Department of Neurology (A.L.), Hospital La Fe, Valencia; Department of Neurology (J.M.), Hospital Virgen de las Nieves, Granada; and Department of Neurology (M.R.-Y.), Hospital Santiago de Compostela, Santiago de Compostela, Spain
| | - Manuel Gómez-Choco
- From the Department of Neurology (J.M.-F., L.P.-S., R.M., R.D.-M., A.M.-D., P.C.-R., E.J.-X.) and Epidemiology (I.G.), Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute, Barcelona; Departments of Radiology (S.M.-M.) and Neurology (A.R.-C.), Hospital del Mar-Parc de Salut Mar, Barcelona; Unitat RM IDI (E.M.) and Department of Neurosciences (M.H.-P.), Hospital Germans Trias i Pujol, Badalona; Department of Neurology (M.Z.), Arcispedale Santa Maria Nuova IRCCS, Reggio Emilia, Italy; Department of Neurology (M.G.-C.), Hospital de Sant Joan Despí Moises Broggi, Sant Joan Despí, Spain; Department of Neurology (L. Lara), Hospital de León; Department of Neurology (A.B.), Hospital Universitari Son Espases, Palma de Mallorca; Department of Neurology (A.C.), Hospital de Valladolid; Department of Neurology (A.M.D.A.-B.), Hospital de Donostia; Department of Neurology (Y.B.), Hospital de Burgos; Department of Neurology (B.F.), Hospital Universitario La Paz, Universidad Autónoma de Madrid, Instituto de Investigación IdiPaz, Madrid; Department of Neurology (D. Cánovas), Hospital Parc Taulí, Sabadell; Department of Neurology (L. Llull), Hospital Clínic, Barcelona; Department of Neurology (B.Z.), Hospital de Navarra, Pamplona; Department of Neurology (M.F.), Hospital de Basurto, Bilbao; Department of Neurology (I.C.-N.), Hospital San Pedro de Alcántara, Cáceres; Department of Neurology (J.S.), Hospital Arnau de Vilanova, Lleida; Department of Neurology (D. Cocho), Hospital de Granollers; Department of Neurology (J.K.), F.Ass. Mutua Terrassa; Department of Neurology (E.P.), Hospital de Mataró; Department of Neurology (A.D.F.), Hospital Ramón y Cajal, Madrid; Department of Neurology (M.S.), Hospital La Rioja, Logroño; Department of Neurology (E.Z.-A.), Hospital Virgen del Rocío, Sevilla; Department of Neurology (J.Z.-B.), Hospital Verge de la Cinta, Tortosa; Department of Neurology (I.D.-M.), Hospital de Albacete; Department of Neurology (J.F.-D.), Centro Médico Asturias, Oviedo; Department of Neurology (A.L.), Hospital La Fe, Valencia; Department of Neurology (J.M.), Hospital Virgen de las Nieves, Granada; and Department of Neurology (M.R.-Y.), Hospital Santiago de Compostela, Santiago de Compostela, Spain
| | - Lidia Lara
- From the Department of Neurology (J.M.-F., L.P.-S., R.M., R.D.-M., A.M.-D., P.C.-R., E.J.-X.) and Epidemiology (I.G.), Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute, Barcelona; Departments of Radiology (S.M.-M.) and Neurology (A.R.-C.), Hospital del Mar-Parc de Salut Mar, Barcelona; Unitat RM IDI (E.M.) and Department of Neurosciences (M.H.-P.), Hospital Germans Trias i Pujol, Badalona; Department of Neurology (M.Z.), Arcispedale Santa Maria Nuova IRCCS, Reggio Emilia, Italy; Department of Neurology (M.G.-C.), Hospital de Sant Joan Despí Moises Broggi, Sant Joan Despí, Spain; Department of Neurology (L. Lara), Hospital de León; Department of Neurology (A.B.), Hospital Universitari Son Espases, Palma de Mallorca; Department of Neurology (A.C.), Hospital de Valladolid; Department of Neurology (A.M.D.A.-B.), Hospital de Donostia; Department of Neurology (Y.B.), Hospital de Burgos; Department of Neurology (B.F.), Hospital Universitario La Paz, Universidad Autónoma de Madrid, Instituto de Investigación IdiPaz, Madrid; Department of Neurology (D. Cánovas), Hospital Parc Taulí, Sabadell; Department of Neurology (L. Llull), Hospital Clínic, Barcelona; Department of Neurology (B.Z.), Hospital de Navarra, Pamplona; Department of Neurology (M.F.), Hospital de Basurto, Bilbao; Department of Neurology (I.C.-N.), Hospital San Pedro de Alcántara, Cáceres; Department of Neurology (J.S.), Hospital Arnau de Vilanova, Lleida; Department of Neurology (D. Cocho), Hospital de Granollers; Department of Neurology (J.K.), F.Ass. Mutua Terrassa; Department of Neurology (E.P.), Hospital de Mataró; Department of Neurology (A.D.F.), Hospital Ramón y Cajal, Madrid; Department of Neurology (M.S.), Hospital La Rioja, Logroño; Department of Neurology (E.Z.-A.), Hospital Virgen del Rocío, Sevilla; Department of Neurology (J.Z.-B.), Hospital Verge de la Cinta, Tortosa; Department of Neurology (I.D.-M.), Hospital de Albacete; Department of Neurology (J.F.-D.), Centro Médico Asturias, Oviedo; Department of Neurology (A.L.), Hospital La Fe, Valencia; Department of Neurology (J.M.), Hospital Virgen de las Nieves, Granada; and Department of Neurology (M.R.-Y.), Hospital Santiago de Compostela, Santiago de Compostela, Spain
| | - Amèlia Boix
- From the Department of Neurology (J.M.-F., L.P.-S., R.M., R.D.-M., A.M.-D., P.C.-R., E.J.-X.) and Epidemiology (I.G.), Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute, Barcelona; Departments of Radiology (S.M.-M.) and Neurology (A.R.-C.), Hospital del Mar-Parc de Salut Mar, Barcelona; Unitat RM IDI (E.M.) and Department of Neurosciences (M.H.-P.), Hospital Germans Trias i Pujol, Badalona; Department of Neurology (M.Z.), Arcispedale Santa Maria Nuova IRCCS, Reggio Emilia, Italy; Department of Neurology (M.G.-C.), Hospital de Sant Joan Despí Moises Broggi, Sant Joan Despí, Spain; Department of Neurology (L. Lara), Hospital de León; Department of Neurology (A.B.), Hospital Universitari Son Espases, Palma de Mallorca; Department of Neurology (A.C.), Hospital de Valladolid; Department of Neurology (A.M.D.A.-B.), Hospital de Donostia; Department of Neurology (Y.B.), Hospital de Burgos; Department of Neurology (B.F.), Hospital Universitario La Paz, Universidad Autónoma de Madrid, Instituto de Investigación IdiPaz, Madrid; Department of Neurology (D. Cánovas), Hospital Parc Taulí, Sabadell; Department of Neurology (L. Llull), Hospital Clínic, Barcelona; Department of Neurology (B.Z.), Hospital de Navarra, Pamplona; Department of Neurology (M.F.), Hospital de Basurto, Bilbao; Department of Neurology (I.C.-N.), Hospital San Pedro de Alcántara, Cáceres; Department of Neurology (J.S.), Hospital Arnau de Vilanova, Lleida; Department of Neurology (D. Cocho), Hospital de Granollers; Department of Neurology (J.K.), F.Ass. Mutua Terrassa; Department of Neurology (E.P.), Hospital de Mataró; Department of Neurology (A.D.F.), Hospital Ramón y Cajal, Madrid; Department of Neurology (M.S.), Hospital La Rioja, Logroño; Department of Neurology (E.Z.-A.), Hospital Virgen del Rocío, Sevilla; Department of Neurology (J.Z.-B.), Hospital Verge de la Cinta, Tortosa; Department of Neurology (I.D.-M.), Hospital de Albacete; Department of Neurology (J.F.-D.), Centro Médico Asturias, Oviedo; Department of Neurology (A.L.), Hospital La Fe, Valencia; Department of Neurology (J.M.), Hospital Virgen de las Nieves, Granada; and Department of Neurology (M.R.-Y.), Hospital Santiago de Compostela, Santiago de Compostela, Spain
| | - Ana Calleja
- From the Department of Neurology (J.M.-F., L.P.-S., R.M., R.D.-M., A.M.-D., P.C.-R., E.J.-X.) and Epidemiology (I.G.), Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute, Barcelona; Departments of Radiology (S.M.-M.) and Neurology (A.R.-C.), Hospital del Mar-Parc de Salut Mar, Barcelona; Unitat RM IDI (E.M.) and Department of Neurosciences (M.H.-P.), Hospital Germans Trias i Pujol, Badalona; Department of Neurology (M.Z.), Arcispedale Santa Maria Nuova IRCCS, Reggio Emilia, Italy; Department of Neurology (M.G.-C.), Hospital de Sant Joan Despí Moises Broggi, Sant Joan Despí, Spain; Department of Neurology (L. Lara), Hospital de León; Department of Neurology (A.B.), Hospital Universitari Son Espases, Palma de Mallorca; Department of Neurology (A.C.), Hospital de Valladolid; Department of Neurology (A.M.D.A.-B.), Hospital de Donostia; Department of Neurology (Y.B.), Hospital de Burgos; Department of Neurology (B.F.), Hospital Universitario La Paz, Universidad Autónoma de Madrid, Instituto de Investigación IdiPaz, Madrid; Department of Neurology (D. Cánovas), Hospital Parc Taulí, Sabadell; Department of Neurology (L. Llull), Hospital Clínic, Barcelona; Department of Neurology (B.Z.), Hospital de Navarra, Pamplona; Department of Neurology (M.F.), Hospital de Basurto, Bilbao; Department of Neurology (I.C.-N.), Hospital San Pedro de Alcántara, Cáceres; Department of Neurology (J.S.), Hospital Arnau de Vilanova, Lleida; Department of Neurology (D. Cocho), Hospital de Granollers; Department of Neurology (J.K.), F.Ass. Mutua Terrassa; Department of Neurology (E.P.), Hospital de Mataró; Department of Neurology (A.D.F.), Hospital Ramón y Cajal, Madrid; Department of Neurology (M.S.), Hospital La Rioja, Logroño; Department of Neurology (E.Z.-A.), Hospital Virgen del Rocío, Sevilla; Department of Neurology (J.Z.-B.), Hospital Verge de la Cinta, Tortosa; Department of Neurology (I.D.-M.), Hospital de Albacete; Department of Neurology (J.F.-D.), Centro Médico Asturias, Oviedo; Department of Neurology (A.L.), Hospital La Fe, Valencia; Department of Neurology (J.M.), Hospital Virgen de las Nieves, Granada; and Department of Neurology (M.R.-Y.), Hospital Santiago de Compostela, Santiago de Compostela, Spain
| | - Ana María De Arce-Borda
- From the Department of Neurology (J.M.-F., L.P.-S., R.M., R.D.-M., A.M.-D., P.C.-R., E.J.-X.) and Epidemiology (I.G.), Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute, Barcelona; Departments of Radiology (S.M.-M.) and Neurology (A.R.-C.), Hospital del Mar-Parc de Salut Mar, Barcelona; Unitat RM IDI (E.M.) and Department of Neurosciences (M.H.-P.), Hospital Germans Trias i Pujol, Badalona; Department of Neurology (M.Z.), Arcispedale Santa Maria Nuova IRCCS, Reggio Emilia, Italy; Department of Neurology (M.G.-C.), Hospital de Sant Joan Despí Moises Broggi, Sant Joan Despí, Spain; Department of Neurology (L. Lara), Hospital de León; Department of Neurology (A.B.), Hospital Universitari Son Espases, Palma de Mallorca; Department of Neurology (A.C.), Hospital de Valladolid; Department of Neurology (A.M.D.A.-B.), Hospital de Donostia; Department of Neurology (Y.B.), Hospital de Burgos; Department of Neurology (B.F.), Hospital Universitario La Paz, Universidad Autónoma de Madrid, Instituto de Investigación IdiPaz, Madrid; Department of Neurology (D. Cánovas), Hospital Parc Taulí, Sabadell; Department of Neurology (L. Llull), Hospital Clínic, Barcelona; Department of Neurology (B.Z.), Hospital de Navarra, Pamplona; Department of Neurology (M.F.), Hospital de Basurto, Bilbao; Department of Neurology (I.C.-N.), Hospital San Pedro de Alcántara, Cáceres; Department of Neurology (J.S.), Hospital Arnau de Vilanova, Lleida; Department of Neurology (D. Cocho), Hospital de Granollers; Department of Neurology (J.K.), F.Ass. Mutua Terrassa; Department of Neurology (E.P.), Hospital de Mataró; Department of Neurology (A.D.F.), Hospital Ramón y Cajal, Madrid; Department of Neurology (M.S.), Hospital La Rioja, Logroño; Department of Neurology (E.Z.-A.), Hospital Virgen del Rocío, Sevilla; Department of Neurology (J.Z.-B.), Hospital Verge de la Cinta, Tortosa; Department of Neurology (I.D.-M.), Hospital de Albacete; Department of Neurology (J.F.-D.), Centro Médico Asturias, Oviedo; Department of Neurology (A.L.), Hospital La Fe, Valencia; Department of Neurology (J.M.), Hospital Virgen de las Nieves, Granada; and Department of Neurology (M.R.-Y.), Hospital Santiago de Compostela, Santiago de Compostela, Spain
| | - Yolanda Bravo
- From the Department of Neurology (J.M.-F., L.P.-S., R.M., R.D.-M., A.M.-D., P.C.-R., E.J.-X.) and Epidemiology (I.G.), Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute, Barcelona; Departments of Radiology (S.M.-M.) and Neurology (A.R.-C.), Hospital del Mar-Parc de Salut Mar, Barcelona; Unitat RM IDI (E.M.) and Department of Neurosciences (M.H.-P.), Hospital Germans Trias i Pujol, Badalona; Department of Neurology (M.Z.), Arcispedale Santa Maria Nuova IRCCS, Reggio Emilia, Italy; Department of Neurology (M.G.-C.), Hospital de Sant Joan Despí Moises Broggi, Sant Joan Despí, Spain; Department of Neurology (L. Lara), Hospital de León; Department of Neurology (A.B.), Hospital Universitari Son Espases, Palma de Mallorca; Department of Neurology (A.C.), Hospital de Valladolid; Department of Neurology (A.M.D.A.-B.), Hospital de Donostia; Department of Neurology (Y.B.), Hospital de Burgos; Department of Neurology (B.F.), Hospital Universitario La Paz, Universidad Autónoma de Madrid, Instituto de Investigación IdiPaz, Madrid; Department of Neurology (D. Cánovas), Hospital Parc Taulí, Sabadell; Department of Neurology (L. Llull), Hospital Clínic, Barcelona; Department of Neurology (B.Z.), Hospital de Navarra, Pamplona; Department of Neurology (M.F.), Hospital de Basurto, Bilbao; Department of Neurology (I.C.-N.), Hospital San Pedro de Alcántara, Cáceres; Department of Neurology (J.S.), Hospital Arnau de Vilanova, Lleida; Department of Neurology (D. Cocho), Hospital de Granollers; Department of Neurology (J.K.), F.Ass. Mutua Terrassa; Department of Neurology (E.P.), Hospital de Mataró; Department of Neurology (A.D.F.), Hospital Ramón y Cajal, Madrid; Department of Neurology (M.S.), Hospital La Rioja, Logroño; Department of Neurology (E.Z.-A.), Hospital Virgen del Rocío, Sevilla; Department of Neurology (J.Z.-B.), Hospital Verge de la Cinta, Tortosa; Department of Neurology (I.D.-M.), Hospital de Albacete; Department of Neurology (J.F.-D.), Centro Médico Asturias, Oviedo; Department of Neurology (A.L.), Hospital La Fe, Valencia; Department of Neurology (J.M.), Hospital Virgen de las Nieves, Granada; and Department of Neurology (M.R.-Y.), Hospital Santiago de Compostela, Santiago de Compostela, Spain
| | - Blanca Fuentes
- From the Department of Neurology (J.M.-F., L.P.-S., R.M., R.D.-M., A.M.-D., P.C.-R., E.J.-X.) and Epidemiology (I.G.), Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute, Barcelona; Departments of Radiology (S.M.-M.) and Neurology (A.R.-C.), Hospital del Mar-Parc de Salut Mar, Barcelona; Unitat RM IDI (E.M.) and Department of Neurosciences (M.H.-P.), Hospital Germans Trias i Pujol, Badalona; Department of Neurology (M.Z.), Arcispedale Santa Maria Nuova IRCCS, Reggio Emilia, Italy; Department of Neurology (M.G.-C.), Hospital de Sant Joan Despí Moises Broggi, Sant Joan Despí, Spain; Department of Neurology (L. Lara), Hospital de León; Department of Neurology (A.B.), Hospital Universitari Son Espases, Palma de Mallorca; Department of Neurology (A.C.), Hospital de Valladolid; Department of Neurology (A.M.D.A.-B.), Hospital de Donostia; Department of Neurology (Y.B.), Hospital de Burgos; Department of Neurology (B.F.), Hospital Universitario La Paz, Universidad Autónoma de Madrid, Instituto de Investigación IdiPaz, Madrid; Department of Neurology (D. Cánovas), Hospital Parc Taulí, Sabadell; Department of Neurology (L. Llull), Hospital Clínic, Barcelona; Department of Neurology (B.Z.), Hospital de Navarra, Pamplona; Department of Neurology (M.F.), Hospital de Basurto, Bilbao; Department of Neurology (I.C.-N.), Hospital San Pedro de Alcántara, Cáceres; Department of Neurology (J.S.), Hospital Arnau de Vilanova, Lleida; Department of Neurology (D. Cocho), Hospital de Granollers; Department of Neurology (J.K.), F.Ass. Mutua Terrassa; Department of Neurology (E.P.), Hospital de Mataró; Department of Neurology (A.D.F.), Hospital Ramón y Cajal, Madrid; Department of Neurology (M.S.), Hospital La Rioja, Logroño; Department of Neurology (E.Z.-A.), Hospital Virgen del Rocío, Sevilla; Department of Neurology (J.Z.-B.), Hospital Verge de la Cinta, Tortosa; Department of Neurology (I.D.-M.), Hospital de Albacete; Department of Neurology (J.F.-D.), Centro Médico Asturias, Oviedo; Department of Neurology (A.L.), Hospital La Fe, Valencia; Department of Neurology (J.M.), Hospital Virgen de las Nieves, Granada; and Department of Neurology (M.R.-Y.), Hospital Santiago de Compostela, Santiago de Compostela, Spain
| | - María Hernández-Pérez
- From the Department of Neurology (J.M.-F., L.P.-S., R.M., R.D.-M., A.M.-D., P.C.-R., E.J.-X.) and Epidemiology (I.G.), Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute, Barcelona; Departments of Radiology (S.M.-M.) and Neurology (A.R.-C.), Hospital del Mar-Parc de Salut Mar, Barcelona; Unitat RM IDI (E.M.) and Department of Neurosciences (M.H.-P.), Hospital Germans Trias i Pujol, Badalona; Department of Neurology (M.Z.), Arcispedale Santa Maria Nuova IRCCS, Reggio Emilia, Italy; Department of Neurology (M.G.-C.), Hospital de Sant Joan Despí Moises Broggi, Sant Joan Despí, Spain; Department of Neurology (L. Lara), Hospital de León; Department of Neurology (A.B.), Hospital Universitari Son Espases, Palma de Mallorca; Department of Neurology (A.C.), Hospital de Valladolid; Department of Neurology (A.M.D.A.-B.), Hospital de Donostia; Department of Neurology (Y.B.), Hospital de Burgos; Department of Neurology (B.F.), Hospital Universitario La Paz, Universidad Autónoma de Madrid, Instituto de Investigación IdiPaz, Madrid; Department of Neurology (D. Cánovas), Hospital Parc Taulí, Sabadell; Department of Neurology (L. Llull), Hospital Clínic, Barcelona; Department of Neurology (B.Z.), Hospital de Navarra, Pamplona; Department of Neurology (M.F.), Hospital de Basurto, Bilbao; Department of Neurology (I.C.-N.), Hospital San Pedro de Alcántara, Cáceres; Department of Neurology (J.S.), Hospital Arnau de Vilanova, Lleida; Department of Neurology (D. Cocho), Hospital de Granollers; Department of Neurology (J.K.), F.Ass. Mutua Terrassa; Department of Neurology (E.P.), Hospital de Mataró; Department of Neurology (A.D.F.), Hospital Ramón y Cajal, Madrid; Department of Neurology (M.S.), Hospital La Rioja, Logroño; Department of Neurology (E.Z.-A.), Hospital Virgen del Rocío, Sevilla; Department of Neurology (J.Z.-B.), Hospital Verge de la Cinta, Tortosa; Department of Neurology (I.D.-M.), Hospital de Albacete; Department of Neurology (J.F.-D.), Centro Médico Asturias, Oviedo; Department of Neurology (A.L.), Hospital La Fe, Valencia; Department of Neurology (J.M.), Hospital Virgen de las Nieves, Granada; and Department of Neurology (M.R.-Y.), Hospital Santiago de Compostela, Santiago de Compostela, Spain
| | - David Cánovas
- From the Department of Neurology (J.M.-F., L.P.-S., R.M., R.D.-M., A.M.-D., P.C.-R., E.J.-X.) and Epidemiology (I.G.), Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute, Barcelona; Departments of Radiology (S.M.-M.) and Neurology (A.R.-C.), Hospital del Mar-Parc de Salut Mar, Barcelona; Unitat RM IDI (E.M.) and Department of Neurosciences (M.H.-P.), Hospital Germans Trias i Pujol, Badalona; Department of Neurology (M.Z.), Arcispedale Santa Maria Nuova IRCCS, Reggio Emilia, Italy; Department of Neurology (M.G.-C.), Hospital de Sant Joan Despí Moises Broggi, Sant Joan Despí, Spain; Department of Neurology (L. Lara), Hospital de León; Department of Neurology (A.B.), Hospital Universitari Son Espases, Palma de Mallorca; Department of Neurology (A.C.), Hospital de Valladolid; Department of Neurology (A.M.D.A.-B.), Hospital de Donostia; Department of Neurology (Y.B.), Hospital de Burgos; Department of Neurology (B.F.), Hospital Universitario La Paz, Universidad Autónoma de Madrid, Instituto de Investigación IdiPaz, Madrid; Department of Neurology (D. Cánovas), Hospital Parc Taulí, Sabadell; Department of Neurology (L. Llull), Hospital Clínic, Barcelona; Department of Neurology (B.Z.), Hospital de Navarra, Pamplona; Department of Neurology (M.F.), Hospital de Basurto, Bilbao; Department of Neurology (I.C.-N.), Hospital San Pedro de Alcántara, Cáceres; Department of Neurology (J.S.), Hospital Arnau de Vilanova, Lleida; Department of Neurology (D. Cocho), Hospital de Granollers; Department of Neurology (J.K.), F.Ass. Mutua Terrassa; Department of Neurology (E.P.), Hospital de Mataró; Department of Neurology (A.D.F.), Hospital Ramón y Cajal, Madrid; Department of Neurology (M.S.), Hospital La Rioja, Logroño; Department of Neurology (E.Z.-A.), Hospital Virgen del Rocío, Sevilla; Department of Neurology (J.Z.-B.), Hospital Verge de la Cinta, Tortosa; Department of Neurology (I.D.-M.), Hospital de Albacete; Department of Neurology (J.F.-D.), Centro Médico Asturias, Oviedo; Department of Neurology (A.L.), Hospital La Fe, Valencia; Department of Neurology (J.M.), Hospital Virgen de las Nieves, Granada; and Department of Neurology (M.R.-Y.), Hospital Santiago de Compostela, Santiago de Compostela, Spain
| | - Laura Llull
- From the Department of Neurology (J.M.-F., L.P.-S., R.M., R.D.-M., A.M.-D., P.C.-R., E.J.-X.) and Epidemiology (I.G.), Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute, Barcelona; Departments of Radiology (S.M.-M.) and Neurology (A.R.-C.), Hospital del Mar-Parc de Salut Mar, Barcelona; Unitat RM IDI (E.M.) and Department of Neurosciences (M.H.-P.), Hospital Germans Trias i Pujol, Badalona; Department of Neurology (M.Z.), Arcispedale Santa Maria Nuova IRCCS, Reggio Emilia, Italy; Department of Neurology (M.G.-C.), Hospital de Sant Joan Despí Moises Broggi, Sant Joan Despí, Spain; Department of Neurology (L. Lara), Hospital de León; Department of Neurology (A.B.), Hospital Universitari Son Espases, Palma de Mallorca; Department of Neurology (A.C.), Hospital de Valladolid; Department of Neurology (A.M.D.A.-B.), Hospital de Donostia; Department of Neurology (Y.B.), Hospital de Burgos; Department of Neurology (B.F.), Hospital Universitario La Paz, Universidad Autónoma de Madrid, Instituto de Investigación IdiPaz, Madrid; Department of Neurology (D. Cánovas), Hospital Parc Taulí, Sabadell; Department of Neurology (L. Llull), Hospital Clínic, Barcelona; Department of Neurology (B.Z.), Hospital de Navarra, Pamplona; Department of Neurology (M.F.), Hospital de Basurto, Bilbao; Department of Neurology (I.C.-N.), Hospital San Pedro de Alcántara, Cáceres; Department of Neurology (J.S.), Hospital Arnau de Vilanova, Lleida; Department of Neurology (D. Cocho), Hospital de Granollers; Department of Neurology (J.K.), F.Ass. Mutua Terrassa; Department of Neurology (E.P.), Hospital de Mataró; Department of Neurology (A.D.F.), Hospital Ramón y Cajal, Madrid; Department of Neurology (M.S.), Hospital La Rioja, Logroño; Department of Neurology (E.Z.-A.), Hospital Virgen del Rocío, Sevilla; Department of Neurology (J.Z.-B.), Hospital Verge de la Cinta, Tortosa; Department of Neurology (I.D.-M.), Hospital de Albacete; Department of Neurology (J.F.-D.), Centro Médico Asturias, Oviedo; Department of Neurology (A.L.), Hospital La Fe, Valencia; Department of Neurology (J.M.), Hospital Virgen de las Nieves, Granada; and Department of Neurology (M.R.-Y.), Hospital Santiago de Compostela, Santiago de Compostela, Spain
| | - Beatriz Zandio
- From the Department of Neurology (J.M.-F., L.P.-S., R.M., R.D.-M., A.M.-D., P.C.-R., E.J.-X.) and Epidemiology (I.G.), Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute, Barcelona; Departments of Radiology (S.M.-M.) and Neurology (A.R.-C.), Hospital del Mar-Parc de Salut Mar, Barcelona; Unitat RM IDI (E.M.) and Department of Neurosciences (M.H.-P.), Hospital Germans Trias i Pujol, Badalona; Department of Neurology (M.Z.), Arcispedale Santa Maria Nuova IRCCS, Reggio Emilia, Italy; Department of Neurology (M.G.-C.), Hospital de Sant Joan Despí Moises Broggi, Sant Joan Despí, Spain; Department of Neurology (L. Lara), Hospital de León; Department of Neurology (A.B.), Hospital Universitari Son Espases, Palma de Mallorca; Department of Neurology (A.C.), Hospital de Valladolid; Department of Neurology (A.M.D.A.-B.), Hospital de Donostia; Department of Neurology (Y.B.), Hospital de Burgos; Department of Neurology (B.F.), Hospital Universitario La Paz, Universidad Autónoma de Madrid, Instituto de Investigación IdiPaz, Madrid; Department of Neurology (D. Cánovas), Hospital Parc Taulí, Sabadell; Department of Neurology (L. Llull), Hospital Clínic, Barcelona; Department of Neurology (B.Z.), Hospital de Navarra, Pamplona; Department of Neurology (M.F.), Hospital de Basurto, Bilbao; Department of Neurology (I.C.-N.), Hospital San Pedro de Alcántara, Cáceres; Department of Neurology (J.S.), Hospital Arnau de Vilanova, Lleida; Department of Neurology (D. Cocho), Hospital de Granollers; Department of Neurology (J.K.), F.Ass. Mutua Terrassa; Department of Neurology (E.P.), Hospital de Mataró; Department of Neurology (A.D.F.), Hospital Ramón y Cajal, Madrid; Department of Neurology (M.S.), Hospital La Rioja, Logroño; Department of Neurology (E.Z.-A.), Hospital Virgen del Rocío, Sevilla; Department of Neurology (J.Z.-B.), Hospital Verge de la Cinta, Tortosa; Department of Neurology (I.D.-M.), Hospital de Albacete; Department of Neurology (J.F.-D.), Centro Médico Asturias, Oviedo; Department of Neurology (A.L.), Hospital La Fe, Valencia; Department of Neurology (J.M.), Hospital Virgen de las Nieves, Granada; and Department of Neurology (M.R.-Y.), Hospital Santiago de Compostela, Santiago de Compostela, Spain
| | - Marimar Freijo
- From the Department of Neurology (J.M.-F., L.P.-S., R.M., R.D.-M., A.M.-D., P.C.-R., E.J.-X.) and Epidemiology (I.G.), Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute, Barcelona; Departments of Radiology (S.M.-M.) and Neurology (A.R.-C.), Hospital del Mar-Parc de Salut Mar, Barcelona; Unitat RM IDI (E.M.) and Department of Neurosciences (M.H.-P.), Hospital Germans Trias i Pujol, Badalona; Department of Neurology (M.Z.), Arcispedale Santa Maria Nuova IRCCS, Reggio Emilia, Italy; Department of Neurology (M.G.-C.), Hospital de Sant Joan Despí Moises Broggi, Sant Joan Despí, Spain; Department of Neurology (L. Lara), Hospital de León; Department of Neurology (A.B.), Hospital Universitari Son Espases, Palma de Mallorca; Department of Neurology (A.C.), Hospital de Valladolid; Department of Neurology (A.M.D.A.-B.), Hospital de Donostia; Department of Neurology (Y.B.), Hospital de Burgos; Department of Neurology (B.F.), Hospital Universitario La Paz, Universidad Autónoma de Madrid, Instituto de Investigación IdiPaz, Madrid; Department of Neurology (D. Cánovas), Hospital Parc Taulí, Sabadell; Department of Neurology (L. Llull), Hospital Clínic, Barcelona; Department of Neurology (B.Z.), Hospital de Navarra, Pamplona; Department of Neurology (M.F.), Hospital de Basurto, Bilbao; Department of Neurology (I.C.-N.), Hospital San Pedro de Alcántara, Cáceres; Department of Neurology (J.S.), Hospital Arnau de Vilanova, Lleida; Department of Neurology (D. Cocho), Hospital de Granollers; Department of Neurology (J.K.), F.Ass. Mutua Terrassa; Department of Neurology (E.P.), Hospital de Mataró; Department of Neurology (A.D.F.), Hospital Ramón y Cajal, Madrid; Department of Neurology (M.S.), Hospital La Rioja, Logroño; Department of Neurology (E.Z.-A.), Hospital Virgen del Rocío, Sevilla; Department of Neurology (J.Z.-B.), Hospital Verge de la Cinta, Tortosa; Department of Neurology (I.D.-M.), Hospital de Albacete; Department of Neurology (J.F.-D.), Centro Médico Asturias, Oviedo; Department of Neurology (A.L.), Hospital La Fe, Valencia; Department of Neurology (J.M.), Hospital Virgen de las Nieves, Granada; and Department of Neurology (M.R.-Y.), Hospital Santiago de Compostela, Santiago de Compostela, Spain
| | - Ignacio Casado-Naranjo
- From the Department of Neurology (J.M.-F., L.P.-S., R.M., R.D.-M., A.M.-D., P.C.-R., E.J.-X.) and Epidemiology (I.G.), Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute, Barcelona; Departments of Radiology (S.M.-M.) and Neurology (A.R.-C.), Hospital del Mar-Parc de Salut Mar, Barcelona; Unitat RM IDI (E.M.) and Department of Neurosciences (M.H.-P.), Hospital Germans Trias i Pujol, Badalona; Department of Neurology (M.Z.), Arcispedale Santa Maria Nuova IRCCS, Reggio Emilia, Italy; Department of Neurology (M.G.-C.), Hospital de Sant Joan Despí Moises Broggi, Sant Joan Despí, Spain; Department of Neurology (L. Lara), Hospital de León; Department of Neurology (A.B.), Hospital Universitari Son Espases, Palma de Mallorca; Department of Neurology (A.C.), Hospital de Valladolid; Department of Neurology (A.M.D.A.-B.), Hospital de Donostia; Department of Neurology (Y.B.), Hospital de Burgos; Department of Neurology (B.F.), Hospital Universitario La Paz, Universidad Autónoma de Madrid, Instituto de Investigación IdiPaz, Madrid; Department of Neurology (D. Cánovas), Hospital Parc Taulí, Sabadell; Department of Neurology (L. Llull), Hospital Clínic, Barcelona; Department of Neurology (B.Z.), Hospital de Navarra, Pamplona; Department of Neurology (M.F.), Hospital de Basurto, Bilbao; Department of Neurology (I.C.-N.), Hospital San Pedro de Alcántara, Cáceres; Department of Neurology (J.S.), Hospital Arnau de Vilanova, Lleida; Department of Neurology (D. Cocho), Hospital de Granollers; Department of Neurology (J.K.), F.Ass. Mutua Terrassa; Department of Neurology (E.P.), Hospital de Mataró; Department of Neurology (A.D.F.), Hospital Ramón y Cajal, Madrid; Department of Neurology (M.S.), Hospital La Rioja, Logroño; Department of Neurology (E.Z.-A.), Hospital Virgen del Rocío, Sevilla; Department of Neurology (J.Z.-B.), Hospital Verge de la Cinta, Tortosa; Department of Neurology (I.D.-M.), Hospital de Albacete; Department of Neurology (J.F.-D.), Centro Médico Asturias, Oviedo; Department of Neurology (A.L.), Hospital La Fe, Valencia; Department of Neurology (J.M.), Hospital Virgen de las Nieves, Granada; and Department of Neurology (M.R.-Y.), Hospital Santiago de Compostela, Santiago de Compostela, Spain
| | - Jordi Sanahuja
- From the Department of Neurology (J.M.-F., L.P.-S., R.M., R.D.-M., A.M.-D., P.C.-R., E.J.-X.) and Epidemiology (I.G.), Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute, Barcelona; Departments of Radiology (S.M.-M.) and Neurology (A.R.-C.), Hospital del Mar-Parc de Salut Mar, Barcelona; Unitat RM IDI (E.M.) and Department of Neurosciences (M.H.-P.), Hospital Germans Trias i Pujol, Badalona; Department of Neurology (M.Z.), Arcispedale Santa Maria Nuova IRCCS, Reggio Emilia, Italy; Department of Neurology (M.G.-C.), Hospital de Sant Joan Despí Moises Broggi, Sant Joan Despí, Spain; Department of Neurology (L. Lara), Hospital de León; Department of Neurology (A.B.), Hospital Universitari Son Espases, Palma de Mallorca; Department of Neurology (A.C.), Hospital de Valladolid; Department of Neurology (A.M.D.A.-B.), Hospital de Donostia; Department of Neurology (Y.B.), Hospital de Burgos; Department of Neurology (B.F.), Hospital Universitario La Paz, Universidad Autónoma de Madrid, Instituto de Investigación IdiPaz, Madrid; Department of Neurology (D. Cánovas), Hospital Parc Taulí, Sabadell; Department of Neurology (L. Llull), Hospital Clínic, Barcelona; Department of Neurology (B.Z.), Hospital de Navarra, Pamplona; Department of Neurology (M.F.), Hospital de Basurto, Bilbao; Department of Neurology (I.C.-N.), Hospital San Pedro de Alcántara, Cáceres; Department of Neurology (J.S.), Hospital Arnau de Vilanova, Lleida; Department of Neurology (D. Cocho), Hospital de Granollers; Department of Neurology (J.K.), F.Ass. Mutua Terrassa; Department of Neurology (E.P.), Hospital de Mataró; Department of Neurology (A.D.F.), Hospital Ramón y Cajal, Madrid; Department of Neurology (M.S.), Hospital La Rioja, Logroño; Department of Neurology (E.Z.-A.), Hospital Virgen del Rocío, Sevilla; Department of Neurology (J.Z.-B.), Hospital Verge de la Cinta, Tortosa; Department of Neurology (I.D.-M.), Hospital de Albacete; Department of Neurology (J.F.-D.), Centro Médico Asturias, Oviedo; Department of Neurology (A.L.), Hospital La Fe, Valencia; Department of Neurology (J.M.), Hospital Virgen de las Nieves, Granada; and Department of Neurology (M.R.-Y.), Hospital Santiago de Compostela, Santiago de Compostela, Spain
| | - Dolores Cocho
- From the Department of Neurology (J.M.-F., L.P.-S., R.M., R.D.-M., A.M.-D., P.C.-R., E.J.-X.) and Epidemiology (I.G.), Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute, Barcelona; Departments of Radiology (S.M.-M.) and Neurology (A.R.-C.), Hospital del Mar-Parc de Salut Mar, Barcelona; Unitat RM IDI (E.M.) and Department of Neurosciences (M.H.-P.), Hospital Germans Trias i Pujol, Badalona; Department of Neurology (M.Z.), Arcispedale Santa Maria Nuova IRCCS, Reggio Emilia, Italy; Department of Neurology (M.G.-C.), Hospital de Sant Joan Despí Moises Broggi, Sant Joan Despí, Spain; Department of Neurology (L. Lara), Hospital de León; Department of Neurology (A.B.), Hospital Universitari Son Espases, Palma de Mallorca; Department of Neurology (A.C.), Hospital de Valladolid; Department of Neurology (A.M.D.A.-B.), Hospital de Donostia; Department of Neurology (Y.B.), Hospital de Burgos; Department of Neurology (B.F.), Hospital Universitario La Paz, Universidad Autónoma de Madrid, Instituto de Investigación IdiPaz, Madrid; Department of Neurology (D. Cánovas), Hospital Parc Taulí, Sabadell; Department of Neurology (L. Llull), Hospital Clínic, Barcelona; Department of Neurology (B.Z.), Hospital de Navarra, Pamplona; Department of Neurology (M.F.), Hospital de Basurto, Bilbao; Department of Neurology (I.C.-N.), Hospital San Pedro de Alcántara, Cáceres; Department of Neurology (J.S.), Hospital Arnau de Vilanova, Lleida; Department of Neurology (D. Cocho), Hospital de Granollers; Department of Neurology (J.K.), F.Ass. Mutua Terrassa; Department of Neurology (E.P.), Hospital de Mataró; Department of Neurology (A.D.F.), Hospital Ramón y Cajal, Madrid; Department of Neurology (M.S.), Hospital La Rioja, Logroño; Department of Neurology (E.Z.-A.), Hospital Virgen del Rocío, Sevilla; Department of Neurology (J.Z.-B.), Hospital Verge de la Cinta, Tortosa; Department of Neurology (I.D.-M.), Hospital de Albacete; Department of Neurology (J.F.-D.), Centro Médico Asturias, Oviedo; Department of Neurology (A.L.), Hospital La Fe, Valencia; Department of Neurology (J.M.), Hospital Virgen de las Nieves, Granada; and Department of Neurology (M.R.-Y.), Hospital Santiago de Compostela, Santiago de Compostela, Spain
| | - Jerzy Krupinski
- From the Department of Neurology (J.M.-F., L.P.-S., R.M., R.D.-M., A.M.-D., P.C.-R., E.J.-X.) and Epidemiology (I.G.), Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute, Barcelona; Departments of Radiology (S.M.-M.) and Neurology (A.R.-C.), Hospital del Mar-Parc de Salut Mar, Barcelona; Unitat RM IDI (E.M.) and Department of Neurosciences (M.H.-P.), Hospital Germans Trias i Pujol, Badalona; Department of Neurology (M.Z.), Arcispedale Santa Maria Nuova IRCCS, Reggio Emilia, Italy; Department of Neurology (M.G.-C.), Hospital de Sant Joan Despí Moises Broggi, Sant Joan Despí, Spain; Department of Neurology (L. Lara), Hospital de León; Department of Neurology (A.B.), Hospital Universitari Son Espases, Palma de Mallorca; Department of Neurology (A.C.), Hospital de Valladolid; Department of Neurology (A.M.D.A.-B.), Hospital de Donostia; Department of Neurology (Y.B.), Hospital de Burgos; Department of Neurology (B.F.), Hospital Universitario La Paz, Universidad Autónoma de Madrid, Instituto de Investigación IdiPaz, Madrid; Department of Neurology (D. Cánovas), Hospital Parc Taulí, Sabadell; Department of Neurology (L. Llull), Hospital Clínic, Barcelona; Department of Neurology (B.Z.), Hospital de Navarra, Pamplona; Department of Neurology (M.F.), Hospital de Basurto, Bilbao; Department of Neurology (I.C.-N.), Hospital San Pedro de Alcántara, Cáceres; Department of Neurology (J.S.), Hospital Arnau de Vilanova, Lleida; Department of Neurology (D. Cocho), Hospital de Granollers; Department of Neurology (J.K.), F.Ass. Mutua Terrassa; Department of Neurology (E.P.), Hospital de Mataró; Department of Neurology (A.D.F.), Hospital Ramón y Cajal, Madrid; Department of Neurology (M.S.), Hospital La Rioja, Logroño; Department of Neurology (E.Z.-A.), Hospital Virgen del Rocío, Sevilla; Department of Neurology (J.Z.-B.), Hospital Verge de la Cinta, Tortosa; Department of Neurology (I.D.-M.), Hospital de Albacete; Department of Neurology (J.F.-D.), Centro Médico Asturias, Oviedo; Department of Neurology (A.L.), Hospital La Fe, Valencia; Department of Neurology (J.M.), Hospital Virgen de las Nieves, Granada; and Department of Neurology (M.R.-Y.), Hospital Santiago de Compostela, Santiago de Compostela, Spain
| | - Ana Rodríguez-Campello
- From the Department of Neurology (J.M.-F., L.P.-S., R.M., R.D.-M., A.M.-D., P.C.-R., E.J.-X.) and Epidemiology (I.G.), Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute, Barcelona; Departments of Radiology (S.M.-M.) and Neurology (A.R.-C.), Hospital del Mar-Parc de Salut Mar, Barcelona; Unitat RM IDI (E.M.) and Department of Neurosciences (M.H.-P.), Hospital Germans Trias i Pujol, Badalona; Department of Neurology (M.Z.), Arcispedale Santa Maria Nuova IRCCS, Reggio Emilia, Italy; Department of Neurology (M.G.-C.), Hospital de Sant Joan Despí Moises Broggi, Sant Joan Despí, Spain; Department of Neurology (L. Lara), Hospital de León; Department of Neurology (A.B.), Hospital Universitari Son Espases, Palma de Mallorca; Department of Neurology (A.C.), Hospital de Valladolid; Department of Neurology (A.M.D.A.-B.), Hospital de Donostia; Department of Neurology (Y.B.), Hospital de Burgos; Department of Neurology (B.F.), Hospital Universitario La Paz, Universidad Autónoma de Madrid, Instituto de Investigación IdiPaz, Madrid; Department of Neurology (D. Cánovas), Hospital Parc Taulí, Sabadell; Department of Neurology (L. Llull), Hospital Clínic, Barcelona; Department of Neurology (B.Z.), Hospital de Navarra, Pamplona; Department of Neurology (M.F.), Hospital de Basurto, Bilbao; Department of Neurology (I.C.-N.), Hospital San Pedro de Alcántara, Cáceres; Department of Neurology (J.S.), Hospital Arnau de Vilanova, Lleida; Department of Neurology (D. Cocho), Hospital de Granollers; Department of Neurology (J.K.), F.Ass. Mutua Terrassa; Department of Neurology (E.P.), Hospital de Mataró; Department of Neurology (A.D.F.), Hospital Ramón y Cajal, Madrid; Department of Neurology (M.S.), Hospital La Rioja, Logroño; Department of Neurology (E.Z.-A.), Hospital Virgen del Rocío, Sevilla; Department of Neurology (J.Z.-B.), Hospital Verge de la Cinta, Tortosa; Department of Neurology (I.D.-M.), Hospital de Albacete; Department of Neurology (J.F.-D.), Centro Médico Asturias, Oviedo; Department of Neurology (A.L.), Hospital La Fe, Valencia; Department of Neurology (J.M.), Hospital Virgen de las Nieves, Granada; and Department of Neurology (M.R.-Y.), Hospital Santiago de Compostela, Santiago de Compostela, Spain
| | - Ernest Palomeras
- From the Department of Neurology (J.M.-F., L.P.-S., R.M., R.D.-M., A.M.-D., P.C.-R., E.J.-X.) and Epidemiology (I.G.), Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute, Barcelona; Departments of Radiology (S.M.-M.) and Neurology (A.R.-C.), Hospital del Mar-Parc de Salut Mar, Barcelona; Unitat RM IDI (E.M.) and Department of Neurosciences (M.H.-P.), Hospital Germans Trias i Pujol, Badalona; Department of Neurology (M.Z.), Arcispedale Santa Maria Nuova IRCCS, Reggio Emilia, Italy; Department of Neurology (M.G.-C.), Hospital de Sant Joan Despí Moises Broggi, Sant Joan Despí, Spain; Department of Neurology (L. Lara), Hospital de León; Department of Neurology (A.B.), Hospital Universitari Son Espases, Palma de Mallorca; Department of Neurology (A.C.), Hospital de Valladolid; Department of Neurology (A.M.D.A.-B.), Hospital de Donostia; Department of Neurology (Y.B.), Hospital de Burgos; Department of Neurology (B.F.), Hospital Universitario La Paz, Universidad Autónoma de Madrid, Instituto de Investigación IdiPaz, Madrid; Department of Neurology (D. Cánovas), Hospital Parc Taulí, Sabadell; Department of Neurology (L. Llull), Hospital Clínic, Barcelona; Department of Neurology (B.Z.), Hospital de Navarra, Pamplona; Department of Neurology (M.F.), Hospital de Basurto, Bilbao; Department of Neurology (I.C.-N.), Hospital San Pedro de Alcántara, Cáceres; Department of Neurology (J.S.), Hospital Arnau de Vilanova, Lleida; Department of Neurology (D. Cocho), Hospital de Granollers; Department of Neurology (J.K.), F.Ass. Mutua Terrassa; Department of Neurology (E.P.), Hospital de Mataró; Department of Neurology (A.D.F.), Hospital Ramón y Cajal, Madrid; Department of Neurology (M.S.), Hospital La Rioja, Logroño; Department of Neurology (E.Z.-A.), Hospital Virgen del Rocío, Sevilla; Department of Neurology (J.Z.-B.), Hospital Verge de la Cinta, Tortosa; Department of Neurology (I.D.-M.), Hospital de Albacete; Department of Neurology (J.F.-D.), Centro Médico Asturias, Oviedo; Department of Neurology (A.L.), Hospital La Fe, Valencia; Department of Neurology (J.M.), Hospital Virgen de las Nieves, Granada; and Department of Neurology (M.R.-Y.), Hospital Santiago de Compostela, Santiago de Compostela, Spain
| | - Alicia De Felipe
- From the Department of Neurology (J.M.-F., L.P.-S., R.M., R.D.-M., A.M.-D., P.C.-R., E.J.-X.) and Epidemiology (I.G.), Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute, Barcelona; Departments of Radiology (S.M.-M.) and Neurology (A.R.-C.), Hospital del Mar-Parc de Salut Mar, Barcelona; Unitat RM IDI (E.M.) and Department of Neurosciences (M.H.-P.), Hospital Germans Trias i Pujol, Badalona; Department of Neurology (M.Z.), Arcispedale Santa Maria Nuova IRCCS, Reggio Emilia, Italy; Department of Neurology (M.G.-C.), Hospital de Sant Joan Despí Moises Broggi, Sant Joan Despí, Spain; Department of Neurology (L. Lara), Hospital de León; Department of Neurology (A.B.), Hospital Universitari Son Espases, Palma de Mallorca; Department of Neurology (A.C.), Hospital de Valladolid; Department of Neurology (A.M.D.A.-B.), Hospital de Donostia; Department of Neurology (Y.B.), Hospital de Burgos; Department of Neurology (B.F.), Hospital Universitario La Paz, Universidad Autónoma de Madrid, Instituto de Investigación IdiPaz, Madrid; Department of Neurology (D. Cánovas), Hospital Parc Taulí, Sabadell; Department of Neurology (L. Llull), Hospital Clínic, Barcelona; Department of Neurology (B.Z.), Hospital de Navarra, Pamplona; Department of Neurology (M.F.), Hospital de Basurto, Bilbao; Department of Neurology (I.C.-N.), Hospital San Pedro de Alcántara, Cáceres; Department of Neurology (J.S.), Hospital Arnau de Vilanova, Lleida; Department of Neurology (D. Cocho), Hospital de Granollers; Department of Neurology (J.K.), F.Ass. Mutua Terrassa; Department of Neurology (E.P.), Hospital de Mataró; Department of Neurology (A.D.F.), Hospital Ramón y Cajal, Madrid; Department of Neurology (M.S.), Hospital La Rioja, Logroño; Department of Neurology (E.Z.-A.), Hospital Virgen del Rocío, Sevilla; Department of Neurology (J.Z.-B.), Hospital Verge de la Cinta, Tortosa; Department of Neurology (I.D.-M.), Hospital de Albacete; Department of Neurology (J.F.-D.), Centro Médico Asturias, Oviedo; Department of Neurology (A.L.), Hospital La Fe, Valencia; Department of Neurology (J.M.), Hospital Virgen de las Nieves, Granada; and Department of Neurology (M.R.-Y.), Hospital Santiago de Compostela, Santiago de Compostela, Spain
| | - Marta Serrano
- From the Department of Neurology (J.M.-F., L.P.-S., R.M., R.D.-M., A.M.-D., P.C.-R., E.J.-X.) and Epidemiology (I.G.), Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute, Barcelona; Departments of Radiology (S.M.-M.) and Neurology (A.R.-C.), Hospital del Mar-Parc de Salut Mar, Barcelona; Unitat RM IDI (E.M.) and Department of Neurosciences (M.H.-P.), Hospital Germans Trias i Pujol, Badalona; Department of Neurology (M.Z.), Arcispedale Santa Maria Nuova IRCCS, Reggio Emilia, Italy; Department of Neurology (M.G.-C.), Hospital de Sant Joan Despí Moises Broggi, Sant Joan Despí, Spain; Department of Neurology (L. Lara), Hospital de León; Department of Neurology (A.B.), Hospital Universitari Son Espases, Palma de Mallorca; Department of Neurology (A.C.), Hospital de Valladolid; Department of Neurology (A.M.D.A.-B.), Hospital de Donostia; Department of Neurology (Y.B.), Hospital de Burgos; Department of Neurology (B.F.), Hospital Universitario La Paz, Universidad Autónoma de Madrid, Instituto de Investigación IdiPaz, Madrid; Department of Neurology (D. Cánovas), Hospital Parc Taulí, Sabadell; Department of Neurology (L. Llull), Hospital Clínic, Barcelona; Department of Neurology (B.Z.), Hospital de Navarra, Pamplona; Department of Neurology (M.F.), Hospital de Basurto, Bilbao; Department of Neurology (I.C.-N.), Hospital San Pedro de Alcántara, Cáceres; Department of Neurology (J.S.), Hospital Arnau de Vilanova, Lleida; Department of Neurology (D. Cocho), Hospital de Granollers; Department of Neurology (J.K.), F.Ass. Mutua Terrassa; Department of Neurology (E.P.), Hospital de Mataró; Department of Neurology (A.D.F.), Hospital Ramón y Cajal, Madrid; Department of Neurology (M.S.), Hospital La Rioja, Logroño; Department of Neurology (E.Z.-A.), Hospital Virgen del Rocío, Sevilla; Department of Neurology (J.Z.-B.), Hospital Verge de la Cinta, Tortosa; Department of Neurology (I.D.-M.), Hospital de Albacete; Department of Neurology (J.F.-D.), Centro Médico Asturias, Oviedo; Department of Neurology (A.L.), Hospital La Fe, Valencia; Department of Neurology (J.M.), Hospital Virgen de las Nieves, Granada; and Department of Neurology (M.R.-Y.), Hospital Santiago de Compostela, Santiago de Compostela, Spain
| | - Elena Zapata-Arriaza
- From the Department of Neurology (J.M.-F., L.P.-S., R.M., R.D.-M., A.M.-D., P.C.-R., E.J.-X.) and Epidemiology (I.G.), Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute, Barcelona; Departments of Radiology (S.M.-M.) and Neurology (A.R.-C.), Hospital del Mar-Parc de Salut Mar, Barcelona; Unitat RM IDI (E.M.) and Department of Neurosciences (M.H.-P.), Hospital Germans Trias i Pujol, Badalona; Department of Neurology (M.Z.), Arcispedale Santa Maria Nuova IRCCS, Reggio Emilia, Italy; Department of Neurology (M.G.-C.), Hospital de Sant Joan Despí Moises Broggi, Sant Joan Despí, Spain; Department of Neurology (L. Lara), Hospital de León; Department of Neurology (A.B.), Hospital Universitari Son Espases, Palma de Mallorca; Department of Neurology (A.C.), Hospital de Valladolid; Department of Neurology (A.M.D.A.-B.), Hospital de Donostia; Department of Neurology (Y.B.), Hospital de Burgos; Department of Neurology (B.F.), Hospital Universitario La Paz, Universidad Autónoma de Madrid, Instituto de Investigación IdiPaz, Madrid; Department of Neurology (D. Cánovas), Hospital Parc Taulí, Sabadell; Department of Neurology (L. Llull), Hospital Clínic, Barcelona; Department of Neurology (B.Z.), Hospital de Navarra, Pamplona; Department of Neurology (M.F.), Hospital de Basurto, Bilbao; Department of Neurology (I.C.-N.), Hospital San Pedro de Alcántara, Cáceres; Department of Neurology (J.S.), Hospital Arnau de Vilanova, Lleida; Department of Neurology (D. Cocho), Hospital de Granollers; Department of Neurology (J.K.), F.Ass. Mutua Terrassa; Department of Neurology (E.P.), Hospital de Mataró; Department of Neurology (A.D.F.), Hospital Ramón y Cajal, Madrid; Department of Neurology (M.S.), Hospital La Rioja, Logroño; Department of Neurology (E.Z.-A.), Hospital Virgen del Rocío, Sevilla; Department of Neurology (J.Z.-B.), Hospital Verge de la Cinta, Tortosa; Department of Neurology (I.D.-M.), Hospital de Albacete; Department of Neurology (J.F.-D.), Centro Médico Asturias, Oviedo; Department of Neurology (A.L.), Hospital La Fe, Valencia; Department of Neurology (J.M.), Hospital Virgen de las Nieves, Granada; and Department of Neurology (M.R.-Y.), Hospital Santiago de Compostela, Santiago de Compostela, Spain
| | - Josep Zaragoza-Brunet
- From the Department of Neurology (J.M.-F., L.P.-S., R.M., R.D.-M., A.M.-D., P.C.-R., E.J.-X.) and Epidemiology (I.G.), Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute, Barcelona; Departments of Radiology (S.M.-M.) and Neurology (A.R.-C.), Hospital del Mar-Parc de Salut Mar, Barcelona; Unitat RM IDI (E.M.) and Department of Neurosciences (M.H.-P.), Hospital Germans Trias i Pujol, Badalona; Department of Neurology (M.Z.), Arcispedale Santa Maria Nuova IRCCS, Reggio Emilia, Italy; Department of Neurology (M.G.-C.), Hospital de Sant Joan Despí Moises Broggi, Sant Joan Despí, Spain; Department of Neurology (L. Lara), Hospital de León; Department of Neurology (A.B.), Hospital Universitari Son Espases, Palma de Mallorca; Department of Neurology (A.C.), Hospital de Valladolid; Department of Neurology (A.M.D.A.-B.), Hospital de Donostia; Department of Neurology (Y.B.), Hospital de Burgos; Department of Neurology (B.F.), Hospital Universitario La Paz, Universidad Autónoma de Madrid, Instituto de Investigación IdiPaz, Madrid; Department of Neurology (D. Cánovas), Hospital Parc Taulí, Sabadell; Department of Neurology (L. Llull), Hospital Clínic, Barcelona; Department of Neurology (B.Z.), Hospital de Navarra, Pamplona; Department of Neurology (M.F.), Hospital de Basurto, Bilbao; Department of Neurology (I.C.-N.), Hospital San Pedro de Alcántara, Cáceres; Department of Neurology (J.S.), Hospital Arnau de Vilanova, Lleida; Department of Neurology (D. Cocho), Hospital de Granollers; Department of Neurology (J.K.), F.Ass. Mutua Terrassa; Department of Neurology (E.P.), Hospital de Mataró; Department of Neurology (A.D.F.), Hospital Ramón y Cajal, Madrid; Department of Neurology (M.S.), Hospital La Rioja, Logroño; Department of Neurology (E.Z.-A.), Hospital Virgen del Rocío, Sevilla; Department of Neurology (J.Z.-B.), Hospital Verge de la Cinta, Tortosa; Department of Neurology (I.D.-M.), Hospital de Albacete; Department of Neurology (J.F.-D.), Centro Médico Asturias, Oviedo; Department of Neurology (A.L.), Hospital La Fe, Valencia; Department of Neurology (J.M.), Hospital Virgen de las Nieves, Granada; and Department of Neurology (M.R.-Y.), Hospital Santiago de Compostela, Santiago de Compostela, Spain
| | - Inmaculada Díaz-Maroto
- From the Department of Neurology (J.M.-F., L.P.-S., R.M., R.D.-M., A.M.-D., P.C.-R., E.J.-X.) and Epidemiology (I.G.), Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute, Barcelona; Departments of Radiology (S.M.-M.) and Neurology (A.R.-C.), Hospital del Mar-Parc de Salut Mar, Barcelona; Unitat RM IDI (E.M.) and Department of Neurosciences (M.H.-P.), Hospital Germans Trias i Pujol, Badalona; Department of Neurology (M.Z.), Arcispedale Santa Maria Nuova IRCCS, Reggio Emilia, Italy; Department of Neurology (M.G.-C.), Hospital de Sant Joan Despí Moises Broggi, Sant Joan Despí, Spain; Department of Neurology (L. Lara), Hospital de León; Department of Neurology (A.B.), Hospital Universitari Son Espases, Palma de Mallorca; Department of Neurology (A.C.), Hospital de Valladolid; Department of Neurology (A.M.D.A.-B.), Hospital de Donostia; Department of Neurology (Y.B.), Hospital de Burgos; Department of Neurology (B.F.), Hospital Universitario La Paz, Universidad Autónoma de Madrid, Instituto de Investigación IdiPaz, Madrid; Department of Neurology (D. Cánovas), Hospital Parc Taulí, Sabadell; Department of Neurology (L. Llull), Hospital Clínic, Barcelona; Department of Neurology (B.Z.), Hospital de Navarra, Pamplona; Department of Neurology (M.F.), Hospital de Basurto, Bilbao; Department of Neurology (I.C.-N.), Hospital San Pedro de Alcántara, Cáceres; Department of Neurology (J.S.), Hospital Arnau de Vilanova, Lleida; Department of Neurology (D. Cocho), Hospital de Granollers; Department of Neurology (J.K.), F.Ass. Mutua Terrassa; Department of Neurology (E.P.), Hospital de Mataró; Department of Neurology (A.D.F.), Hospital Ramón y Cajal, Madrid; Department of Neurology (M.S.), Hospital La Rioja, Logroño; Department of Neurology (E.Z.-A.), Hospital Virgen del Rocío, Sevilla; Department of Neurology (J.Z.-B.), Hospital Verge de la Cinta, Tortosa; Department of Neurology (I.D.-M.), Hospital de Albacete; Department of Neurology (J.F.-D.), Centro Médico Asturias, Oviedo; Department of Neurology (A.L.), Hospital La Fe, Valencia; Department of Neurology (J.M.), Hospital Virgen de las Nieves, Granada; and Department of Neurology (M.R.-Y.), Hospital Santiago de Compostela, Santiago de Compostela, Spain
| | - Jessica Fernández-Domínguez
- From the Department of Neurology (J.M.-F., L.P.-S., R.M., R.D.-M., A.M.-D., P.C.-R., E.J.-X.) and Epidemiology (I.G.), Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute, Barcelona; Departments of Radiology (S.M.-M.) and Neurology (A.R.-C.), Hospital del Mar-Parc de Salut Mar, Barcelona; Unitat RM IDI (E.M.) and Department of Neurosciences (M.H.-P.), Hospital Germans Trias i Pujol, Badalona; Department of Neurology (M.Z.), Arcispedale Santa Maria Nuova IRCCS, Reggio Emilia, Italy; Department of Neurology (M.G.-C.), Hospital de Sant Joan Despí Moises Broggi, Sant Joan Despí, Spain; Department of Neurology (L. Lara), Hospital de León; Department of Neurology (A.B.), Hospital Universitari Son Espases, Palma de Mallorca; Department of Neurology (A.C.), Hospital de Valladolid; Department of Neurology (A.M.D.A.-B.), Hospital de Donostia; Department of Neurology (Y.B.), Hospital de Burgos; Department of Neurology (B.F.), Hospital Universitario La Paz, Universidad Autónoma de Madrid, Instituto de Investigación IdiPaz, Madrid; Department of Neurology (D. Cánovas), Hospital Parc Taulí, Sabadell; Department of Neurology (L. Llull), Hospital Clínic, Barcelona; Department of Neurology (B.Z.), Hospital de Navarra, Pamplona; Department of Neurology (M.F.), Hospital de Basurto, Bilbao; Department of Neurology (I.C.-N.), Hospital San Pedro de Alcántara, Cáceres; Department of Neurology (J.S.), Hospital Arnau de Vilanova, Lleida; Department of Neurology (D. Cocho), Hospital de Granollers; Department of Neurology (J.K.), F.Ass. Mutua Terrassa; Department of Neurology (E.P.), Hospital de Mataró; Department of Neurology (A.D.F.), Hospital Ramón y Cajal, Madrid; Department of Neurology (M.S.), Hospital La Rioja, Logroño; Department of Neurology (E.Z.-A.), Hospital Virgen del Rocío, Sevilla; Department of Neurology (J.Z.-B.), Hospital Verge de la Cinta, Tortosa; Department of Neurology (I.D.-M.), Hospital de Albacete; Department of Neurology (J.F.-D.), Centro Médico Asturias, Oviedo; Department of Neurology (A.L.), Hospital La Fe, Valencia; Department of Neurology (J.M.), Hospital Virgen de las Nieves, Granada; and Department of Neurology (M.R.-Y.), Hospital Santiago de Compostela, Santiago de Compostela, Spain
| | - Aida Lago
- From the Department of Neurology (J.M.-F., L.P.-S., R.M., R.D.-M., A.M.-D., P.C.-R., E.J.-X.) and Epidemiology (I.G.), Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute, Barcelona; Departments of Radiology (S.M.-M.) and Neurology (A.R.-C.), Hospital del Mar-Parc de Salut Mar, Barcelona; Unitat RM IDI (E.M.) and Department of Neurosciences (M.H.-P.), Hospital Germans Trias i Pujol, Badalona; Department of Neurology (M.Z.), Arcispedale Santa Maria Nuova IRCCS, Reggio Emilia, Italy; Department of Neurology (M.G.-C.), Hospital de Sant Joan Despí Moises Broggi, Sant Joan Despí, Spain; Department of Neurology (L. Lara), Hospital de León; Department of Neurology (A.B.), Hospital Universitari Son Espases, Palma de Mallorca; Department of Neurology (A.C.), Hospital de Valladolid; Department of Neurology (A.M.D.A.-B.), Hospital de Donostia; Department of Neurology (Y.B.), Hospital de Burgos; Department of Neurology (B.F.), Hospital Universitario La Paz, Universidad Autónoma de Madrid, Instituto de Investigación IdiPaz, Madrid; Department of Neurology (D. Cánovas), Hospital Parc Taulí, Sabadell; Department of Neurology (L. Llull), Hospital Clínic, Barcelona; Department of Neurology (B.Z.), Hospital de Navarra, Pamplona; Department of Neurology (M.F.), Hospital de Basurto, Bilbao; Department of Neurology (I.C.-N.), Hospital San Pedro de Alcántara, Cáceres; Department of Neurology (J.S.), Hospital Arnau de Vilanova, Lleida; Department of Neurology (D. Cocho), Hospital de Granollers; Department of Neurology (J.K.), F.Ass. Mutua Terrassa; Department of Neurology (E.P.), Hospital de Mataró; Department of Neurology (A.D.F.), Hospital Ramón y Cajal, Madrid; Department of Neurology (M.S.), Hospital La Rioja, Logroño; Department of Neurology (E.Z.-A.), Hospital Virgen del Rocío, Sevilla; Department of Neurology (J.Z.-B.), Hospital Verge de la Cinta, Tortosa; Department of Neurology (I.D.-M.), Hospital de Albacete; Department of Neurology (J.F.-D.), Centro Médico Asturias, Oviedo; Department of Neurology (A.L.), Hospital La Fe, Valencia; Department of Neurology (J.M.), Hospital Virgen de las Nieves, Granada; and Department of Neurology (M.R.-Y.), Hospital Santiago de Compostela, Santiago de Compostela, Spain
| | - José Maestre
- From the Department of Neurology (J.M.-F., L.P.-S., R.M., R.D.-M., A.M.-D., P.C.-R., E.J.-X.) and Epidemiology (I.G.), Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute, Barcelona; Departments of Radiology (S.M.-M.) and Neurology (A.R.-C.), Hospital del Mar-Parc de Salut Mar, Barcelona; Unitat RM IDI (E.M.) and Department of Neurosciences (M.H.-P.), Hospital Germans Trias i Pujol, Badalona; Department of Neurology (M.Z.), Arcispedale Santa Maria Nuova IRCCS, Reggio Emilia, Italy; Department of Neurology (M.G.-C.), Hospital de Sant Joan Despí Moises Broggi, Sant Joan Despí, Spain; Department of Neurology (L. Lara), Hospital de León; Department of Neurology (A.B.), Hospital Universitari Son Espases, Palma de Mallorca; Department of Neurology (A.C.), Hospital de Valladolid; Department of Neurology (A.M.D.A.-B.), Hospital de Donostia; Department of Neurology (Y.B.), Hospital de Burgos; Department of Neurology (B.F.), Hospital Universitario La Paz, Universidad Autónoma de Madrid, Instituto de Investigación IdiPaz, Madrid; Department of Neurology (D. Cánovas), Hospital Parc Taulí, Sabadell; Department of Neurology (L. Llull), Hospital Clínic, Barcelona; Department of Neurology (B.Z.), Hospital de Navarra, Pamplona; Department of Neurology (M.F.), Hospital de Basurto, Bilbao; Department of Neurology (I.C.-N.), Hospital San Pedro de Alcántara, Cáceres; Department of Neurology (J.S.), Hospital Arnau de Vilanova, Lleida; Department of Neurology (D. Cocho), Hospital de Granollers; Department of Neurology (J.K.), F.Ass. Mutua Terrassa; Department of Neurology (E.P.), Hospital de Mataró; Department of Neurology (A.D.F.), Hospital Ramón y Cajal, Madrid; Department of Neurology (M.S.), Hospital La Rioja, Logroño; Department of Neurology (E.Z.-A.), Hospital Virgen del Rocío, Sevilla; Department of Neurology (J.Z.-B.), Hospital Verge de la Cinta, Tortosa; Department of Neurology (I.D.-M.), Hospital de Albacete; Department of Neurology (J.F.-D.), Centro Médico Asturias, Oviedo; Department of Neurology (A.L.), Hospital La Fe, Valencia; Department of Neurology (J.M.), Hospital Virgen de las Nieves, Granada; and Department of Neurology (M.R.-Y.), Hospital Santiago de Compostela, Santiago de Compostela, Spain
| | - Manuel Rodríguez-Yáñez
- From the Department of Neurology (J.M.-F., L.P.-S., R.M., R.D.-M., A.M.-D., P.C.-R., E.J.-X.) and Epidemiology (I.G.), Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute, Barcelona; Departments of Radiology (S.M.-M.) and Neurology (A.R.-C.), Hospital del Mar-Parc de Salut Mar, Barcelona; Unitat RM IDI (E.M.) and Department of Neurosciences (M.H.-P.), Hospital Germans Trias i Pujol, Badalona; Department of Neurology (M.Z.), Arcispedale Santa Maria Nuova IRCCS, Reggio Emilia, Italy; Department of Neurology (M.G.-C.), Hospital de Sant Joan Despí Moises Broggi, Sant Joan Despí, Spain; Department of Neurology (L. Lara), Hospital de León; Department of Neurology (A.B.), Hospital Universitari Son Espases, Palma de Mallorca; Department of Neurology (A.C.), Hospital de Valladolid; Department of Neurology (A.M.D.A.-B.), Hospital de Donostia; Department of Neurology (Y.B.), Hospital de Burgos; Department of Neurology (B.F.), Hospital Universitario La Paz, Universidad Autónoma de Madrid, Instituto de Investigación IdiPaz, Madrid; Department of Neurology (D. Cánovas), Hospital Parc Taulí, Sabadell; Department of Neurology (L. Llull), Hospital Clínic, Barcelona; Department of Neurology (B.Z.), Hospital de Navarra, Pamplona; Department of Neurology (M.F.), Hospital de Basurto, Bilbao; Department of Neurology (I.C.-N.), Hospital San Pedro de Alcántara, Cáceres; Department of Neurology (J.S.), Hospital Arnau de Vilanova, Lleida; Department of Neurology (D. Cocho), Hospital de Granollers; Department of Neurology (J.K.), F.Ass. Mutua Terrassa; Department of Neurology (E.P.), Hospital de Mataró; Department of Neurology (A.D.F.), Hospital Ramón y Cajal, Madrid; Department of Neurology (M.S.), Hospital La Rioja, Logroño; Department of Neurology (E.Z.-A.), Hospital Virgen del Rocío, Sevilla; Department of Neurology (J.Z.-B.), Hospital Verge de la Cinta, Tortosa; Department of Neurology (I.D.-M.), Hospital de Albacete; Department of Neurology (J.F.-D.), Centro Médico Asturias, Oviedo; Department of Neurology (A.L.), Hospital La Fe, Valencia; Department of Neurology (J.M.), Hospital Virgen de las Nieves, Granada; and Department of Neurology (M.R.-Y.), Hospital Santiago de Compostela, Santiago de Compostela, Spain
| | - Ignasi Gich
- From the Department of Neurology (J.M.-F., L.P.-S., R.M., R.D.-M., A.M.-D., P.C.-R., E.J.-X.) and Epidemiology (I.G.), Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute, Barcelona; Departments of Radiology (S.M.-M.) and Neurology (A.R.-C.), Hospital del Mar-Parc de Salut Mar, Barcelona; Unitat RM IDI (E.M.) and Department of Neurosciences (M.H.-P.), Hospital Germans Trias i Pujol, Badalona; Department of Neurology (M.Z.), Arcispedale Santa Maria Nuova IRCCS, Reggio Emilia, Italy; Department of Neurology (M.G.-C.), Hospital de Sant Joan Despí Moises Broggi, Sant Joan Despí, Spain; Department of Neurology (L. Lara), Hospital de León; Department of Neurology (A.B.), Hospital Universitari Son Espases, Palma de Mallorca; Department of Neurology (A.C.), Hospital de Valladolid; Department of Neurology (A.M.D.A.-B.), Hospital de Donostia; Department of Neurology (Y.B.), Hospital de Burgos; Department of Neurology (B.F.), Hospital Universitario La Paz, Universidad Autónoma de Madrid, Instituto de Investigación IdiPaz, Madrid; Department of Neurology (D. Cánovas), Hospital Parc Taulí, Sabadell; Department of Neurology (L. Llull), Hospital Clínic, Barcelona; Department of Neurology (B.Z.), Hospital de Navarra, Pamplona; Department of Neurology (M.F.), Hospital de Basurto, Bilbao; Department of Neurology (I.C.-N.), Hospital San Pedro de Alcántara, Cáceres; Department of Neurology (J.S.), Hospital Arnau de Vilanova, Lleida; Department of Neurology (D. Cocho), Hospital de Granollers; Department of Neurology (J.K.), F.Ass. Mutua Terrassa; Department of Neurology (E.P.), Hospital de Mataró; Department of Neurology (A.D.F.), Hospital Ramón y Cajal, Madrid; Department of Neurology (M.S.), Hospital La Rioja, Logroño; Department of Neurology (E.Z.-A.), Hospital Virgen del Rocío, Sevilla; Department of Neurology (J.Z.-B.), Hospital Verge de la Cinta, Tortosa; Department of Neurology (I.D.-M.), Hospital de Albacete; Department of Neurology (J.F.-D.), Centro Médico Asturias, Oviedo; Department of Neurology (A.L.), Hospital La Fe, Valencia; Department of Neurology (J.M.), Hospital Virgen de las Nieves, Granada; and Department of Neurology (M.R.-Y.), Hospital Santiago de Compostela, Santiago de Compostela, Spain
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14
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Soo Y, Abrigo JM, Leung KT, Tsang SF, Ip HL, Ma SH, Ma K, Fong WC, Li SH, Li R, Ng PW, Wong KK, Liu W, Lam BYK, Wong KSL, Mok V, Chu WCW, Leung TW. Risk of intracerebral haemorrhage in Chinese patients with atrial fibrillation on warfarin with cerebral microbleeds: the IPAAC-Warfarin study. J Neurol Neurosurg Psychiatry 2019; 90:428-435. [PMID: 30554138 DOI: 10.1136/jnnp-2018-319104] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2018] [Revised: 09/27/2018] [Accepted: 10/29/2018] [Indexed: 11/03/2022]
Abstract
BACKGROUND AND PURPOSE Cerebral microbleeds (CMBs), which predict future intracerebral haemorrhage (ICH), may guide anticoagulant decisions for atrial fibrillation (AF). We aimed to evaluate the risk of warfarin-associated ICH in Chinese patients with AF with CMBs. METHODS In this prospective, observational, multicentre study, we recruited Chinese patients with AF who were on or intended to start anticoagulation with warfarin from six hospitals in Hong Kong. CMBs were evaluated with 3T MRI brain at baseline. Primary outcome was clinical ICH at 2-year follow-up. Secondary outcomes were ischaemic stroke, systemic embolism, mortality of all causes and modified Rankin Scale ≥3. Outcome events were compared between patients with and without CMBs. RESULTS A total of 290 patients were recruited; 53 patients were excluded by predefined criteria. Among the 237 patients included in the final analysis, CMBs were observed in 84 (35.4%) patients, and 11 had ≥5 CMBs. The mean follow-up period was 22.4±10.3 months. Compared with patients without CMBs, patients with CMBs had numerically higher rate of ICH (3.6% vs 0.7%, p=0.129). The rate of ICH was lower than ischaemic stroke for patients with 0 to 4 CMBs, but higher for those with ≥5 CMBs. CMB count (C-index 0.82) was more sensitive than HAS-BLED (C-index 0.55) and CHA2DS2-VASc (C-index 0.63) scores in predicting ICH. CONCLUSIONS In Chinese patients with AF on warfarin, presence of multiple CMBs may be associated with higher rate of ICH than ischaemic stroke. Larger studies through international collaboration are needed to determine the risk:benefit ratio of oral anticoagulants in patients with AF of different ethnic origins.
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Affiliation(s)
- Yannie Soo
- Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Ma Liu Shui, Hong Kong
| | - Jill M Abrigo
- Department of Imaging and Interventional Radiology, Prince of Wales Hospital, The Chinese University of Hong Kong, Ma Liu Shui, Hong Kong
| | - Kam Tat Leung
- Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Ma Liu Shui, Hong Kong
| | - Suk Fung Tsang
- Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Ma Liu Shui, Hong Kong
| | - Hing Lung Ip
- Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Ma Liu Shui, Hong Kong
| | - Sze Ho Ma
- Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Ma Liu Shui, Hong Kong
| | - Karen Ma
- Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Ma Liu Shui, Hong Kong
| | - Wing Chi Fong
- Department of Medicine, Queen Elizabeth Hospital, King's Park, Hong Kong
| | - Siu Hung Li
- Department of Medicine, Northern District Hospital, Sheung Shui, Hong Kong
| | - Richard Li
- Department of Medicine, Pamela Youde Nethersole Eastern Hospital, Chai Wan, Hong Kong
| | - Ping Wing Ng
- Department of Medicine and Geriatrics, United Christian Hospital, Kwun Tong, Hong Kong
| | - Kwok Kui Wong
- Department of Medicine, Yan Chai Hospital, Tsuen Wan, Hong Kong
| | - Wenyan Liu
- Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Ma Liu Shui, Hong Kong
| | - Bonnie Y K Lam
- Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Ma Liu Shui, Hong Kong
| | - Ka Sing Lawrence Wong
- Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Ma Liu Shui, Hong Kong
| | - Vincent Mok
- Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Ma Liu Shui, Hong Kong
| | - Winnie Chiu Wing Chu
- Department of Imaging and Interventional Radiology, Prince of Wales Hospital, The Chinese University of Hong Kong, Ma Liu Shui, Hong Kong
| | - Thomas W Leung
- Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Ma Liu Shui, Hong Kong
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15
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Herm J, Schurig J, Martinek MR, Höltgen R, Schirdewan A, Kirchhof P, Wieczorek M, Pürerfellner H, Heuschmann PU, Fiebach JB, Haeusler KG. MRI-detected brain lesions in AF patients without further stroke risk factors undergoing ablation - a retrospective analysis of prospective studies. BMC Cardiovasc Disord 2019; 19:58. [PMID: 30871479 PMCID: PMC6419420 DOI: 10.1186/s12872-019-1035-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2018] [Accepted: 02/27/2019] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Atrial fibrillation (AF) without other stroke risk factors is assumed to have a low annual stroke risk comparable to patients without AF. Therefore, current clinical guidelines do not recommend oral anticoagulation for stroke prevention of AF in patients without stroke risk factors. We analyzed brain magnetic resonance imaging (MRI) imaging to estimate the rate of clinically inapparent ("silent") ischemic brain lesions in these patients. METHODS We pooled individual patient-level data from three prospective studies comprising stroke-free patients with symptomatic AF. All study patients underwent brain MRI within 24-48 h before planned left atrial catheter ablation. MRIs were analyzed by a neuroradiologist blinded to clinical data. RESULTS In total, 175 patients (median age 60 (IQR 54-67) years, 32% female, median CHA2DS2-VASc = 1 (IQR 0-2), 33% persistent AF) were included. In AF patients without or with at least one stroke risk factor, at least one silent ischemic brain lesion was observed in 4 (8%) out of 48 and 10 (8%) out of 127 patients, respectively (p > 0.99). Presence of silent ischemic brain lesions was related to age (p = 0.03) but not to AF pattern (p = 0.77). At least one cerebral microbleed was detected in 5 (13%) out of 30 AF patients without stroke risk factors and 25 (25%) out of 108 AF patients with stroke risk factors (p = 0.2). Presence of cerebral microbleeds was related to male sex (p = 0.04) or peripheral artery occlusive disease (p = 0.03). CONCLUSION In patients with symptomatic AF scheduled for ablation, brain MRI detected silent ischemic brain lesions in approximately one in 12 patients, and microbleeds in one in 5 patients. The prevalence of silent ischemic brain lesions did not differ in AF patients with or without further stroke risk factors.
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Affiliation(s)
- Juliane Herm
- Department of Neurology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Johannes Schurig
- Department of Neurology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Martin R Martinek
- Department of Cardiology, Ordensklinikum Linz Elisabethinen, Linz, Austria
| | - Reinhard Höltgen
- Department of Cardiology and Electrophysiology, St. Agnes-Hospital Bocholt, Bocholt, Germany
| | | | - Paulus Kirchhof
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
| | - Marcus Wieczorek
- Department of Cardiology and Electrophysiology, St. Agnes-Hospital Bocholt, Bocholt, Germany.,Witten/Herdecke University, School of Medicine, Witten, Germany
| | | | - Peter U Heuschmann
- Institute of Clinical Epidemiology and Biometry, University of Würzburg, Würzburg, Germany.,Clinical Trial Center Würzburg, University Hospital Würzburg, Würzburg, Germany.,Comprehensive Heart Failure Center, University of Würzburg, Würzburg, Germany
| | - Jochen B Fiebach
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Karl Georg Haeusler
- Department of Neurology, Universitätsklinikum Würzburg, Josef-Schneider-Str. 11 97080, Würzburg, Germany.
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16
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Cerebral Microbleeds and the Safety of Anticoagulation in Ischemic Stroke Patients: A Systematic Review and Meta-Analysis. Clin Neuropharmacol 2018; 41:202-209. [PMID: 30418264 DOI: 10.1097/wnf.0000000000000306] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVES The objective of this study was to investigate the safety of anticoagulation in ischemic stroke (IS) patients with cerebral microbleeds (CMBs). METHODS PubMed, Web of Science, Elsevier Clinical Key, Google Scholar, and Cochrane Library from 1996 to July 2018 were searched to identify relevant studies that included IS patients, underwent T2*-weighted gradient recalled echo, or susceptibility-weighted imaging for detection CMBs and used anticoagulants during follow-up. Primary outcome of interest was intracerebral hemorrhage (ICH). Secondary outcomes were hemorrhage transformation, IS, total mortality, and new developed CMBs. We critically appraised studies and conducted a systematic review and meta-analysis following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidance. RESULTS We included 7 observational studies. Cerebral microbleeds were associated with a significantly elevated risk of anticoagulation-related ICH (odds ratio, 4.01; 95% confidence interval, 1.82-8.81; P = 0.001). It was significant for warfarin (odds ratio, 8.02; 95% confidence interval, 1.51-42.62; P = 0.015). New developed CMBs in patients on warfarin treatment were associated with baseline CMBs, and the appearance of hemorrhagic transformation did not have a significant relationship with baseline CMBs. CONCLUSIONS The presence of CMBs increases the risk of ICH during anticoagulant treatment (especially warfarin) in IS patients. Further studies with larger numbers of patients are needed to confirm our conclusions.
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17
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Charidimou A, Shams S, Romero JR, Ding J, Veltkamp R, Horstmann S, Eiriksdottir G, van Buchem MA, Gudnason V, Himali J, Gurol ME, Viswanathan A, Imaizumi T, Vernooij MW, Seshadri S, Greenberg SM, Benavente OR, Launer LJ, Shoamanesh A. Clinical significance of cerebral microbleeds on MRI: A comprehensive meta-analysis of risk of intracerebral hemorrhage, ischemic stroke, mortality, and dementia in cohort studies (v1). Int J Stroke 2018; 13:454-468. [PMID: 29338604 PMCID: PMC6123529 DOI: 10.1177/1747493017751931] [Citation(s) in RCA: 76] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background Cerebral microbleeds can confer a high risk of intracerebral hemorrhage, ischemic stroke, death and dementia, but estimated risks remain imprecise and often conflicting. We investigated the association between cerebral microbleeds presence and these outcomes in a large meta-analysis of all published cohorts including: ischemic stroke/TIA, memory clinic, "high risk" elderly populations, and healthy individuals in population-based studies. Methods Cohorts (with > 100 participants) that assessed cerebral microbleeds presence on MRI, with subsequent follow-up (≥3 months) were identified. The association between cerebral microbleeds and each of the outcomes (ischemic stroke, intracerebral hemorrhage, death, and dementia) was quantified using random effects models of (a) unadjusted crude odds ratios and (b) covariate-adjusted hazard rations. Results We identified 31 cohorts ( n = 20,368): 19 ischemic stroke/TIA ( n = 7672), 4 memory clinic ( n = 1957), 3 high risk elderly ( n = 1458) and 5 population-based cohorts ( n = 11,722). Cerebral microbleeds were associated with an increased risk of ischemic stroke (OR: 2.14; 95% CI: 1.58-2.89 and adj-HR: 2.09; 95% CI: 1.71-2.57), but the relative increase in future intracerebral hemorrhage risk was greater (OR: 4.65; 95% CI: 2.68-8.08 and adj-HR: 3.93; 95% CI: 2.71-5.69). Cerebral microbleeds were an independent predictor of all-cause mortality (adj-HR: 1.36; 95% CI: 1.24-1.48). In three population-based studies, cerebral microbleeds were independently associated with incident dementia (adj-HR: 1.35; 95% CI: 1.00-1.82). Results were overall consistent in analyses stratified by different populations, but with different degrees of heterogeneity. Conclusions Our meta-analysis shows that cerebral microbleeds predict an increased risk of stroke, death, and dementia and provides up-to-date effect sizes across different clinical settings. These pooled estimates can inform clinical decisions and trials, further supporting cerebral microbleeds role as biomarkers of underlying subclinical brain pathology in research and clinical settings.
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Affiliation(s)
- Andreas Charidimou
- Department of Neurology, Harvard Medical School, J. Philip
Kistler Stroke Research Center, Massachusetts General Hospital, Boston, MA,
USA
- Cochrane Methods, Individual Patient Data Meta-analysis
Group
| | - Sara Shams
- Department of Clinical Science, Intervention, and
Technology, Division of Medical Imaging and Technology, Karolinska Institutet,
Stockholm, Sweden; Department of Radiology, Karolinska University Hospital,
Stockholm, Sweden
| | - Jose R Romero
- Department of Neurology, Boston University School of
Medicine, and the NHLBI’s Framingham Heart Study, Framingham,
Massachusetts
| | - Jie Ding
- Laboratory of Epidemiology and Population Sciences,
National Institute on Aging, National Institutes of Health, Bethesda, MD, USA
| | - Roland Veltkamp
- Department of Neurology, University of Heidelberg,
Heidelberg, Germany
- Department of Stroke Medicine, Division of Brain Sciences,
Imperial College London, London, UK
| | - Solveig Horstmann
- Department of Neurology, University of Heidelberg,
Heidelberg, Germany
| | | | - Mark A van Buchem
- Department of Radiology, Leiden University Medical Center,
Leiden, the Netherlands
| | | | - JayandraJ Himali
- Department of Neurology, Boston University School of
Medicine, and the NHLBI’s Framingham Heart Study, Framingham,
Massachusetts
- Department of Biostatistics, Boston University School of
Public Health, Boston, MA, USA
| | - M Edip Gurol
- Department of Neurology, Harvard Medical School, J. Philip
Kistler Stroke Research Center, Massachusetts General Hospital, Boston, MA,
USA
| | - Anand Viswanathan
- Department of Neurology, Harvard Medical School, J. Philip
Kistler Stroke Research Center, Massachusetts General Hospital, Boston, MA,
USA
| | - Toshio Imaizumi
- Department of Neurosurgery, Kushiro City General
Hospital, Kushiro, Japan
| | - Meike W Vernooij
- Department of Epidemiology and Department of Radiology
and Nuclear Medicine; Erasmus MC University Medical Center, Rotterdam, the
Netherlands
| | - Sudha Seshadri
- Department of Neurology, Boston University School of
Medicine, and the NHLBI’s Framingham Heart Study, Framingham,
Massachusetts
| | - Steven M Greenberg
- Department of Neurology, Harvard Medical School, J. Philip
Kistler Stroke Research Center, Massachusetts General Hospital, Boston, MA,
USA
| | - Oscar R Benavente
- Division of Neurology, Department of Medicine, Stroke and
Cerebrovascular Health Program, University of British Columbia, UBC Hospital,
Vancouver, British Columbia, Canada
| | - Lenore J Launer
- Laboratory of Epidemiology and Population Sciences,
National Institute on Aging, National Institutes of Health, Bethesda, MD, USA
| | - Ashkan Shoamanesh
- Department of Medicine (Neurology), McMaster University
and Population Health Research Institute, Hamilton, Ontario, Canada
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18
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Wilson D, Ambler G, Shakeshaft C, Brown MM, Charidimou A, Al-Shahi Salman R, Lip GYH, Cohen H, Banerjee G, Houlden H, White MJ, Yousry TA, Harkness K, Flossmann E, Smyth N, Shaw LJ, Warburton E, Muir KW, Jäger HR, Werring DJ. Cerebral microbleeds and intracranial haemorrhage risk in patients anticoagulated for atrial fibrillation after acute ischaemic stroke or transient ischaemic attack (CROMIS-2): a multicentre observational cohort study. Lancet Neurol 2018; 17:539-547. [PMID: 29778365 PMCID: PMC5956310 DOI: 10.1016/s1474-4422(18)30145-5] [Citation(s) in RCA: 165] [Impact Index Per Article: 27.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2018] [Revised: 04/04/2018] [Accepted: 04/06/2018] [Indexed: 02/02/2023]
Abstract
BACKGROUND Cerebral microbleeds are a potential neuroimaging biomarker of cerebral small vessel diseases that are prone to intracranial bleeding. We aimed to determine whether presence of cerebral microbleeds can identify patients at high risk of symptomatic intracranial haemorrhage when anticoagulated for atrial fibrillation after recent ischaemic stroke or transient ischaemic attack. METHODS Our observational, multicentre, prospective inception cohort study recruited adults aged 18 years or older from 79 hospitals in the UK and one in the Netherlands with atrial fibrillation and recent acute ischaemic stroke or transient ischaemic attack, treated with a vitamin K antagonist or direct oral anticoagulant, and followed up for 24 months using general practitioner and patient postal questionnaires, telephone interviews, hospital visits, and National Health Service digital data on hospital admissions or death. We excluded patients if they could not undergo MRI, had a definite contraindication to anticoagulation, or had previously received therapeutic anticoagulation. The primary outcome was symptomatic intracranial haemorrhage occurring at any time before the final follow-up at 24 months. The log-rank test was used to compare rates of intracranial haemorrhage between those with and without cerebral microbleeds. We developed two prediction models using Cox regression: first, including all predictors associated with intracranial haemorrhage at the 20% level in univariable analysis; and second, including cerebral microbleed presence and HAS-BLED score. We then compared these with the HAS-BLED score alone. This study is registered with ClinicalTrials.gov, number NCT02513316. FINDINGS Between Aug 4, 2011, and July 31, 2015, we recruited 1490 participants of whom follow-up data were available for 1447 (97%), over a mean period of 850 days (SD 373; 3366 patient-years). The symptomatic intracranial haemorrhage rate in patients with cerebral microbleeds was 9·8 per 1000 patient-years (95% CI 4·0-20·3) compared with 2·6 per 1000 patient-years (95% CI 1·1-5·4) in those without cerebral microbleeds (adjusted hazard ratio 3·67, 95% CI 1·27-10·60). Compared with the HAS-BLED score alone (C-index 0·41, 95% CI 0·29-0·53), models including cerebral microbleeds and HAS-BLED (0·66, 0·53-0·80) and cerebral microbleeds, diabetes, anticoagulant type, and HAS-BLED (0·74, 0·60-0·88) predicted symptomatic intracranial haemorrhage significantly better (difference in C-index 0·25, 95% CI 0·07-0·43, p=0·0065; and 0·33, 0·14-0·51, p=0·00059, respectively). INTERPRETATION In patients with atrial fibrillation anticoagulated after recent ischaemic stroke or transient ischaemic attack, cerebral microbleed presence is independently associated with symptomatic intracranial haemorrhage risk and could be used to inform anticoagulation decisions. Large-scale collaborative observational cohort analyses are needed to refine and validate intracranial haemorrhage risk scores incorporating cerebral microbleeds to identify patients at risk of net harm from oral anticoagulation. FUNDING The Stroke Association and the British Heart Foundation.
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Affiliation(s)
- Duncan Wilson
- Stroke Research Centre, Department of Brain Repair and Rehabilitation, UCL Institute of Neurology and the National Hospital for Neurology and Neurosurgery, London, UK
| | - Gareth Ambler
- Department of Statistical Science, University College London, London, UK
| | - Clare Shakeshaft
- Stroke Research Centre, Department of Brain Repair and Rehabilitation, UCL Institute of Neurology and the National Hospital for Neurology and Neurosurgery, London, UK
| | - Martin M Brown
- Stroke Research Centre, Department of Brain Repair and Rehabilitation, UCL Institute of Neurology and the National Hospital for Neurology and Neurosurgery, London, UK
| | - Andreas Charidimou
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston, MA, USA
| | - Rustam Al-Shahi Salman
- Centre for Clinical Brain Sciences, School of Clinical Sciences, University of Edinburgh, Edinburgh, UK
| | - Gregory Y H Lip
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
| | - Hannah Cohen
- Haemostasis Research Unit, Department of Haematology, University College London, London, UK
| | - Gargi Banerjee
- Stroke Research Centre, Department of Brain Repair and Rehabilitation, UCL Institute of Neurology and the National Hospital for Neurology and Neurosurgery, London, UK
| | - Henry Houlden
- Department of Molecular Neuroscience, UCL Institute of Neurology and the National Hospital for Neurology and Neurosurgery, London, UK
| | - Mark J White
- Lysholm Department of Neuroradiology and the Neuroradiological Academic Unit, Department of Brain Repair and Rehabilitation, UCL Institute of Neurology and the National Hospital for Neurology and Neurosurgery, London, UK
| | - Tarek A Yousry
- Lysholm Department of Neuroradiology and the Neuroradiological Academic Unit, Department of Brain Repair and Rehabilitation, UCL Institute of Neurology and the National Hospital for Neurology and Neurosurgery, London, UK
| | - Kirsty Harkness
- Department of Neurology, Royal Hallamshire Hospital, Sheffield Teaching Hospitals Foundation Trust, Sheffield, UK
| | | | - Nigel Smyth
- Department of Medicine, Royal Hampshire County Hospital, Winchester, UK
| | - Louise J Shaw
- Department of Medicine, Royal United Hospital, Bath, UK
| | | | - Keith W Muir
- Institute of Neuroscience & Psychology, University of Glasgow, Queen Elizabeth University Hospital, Glasgow, UK
| | - Hans Rolf Jäger
- Lysholm Department of Neuroradiology and the Neuroradiological Academic Unit, Department of Brain Repair and Rehabilitation, UCL Institute of Neurology and the National Hospital for Neurology and Neurosurgery, London, UK
| | - David J Werring
- Stroke Research Centre, Department of Brain Repair and Rehabilitation, UCL Institute of Neurology and the National Hospital for Neurology and Neurosurgery, London, UK.
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Lang B, Kindy MS, Kozel FA, Schultz SK, Taheri S. Multi-Parametric Classification of Vascular Cognitive Impairment and Dementia: The Impact of Diverse Cerebrovascular Injury Biomarkers. J Alzheimers Dis 2018; 62:39-60. [DOI: 10.3233/jad-170733] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
- Brittany Lang
- Clinical Psychology Program, University of South Florida, Tampa, FL, USA
| | - Mark S. Kindy
- Department of Pharmaceutical Sciences, College of Pharmacy, University of South Florida Tampa, FL, USA
- James A. Haley VA Medical Center, Tampa, FL, USA
| | - F. Andrew Kozel
- James A. Haley VA Medical Center, Tampa, FL, USA
- Psychiatry and Behavioral Sciences, University of South Florida, Tampa, FL, USA
| | - Susan K. Schultz
- James A. Haley VA Medical Center, Tampa, FL, USA
- Psychiatry and Behavioral Sciences, University of South Florida, Tampa, FL, USA
| | - Saeid Taheri
- Department of Pharmaceutical Sciences, College of Pharmacy, University of South Florida Tampa, FL, USA
- Byrd Alzheimer’s Institute, Tampa, FL, USA
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Shoamanesh A, Charidimou A, Sharma M, Hart RG. Should Patients With Ischemic Stroke or Transient Ischemic Attack With Atrial Fibrillation and Microbleeds Be Anticoagulated? Stroke 2017; 48:3408-3412. [DOI: 10.1161/strokeaha.117.018467] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2017] [Revised: 09/05/2017] [Accepted: 09/29/2017] [Indexed: 11/16/2022]
Affiliation(s)
- Ashkan Shoamanesh
- From the Department of Medicine, Division of Neurology, McMaster University, Hamilton, Ontario, Canada (A.S., M.S., R.G.H.); Stroke and Cognition Program, Population Health Research Institute, Hamilton, Ontario, Canada (A.S., M.S., R.G.H.); and Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston (A.C.)
| | - Andreas Charidimou
- From the Department of Medicine, Division of Neurology, McMaster University, Hamilton, Ontario, Canada (A.S., M.S., R.G.H.); Stroke and Cognition Program, Population Health Research Institute, Hamilton, Ontario, Canada (A.S., M.S., R.G.H.); and Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston (A.C.)
| | - Mukul Sharma
- From the Department of Medicine, Division of Neurology, McMaster University, Hamilton, Ontario, Canada (A.S., M.S., R.G.H.); Stroke and Cognition Program, Population Health Research Institute, Hamilton, Ontario, Canada (A.S., M.S., R.G.H.); and Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston (A.C.)
| | - Robert G. Hart
- From the Department of Medicine, Division of Neurology, McMaster University, Hamilton, Ontario, Canada (A.S., M.S., R.G.H.); Stroke and Cognition Program, Population Health Research Institute, Hamilton, Ontario, Canada (A.S., M.S., R.G.H.); and Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston (A.C.)
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Charidimou A, Karayiannis C, Song TJ, Orken DN, Thijs V, Lemmens R, Kim J, Goh SM, Phan TG, Soufan C, Chandra RV, Slater LA, Haji S, Mok V, Horstmann S, Leung KT, Kawamura Y, Sato N, Hasebe N, Saito T, Wong LKS, Soo Y, Veltkamp R, Flemming KD, Imaizumi T, Srikanth V, Heo JH. Brain microbleeds, anticoagulation, and hemorrhage risk: Meta-analysis in stroke patients with AF. Neurology 2017; 89:2317-2326. [PMID: 29117953 DOI: 10.1212/wnl.0000000000004704] [Citation(s) in RCA: 72] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2016] [Accepted: 09/18/2017] [Indexed: 12/20/2022] Open
Abstract
OBJECTIVES To assess the association between cerebral microbleeds (CMBs) and future spontaneous intracerebral hemorrhage (ICH) risk in ischemic stroke patients with nonvalvular atrial fibrillation (AF) taking oral anticoagulants. METHODS This was a meta-analysis of cohort studies with >50 patients with recent ischemic stroke and documented AF, brain MRI at baseline, long-term oral anticoagulation treatment, and ≥6 months of follow-up. Authors provided summary-level data on stroke outcomes stratified by CMB status. We estimated pooled annualized ICH and ischemic stroke rates from Poisson regression. We calculated odds ratios (ORs) of ICH by CMB presence/absence, ≥5 CMBs, and CMB topography (strictly lobar, mixed, and strictly deep) using random-effects models. RESULTS We established an international collaboration and pooled data from 8 centers including 1,552 patients. The crude CMB prevalence was 30% and 7% for ≥5 CMBs. Baseline CMB presence (vs no CMB) was associated with ICH during follow-up (OR 2.68, 95% confidence interval [CI] 1.19-6.01, p = 0.017). Presence of ≥5 CMB was related to higher future ICH risk (OR 5.50, 95% CI 2.07-14.66, p = 0.001). The pooled annual ICH incidence increased from 0.30% (95% CI 0.04-0.55) among CMB-negative patients to 0.81% (95% CI 0.17-1.45) in CMB-positive patients (p = 0.01) and 2.48% (95% CI 1.2-6.2) in patients with ≥5 CMBs (p = 0.001). There was no association between CMBs and recurrent ischemic stroke. CONCLUSIONS The presence of CMB on MRI and the dichotomized cutoff of ≥5 CMBs might identify subgroups of ischemic stroke patients with AF with high ICH risk and after further validation could help in risk stratification, in anticoagulation decisions, and in guiding randomized trials and ongoing large observational studies.
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Affiliation(s)
- Andreas Charidimou
- From the J. Philip Kistler Stroke Research Center (A.C.), Department of Neurology, Massachusetts General Hospital; Harvard Medical School (A.C.), Boston, MA; META-MICROBLEEDS Initiative/Consortium (A.C.); Stroke and Ageing Research Centre (C.K., S.M.G., T.G.P., R.V.C., V.S.), Department of Medicine, School for Clinical Sciences at Monash Health, Monash University, Melbourne, Australia; Department of Neurology (J.H.H.), Yonsei University College of Medicine, Seoul, Korea; Sisli Hamidiye Etfal Education and Research Hospital (D.N.O.), Department of Neurology, Istanbul, Turkey; Department of Neurology (V.T.), Austin Health and Florey Institute of Neuroscience and Mental Health, Heidelberg, Victoria, Australia; Department of Neurology (J.K.), CHA Bundang Medical Centre, CHA University, Seongnam, Korea; Stroke Unit (T.G.P., V.S.), Neurosciences, and Neuroradiology Service (C.S., R.V.C., L.-A.S.), Monash Imaging, Monash Health, Melbourne, Australia; Department of Neurology (S.H.), Mayo Clinic, Rochester, MN; Department of Medicine and Therapeutics (V.M., K.T.L., L.K.S.W., Y.S.), Chinese University of Hong Kong; Department of Neurology (S.H., R.V., T.I.), University of Heidelberg, Germany; Department of Internal Medicine (Y.K., N.S., N.H., T.S.), Cardiovascular, Respiratory and Neurology Division, Asahikawa Medical University, Japan; Department of Stroke Medicine (R.V.), Division of Brain Sciences, Imperial College London, UK; Department of Neurosurgery (K.D.F.), Kushiro City General Hospital, Hokkaido, Japan; KU Leuven-University of Leuven (R.L.), Department of Neurosciences, Experimental Neurology and Leuven Research Institute for Neuroscience and Disease; VIB (R.L.), Vesalius Research Center, Laboratory of Neurobiology; University Hospitals Leuven (R.L.), Department of Neurology, Belgium; and Department of Neurology (T.-J.S.), College of Medicine, Ewha Woman's University, Yangcheon-gu, Seoul, Korea.
| | - Christopher Karayiannis
- From the J. Philip Kistler Stroke Research Center (A.C.), Department of Neurology, Massachusetts General Hospital; Harvard Medical School (A.C.), Boston, MA; META-MICROBLEEDS Initiative/Consortium (A.C.); Stroke and Ageing Research Centre (C.K., S.M.G., T.G.P., R.V.C., V.S.), Department of Medicine, School for Clinical Sciences at Monash Health, Monash University, Melbourne, Australia; Department of Neurology (J.H.H.), Yonsei University College of Medicine, Seoul, Korea; Sisli Hamidiye Etfal Education and Research Hospital (D.N.O.), Department of Neurology, Istanbul, Turkey; Department of Neurology (V.T.), Austin Health and Florey Institute of Neuroscience and Mental Health, Heidelberg, Victoria, Australia; Department of Neurology (J.K.), CHA Bundang Medical Centre, CHA University, Seongnam, Korea; Stroke Unit (T.G.P., V.S.), Neurosciences, and Neuroradiology Service (C.S., R.V.C., L.-A.S.), Monash Imaging, Monash Health, Melbourne, Australia; Department of Neurology (S.H.), Mayo Clinic, Rochester, MN; Department of Medicine and Therapeutics (V.M., K.T.L., L.K.S.W., Y.S.), Chinese University of Hong Kong; Department of Neurology (S.H., R.V., T.I.), University of Heidelberg, Germany; Department of Internal Medicine (Y.K., N.S., N.H., T.S.), Cardiovascular, Respiratory and Neurology Division, Asahikawa Medical University, Japan; Department of Stroke Medicine (R.V.), Division of Brain Sciences, Imperial College London, UK; Department of Neurosurgery (K.D.F.), Kushiro City General Hospital, Hokkaido, Japan; KU Leuven-University of Leuven (R.L.), Department of Neurosciences, Experimental Neurology and Leuven Research Institute for Neuroscience and Disease; VIB (R.L.), Vesalius Research Center, Laboratory of Neurobiology; University Hospitals Leuven (R.L.), Department of Neurology, Belgium; and Department of Neurology (T.-J.S.), College of Medicine, Ewha Woman's University, Yangcheon-gu, Seoul, Korea
| | - Tae-Jin Song
- From the J. Philip Kistler Stroke Research Center (A.C.), Department of Neurology, Massachusetts General Hospital; Harvard Medical School (A.C.), Boston, MA; META-MICROBLEEDS Initiative/Consortium (A.C.); Stroke and Ageing Research Centre (C.K., S.M.G., T.G.P., R.V.C., V.S.), Department of Medicine, School for Clinical Sciences at Monash Health, Monash University, Melbourne, Australia; Department of Neurology (J.H.H.), Yonsei University College of Medicine, Seoul, Korea; Sisli Hamidiye Etfal Education and Research Hospital (D.N.O.), Department of Neurology, Istanbul, Turkey; Department of Neurology (V.T.), Austin Health and Florey Institute of Neuroscience and Mental Health, Heidelberg, Victoria, Australia; Department of Neurology (J.K.), CHA Bundang Medical Centre, CHA University, Seongnam, Korea; Stroke Unit (T.G.P., V.S.), Neurosciences, and Neuroradiology Service (C.S., R.V.C., L.-A.S.), Monash Imaging, Monash Health, Melbourne, Australia; Department of Neurology (S.H.), Mayo Clinic, Rochester, MN; Department of Medicine and Therapeutics (V.M., K.T.L., L.K.S.W., Y.S.), Chinese University of Hong Kong; Department of Neurology (S.H., R.V., T.I.), University of Heidelberg, Germany; Department of Internal Medicine (Y.K., N.S., N.H., T.S.), Cardiovascular, Respiratory and Neurology Division, Asahikawa Medical University, Japan; Department of Stroke Medicine (R.V.), Division of Brain Sciences, Imperial College London, UK; Department of Neurosurgery (K.D.F.), Kushiro City General Hospital, Hokkaido, Japan; KU Leuven-University of Leuven (R.L.), Department of Neurosciences, Experimental Neurology and Leuven Research Institute for Neuroscience and Disease; VIB (R.L.), Vesalius Research Center, Laboratory of Neurobiology; University Hospitals Leuven (R.L.), Department of Neurology, Belgium; and Department of Neurology (T.-J.S.), College of Medicine, Ewha Woman's University, Yangcheon-gu, Seoul, Korea
| | - Dilek Necioglu Orken
- From the J. Philip Kistler Stroke Research Center (A.C.), Department of Neurology, Massachusetts General Hospital; Harvard Medical School (A.C.), Boston, MA; META-MICROBLEEDS Initiative/Consortium (A.C.); Stroke and Ageing Research Centre (C.K., S.M.G., T.G.P., R.V.C., V.S.), Department of Medicine, School for Clinical Sciences at Monash Health, Monash University, Melbourne, Australia; Department of Neurology (J.H.H.), Yonsei University College of Medicine, Seoul, Korea; Sisli Hamidiye Etfal Education and Research Hospital (D.N.O.), Department of Neurology, Istanbul, Turkey; Department of Neurology (V.T.), Austin Health and Florey Institute of Neuroscience and Mental Health, Heidelberg, Victoria, Australia; Department of Neurology (J.K.), CHA Bundang Medical Centre, CHA University, Seongnam, Korea; Stroke Unit (T.G.P., V.S.), Neurosciences, and Neuroradiology Service (C.S., R.V.C., L.-A.S.), Monash Imaging, Monash Health, Melbourne, Australia; Department of Neurology (S.H.), Mayo Clinic, Rochester, MN; Department of Medicine and Therapeutics (V.M., K.T.L., L.K.S.W., Y.S.), Chinese University of Hong Kong; Department of Neurology (S.H., R.V., T.I.), University of Heidelberg, Germany; Department of Internal Medicine (Y.K., N.S., N.H., T.S.), Cardiovascular, Respiratory and Neurology Division, Asahikawa Medical University, Japan; Department of Stroke Medicine (R.V.), Division of Brain Sciences, Imperial College London, UK; Department of Neurosurgery (K.D.F.), Kushiro City General Hospital, Hokkaido, Japan; KU Leuven-University of Leuven (R.L.), Department of Neurosciences, Experimental Neurology and Leuven Research Institute for Neuroscience and Disease; VIB (R.L.), Vesalius Research Center, Laboratory of Neurobiology; University Hospitals Leuven (R.L.), Department of Neurology, Belgium; and Department of Neurology (T.-J.S.), College of Medicine, Ewha Woman's University, Yangcheon-gu, Seoul, Korea
| | - Vincent Thijs
- From the J. Philip Kistler Stroke Research Center (A.C.), Department of Neurology, Massachusetts General Hospital; Harvard Medical School (A.C.), Boston, MA; META-MICROBLEEDS Initiative/Consortium (A.C.); Stroke and Ageing Research Centre (C.K., S.M.G., T.G.P., R.V.C., V.S.), Department of Medicine, School for Clinical Sciences at Monash Health, Monash University, Melbourne, Australia; Department of Neurology (J.H.H.), Yonsei University College of Medicine, Seoul, Korea; Sisli Hamidiye Etfal Education and Research Hospital (D.N.O.), Department of Neurology, Istanbul, Turkey; Department of Neurology (V.T.), Austin Health and Florey Institute of Neuroscience and Mental Health, Heidelberg, Victoria, Australia; Department of Neurology (J.K.), CHA Bundang Medical Centre, CHA University, Seongnam, Korea; Stroke Unit (T.G.P., V.S.), Neurosciences, and Neuroradiology Service (C.S., R.V.C., L.-A.S.), Monash Imaging, Monash Health, Melbourne, Australia; Department of Neurology (S.H.), Mayo Clinic, Rochester, MN; Department of Medicine and Therapeutics (V.M., K.T.L., L.K.S.W., Y.S.), Chinese University of Hong Kong; Department of Neurology (S.H., R.V., T.I.), University of Heidelberg, Germany; Department of Internal Medicine (Y.K., N.S., N.H., T.S.), Cardiovascular, Respiratory and Neurology Division, Asahikawa Medical University, Japan; Department of Stroke Medicine (R.V.), Division of Brain Sciences, Imperial College London, UK; Department of Neurosurgery (K.D.F.), Kushiro City General Hospital, Hokkaido, Japan; KU Leuven-University of Leuven (R.L.), Department of Neurosciences, Experimental Neurology and Leuven Research Institute for Neuroscience and Disease; VIB (R.L.), Vesalius Research Center, Laboratory of Neurobiology; University Hospitals Leuven (R.L.), Department of Neurology, Belgium; and Department of Neurology (T.-J.S.), College of Medicine, Ewha Woman's University, Yangcheon-gu, Seoul, Korea
| | - Robin Lemmens
- From the J. Philip Kistler Stroke Research Center (A.C.), Department of Neurology, Massachusetts General Hospital; Harvard Medical School (A.C.), Boston, MA; META-MICROBLEEDS Initiative/Consortium (A.C.); Stroke and Ageing Research Centre (C.K., S.M.G., T.G.P., R.V.C., V.S.), Department of Medicine, School for Clinical Sciences at Monash Health, Monash University, Melbourne, Australia; Department of Neurology (J.H.H.), Yonsei University College of Medicine, Seoul, Korea; Sisli Hamidiye Etfal Education and Research Hospital (D.N.O.), Department of Neurology, Istanbul, Turkey; Department of Neurology (V.T.), Austin Health and Florey Institute of Neuroscience and Mental Health, Heidelberg, Victoria, Australia; Department of Neurology (J.K.), CHA Bundang Medical Centre, CHA University, Seongnam, Korea; Stroke Unit (T.G.P., V.S.), Neurosciences, and Neuroradiology Service (C.S., R.V.C., L.-A.S.), Monash Imaging, Monash Health, Melbourne, Australia; Department of Neurology (S.H.), Mayo Clinic, Rochester, MN; Department of Medicine and Therapeutics (V.M., K.T.L., L.K.S.W., Y.S.), Chinese University of Hong Kong; Department of Neurology (S.H., R.V., T.I.), University of Heidelberg, Germany; Department of Internal Medicine (Y.K., N.S., N.H., T.S.), Cardiovascular, Respiratory and Neurology Division, Asahikawa Medical University, Japan; Department of Stroke Medicine (R.V.), Division of Brain Sciences, Imperial College London, UK; Department of Neurosurgery (K.D.F.), Kushiro City General Hospital, Hokkaido, Japan; KU Leuven-University of Leuven (R.L.), Department of Neurosciences, Experimental Neurology and Leuven Research Institute for Neuroscience and Disease; VIB (R.L.), Vesalius Research Center, Laboratory of Neurobiology; University Hospitals Leuven (R.L.), Department of Neurology, Belgium; and Department of Neurology (T.-J.S.), College of Medicine, Ewha Woman's University, Yangcheon-gu, Seoul, Korea
| | - Jinkwon Kim
- From the J. Philip Kistler Stroke Research Center (A.C.), Department of Neurology, Massachusetts General Hospital; Harvard Medical School (A.C.), Boston, MA; META-MICROBLEEDS Initiative/Consortium (A.C.); Stroke and Ageing Research Centre (C.K., S.M.G., T.G.P., R.V.C., V.S.), Department of Medicine, School for Clinical Sciences at Monash Health, Monash University, Melbourne, Australia; Department of Neurology (J.H.H.), Yonsei University College of Medicine, Seoul, Korea; Sisli Hamidiye Etfal Education and Research Hospital (D.N.O.), Department of Neurology, Istanbul, Turkey; Department of Neurology (V.T.), Austin Health and Florey Institute of Neuroscience and Mental Health, Heidelberg, Victoria, Australia; Department of Neurology (J.K.), CHA Bundang Medical Centre, CHA University, Seongnam, Korea; Stroke Unit (T.G.P., V.S.), Neurosciences, and Neuroradiology Service (C.S., R.V.C., L.-A.S.), Monash Imaging, Monash Health, Melbourne, Australia; Department of Neurology (S.H.), Mayo Clinic, Rochester, MN; Department of Medicine and Therapeutics (V.M., K.T.L., L.K.S.W., Y.S.), Chinese University of Hong Kong; Department of Neurology (S.H., R.V., T.I.), University of Heidelberg, Germany; Department of Internal Medicine (Y.K., N.S., N.H., T.S.), Cardiovascular, Respiratory and Neurology Division, Asahikawa Medical University, Japan; Department of Stroke Medicine (R.V.), Division of Brain Sciences, Imperial College London, UK; Department of Neurosurgery (K.D.F.), Kushiro City General Hospital, Hokkaido, Japan; KU Leuven-University of Leuven (R.L.), Department of Neurosciences, Experimental Neurology and Leuven Research Institute for Neuroscience and Disease; VIB (R.L.), Vesalius Research Center, Laboratory of Neurobiology; University Hospitals Leuven (R.L.), Department of Neurology, Belgium; and Department of Neurology (T.-J.S.), College of Medicine, Ewha Woman's University, Yangcheon-gu, Seoul, Korea
| | - Su Mei Goh
- From the J. Philip Kistler Stroke Research Center (A.C.), Department of Neurology, Massachusetts General Hospital; Harvard Medical School (A.C.), Boston, MA; META-MICROBLEEDS Initiative/Consortium (A.C.); Stroke and Ageing Research Centre (C.K., S.M.G., T.G.P., R.V.C., V.S.), Department of Medicine, School for Clinical Sciences at Monash Health, Monash University, Melbourne, Australia; Department of Neurology (J.H.H.), Yonsei University College of Medicine, Seoul, Korea; Sisli Hamidiye Etfal Education and Research Hospital (D.N.O.), Department of Neurology, Istanbul, Turkey; Department of Neurology (V.T.), Austin Health and Florey Institute of Neuroscience and Mental Health, Heidelberg, Victoria, Australia; Department of Neurology (J.K.), CHA Bundang Medical Centre, CHA University, Seongnam, Korea; Stroke Unit (T.G.P., V.S.), Neurosciences, and Neuroradiology Service (C.S., R.V.C., L.-A.S.), Monash Imaging, Monash Health, Melbourne, Australia; Department of Neurology (S.H.), Mayo Clinic, Rochester, MN; Department of Medicine and Therapeutics (V.M., K.T.L., L.K.S.W., Y.S.), Chinese University of Hong Kong; Department of Neurology (S.H., R.V., T.I.), University of Heidelberg, Germany; Department of Internal Medicine (Y.K., N.S., N.H., T.S.), Cardiovascular, Respiratory and Neurology Division, Asahikawa Medical University, Japan; Department of Stroke Medicine (R.V.), Division of Brain Sciences, Imperial College London, UK; Department of Neurosurgery (K.D.F.), Kushiro City General Hospital, Hokkaido, Japan; KU Leuven-University of Leuven (R.L.), Department of Neurosciences, Experimental Neurology and Leuven Research Institute for Neuroscience and Disease; VIB (R.L.), Vesalius Research Center, Laboratory of Neurobiology; University Hospitals Leuven (R.L.), Department of Neurology, Belgium; and Department of Neurology (T.-J.S.), College of Medicine, Ewha Woman's University, Yangcheon-gu, Seoul, Korea
| | - Thanh G Phan
- From the J. Philip Kistler Stroke Research Center (A.C.), Department of Neurology, Massachusetts General Hospital; Harvard Medical School (A.C.), Boston, MA; META-MICROBLEEDS Initiative/Consortium (A.C.); Stroke and Ageing Research Centre (C.K., S.M.G., T.G.P., R.V.C., V.S.), Department of Medicine, School for Clinical Sciences at Monash Health, Monash University, Melbourne, Australia; Department of Neurology (J.H.H.), Yonsei University College of Medicine, Seoul, Korea; Sisli Hamidiye Etfal Education and Research Hospital (D.N.O.), Department of Neurology, Istanbul, Turkey; Department of Neurology (V.T.), Austin Health and Florey Institute of Neuroscience and Mental Health, Heidelberg, Victoria, Australia; Department of Neurology (J.K.), CHA Bundang Medical Centre, CHA University, Seongnam, Korea; Stroke Unit (T.G.P., V.S.), Neurosciences, and Neuroradiology Service (C.S., R.V.C., L.-A.S.), Monash Imaging, Monash Health, Melbourne, Australia; Department of Neurology (S.H.), Mayo Clinic, Rochester, MN; Department of Medicine and Therapeutics (V.M., K.T.L., L.K.S.W., Y.S.), Chinese University of Hong Kong; Department of Neurology (S.H., R.V., T.I.), University of Heidelberg, Germany; Department of Internal Medicine (Y.K., N.S., N.H., T.S.), Cardiovascular, Respiratory and Neurology Division, Asahikawa Medical University, Japan; Department of Stroke Medicine (R.V.), Division of Brain Sciences, Imperial College London, UK; Department of Neurosurgery (K.D.F.), Kushiro City General Hospital, Hokkaido, Japan; KU Leuven-University of Leuven (R.L.), Department of Neurosciences, Experimental Neurology and Leuven Research Institute for Neuroscience and Disease; VIB (R.L.), Vesalius Research Center, Laboratory of Neurobiology; University Hospitals Leuven (R.L.), Department of Neurology, Belgium; and Department of Neurology (T.-J.S.), College of Medicine, Ewha Woman's University, Yangcheon-gu, Seoul, Korea
| | - Cathy Soufan
- From the J. Philip Kistler Stroke Research Center (A.C.), Department of Neurology, Massachusetts General Hospital; Harvard Medical School (A.C.), Boston, MA; META-MICROBLEEDS Initiative/Consortium (A.C.); Stroke and Ageing Research Centre (C.K., S.M.G., T.G.P., R.V.C., V.S.), Department of Medicine, School for Clinical Sciences at Monash Health, Monash University, Melbourne, Australia; Department of Neurology (J.H.H.), Yonsei University College of Medicine, Seoul, Korea; Sisli Hamidiye Etfal Education and Research Hospital (D.N.O.), Department of Neurology, Istanbul, Turkey; Department of Neurology (V.T.), Austin Health and Florey Institute of Neuroscience and Mental Health, Heidelberg, Victoria, Australia; Department of Neurology (J.K.), CHA Bundang Medical Centre, CHA University, Seongnam, Korea; Stroke Unit (T.G.P., V.S.), Neurosciences, and Neuroradiology Service (C.S., R.V.C., L.-A.S.), Monash Imaging, Monash Health, Melbourne, Australia; Department of Neurology (S.H.), Mayo Clinic, Rochester, MN; Department of Medicine and Therapeutics (V.M., K.T.L., L.K.S.W., Y.S.), Chinese University of Hong Kong; Department of Neurology (S.H., R.V., T.I.), University of Heidelberg, Germany; Department of Internal Medicine (Y.K., N.S., N.H., T.S.), Cardiovascular, Respiratory and Neurology Division, Asahikawa Medical University, Japan; Department of Stroke Medicine (R.V.), Division of Brain Sciences, Imperial College London, UK; Department of Neurosurgery (K.D.F.), Kushiro City General Hospital, Hokkaido, Japan; KU Leuven-University of Leuven (R.L.), Department of Neurosciences, Experimental Neurology and Leuven Research Institute for Neuroscience and Disease; VIB (R.L.), Vesalius Research Center, Laboratory of Neurobiology; University Hospitals Leuven (R.L.), Department of Neurology, Belgium; and Department of Neurology (T.-J.S.), College of Medicine, Ewha Woman's University, Yangcheon-gu, Seoul, Korea
| | - Ronil V Chandra
- From the J. Philip Kistler Stroke Research Center (A.C.), Department of Neurology, Massachusetts General Hospital; Harvard Medical School (A.C.), Boston, MA; META-MICROBLEEDS Initiative/Consortium (A.C.); Stroke and Ageing Research Centre (C.K., S.M.G., T.G.P., R.V.C., V.S.), Department of Medicine, School for Clinical Sciences at Monash Health, Monash University, Melbourne, Australia; Department of Neurology (J.H.H.), Yonsei University College of Medicine, Seoul, Korea; Sisli Hamidiye Etfal Education and Research Hospital (D.N.O.), Department of Neurology, Istanbul, Turkey; Department of Neurology (V.T.), Austin Health and Florey Institute of Neuroscience and Mental Health, Heidelberg, Victoria, Australia; Department of Neurology (J.K.), CHA Bundang Medical Centre, CHA University, Seongnam, Korea; Stroke Unit (T.G.P., V.S.), Neurosciences, and Neuroradiology Service (C.S., R.V.C., L.-A.S.), Monash Imaging, Monash Health, Melbourne, Australia; Department of Neurology (S.H.), Mayo Clinic, Rochester, MN; Department of Medicine and Therapeutics (V.M., K.T.L., L.K.S.W., Y.S.), Chinese University of Hong Kong; Department of Neurology (S.H., R.V., T.I.), University of Heidelberg, Germany; Department of Internal Medicine (Y.K., N.S., N.H., T.S.), Cardiovascular, Respiratory and Neurology Division, Asahikawa Medical University, Japan; Department of Stroke Medicine (R.V.), Division of Brain Sciences, Imperial College London, UK; Department of Neurosurgery (K.D.F.), Kushiro City General Hospital, Hokkaido, Japan; KU Leuven-University of Leuven (R.L.), Department of Neurosciences, Experimental Neurology and Leuven Research Institute for Neuroscience and Disease; VIB (R.L.), Vesalius Research Center, Laboratory of Neurobiology; University Hospitals Leuven (R.L.), Department of Neurology, Belgium; and Department of Neurology (T.-J.S.), College of Medicine, Ewha Woman's University, Yangcheon-gu, Seoul, Korea
| | - Lee-Anne Slater
- From the J. Philip Kistler Stroke Research Center (A.C.), Department of Neurology, Massachusetts General Hospital; Harvard Medical School (A.C.), Boston, MA; META-MICROBLEEDS Initiative/Consortium (A.C.); Stroke and Ageing Research Centre (C.K., S.M.G., T.G.P., R.V.C., V.S.), Department of Medicine, School for Clinical Sciences at Monash Health, Monash University, Melbourne, Australia; Department of Neurology (J.H.H.), Yonsei University College of Medicine, Seoul, Korea; Sisli Hamidiye Etfal Education and Research Hospital (D.N.O.), Department of Neurology, Istanbul, Turkey; Department of Neurology (V.T.), Austin Health and Florey Institute of Neuroscience and Mental Health, Heidelberg, Victoria, Australia; Department of Neurology (J.K.), CHA Bundang Medical Centre, CHA University, Seongnam, Korea; Stroke Unit (T.G.P., V.S.), Neurosciences, and Neuroradiology Service (C.S., R.V.C., L.-A.S.), Monash Imaging, Monash Health, Melbourne, Australia; Department of Neurology (S.H.), Mayo Clinic, Rochester, MN; Department of Medicine and Therapeutics (V.M., K.T.L., L.K.S.W., Y.S.), Chinese University of Hong Kong; Department of Neurology (S.H., R.V., T.I.), University of Heidelberg, Germany; Department of Internal Medicine (Y.K., N.S., N.H., T.S.), Cardiovascular, Respiratory and Neurology Division, Asahikawa Medical University, Japan; Department of Stroke Medicine (R.V.), Division of Brain Sciences, Imperial College London, UK; Department of Neurosurgery (K.D.F.), Kushiro City General Hospital, Hokkaido, Japan; KU Leuven-University of Leuven (R.L.), Department of Neurosciences, Experimental Neurology and Leuven Research Institute for Neuroscience and Disease; VIB (R.L.), Vesalius Research Center, Laboratory of Neurobiology; University Hospitals Leuven (R.L.), Department of Neurology, Belgium; and Department of Neurology (T.-J.S.), College of Medicine, Ewha Woman's University, Yangcheon-gu, Seoul, Korea
| | - Shamir Haji
- From the J. Philip Kistler Stroke Research Center (A.C.), Department of Neurology, Massachusetts General Hospital; Harvard Medical School (A.C.), Boston, MA; META-MICROBLEEDS Initiative/Consortium (A.C.); Stroke and Ageing Research Centre (C.K., S.M.G., T.G.P., R.V.C., V.S.), Department of Medicine, School for Clinical Sciences at Monash Health, Monash University, Melbourne, Australia; Department of Neurology (J.H.H.), Yonsei University College of Medicine, Seoul, Korea; Sisli Hamidiye Etfal Education and Research Hospital (D.N.O.), Department of Neurology, Istanbul, Turkey; Department of Neurology (V.T.), Austin Health and Florey Institute of Neuroscience and Mental Health, Heidelberg, Victoria, Australia; Department of Neurology (J.K.), CHA Bundang Medical Centre, CHA University, Seongnam, Korea; Stroke Unit (T.G.P., V.S.), Neurosciences, and Neuroradiology Service (C.S., R.V.C., L.-A.S.), Monash Imaging, Monash Health, Melbourne, Australia; Department of Neurology (S.H.), Mayo Clinic, Rochester, MN; Department of Medicine and Therapeutics (V.M., K.T.L., L.K.S.W., Y.S.), Chinese University of Hong Kong; Department of Neurology (S.H., R.V., T.I.), University of Heidelberg, Germany; Department of Internal Medicine (Y.K., N.S., N.H., T.S.), Cardiovascular, Respiratory and Neurology Division, Asahikawa Medical University, Japan; Department of Stroke Medicine (R.V.), Division of Brain Sciences, Imperial College London, UK; Department of Neurosurgery (K.D.F.), Kushiro City General Hospital, Hokkaido, Japan; KU Leuven-University of Leuven (R.L.), Department of Neurosciences, Experimental Neurology and Leuven Research Institute for Neuroscience and Disease; VIB (R.L.), Vesalius Research Center, Laboratory of Neurobiology; University Hospitals Leuven (R.L.), Department of Neurology, Belgium; and Department of Neurology (T.-J.S.), College of Medicine, Ewha Woman's University, Yangcheon-gu, Seoul, Korea
| | - Vincent Mok
- From the J. Philip Kistler Stroke Research Center (A.C.), Department of Neurology, Massachusetts General Hospital; Harvard Medical School (A.C.), Boston, MA; META-MICROBLEEDS Initiative/Consortium (A.C.); Stroke and Ageing Research Centre (C.K., S.M.G., T.G.P., R.V.C., V.S.), Department of Medicine, School for Clinical Sciences at Monash Health, Monash University, Melbourne, Australia; Department of Neurology (J.H.H.), Yonsei University College of Medicine, Seoul, Korea; Sisli Hamidiye Etfal Education and Research Hospital (D.N.O.), Department of Neurology, Istanbul, Turkey; Department of Neurology (V.T.), Austin Health and Florey Institute of Neuroscience and Mental Health, Heidelberg, Victoria, Australia; Department of Neurology (J.K.), CHA Bundang Medical Centre, CHA University, Seongnam, Korea; Stroke Unit (T.G.P., V.S.), Neurosciences, and Neuroradiology Service (C.S., R.V.C., L.-A.S.), Monash Imaging, Monash Health, Melbourne, Australia; Department of Neurology (S.H.), Mayo Clinic, Rochester, MN; Department of Medicine and Therapeutics (V.M., K.T.L., L.K.S.W., Y.S.), Chinese University of Hong Kong; Department of Neurology (S.H., R.V., T.I.), University of Heidelberg, Germany; Department of Internal Medicine (Y.K., N.S., N.H., T.S.), Cardiovascular, Respiratory and Neurology Division, Asahikawa Medical University, Japan; Department of Stroke Medicine (R.V.), Division of Brain Sciences, Imperial College London, UK; Department of Neurosurgery (K.D.F.), Kushiro City General Hospital, Hokkaido, Japan; KU Leuven-University of Leuven (R.L.), Department of Neurosciences, Experimental Neurology and Leuven Research Institute for Neuroscience and Disease; VIB (R.L.), Vesalius Research Center, Laboratory of Neurobiology; University Hospitals Leuven (R.L.), Department of Neurology, Belgium; and Department of Neurology (T.-J.S.), College of Medicine, Ewha Woman's University, Yangcheon-gu, Seoul, Korea
| | - Solveig Horstmann
- From the J. Philip Kistler Stroke Research Center (A.C.), Department of Neurology, Massachusetts General Hospital; Harvard Medical School (A.C.), Boston, MA; META-MICROBLEEDS Initiative/Consortium (A.C.); Stroke and Ageing Research Centre (C.K., S.M.G., T.G.P., R.V.C., V.S.), Department of Medicine, School for Clinical Sciences at Monash Health, Monash University, Melbourne, Australia; Department of Neurology (J.H.H.), Yonsei University College of Medicine, Seoul, Korea; Sisli Hamidiye Etfal Education and Research Hospital (D.N.O.), Department of Neurology, Istanbul, Turkey; Department of Neurology (V.T.), Austin Health and Florey Institute of Neuroscience and Mental Health, Heidelberg, Victoria, Australia; Department of Neurology (J.K.), CHA Bundang Medical Centre, CHA University, Seongnam, Korea; Stroke Unit (T.G.P., V.S.), Neurosciences, and Neuroradiology Service (C.S., R.V.C., L.-A.S.), Monash Imaging, Monash Health, Melbourne, Australia; Department of Neurology (S.H.), Mayo Clinic, Rochester, MN; Department of Medicine and Therapeutics (V.M., K.T.L., L.K.S.W., Y.S.), Chinese University of Hong Kong; Department of Neurology (S.H., R.V., T.I.), University of Heidelberg, Germany; Department of Internal Medicine (Y.K., N.S., N.H., T.S.), Cardiovascular, Respiratory and Neurology Division, Asahikawa Medical University, Japan; Department of Stroke Medicine (R.V.), Division of Brain Sciences, Imperial College London, UK; Department of Neurosurgery (K.D.F.), Kushiro City General Hospital, Hokkaido, Japan; KU Leuven-University of Leuven (R.L.), Department of Neurosciences, Experimental Neurology and Leuven Research Institute for Neuroscience and Disease; VIB (R.L.), Vesalius Research Center, Laboratory of Neurobiology; University Hospitals Leuven (R.L.), Department of Neurology, Belgium; and Department of Neurology (T.-J.S.), College of Medicine, Ewha Woman's University, Yangcheon-gu, Seoul, Korea
| | - Kam Tat Leung
- From the J. Philip Kistler Stroke Research Center (A.C.), Department of Neurology, Massachusetts General Hospital; Harvard Medical School (A.C.), Boston, MA; META-MICROBLEEDS Initiative/Consortium (A.C.); Stroke and Ageing Research Centre (C.K., S.M.G., T.G.P., R.V.C., V.S.), Department of Medicine, School for Clinical Sciences at Monash Health, Monash University, Melbourne, Australia; Department of Neurology (J.H.H.), Yonsei University College of Medicine, Seoul, Korea; Sisli Hamidiye Etfal Education and Research Hospital (D.N.O.), Department of Neurology, Istanbul, Turkey; Department of Neurology (V.T.), Austin Health and Florey Institute of Neuroscience and Mental Health, Heidelberg, Victoria, Australia; Department of Neurology (J.K.), CHA Bundang Medical Centre, CHA University, Seongnam, Korea; Stroke Unit (T.G.P., V.S.), Neurosciences, and Neuroradiology Service (C.S., R.V.C., L.-A.S.), Monash Imaging, Monash Health, Melbourne, Australia; Department of Neurology (S.H.), Mayo Clinic, Rochester, MN; Department of Medicine and Therapeutics (V.M., K.T.L., L.K.S.W., Y.S.), Chinese University of Hong Kong; Department of Neurology (S.H., R.V., T.I.), University of Heidelberg, Germany; Department of Internal Medicine (Y.K., N.S., N.H., T.S.), Cardiovascular, Respiratory and Neurology Division, Asahikawa Medical University, Japan; Department of Stroke Medicine (R.V.), Division of Brain Sciences, Imperial College London, UK; Department of Neurosurgery (K.D.F.), Kushiro City General Hospital, Hokkaido, Japan; KU Leuven-University of Leuven (R.L.), Department of Neurosciences, Experimental Neurology and Leuven Research Institute for Neuroscience and Disease; VIB (R.L.), Vesalius Research Center, Laboratory of Neurobiology; University Hospitals Leuven (R.L.), Department of Neurology, Belgium; and Department of Neurology (T.-J.S.), College of Medicine, Ewha Woman's University, Yangcheon-gu, Seoul, Korea
| | - Yuichiro Kawamura
- From the J. Philip Kistler Stroke Research Center (A.C.), Department of Neurology, Massachusetts General Hospital; Harvard Medical School (A.C.), Boston, MA; META-MICROBLEEDS Initiative/Consortium (A.C.); Stroke and Ageing Research Centre (C.K., S.M.G., T.G.P., R.V.C., V.S.), Department of Medicine, School for Clinical Sciences at Monash Health, Monash University, Melbourne, Australia; Department of Neurology (J.H.H.), Yonsei University College of Medicine, Seoul, Korea; Sisli Hamidiye Etfal Education and Research Hospital (D.N.O.), Department of Neurology, Istanbul, Turkey; Department of Neurology (V.T.), Austin Health and Florey Institute of Neuroscience and Mental Health, Heidelberg, Victoria, Australia; Department of Neurology (J.K.), CHA Bundang Medical Centre, CHA University, Seongnam, Korea; Stroke Unit (T.G.P., V.S.), Neurosciences, and Neuroradiology Service (C.S., R.V.C., L.-A.S.), Monash Imaging, Monash Health, Melbourne, Australia; Department of Neurology (S.H.), Mayo Clinic, Rochester, MN; Department of Medicine and Therapeutics (V.M., K.T.L., L.K.S.W., Y.S.), Chinese University of Hong Kong; Department of Neurology (S.H., R.V., T.I.), University of Heidelberg, Germany; Department of Internal Medicine (Y.K., N.S., N.H., T.S.), Cardiovascular, Respiratory and Neurology Division, Asahikawa Medical University, Japan; Department of Stroke Medicine (R.V.), Division of Brain Sciences, Imperial College London, UK; Department of Neurosurgery (K.D.F.), Kushiro City General Hospital, Hokkaido, Japan; KU Leuven-University of Leuven (R.L.), Department of Neurosciences, Experimental Neurology and Leuven Research Institute for Neuroscience and Disease; VIB (R.L.), Vesalius Research Center, Laboratory of Neurobiology; University Hospitals Leuven (R.L.), Department of Neurology, Belgium; and Department of Neurology (T.-J.S.), College of Medicine, Ewha Woman's University, Yangcheon-gu, Seoul, Korea
| | - Nobuyuki Sato
- From the J. Philip Kistler Stroke Research Center (A.C.), Department of Neurology, Massachusetts General Hospital; Harvard Medical School (A.C.), Boston, MA; META-MICROBLEEDS Initiative/Consortium (A.C.); Stroke and Ageing Research Centre (C.K., S.M.G., T.G.P., R.V.C., V.S.), Department of Medicine, School for Clinical Sciences at Monash Health, Monash University, Melbourne, Australia; Department of Neurology (J.H.H.), Yonsei University College of Medicine, Seoul, Korea; Sisli Hamidiye Etfal Education and Research Hospital (D.N.O.), Department of Neurology, Istanbul, Turkey; Department of Neurology (V.T.), Austin Health and Florey Institute of Neuroscience and Mental Health, Heidelberg, Victoria, Australia; Department of Neurology (J.K.), CHA Bundang Medical Centre, CHA University, Seongnam, Korea; Stroke Unit (T.G.P., V.S.), Neurosciences, and Neuroradiology Service (C.S., R.V.C., L.-A.S.), Monash Imaging, Monash Health, Melbourne, Australia; Department of Neurology (S.H.), Mayo Clinic, Rochester, MN; Department of Medicine and Therapeutics (V.M., K.T.L., L.K.S.W., Y.S.), Chinese University of Hong Kong; Department of Neurology (S.H., R.V., T.I.), University of Heidelberg, Germany; Department of Internal Medicine (Y.K., N.S., N.H., T.S.), Cardiovascular, Respiratory and Neurology Division, Asahikawa Medical University, Japan; Department of Stroke Medicine (R.V.), Division of Brain Sciences, Imperial College London, UK; Department of Neurosurgery (K.D.F.), Kushiro City General Hospital, Hokkaido, Japan; KU Leuven-University of Leuven (R.L.), Department of Neurosciences, Experimental Neurology and Leuven Research Institute for Neuroscience and Disease; VIB (R.L.), Vesalius Research Center, Laboratory of Neurobiology; University Hospitals Leuven (R.L.), Department of Neurology, Belgium; and Department of Neurology (T.-J.S.), College of Medicine, Ewha Woman's University, Yangcheon-gu, Seoul, Korea
| | - Naoyuki Hasebe
- From the J. Philip Kistler Stroke Research Center (A.C.), Department of Neurology, Massachusetts General Hospital; Harvard Medical School (A.C.), Boston, MA; META-MICROBLEEDS Initiative/Consortium (A.C.); Stroke and Ageing Research Centre (C.K., S.M.G., T.G.P., R.V.C., V.S.), Department of Medicine, School for Clinical Sciences at Monash Health, Monash University, Melbourne, Australia; Department of Neurology (J.H.H.), Yonsei University College of Medicine, Seoul, Korea; Sisli Hamidiye Etfal Education and Research Hospital (D.N.O.), Department of Neurology, Istanbul, Turkey; Department of Neurology (V.T.), Austin Health and Florey Institute of Neuroscience and Mental Health, Heidelberg, Victoria, Australia; Department of Neurology (J.K.), CHA Bundang Medical Centre, CHA University, Seongnam, Korea; Stroke Unit (T.G.P., V.S.), Neurosciences, and Neuroradiology Service (C.S., R.V.C., L.-A.S.), Monash Imaging, Monash Health, Melbourne, Australia; Department of Neurology (S.H.), Mayo Clinic, Rochester, MN; Department of Medicine and Therapeutics (V.M., K.T.L., L.K.S.W., Y.S.), Chinese University of Hong Kong; Department of Neurology (S.H., R.V., T.I.), University of Heidelberg, Germany; Department of Internal Medicine (Y.K., N.S., N.H., T.S.), Cardiovascular, Respiratory and Neurology Division, Asahikawa Medical University, Japan; Department of Stroke Medicine (R.V.), Division of Brain Sciences, Imperial College London, UK; Department of Neurosurgery (K.D.F.), Kushiro City General Hospital, Hokkaido, Japan; KU Leuven-University of Leuven (R.L.), Department of Neurosciences, Experimental Neurology and Leuven Research Institute for Neuroscience and Disease; VIB (R.L.), Vesalius Research Center, Laboratory of Neurobiology; University Hospitals Leuven (R.L.), Department of Neurology, Belgium; and Department of Neurology (T.-J.S.), College of Medicine, Ewha Woman's University, Yangcheon-gu, Seoul, Korea
| | - Tsukasa Saito
- From the J. Philip Kistler Stroke Research Center (A.C.), Department of Neurology, Massachusetts General Hospital; Harvard Medical School (A.C.), Boston, MA; META-MICROBLEEDS Initiative/Consortium (A.C.); Stroke and Ageing Research Centre (C.K., S.M.G., T.G.P., R.V.C., V.S.), Department of Medicine, School for Clinical Sciences at Monash Health, Monash University, Melbourne, Australia; Department of Neurology (J.H.H.), Yonsei University College of Medicine, Seoul, Korea; Sisli Hamidiye Etfal Education and Research Hospital (D.N.O.), Department of Neurology, Istanbul, Turkey; Department of Neurology (V.T.), Austin Health and Florey Institute of Neuroscience and Mental Health, Heidelberg, Victoria, Australia; Department of Neurology (J.K.), CHA Bundang Medical Centre, CHA University, Seongnam, Korea; Stroke Unit (T.G.P., V.S.), Neurosciences, and Neuroradiology Service (C.S., R.V.C., L.-A.S.), Monash Imaging, Monash Health, Melbourne, Australia; Department of Neurology (S.H.), Mayo Clinic, Rochester, MN; Department of Medicine and Therapeutics (V.M., K.T.L., L.K.S.W., Y.S.), Chinese University of Hong Kong; Department of Neurology (S.H., R.V., T.I.), University of Heidelberg, Germany; Department of Internal Medicine (Y.K., N.S., N.H., T.S.), Cardiovascular, Respiratory and Neurology Division, Asahikawa Medical University, Japan; Department of Stroke Medicine (R.V.), Division of Brain Sciences, Imperial College London, UK; Department of Neurosurgery (K.D.F.), Kushiro City General Hospital, Hokkaido, Japan; KU Leuven-University of Leuven (R.L.), Department of Neurosciences, Experimental Neurology and Leuven Research Institute for Neuroscience and Disease; VIB (R.L.), Vesalius Research Center, Laboratory of Neurobiology; University Hospitals Leuven (R.L.), Department of Neurology, Belgium; and Department of Neurology (T.-J.S.), College of Medicine, Ewha Woman's University, Yangcheon-gu, Seoul, Korea
| | - Lawrence K S Wong
- From the J. Philip Kistler Stroke Research Center (A.C.), Department of Neurology, Massachusetts General Hospital; Harvard Medical School (A.C.), Boston, MA; META-MICROBLEEDS Initiative/Consortium (A.C.); Stroke and Ageing Research Centre (C.K., S.M.G., T.G.P., R.V.C., V.S.), Department of Medicine, School for Clinical Sciences at Monash Health, Monash University, Melbourne, Australia; Department of Neurology (J.H.H.), Yonsei University College of Medicine, Seoul, Korea; Sisli Hamidiye Etfal Education and Research Hospital (D.N.O.), Department of Neurology, Istanbul, Turkey; Department of Neurology (V.T.), Austin Health and Florey Institute of Neuroscience and Mental Health, Heidelberg, Victoria, Australia; Department of Neurology (J.K.), CHA Bundang Medical Centre, CHA University, Seongnam, Korea; Stroke Unit (T.G.P., V.S.), Neurosciences, and Neuroradiology Service (C.S., R.V.C., L.-A.S.), Monash Imaging, Monash Health, Melbourne, Australia; Department of Neurology (S.H.), Mayo Clinic, Rochester, MN; Department of Medicine and Therapeutics (V.M., K.T.L., L.K.S.W., Y.S.), Chinese University of Hong Kong; Department of Neurology (S.H., R.V., T.I.), University of Heidelberg, Germany; Department of Internal Medicine (Y.K., N.S., N.H., T.S.), Cardiovascular, Respiratory and Neurology Division, Asahikawa Medical University, Japan; Department of Stroke Medicine (R.V.), Division of Brain Sciences, Imperial College London, UK; Department of Neurosurgery (K.D.F.), Kushiro City General Hospital, Hokkaido, Japan; KU Leuven-University of Leuven (R.L.), Department of Neurosciences, Experimental Neurology and Leuven Research Institute for Neuroscience and Disease; VIB (R.L.), Vesalius Research Center, Laboratory of Neurobiology; University Hospitals Leuven (R.L.), Department of Neurology, Belgium; and Department of Neurology (T.-J.S.), College of Medicine, Ewha Woman's University, Yangcheon-gu, Seoul, Korea
| | - Yannie Soo
- From the J. Philip Kistler Stroke Research Center (A.C.), Department of Neurology, Massachusetts General Hospital; Harvard Medical School (A.C.), Boston, MA; META-MICROBLEEDS Initiative/Consortium (A.C.); Stroke and Ageing Research Centre (C.K., S.M.G., T.G.P., R.V.C., V.S.), Department of Medicine, School for Clinical Sciences at Monash Health, Monash University, Melbourne, Australia; Department of Neurology (J.H.H.), Yonsei University College of Medicine, Seoul, Korea; Sisli Hamidiye Etfal Education and Research Hospital (D.N.O.), Department of Neurology, Istanbul, Turkey; Department of Neurology (V.T.), Austin Health and Florey Institute of Neuroscience and Mental Health, Heidelberg, Victoria, Australia; Department of Neurology (J.K.), CHA Bundang Medical Centre, CHA University, Seongnam, Korea; Stroke Unit (T.G.P., V.S.), Neurosciences, and Neuroradiology Service (C.S., R.V.C., L.-A.S.), Monash Imaging, Monash Health, Melbourne, Australia; Department of Neurology (S.H.), Mayo Clinic, Rochester, MN; Department of Medicine and Therapeutics (V.M., K.T.L., L.K.S.W., Y.S.), Chinese University of Hong Kong; Department of Neurology (S.H., R.V., T.I.), University of Heidelberg, Germany; Department of Internal Medicine (Y.K., N.S., N.H., T.S.), Cardiovascular, Respiratory and Neurology Division, Asahikawa Medical University, Japan; Department of Stroke Medicine (R.V.), Division of Brain Sciences, Imperial College London, UK; Department of Neurosurgery (K.D.F.), Kushiro City General Hospital, Hokkaido, Japan; KU Leuven-University of Leuven (R.L.), Department of Neurosciences, Experimental Neurology and Leuven Research Institute for Neuroscience and Disease; VIB (R.L.), Vesalius Research Center, Laboratory of Neurobiology; University Hospitals Leuven (R.L.), Department of Neurology, Belgium; and Department of Neurology (T.-J.S.), College of Medicine, Ewha Woman's University, Yangcheon-gu, Seoul, Korea
| | - Roland Veltkamp
- From the J. Philip Kistler Stroke Research Center (A.C.), Department of Neurology, Massachusetts General Hospital; Harvard Medical School (A.C.), Boston, MA; META-MICROBLEEDS Initiative/Consortium (A.C.); Stroke and Ageing Research Centre (C.K., S.M.G., T.G.P., R.V.C., V.S.), Department of Medicine, School for Clinical Sciences at Monash Health, Monash University, Melbourne, Australia; Department of Neurology (J.H.H.), Yonsei University College of Medicine, Seoul, Korea; Sisli Hamidiye Etfal Education and Research Hospital (D.N.O.), Department of Neurology, Istanbul, Turkey; Department of Neurology (V.T.), Austin Health and Florey Institute of Neuroscience and Mental Health, Heidelberg, Victoria, Australia; Department of Neurology (J.K.), CHA Bundang Medical Centre, CHA University, Seongnam, Korea; Stroke Unit (T.G.P., V.S.), Neurosciences, and Neuroradiology Service (C.S., R.V.C., L.-A.S.), Monash Imaging, Monash Health, Melbourne, Australia; Department of Neurology (S.H.), Mayo Clinic, Rochester, MN; Department of Medicine and Therapeutics (V.M., K.T.L., L.K.S.W., Y.S.), Chinese University of Hong Kong; Department of Neurology (S.H., R.V., T.I.), University of Heidelberg, Germany; Department of Internal Medicine (Y.K., N.S., N.H., T.S.), Cardiovascular, Respiratory and Neurology Division, Asahikawa Medical University, Japan; Department of Stroke Medicine (R.V.), Division of Brain Sciences, Imperial College London, UK; Department of Neurosurgery (K.D.F.), Kushiro City General Hospital, Hokkaido, Japan; KU Leuven-University of Leuven (R.L.), Department of Neurosciences, Experimental Neurology and Leuven Research Institute for Neuroscience and Disease; VIB (R.L.), Vesalius Research Center, Laboratory of Neurobiology; University Hospitals Leuven (R.L.), Department of Neurology, Belgium; and Department of Neurology (T.-J.S.), College of Medicine, Ewha Woman's University, Yangcheon-gu, Seoul, Korea
| | - Kelly D Flemming
- From the J. Philip Kistler Stroke Research Center (A.C.), Department of Neurology, Massachusetts General Hospital; Harvard Medical School (A.C.), Boston, MA; META-MICROBLEEDS Initiative/Consortium (A.C.); Stroke and Ageing Research Centre (C.K., S.M.G., T.G.P., R.V.C., V.S.), Department of Medicine, School for Clinical Sciences at Monash Health, Monash University, Melbourne, Australia; Department of Neurology (J.H.H.), Yonsei University College of Medicine, Seoul, Korea; Sisli Hamidiye Etfal Education and Research Hospital (D.N.O.), Department of Neurology, Istanbul, Turkey; Department of Neurology (V.T.), Austin Health and Florey Institute of Neuroscience and Mental Health, Heidelberg, Victoria, Australia; Department of Neurology (J.K.), CHA Bundang Medical Centre, CHA University, Seongnam, Korea; Stroke Unit (T.G.P., V.S.), Neurosciences, and Neuroradiology Service (C.S., R.V.C., L.-A.S.), Monash Imaging, Monash Health, Melbourne, Australia; Department of Neurology (S.H.), Mayo Clinic, Rochester, MN; Department of Medicine and Therapeutics (V.M., K.T.L., L.K.S.W., Y.S.), Chinese University of Hong Kong; Department of Neurology (S.H., R.V., T.I.), University of Heidelberg, Germany; Department of Internal Medicine (Y.K., N.S., N.H., T.S.), Cardiovascular, Respiratory and Neurology Division, Asahikawa Medical University, Japan; Department of Stroke Medicine (R.V.), Division of Brain Sciences, Imperial College London, UK; Department of Neurosurgery (K.D.F.), Kushiro City General Hospital, Hokkaido, Japan; KU Leuven-University of Leuven (R.L.), Department of Neurosciences, Experimental Neurology and Leuven Research Institute for Neuroscience and Disease; VIB (R.L.), Vesalius Research Center, Laboratory of Neurobiology; University Hospitals Leuven (R.L.), Department of Neurology, Belgium; and Department of Neurology (T.-J.S.), College of Medicine, Ewha Woman's University, Yangcheon-gu, Seoul, Korea
| | - Toshio Imaizumi
- From the J. Philip Kistler Stroke Research Center (A.C.), Department of Neurology, Massachusetts General Hospital; Harvard Medical School (A.C.), Boston, MA; META-MICROBLEEDS Initiative/Consortium (A.C.); Stroke and Ageing Research Centre (C.K., S.M.G., T.G.P., R.V.C., V.S.), Department of Medicine, School for Clinical Sciences at Monash Health, Monash University, Melbourne, Australia; Department of Neurology (J.H.H.), Yonsei University College of Medicine, Seoul, Korea; Sisli Hamidiye Etfal Education and Research Hospital (D.N.O.), Department of Neurology, Istanbul, Turkey; Department of Neurology (V.T.), Austin Health and Florey Institute of Neuroscience and Mental Health, Heidelberg, Victoria, Australia; Department of Neurology (J.K.), CHA Bundang Medical Centre, CHA University, Seongnam, Korea; Stroke Unit (T.G.P., V.S.), Neurosciences, and Neuroradiology Service (C.S., R.V.C., L.-A.S.), Monash Imaging, Monash Health, Melbourne, Australia; Department of Neurology (S.H.), Mayo Clinic, Rochester, MN; Department of Medicine and Therapeutics (V.M., K.T.L., L.K.S.W., Y.S.), Chinese University of Hong Kong; Department of Neurology (S.H., R.V., T.I.), University of Heidelberg, Germany; Department of Internal Medicine (Y.K., N.S., N.H., T.S.), Cardiovascular, Respiratory and Neurology Division, Asahikawa Medical University, Japan; Department of Stroke Medicine (R.V.), Division of Brain Sciences, Imperial College London, UK; Department of Neurosurgery (K.D.F.), Kushiro City General Hospital, Hokkaido, Japan; KU Leuven-University of Leuven (R.L.), Department of Neurosciences, Experimental Neurology and Leuven Research Institute for Neuroscience and Disease; VIB (R.L.), Vesalius Research Center, Laboratory of Neurobiology; University Hospitals Leuven (R.L.), Department of Neurology, Belgium; and Department of Neurology (T.-J.S.), College of Medicine, Ewha Woman's University, Yangcheon-gu, Seoul, Korea
| | - Velandai Srikanth
- From the J. Philip Kistler Stroke Research Center (A.C.), Department of Neurology, Massachusetts General Hospital; Harvard Medical School (A.C.), Boston, MA; META-MICROBLEEDS Initiative/Consortium (A.C.); Stroke and Ageing Research Centre (C.K., S.M.G., T.G.P., R.V.C., V.S.), Department of Medicine, School for Clinical Sciences at Monash Health, Monash University, Melbourne, Australia; Department of Neurology (J.H.H.), Yonsei University College of Medicine, Seoul, Korea; Sisli Hamidiye Etfal Education and Research Hospital (D.N.O.), Department of Neurology, Istanbul, Turkey; Department of Neurology (V.T.), Austin Health and Florey Institute of Neuroscience and Mental Health, Heidelberg, Victoria, Australia; Department of Neurology (J.K.), CHA Bundang Medical Centre, CHA University, Seongnam, Korea; Stroke Unit (T.G.P., V.S.), Neurosciences, and Neuroradiology Service (C.S., R.V.C., L.-A.S.), Monash Imaging, Monash Health, Melbourne, Australia; Department of Neurology (S.H.), Mayo Clinic, Rochester, MN; Department of Medicine and Therapeutics (V.M., K.T.L., L.K.S.W., Y.S.), Chinese University of Hong Kong; Department of Neurology (S.H., R.V., T.I.), University of Heidelberg, Germany; Department of Internal Medicine (Y.K., N.S., N.H., T.S.), Cardiovascular, Respiratory and Neurology Division, Asahikawa Medical University, Japan; Department of Stroke Medicine (R.V.), Division of Brain Sciences, Imperial College London, UK; Department of Neurosurgery (K.D.F.), Kushiro City General Hospital, Hokkaido, Japan; KU Leuven-University of Leuven (R.L.), Department of Neurosciences, Experimental Neurology and Leuven Research Institute for Neuroscience and Disease; VIB (R.L.), Vesalius Research Center, Laboratory of Neurobiology; University Hospitals Leuven (R.L.), Department of Neurology, Belgium; and Department of Neurology (T.-J.S.), College of Medicine, Ewha Woman's University, Yangcheon-gu, Seoul, Korea
| | - Ji Hoe Heo
- From the J. Philip Kistler Stroke Research Center (A.C.), Department of Neurology, Massachusetts General Hospital; Harvard Medical School (A.C.), Boston, MA; META-MICROBLEEDS Initiative/Consortium (A.C.); Stroke and Ageing Research Centre (C.K., S.M.G., T.G.P., R.V.C., V.S.), Department of Medicine, School for Clinical Sciences at Monash Health, Monash University, Melbourne, Australia; Department of Neurology (J.H.H.), Yonsei University College of Medicine, Seoul, Korea; Sisli Hamidiye Etfal Education and Research Hospital (D.N.O.), Department of Neurology, Istanbul, Turkey; Department of Neurology (V.T.), Austin Health and Florey Institute of Neuroscience and Mental Health, Heidelberg, Victoria, Australia; Department of Neurology (J.K.), CHA Bundang Medical Centre, CHA University, Seongnam, Korea; Stroke Unit (T.G.P., V.S.), Neurosciences, and Neuroradiology Service (C.S., R.V.C., L.-A.S.), Monash Imaging, Monash Health, Melbourne, Australia; Department of Neurology (S.H.), Mayo Clinic, Rochester, MN; Department of Medicine and Therapeutics (V.M., K.T.L., L.K.S.W., Y.S.), Chinese University of Hong Kong; Department of Neurology (S.H., R.V., T.I.), University of Heidelberg, Germany; Department of Internal Medicine (Y.K., N.S., N.H., T.S.), Cardiovascular, Respiratory and Neurology Division, Asahikawa Medical University, Japan; Department of Stroke Medicine (R.V.), Division of Brain Sciences, Imperial College London, UK; Department of Neurosurgery (K.D.F.), Kushiro City General Hospital, Hokkaido, Japan; KU Leuven-University of Leuven (R.L.), Department of Neurosciences, Experimental Neurology and Leuven Research Institute for Neuroscience and Disease; VIB (R.L.), Vesalius Research Center, Laboratory of Neurobiology; University Hospitals Leuven (R.L.), Department of Neurology, Belgium; and Department of Neurology (T.-J.S.), College of Medicine, Ewha Woman's University, Yangcheon-gu, Seoul, Korea
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Singh A, Hussain S, Najmi AK. Number of studies, heterogeneity, generalisability, and the choice of method for meta-analysis. J Neurol Sci 2017; 381:347. [PMID: 28967410 DOI: 10.1016/j.jns.2017.09.026] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2017] [Accepted: 09/17/2017] [Indexed: 11/30/2022]
Affiliation(s)
- Ambrish Singh
- 36-H, Pocket A3, Mayur Vihar Phase-III, New Delhi, India.
| | - Salman Hussain
- (Department of Pharmaceutical Medicine (Division of Pharmacology), School of Pharmaceutical Education and Research, Jamia Hamdard (Hamdard University), New Delhi, India)
| | - Abul Kalam Najmi
- (Department of Pharmacology, School of Pharmaceutical Education and Research, Jamia Hamdard (Hamdard University), New Delhi, India)
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Charidimou A, Boulouis G, Shams S, Calvet D, Shoamanesh A. Intracerebral haemorrhage risk in microbleed-positive ischaemic stroke patients with atrial fibrillation: Preliminary meta-analysis of cohorts and anticoagulation decision schema. J Neurol Sci 2017; 378:102-109. [PMID: 28566143 DOI: 10.1016/j.jns.2017.04.042] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2017] [Revised: 03/31/2017] [Accepted: 04/25/2017] [Indexed: 12/19/2022]
Abstract
INTRODUCTION Whether ischaemic stroke patients with atrial fibrillation (AF) and cerebral microbleeds (CMBs) on MRI can be safely anticoagulated is a hotly debated topic. We performed a systematic review and meta-analysis of published aggregate data, to investigate the risk of subsequent intracerebral haemorrhage (ICH) based on CMBs presence in this stroke population, generally considered for oral anticoagulation. We also suggest a decision-making schema for anticoagulation use in this setting. METHODS We searched PubMed for relevant observational studies. Random effects models with DerSimonian-Laird weights were used to investigated the association between CMBs presence at baseline MRI and ICH or ischaemic stroke during follow-up. RESULTS Four studies, with slightly heterogeneous design, including 990 ischaemic stroke patients were pooled in a meta-analysis (crude CMBs prevalence: 25%; 95%CI: 17%-33%). The median follow-up ranged between 17 and 37months. The future symptomatic ICH rate was 1.6% (16/990), while recurrent ischaemic stroke rate was 5.9% (58/990). Baseline CMB presence was associated with increased risk of symptomatic ICH during follow-up compared to patients without CMBs (OR: 4.16; 95%CI: 1.54-11.25; p=0.005). There was no association between CMBs presence and recurrent ischaemic stroke risk. CONCLUSION We have shown that the presence of CMBs in cohorts of ischaemic stroke patients, most with AF on warfarin, is associated with a 4-fold increase in subsequent ICH (but not ischaemic stroke) risk (Class III evidence). These pooled estimates are useful for future trials design. We propose a simple data-driven anticoagulation schema which awaits validation and refinement as new prospective data are accumulated.
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Affiliation(s)
- Andreas Charidimou
- Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston, MA, USA.
| | - Gregoire Boulouis
- Université Paris-Descartes, INSERM U894, CH Sainte-Anne, Department of Neuroradiology, Paris, France
| | - Sara Shams
- Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - David Calvet
- Department of Neurology, Centre Hospitalier Sainte-Anne, Université Paris Descartes, DHU Neurovasc Sorbonne Paris Cité, INSERM U894, Paris, France
| | - Ashkan Shoamanesh
- Department of Medicine (Neurology), McMaster University, Population Health Research Institute, Hamilton, Ontario, L8L 2X2, Canada
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Kawada T. Risk assessment of cerebral microbleeds and white matter hyperintensities in patients with non-valvular atrial fibrillation. J Neurol Sci 2017; 373:249. [PMID: 28131198 DOI: 10.1016/j.jns.2017.01.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2016] [Accepted: 01/05/2017] [Indexed: 11/19/2022]
Affiliation(s)
- Tomoyuki Kawada
- Department of Hygiene and Public Health, Nippon Medical School, Japan.
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