1
|
Naftali J, Tsur G, Auriel E, Barnea R, Findler M, Raphaeli G, Brauner R, Pardo K, Perlow A, Weinstein G, Weiss P, Glik A, Keret O. Impact of dementia status on intravenous thrombolysis and endovascular treatment for acute ischemic stroke: Retrospective study. J Neurol Sci 2024; 459:122954. [PMID: 38461762 DOI: 10.1016/j.jns.2024.122954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2023] [Revised: 02/13/2024] [Accepted: 03/06/2024] [Indexed: 03/12/2024]
Abstract
INTRODUCTION Individuals with dementia are underrepresented in interventional studies for acute ischemic stroke (AIS). This research gap creates a bias against their treatment in clinical practice. Our goal was to compare the safety and efficacy of intravenous-thrombolysis (t-PA) and endovascular treatment (EVT) in individuals with or without pre-AIS dementia. METHOD A retrospective study of AIS patients receiving t-PA or EVT between 2019 and 2022. Patients were classified as dementia on a case-by-case review of baseline assessment. Additional variables included demographic, vascular risk factors, AIS severity and treatment. Outcomes of interest were intracerebral hemorrhage, mortality in 90-days, and the difference in modified rankin scale (mRS) before AIS and in 90-days follow-up. Outcomes were compared across non-matched groups and following propensity-score matching. RESULTS Altogether, 628 patients were included, of which 68 had pre-AIS dementia. Compared to non-dementia group, dementia group were older, had a higher rate of vascular risk factors, higher pre-stroke mRS and higher baseline NIHSS. Individuals with dementia had higher rates of mortality (25% vs.11%,p < 0.01) on non-matched comparison. All cohort and restricted t-PA EVT matched analysis showed no difference in any outcome. Regression analysis confirmed that AIS severity at presentation and its treatment, not dementia, were the chief contributors to patients' outcomes. DISCUSSION Our results indicate that pre-AIS dementia does not impact the efficacy or safety of EVT or t-PA for AIS. We thus call for more inclusive research on stroke therapy with regards to baseline cognitive status. Such studies are urgently required to inform stroke guidelines and enhance care.
Collapse
Affiliation(s)
- Jonathan Naftali
- Department of Neurology, Rabin Medical Center, Petach Tikva, Israel; Faculty of Medicine, Tel Aviv University, Tel-Aviv, Israel.
| | - Gal Tsur
- Department of Neurology, Rabin Medical Center, Petach Tikva, Israel
| | - Eitan Auriel
- Department of Neurology, Rabin Medical Center, Petach Tikva, Israel; Faculty of Medicine, Tel Aviv University, Tel-Aviv, Israel
| | - Rani Barnea
- Department of Neurology, Rabin Medical Center, Petach Tikva, Israel; Faculty of Medicine, Tel Aviv University, Tel-Aviv, Israel
| | - Michael Findler
- Department of Neurology, Rabin Medical Center, Petach Tikva, Israel; Faculty of Medicine, Tel Aviv University, Tel-Aviv, Israel; Interventional Neuroradiology Unit, Rabin Medical Center, Petach Tikva, Israel
| | - Guy Raphaeli
- Department of Neurology, Rabin Medical Center, Petach Tikva, Israel; Faculty of Medicine, Tel Aviv University, Tel-Aviv, Israel; Interventional Neuroradiology Unit, Rabin Medical Center, Petach Tikva, Israel
| | - Ran Brauner
- Department of Neurology, Rabin Medical Center, Petach Tikva, Israel; Faculty of Medicine, Tel Aviv University, Tel-Aviv, Israel; Interventional Neuroradiology Unit, Rabin Medical Center, Petach Tikva, Israel
| | - Keshet Pardo
- Department of Neurology, Rabin Medical Center, Petach Tikva, Israel
| | - Alain Perlow
- Faculty of Medicine, Tel Aviv University, Tel-Aviv, Israel; Interventional Neuroradiology Unit, Rabin Medical Center, Petach Tikva, Israel
| | | | - Penina Weiss
- Occupational Therapy Department, Rabin Medical Center, Beilinson Hospital, Petach Tikva, Israel
| | - Amir Glik
- Department of Neurology, Rabin Medical Center, Petach Tikva, Israel; Faculty of Medicine, Tel Aviv University, Tel-Aviv, Israel; Cognitive Neurology Clinic, Rabin Medical Center, Petach Tikva, Israel
| | - Ophir Keret
- Department of Neurology, Rabin Medical Center, Petach Tikva, Israel; Faculty of Medicine, Tel Aviv University, Tel-Aviv, Israel; Cognitive Neurology Clinic, Rabin Medical Center, Petach Tikva, Israel
| |
Collapse
|
2
|
Shahjouei S, Chaudhary D, Sadighi A, Khan A, Romeo A, Cabrera F, Ishaq F, Aghayari Sheikh Neshin S, Bayan N, Abedi V, Zand R. Prevalence and associated factors of cerebral microbleeds in a rural population of the United States. J Stroke Cerebrovasc Dis 2024; 33:107527. [PMID: 38183963 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107527] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Revised: 11/20/2023] [Accepted: 12/07/2023] [Indexed: 01/08/2024] Open
Abstract
OBJECTIVE Cerebral microbleeds (CMBs) can carry an advanced risk for the development and burden of cerebrovascular and cognitive disorders. Large-scale population-based studies are required to identify the at-risk population. METHOD Ten percent (N = 3,056) of the Geisinger DiscovEHR Initiative Cohort participants who had brain magnetic resonance imaging (MRI) for any indication were randomly selected. Patients with CMBs were compared to an age-, gender-, body mass index-, and hypertension-matched cohort of patients without CMB. The prevalence of comorbidities and use of anticoagulation therapy was investigated in association with CMB presence (binary logistic regression), quantity (ordinal regression), and topography (multinomial regression). RESULTS Among 3,056 selected participants, 477 (15.6 %) had CMBs in their MRI. Patients with CMBs were older and were more prevalently hypertensive, with ischemic stroke, arrhythmia, dyslipidemia, coronary artery disease, and the use of warfarin. After propensity-score matching, 477 patients with CMBs and 974 without were included for further analyses. Predictors of ≥5 CMBs were ischemic stroke (OR, 1.6; 95 % CI, 1.2 -2.0), peripheral vascular disease (OR, 1.6; 95 % CI, 1.1-2.3), and thrombocytopenia (OR, 1.9; 95 % CI, 1.2-2.9). Ischemic stroke was associated with strictly lobar CMBs more strongly than deep/infra-tentorial CMBs (OR, 2.1; 95 % CI, 1.5-3.1; vs. OR, 1.4; CI, 1.1-1.8). CONCLUSIONS CMBs were prevalent in our white population. Old age, hypertension, anticoagulant treatment, thrombocytopenia, and a history of vascular diseases including stroke, were associated with CMBs.
Collapse
Affiliation(s)
- Shima Shahjouei
- Department of Neurology, Milton S. Hershey Medical Center, Penn State Health, Hershey, PA, USA; Neurology Department, Neuroscience Institute, Geisinger Health System, PA, USA
| | - Durgesh Chaudhary
- Department of Neurology, Milton S. Hershey Medical Center, Penn State Health, Hershey, PA, USA; Neurology Department, Neuroscience Institute, Geisinger Health System, PA, USA
| | - Alireza Sadighi
- Neurology Department, Neuroscience Institute, Geisinger Health System, PA, USA
| | - Ayesha Khan
- Neurology Department, Neuroscience Institute, Geisinger Health System, PA, USA
| | - Alexander Romeo
- Neurology Department, Neuroscience Institute, Geisinger Health System, PA, USA
| | - Fedor Cabrera
- Neurology Department, Neuroscience Institute, Geisinger Health System, PA, USA
| | - Farhan Ishaq
- Neurology Department, Neuroscience Institute, Geisinger Health System, PA, USA
| | | | - Nikoo Bayan
- School of Medicine, Tehran University of Medical Sciences, Tehran, Iran; Interdisciplinary Neuroscience Research Program (INRP), Tehran University of Medical Sciences, Tehran, Iran
| | - Vida Abedi
- Neurology Department, Neuroscience Institute, Geisinger Health System, PA, USA; Department of Public Health Sciences, College of Medicine, The Pennsylvania State University, Hershey, PA, USA
| | - Ramin Zand
- Department of Neurology, Milton S. Hershey Medical Center, Penn State Health, Hershey, PA, USA; Neurology Department, Neuroscience Institute, Geisinger Health System, PA, USA.
| |
Collapse
|
3
|
Bilodeau PA, Dickson JR, Kozberg MG. The Impact of Anti-Amyloid Immunotherapies on Stroke Care. J Clin Med 2024; 13:1245. [PMID: 38592119 PMCID: PMC10931618 DOI: 10.3390/jcm13051245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Revised: 02/13/2024] [Accepted: 02/17/2024] [Indexed: 04/10/2024] Open
Abstract
Anti-amyloid immunotherapies have recently emerged as treatments for Alzheimer's disease. While these therapies have demonstrated efficacy in clearing amyloid-β and slowing cognitive decline, they have also been associated with amyloid-related imaging abnormalities (ARIA) which include both edema (ARIA-E) and hemorrhage (ARIA-H). Given that ARIA have been associated with significant morbidity in cases of antithrombotic or thrombolytic therapy, an understanding of mechanisms of and risk factors for ARIA is of critical importance for stroke care. We discuss the latest data regarding mechanisms of ARIA, including the role of underlying cerebral amyloid angiopathy, and implications for ischemic stroke prevention and management.
Collapse
Affiliation(s)
- Philippe A. Bilodeau
- Division of Neuroimmunology and Neuroinfectious Diseases, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA;
| | - John R. Dickson
- MassGeneral Institute for Neurodegenerative Disease, Massachusetts General Hospital, Harvard Medical School, 114 16th Street, Charlestown, Boston, MA 02129, USA;
| | - Mariel G. Kozberg
- MassGeneral Institute for Neurodegenerative Disease, Massachusetts General Hospital, Harvard Medical School, 114 16th Street, Charlestown, Boston, MA 02129, USA;
- J. Philip Kistler Stroke Research Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
| |
Collapse
|
4
|
Tipirneni S, Stanwell P, Weissert R, Bhaskar SMM. Prevalence and Impact of Cerebral Microbleeds on Clinical and Safety Outcomes in Acute Ischaemic Stroke Patients Receiving Reperfusion Therapy: A Systematic Review and Meta-Analysis. Biomedicines 2023; 11:2865. [PMID: 37893237 PMCID: PMC10604359 DOI: 10.3390/biomedicines11102865] [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: 09/27/2023] [Revised: 10/15/2023] [Accepted: 10/16/2023] [Indexed: 10/29/2023] Open
Abstract
BACKGROUND Cerebral microbleeds (CMBs), a notable neuroimaging finding often associated with cerebral microangiopathy, demonstrate a heightened prevalence in patients diagnosed with acute ischemic stroke (AIS), which is in turn linked to less favourable clinical prognoses. Nevertheless, the exact prevalence of CMBs and their influence on post-reperfusion therapy outcomes remain inadequately elucidated. MATERIALS AND METHODS Through systematic searches of PubMed, Embase and Cochrane databases, studies were identified adhering to specific inclusion criteria: (a) AIS patients, (b) age ≥ 18 years, (c) CMBs at baseline, (d) availability of comparative data between CMB-positive and CMB-negative groups, along with relevant post-reperfusion therapy outcomes. The data extracted were analysed using forest plots of odds ratios, and random-effects modelling was applied to investigate the association between CMBs and symptomatic intracerebral haemorrhage (sICH), haemorrhagic transformation (HT), 90-day functional outcomes, and 90-day mortality post-reperfusion therapy. RESULTS In a total cohort of 9776 AIS patients who underwent reperfusion therapy, 1709 had CMBs, with a pooled prevalence of 19% (ES 0.19; 95% CI: 0.16, 0.23, p < 0.001). CMBs significantly increased the odds of sICH (OR 2.57; 95% CI: 1.72; 3.83; p < 0.0001), HT (OR 1.53; 95% CI: 1.25; 1.88; p < 0.0001), as well as poor functional outcomes at 90 days (OR 1.59; 95% CI: 1.34; 1.89; p < 0.0001) and 90-day mortality (OR 1.65; 95% CI: 1.27; 2.16; p < 0.0001), relative to those without CMBs, in AIS patients undergoing reperfusion therapy (encompassing intravenous thrombolysis [IVT], endovascular thrombectomy [EVT], either IVT or EVT, and bridging therapy). Variations in the level of association can be observed among different subgroups of reperfusion therapy. CONCLUSIONS This meta-analysis underscores a significant association between CMBs and adverse postprocedural safety outcomes encompassing sICH, HT, poor functional outcome, and increased mortality in AIS patients undergoing reperfusion therapy. The notable prevalence of CMBs in both the overall AIS population and those undergoing reperfusion therapy emphasizes their importance in post-stroke prognostication.
Collapse
Affiliation(s)
- Shraddha Tipirneni
- Global Health Neurology Lab, Sydney, NSW 2150, Australia
- UNSW Medicine and Health, South Western Sydney Clinical Campuses, University of New South Wales (UNSW), Sydney, NSW 2170, Australia
- Neurovascular Imaging Laboratory, Ingham Institute for Applied Medical Research, Clinical Sciences Stream, Sydney, NSW 2170, Australia
| | - Peter Stanwell
- School of Health Sciences, University of Newcastle, Newcastle, NSW 2308, Australia
| | - Robert Weissert
- Department of Neurology, Regensburg University Hospital, University of Regensburg, 93053 Regensburg, Germany
| | - Sonu M. M. Bhaskar
- Global Health Neurology Lab, Sydney, NSW 2150, Australia
- Neurovascular Imaging Laboratory, Ingham Institute for Applied Medical Research, Clinical Sciences Stream, Sydney, NSW 2170, Australia
- NSW Brain Clot Bank, NSW Health Pathology, Sydney, NSW 2170, Australia
- Department of Neurology & Neurophysiology, Liverpool Hospital & South Western Sydney Local Health District (SWSLHD), Liverpool, NSW 2170, Australia
| |
Collapse
|
5
|
Exploring the Impact of Cerebral Microbleeds on Stroke Management. Neurol Int 2023; 15:188-224. [PMID: 36810469 PMCID: PMC9944881 DOI: 10.3390/neurolint15010014] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Revised: 01/17/2023] [Accepted: 01/26/2023] [Indexed: 02/04/2023] Open
Abstract
Stroke constitutes a major cause of functional disability and mortality, with increasing prevalence. Thus, the timely and accurate prognosis of stroke outcomes based on clinical or radiological markers is vital for both physicians and stroke survivors. Among radiological markers, cerebral microbleeds (CMBs) constitute markers of blood leakage from pathologically fragile small vessels. In the present review, we evaluated whether CMBs affect ischemic and hemorrhagic stroke outcomes and explored the fundamental question of whether CMBs may shift the risk-benefit balance away from reperfusion therapy or antithrombotic use in acute ischemic stroke patients. A literature review of two databases (MEDLINE and Scopus) was conducted to identify all the relevant studies published between 1 January 2012 and 9 November 2022. Only full-text articles published in the English language were included. Forty-one articles were traced and included in the present review. Our findings highlight the utility of CMB assessments, not only in the prognostication of hemorrhagic complications of reperfusion therapy, but also in forecasting hemorrhagic and ischemic stroke patients' functional outcomes, thus indicating that a biomarker-based approach may aid in the provision of counseling for patients and families, improve the selection of more appropriate medical therapies, and contribute to a more accurate choice of patients for reperfusion therapy.
Collapse
|
6
|
Meta-Analysis of Predictive Role of Early Neurological Deterioration after Intravenous Thrombolysis. Emerg Med Int 2022; 2022:2894426. [PMID: 35912390 PMCID: PMC9337960 DOI: 10.1155/2022/2894426] [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: 04/08/2022] [Revised: 05/25/2022] [Accepted: 06/02/2022] [Indexed: 11/17/2022] Open
Abstract
With the popularization of intravenous thrombolysis, more and more people use intravenous thrombolysis to treat related diseases, but problems also arise. There are still a considerable number of patients with early disease after thrombolytic therapy not only not significantly improving, but also progressing, that is, early neurological deterioration (END). In view of this problem, the prediction of END after intravenous thrombolysis becomes very important. With the development of medical technology, research on the prediction of END after intravenous thrombolysis has gradually been carried out. Effective prediction is of great significance for the prevention and treatment of END after intravenous thrombolysis. This article aimed to carry out a meta-analysis of the predictive role of END after intravenous thrombolysis. Through an informed analysis of all studies of this type in this field, this article determines a method for predicting END after intravenous thrombolysis. The actual effect of its role is revealed in this paper, and its purpose is to promote the development of this field. This article addresses the same type of study on the predictive role of neurological deterioration after intravenous thrombolysis. The article performs test and meta-analysis of its role by conditionally searching for literature studies. It is explained using the relevant theoretical formulas. The analysis results show that the prediction of END after intravenous thrombolysis in this paper can effectively help make a preliminary judgment on the possible later neurological deterioration. Although there is an error between the predicted curve and the actual curve, the difference between the two is between 1% and 5%. It can basically effectively predict the occurrence of END. Therefore, the prediction of END after intravenous thrombolysis has a very large preventive effect on the END after intravenous thrombolysis.
Collapse
|
7
|
Li Y, Gao H, Zhang D, Gao X, Lu L, Liu C, Li Q, Miao C, Ma H, Li Y. Clinical Prediction Model for Screening Acute Ischemic Stroke Patients With More Than 10 Cerebral Microbleeds. Front Neurol 2022; 13:833952. [PMID: 35463120 PMCID: PMC9021829 DOI: 10.3389/fneur.2022.833952] [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: 12/12/2021] [Accepted: 03/08/2022] [Indexed: 11/30/2022] Open
Abstract
Background Hemorrhagic transformation is one of the most serious complications in intravenous thrombolysis. Studies show that the existence of more than 10 cerebral microbleeds is strongly associated with hemorrhagic transformation. The current study attempts to develop and validate a clinical prediction model of more than 10 cerebral microbleeds. Methods We reviewed the computed tomography markers of cerebral small vessel diseases and the basic clinical information of acute ischemic stroke patients who were investigated using susceptibility weighted imaging from 2018 to 2021. A clinical prediction model of more than 10 cerebral microbleeds was established. Discrimination, calibration, and the net benefit of the model were assessed. Finally, a validation was conducted to evaluate the accuracy and stability of the model. Results The multivariate logistic regression model showed hypertension, and some computed tomography markers (leukoaraiosis, lacunar infarctions, brain atrophy) were independent risk factors of more than 10 cerebral microbleeds. These risk factors were used for establishing the clinical prediction model. The area under the receiver operating characteristic curve (AUC) was 0.894 (95% CI: 0.870–0.919); Hosmer–Lemeshow chi-squared test yielded χ2 = 3.946 (P = 0.862). The clinical decision cure of the model was higher than the two extreme lines. The simplified score of the model ranged from 0 to 12. The model in the internal and external validation cohort also had good discrimination (AUC 0.902, 95% CI: 0.868–0.937; AUC 0.914, 95% CI: 0.882–0.945) and calibration (P = 0.157, 0.247), and patients gained a net benefit from the model. Conclusions We developed and validated a simple scoring tool for acute ischemic stroke patients with more than 10 cerebral microbleeds; this tool may be beneficial for paradigm decision regarding intravenous recombinant tissue plasminogen activator therapy of acute ischemic stroke.
Collapse
Affiliation(s)
- Yifan Li
- Department of Neurology, Xuanwu Hospital of Capital Medical University, Beijing, China
| | - Haifeng Gao
- Department of Neurology, Tangshan Gongren Hospital, Tangshan, China
| | - Dongsen Zhang
- Department of Neurology, Tangshan Gongren Hospital, Tangshan, China
| | - Xuan Gao
- Department of Neurology, Tangshan Gongren Hospital, Tangshan, China
| | - Lin Lu
- Department of Neurology, Tangshan Gongren Hospital, Tangshan, China
| | - Chunqin Liu
- Department of Neurology, Tangshan Gongren Hospital, Tangshan, China
| | - Qian Li
- Department of Neurology, Tangshan Gongren Hospital, Tangshan, China
| | - Chunzhi Miao
- Department of Neurology, Tangshan Gongren Hospital, Tangshan, China
| | - Hongying Ma
- Department of Neurology, Tangshan Gongren Hospital, Tangshan, China
- *Correspondence: Hongying Ma
| | - Yongqiu Li
- Department of Neurology, Tangshan Gongren Hospital, Tangshan, China
- Yongqiu Li
| |
Collapse
|
8
|
Jabłoński B, Gójska-Grymajło A, Ossowska D, Szurowska E, Wyszomirski A, Rojek B, Karaszewski B. New Remote Cerebral Microbleeds on T2 *-Weighted Echo Planar MRI After Intravenous Thrombolysis for Acute Ischemic Stroke. Front Neurol 2022; 12:744701. [PMID: 35242092 PMCID: PMC8886895 DOI: 10.3389/fneur.2021.744701] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Accepted: 12/16/2021] [Indexed: 11/17/2022] Open
Abstract
Background The main and well-defined complication of intravenous administration of recombinant tissue plasminogen activator (tPA) in patients with acute ischemic stroke (AIS) is symptomatic intracranial hemorrhage (sICH). However, rtPA might also be connected with the formation of cerebral microbleeds (CMBs), located remotely from the ischemic lesions, that may remain clinically silent. This association might be important because the load of CMBs has been associated with cognitive impairment. We investigated whether administration of rtPA in AIS results in the appearance of new CMBs and if the initial load of CMBs is associated with hemorrhagic transformation. Methods A total of fifty-nine consecutive patients with AIS treated with rtPA underwent MRI including T2*-weighted Echo Planar Imaging (T2*-EPI) shortly before and 7–9 days after rtPA administration. We calculated the load of new CMBs located outside the MR diffusion restriction area in the follow-up imaging and assessed hemorrhagic transformation with ECASS-II scoring. Results A total of forty-nine patients were included for the final analysis. On initial T2*-EPI-GRE, 37 baseline microbleeds (CMBs) were observed in 14 patients (28.6%). On follow-up T2*-EPI-GRE amount of CMBs increased to a total number of 103. New CMBs were found in 5 (14.3%) of 35 patients without and in 9 (64.3%) of 14 with any baseline CMBs. Multiple logistic regression analysis indicated that presence of baseline CMBs (risk ratio [RR] 5.95, 95% CI 2.69–13.20, p < 0.001) and lower platelets level (risk ratio [RR] 0.992, 95% CI 0.986–0.998, p = 0.007) were independently associated with new CMBs. The baseline load of CMBs was not associated with the risk of hemorrhagic transformation. Conclusion In this study, new CMBs were found in nearly 30% of patients with AIS on the 7–9 days after rtPA treatment. Baseline CMBs correlated with a higher risk of new CMBs appearing after the rtPA treatment, independently of other factors. At the same time, in our sample, baseline CMBs did not correlate with an increased risk of hemorrhagic transformation. Since the associations between the CMBs load and cognitive impairment have already been proved, further studies are warranted to investigate possible associations between the thrombolytic treatment of patients with AIS, mainly those with baseline CMBs, and the risk of earlier cognitive decline.
Collapse
Affiliation(s)
- Bartosz Jabłoński
- Department of Adult Neurology, University Clinical Center, Medical University of Gdańsk, Gdańsk, Poland
| | - Anna Gójska-Grymajło
- Department of Adult Neurology, University Clinical Center, Medical University of Gdańsk, Gdańsk, Poland
| | - Daria Ossowska
- Department of Adult Neurology, University Clinical Center, Medical University of Gdańsk, Gdańsk, Poland.,II Department of Radiology, Medical University of Gdańsk, Department of Radiology, University Clinical Centre, Gdańsk, Poland
| | - Edyta Szurowska
- II Department of Radiology, Medical University of Gdańsk, Department of Radiology, University Clinical Centre, Gdańsk, Poland
| | - Adam Wyszomirski
- Department of Adult Neurology, University Clinical Center, Medical University of Gdańsk, Gdańsk, Poland
| | - Bartłomiej Rojek
- Department of Adult Neurology, University Clinical Center, Medical University of Gdańsk, Gdańsk, Poland
| | - Bartosz Karaszewski
- Department of Adult Neurology, University Clinical Center, Medical University of Gdańsk, Gdańsk, Poland
| |
Collapse
|
9
|
Goh S, Tan NHW, Tan CH, Leow AST, Sia CH, Ho AFW, Lim MJR, Yeo LLL, Tan BYQ. Evaluating the safety and efficacy of intravenous thrombolysis for acute ischemic stroke patients with a history of intracerebral hemorrhage: a systematic review and meta-analysis. J Thromb Thrombolysis 2021; 53:485-494. [PMID: 34302590 DOI: 10.1007/s11239-021-02531-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/06/2021] [Indexed: 12/29/2022]
Abstract
Previous intracerebral hemorrhage (ICH) is labelled as a contraindication for the use of intravenous tissue plasminogen activator (IV-tPA) in acute ischemic stroke (AIS) based on expert opinion. However, there is a paucity of data available regarding the benefits and risks of IV-tPA in this population. Recent small retrospective cohort studies reporting its off-label use suggest it may be beneficial. This study aims to investigate the safety and efficacy of IV-tPA in AIS patients with previous ICH. We performed a systematic review and meta-analysis of studies reporting on IV-tPA use in AIS patients with and without previous ICH. We searched Embase, PubMed and Cochrane Library from inception to 20 April 2021. Outcomes measured included symptomatic ICH (sICH), 3-month modified Rankin Scale (mRS) score, and 3-month mortality. We included seven retrospective cohort studies comprising 5760 AIS patients who had received IV-tPA, of which 134 had previous ICH. There was no significant difference in the odds of sICH (OR 1.57, 95% CI 0.78-3.15, p = 0.21) and 3-month mRS (mRS 0-1: OR 0.78, 95% CI 0.37-1.65, p = 0.52; mRS 0-2: OR 1.07, 95% CI 0.36-3.15, p = 0.90) between patients with and without previous ICH. There was a trend towards higher 3-month mortality in patients with previous ICH (OR 1.69, 95% CI 0.98-2.91, p = 0.06), although this did not reach statistical significance. The use of IV-tPA in AIS patients with previous ICH was not associated with an increased risk of sICH or disability at 3 months. Further larger studies are needed to establish the safety and efficacy of IV-tPA use in this population.
Collapse
Affiliation(s)
- Sherill Goh
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Natalie H W Tan
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Choon Han Tan
- Department of Medicine, Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
| | - Aloysius S T Leow
- Division of Neurology, Department of Medicine, National University Health System, Singapore, Singapore
| | - Ching-Hui Sia
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Department of Cardiology, National University Heart Centre Singapore, Singapore, Singapore
| | - Andrew F W Ho
- Department of Emergency Medicine, Singapore General Hospital, Singapore, Singapore
- Pre-hospital & Emergency Research Centre, Duke-National University of Singapore Medical School, Singapore National Heart Research Institute Singapore, National Heart Centre, Singapore, Singapore
| | - Mervyn J R Lim
- Division of Neurosurgery, Department of General Surgery, National University Hospital, Singapore, Singapore
| | - Leonard L L Yeo
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.
- Division of Neurology, Department of Medicine, National University Health System, Singapore, Singapore.
| | - Benjamin Y Q Tan
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Division of Neurology, Department of Medicine, National University Health System, Singapore, Singapore
| |
Collapse
|
10
|
Aker L, Abandeh L, Abdelhady M, Aboughalia H, Vattoth S. Susceptibility-weighted Imaging in Neuroradiology: Practical Imaging Principles, Pearls and Pitfalls. Curr Probl Diagn Radiol 2021; 51:568-578. [PMID: 34210556 DOI: 10.1067/j.cpradiol.2021.05.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Accepted: 05/10/2021] [Indexed: 01/13/2023]
Abstract
Susceptibility-weighted imaging (SWI) was one of the recent and helpful advancement in magnetic resonance imaging. Its utilization -provided valuable information for the radiologists in multiple fields, including neuroradiology. SWI was able to demonstrate cerebral paramagnetic and diamagnetic substances. Therefore, the applications of this imaging technique were diverse in research and clinical neuroradiology. This article reviewed the basic technical steps, various clinical applications of SWI, and potential limitations. The practicing radiologist needs to be oriented about using SWI and phase images in the right- and left-handed MRI systems to demonstrate different brain pathologies, including neurovascular diseases, traumatic brain injuries, brain tumors, infectious and inflammatory, and neurodegenerative diseases.
Collapse
Affiliation(s)
- Loai Aker
- Department of Clinical Imaging, Hamad Medical Corporation,Doha,Qatar.
| | - Laith Abandeh
- Department of Radiology, University of Washington, Seattle,WA
| | | | - Hassan Aboughalia
- Radiology Department, Seattle Children's Hospital, University of Washington Medical Center,Seattle,WA
| | - Surjith Vattoth
- Neuroradiology Section, University of Arkansas for Medical Sciences (UAMS),Little Rock,AR
| |
Collapse
|
11
|
Tsivgoulis G, Kargiotis O, De Marchis G, Kohrmann M, Sandset EC, Karapanayiotides T, de Sousa DA, Sarraj A, Safouris A, Psychogios K, Vadikolias K, Leys D, Schellinger PD, Alexandrov AV. Off-label use of intravenous thrombolysis for acute ischemic stroke: a critical appraisal of randomized and real-world evidence. Ther Adv Neurol Disord 2021; 14:1756286421997368. [PMID: 33737956 PMCID: PMC7934037 DOI: 10.1177/1756286421997368] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2021] [Accepted: 01/25/2021] [Indexed: 12/12/2022] Open
Abstract
Intravenous thrombolysis (IVT) represents the only systemic reperfusion therapy able to reverse neurological deficit in patients with acute ischemic stroke (AIS). Despite its effectiveness in patients with or without large vessel occlusion, it can be offered only to a minority of them, because of the short therapeutic window and additional contraindications derived from stringent but arbitrary inclusion and exclusion criteria used in landmark randomized controlled clinical trials. Many absolute or relative contraindications lead to disparities between the official drug label and guidelines or expert recommendations. Based on recent advances in neuroimaging and evidence from cohort studies, off-label use of IVT is increasingly incorporated into the daily practice of many stroke centers. They relate to extension of therapeutic time windows, and expansion of indications in co-existing conditions originally listed in exclusion criteria, such as use of alternative thrombolytic agents, pre-treatment with antiplatelets, anticoagulants or low molecular weight heparins. In this narrative review, we summarize recent randomized and real-world data on the safety and efficacy of off-label use of IVT for AIS. We also make some practical recommendations to stroke physicians regarding the off-label use of thrombolytic agents in complex and uncommon presentations of AIS or other conditions mimicking acute cerebral ischemia. Finally, we provide guidance on the risks and benefits of IVT in numerous AIS subgroups, where equipoise exists and guidelines and treatment practices vary.
Collapse
Affiliation(s)
- Georgios Tsivgoulis
- Second Department of Neurology, National & Kapodistrian University of Athens, School of Medicine, Iras 39, Gerakas Attikis, Athens 15344, Greece
- Department of Neurology, The University of Tennessee Health Science Center, Memphis, TN, USA
| | | | - Gianmarco De Marchis
- Neurology and Stroke Center, Department of Clinical Research, University Hospital of Basel, University of Basel, Basel, Switzerland
| | - Martin Kohrmann
- Department of Neurology, Universitätsklinikum Essen, Essen, Germany
| | | | - Theodore Karapanayiotides
- Department of Neurology, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Diana Aguiar de Sousa
- Department of Neurosciences (Neurology), Hospital de Santa Maria, University of Lisbon, Lisbon, Portugal
| | - Amrou Sarraj
- Department of Neurology, The University of Texas at Houston, Houston, TX, USA
| | - Apostolos Safouris
- Second Department of Neurology, National & Kapodistiran University of Athens, School of Medicine, “Attikon” University Hospital, Athens, Greece
- Stroke Unit, Metropolitan Hospital, Piraeus, Greece
| | | | - Konstantinos Vadikolias
- Department of Neurology, University Hospital of Alexandroupolis, Democritus University of Thrace, School of Medicine, Alexandroupolis, Greece
| | - Didier Leys
- Department of Neurology (Stroke Unit), Lille Neuroscience and Cognition, Degenerative and Vascular Cognitive Disorders, University of Lille, INSERM (U-1172), Lille, France
| | - Peter D. Schellinger
- Department of Neurology, Johannes Wesling Medical Center Minden, UK RUB Minden, Germany
| | - Andrei V. Alexandrov
- Department of Neurology, The University of Tennessee Health Science Center, Memphis, TN, USA
| |
Collapse
|
12
|
Role of neuroimaging before reperfusion therapy. Part 1 - IV thrombolysis - Review. Rev Neurol (Paris) 2021; 177:908-918. [PMID: 33455833 DOI: 10.1016/j.neurol.2020.10.007] [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: 06/18/2020] [Revised: 09/25/2020] [Accepted: 10/05/2020] [Indexed: 11/22/2022]
Abstract
This review paper summarises the yield of the different imaging modalities in the evaluation of patients for IV thrombolysis. Non-contrast CT and CTA or brain MRI combined with MRA are the recommended sequences for the evaluation of patients within the 4.5 hours time window. Multimodal MRI (DWI/PWI), and more recently, CT perfusion, offer reliable surrogate of salvageable penumbra, the target mismatch, which is now currently used as selection criteria for revascularisation treatment in an extended time window. Those sequences may also help the physician for the management of other limited cases when the diagnosis of acute ischemic stroke is difficult. Another approach the DWI/FLAIR mismatch has been proposed to identify among wake-up stroke patients those who have been experiencing an acute ischemic stroke evolving from less than 4.5hrs. Other biomarkers, such as the clot imaging on MRI and CT, help to predict the recanalisation rate after IVT, while the impact of the presence microbleeds on MRI remains to be determined.
Collapse
|
13
|
Wu Y, Chen H, Liu X, Cai X, Kong Y, Wang H, Zhou Y, Zhu J, Zhang L, Fang Q, Li T. A new nomogram for individualized prediction of the probability of hemorrhagic transformation after intravenous thrombolysis for ischemic stroke patients. BMC Neurol 2020; 20:426. [PMID: 33234113 PMCID: PMC7685652 DOI: 10.1186/s12883-020-02002-w] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Accepted: 11/16/2020] [Indexed: 12/14/2022] Open
Abstract
Background A reliable scoring tool to detect the risk of intracerebral hemorrhage (ICH) after intravenous thrombolysis for ischemic stroke is warranted. The present study was designed to develop and validate a new nomogram for individualized prediction of the probability of hemorrhagic transformation (HT) in patients treated with intravenous (IV) recombinant tissue plasminogen activator (rt-PA). Methods We enrolled patients who suffered from acute ischemic stroke (AIS) with IV rt-PA treatment in our emergency green channel between August 2016 and July 2018. The main outcome was defined as any type of intracerebral hemorrhage according to the European Cooperative Acute Stroke Study II (ECASS II). All patients were randomly divided into two cohorts: the primary cohort and the validation cohort. On the basis of multivariate logistic model, the predictive nomogram was generated. The performance of the nomogram was evaluated by Harrell’s concordance index (C-index) and calibration plot. Results A total of 194 patients with complete data were enrolled, of whom 131 comprised the primary cohort and 63 comprised the validation cohort, with HT rate 12.2, 9.5% respectively. The score of chronic disease scale (CDS), the global burden of cerebral small vascular disease (CSVD), National Institutes of Health Stroke Scale (NIHSS) score ≥ 13, and onset-to-treatment time (OTT) ≥ 180 were detected important determinants of ICH and included to construct the nomogram. The nomogram derived from the primary cohort for HT had C- Statistics of 0.9562 and the calibration plot revealed generally fit in predicting the risk of HT. Furthermore, we made a comparison between our new nomogram and several other risk-assessed scales for HT with receiver operating characteristic (ROC) curve analysis, and the results showed the nomogram model gave an area under curve of 0.9562 (95%CI, 0.9221–0.9904, P < 0.01) greater than HAT (Hemorrhage After Thrombolysis), SEDAN (blood Sugar, Early infarct and hyper Dense cerebral artery sign on non-contrast computed tomography, Age, and NIHSS) and SPAN-100 (Stroke Prognostication using Age and NIHSS) scores. Conclusions This proposed nomogram based on the score of CDS, the global burden of CSVD, NIHSS score ≥ 13, and OTT ≥ 180 gives rise to a more accurate and more comprehensive prediction for HT in patients with ischemic stroke receiving IV rt-PA treatment. Supplementary Information Supplementary information accompanies this paper at 10.1186/s12883-020-02002-w.
Collapse
Affiliation(s)
- Yaya Wu
- Department of Neurology, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province, China
| | - Hui Chen
- Department of Intensive Care Medicine, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province, China
| | - Xueyun Liu
- Department of Neurology, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province, China.,Department of Neurology, The Second Hospital of Anhui Medical University, Hefei, Anhui Province, China
| | - Xiuying Cai
- Department of Neurology, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province, China
| | - Yan Kong
- Department of Neurology, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province, China
| | - Hui Wang
- Department of Neurology, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province, China
| | - Yun Zhou
- Department of Neurology, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province, China
| | - Juehua Zhu
- Department of Neurology, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province, China
| | - Lulu Zhang
- Department of Neurology, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province, China
| | - Qi Fang
- Department of Neurology, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province, China.
| | - Tan Li
- Department of Neurology, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province, China.
| |
Collapse
|
14
|
Liu C, Xie J, Sun S, Li H, Li T, Jiang C, Chen X, Wang J, Le A, Wang J, Li Z, Wang J, Wang W. Hemorrhagic Transformation After Tissue Plasminogen Activator Treatment in Acute Ischemic Stroke. Cell Mol Neurobiol 2020; 42:621-646. [PMID: 33125600 DOI: 10.1007/s10571-020-00985-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Accepted: 10/22/2020] [Indexed: 12/17/2022]
Abstract
Hemorrhagic transformation (HT) is a common complication after thrombolysis with recombinant tissue-type plasminogen activator (rt-PA) in ischemic stroke. In this article, recent research progress of HT in vivo and in vitro studies was reviewed. We have discussed new potential mechanisms and possible experimental models of HT development, as well as possible biomarkers and treatment methods. Meanwhile, we compared and analyzed rodent models, large animal models and in vitro BBB models of HT, and the limitations of these models were discussed. The molecular mechanism of HT was investigated in terms of BBB disruption, rt-PA neurotoxicity and the effect of neuroinflammation, matrix metalloproteinases, reactive oxygen species. The clinical features to predict HT were represented including blood biomarkers and clinical factors. Recent progress in neuroprotective strategies to improve HT after stroke treated with rt-PA is outlined. Further efforts need to be made to reduce the risk of HT after rt-PA therapy and improve the clinical prognosis of patients with ischemic stroke.
Collapse
Affiliation(s)
- Chengli Liu
- Department of Traumatic Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, People's Republic of China
| | - Jie Xie
- Department of Traumatic Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, People's Republic of China
| | - Shanshan Sun
- Department of Ultrasound Imaging, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, People's Republic of China
| | - Hui Li
- Department of Traumatic Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, People's Republic of China
| | - Tianyu Li
- Department of Traumatic Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, People's Republic of China
| | - Chao Jiang
- Department of Neurology, The Fifth Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, Henan, People's Republic of China
| | - Xuemei Chen
- Department of Anatomy, College of Basic Medical Sciences, Zhengzhou University, Henan, 450000, People's Republic of China
| | - Junmin Wang
- Department of Anatomy, College of Basic Medical Sciences, Zhengzhou University, Henan, 450000, People's Republic of China
| | - Anh Le
- Washington University in St. Louis, Saint Louis, MO, 63130, USA
| | - Jiarui Wang
- The Johns Hopkins University, Baltimore, MD, 21218, USA
| | - Zhanfei Li
- Department of Traumatic Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, People's Republic of China
| | - Jian Wang
- Department of Anatomy, College of Basic Medical Sciences, Zhengzhou University, Henan, 450000, People's Republic of China.
| | - Wei Wang
- Department of Traumatic Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, People's Republic of China.
| |
Collapse
|
15
|
Capuana ML, Lorenzano S, Caselli MC, Paciaroni M, Toni D. Hemorrhagic risk after intravenous thrombolysis for ischemic stroke in patients with cerebral microbleeds and white matter disease. Neurol Sci 2020; 42:1969-1976. [PMID: 32990857 PMCID: PMC8043883 DOI: 10.1007/s10072-020-04720-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Accepted: 09/12/2020] [Indexed: 12/15/2022]
Abstract
Objectives Aim of this study was to evaluate the association between cerebral microbleeds (CMBs) and white matter disease (WMD) with intracerebral hemorrhage (ICH) after intravenous thrombolysis (IVT) with rt-PA. We also evaluated whether CMBs characteristics and WMD burden correlate with symptomatic ICH and outcome. Methods We included acute ischemic stroke (AIS) patients treated with IVT. The number and location of CMBs as well as severity of WMD were rated analyzing pre- or post-treatment MRI. Multivariable regression analysis was used to determine the impact of CMB and WMD on ICH subgroups and outcome measures. Results 434 patients were included. CMBs were detected in 23.3% of them. ICH occurred in 34.7% of patients with CMBs. Independent predictors of parenchymal hemorrhage were the presence of CMBs (OR 2.724, 95% CI 1.360–5.464, p = 0.005) as well as cortical-subcortical stroke (OR 3.629, 95% CI 1.841–7.151, p < 0.001) and atherothrombotic stroke subtype (OR 3.381, 95% CI 1.335–8.566, p = 0.010). Either the presence, or number, and location of CMBs, as well as WMD, was not independently associated with the development of SICH. No independent association between the presence, number, or location of CMBs or WMD and outcome measures was observed. Conclusions The results of our study suggest that the exclusion of eligible candidates to administration of IV rt-PA only on the basis of CMBs presence is not justified. The clinical decision should be weighed with a case-by-case approach. Additional data are needed to evaluate the benefit-risk profile of rt-PA in patients carrying numerous microbleeds. Electronic supplementary material The online version of this article (10.1007/s10072-020-04720-y) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
| | - Svetlana Lorenzano
- Emergency Department Stroke Unit, Department of Human Neurosciences, Policlinico Umberto I Hospital, Sapienza University of Rome, Viale del Policlinico, 155, 00161, Rome, Italy
| | - Maria Chiara Caselli
- Department of Clinical and Sperimental Medicine, University of Pisa, Pisa, Italy
| | - Maurizio Paciaroni
- Stroke Unit and Division of Internal and Cardiovascular Medicine, Santa Maria della Misericordia Hospital, University of Perugia, Perugia, Italy
| | - Danilo Toni
- Emergency Department Stroke Unit, Department of Human Neurosciences, Policlinico Umberto I Hospital, Sapienza University of Rome, Viale del Policlinico, 155, 00161, Rome, Italy.
| |
Collapse
|
16
|
Han J, Yang H, Bae JH, Kim HY, Kim YS. Computed tomography-negative symptomatic intracerebral hemorrhage in a patient with cerebral small vessel disease: A case report. Medicine (Baltimore) 2020; 99:e21382. [PMID: 32702937 PMCID: PMC7373521 DOI: 10.1097/md.0000000000021382] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
RATIONALE Computed tomography plays a key role in the initial evaluation of suspected acute stroke by ruling out the possibility of hemorrhage before thrombolysis. Recently, many reports have described cases of symptomatic microbleeds, and there may also have been a case of computed tomography- negative intracerebral hemorrhage. PATIENT CONCERNS A 70-year-old female patient who had a history of lacunar infarction and severe small vessel disease developed dysarthria. On brain non-contrast computed tomography there was no evidence of intracerebral hemorrhage. However, brain magnetic resonance imaging performed at 3 hours after the initial computed tomography showed cerebral hemorrhage. DIAGNOSES The diagnosis was computed tomography-negative intracerebral hemorrhage. INTERVENTIONS The patient was treated with cilostazole 100 mg twice a day with blood pressure management. OUTCOMES The dysarthria was fully recovered within 5 days and the patient did not suffer recurrent stroke symptoms over the following 2 years. LESSONS In patients with underlying severe small vessel disease and microbleeds, there could be computed tomography-negative hemorrhage and susceptibility weighted magnetic resonance image could be needed. More attention is required before applying thrombolysis therapy because there is a possibility of cerebral hemorrhage in those patients.
Collapse
|
17
|
Abstract
With the elder proportion increasing and the antithrombotic agents widely using as well as the newly magnetic resonance imaging sequence emerging, the detection rate of cerebral microbleed (CMB) is gradually raising in recent years. As we all know that CMB mainly reflects the severity of deeply small vessel lesions, which predicts hemorrhagic transformation. Whereby, to some patients with both CMB and remarkable antithrombotic indication, treatment becomes a dilemma. We have to face the challenge of weighing the pros and cons of both drug indication and bleeding risk when making a proper decision for patients. This study summarized recent advance on CMB diagnosis and treatment, to provide a useful reference to physicians in their clinical practice.
Collapse
|
18
|
Powers WJ, Rabinstein AA, Ackerson T, Adeoye OM, Bambakidis NC, Becker K, Biller J, Brown M, Demaerschalk BM, Hoh B, Jauch EC, Kidwell CS, Leslie-Mazwi TM, Ovbiagele B, Scott PA, Sheth KN, Southerland AM, Summers DV, Tirschwell DL. Guidelines for the Early Management of Patients With Acute Ischemic Stroke: 2019 Update to the 2018 Guidelines for the Early Management of Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke 2019; 50:e344-e418. [PMID: 31662037 DOI: 10.1161/str.0000000000000211] [Citation(s) in RCA: 3408] [Impact Index Per Article: 681.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Background and Purpose- The purpose of these guidelines is to provide an up-to-date comprehensive set of recommendations in a single document for clinicians caring for adult patients with acute arterial ischemic stroke. The intended audiences are prehospital care providers, physicians, allied health professionals, and hospital administrators. These guidelines supersede the 2013 Acute Ischemic Stroke (AIS) Guidelines and are an update of the 2018 AIS Guidelines. Methods- Members of the writing group were appointed by the American Heart Association (AHA) Stroke Council's Scientific Statements Oversight Committee, representing various areas of medical expertise. Members were not allowed to participate in discussions or to vote on topics relevant to their relations with industry. An update of the 2013 AIS Guidelines was originally published in January 2018. This guideline was approved by the AHA Science Advisory and Coordinating Committee and the AHA Executive Committee. In April 2018, a revision to these guidelines, deleting some recommendations, was published online by the AHA. The writing group was asked review the original document and revise if appropriate. In June 2018, the writing group submitted a document with minor changes and with inclusion of important newly published randomized controlled trials with >100 participants and clinical outcomes at least 90 days after AIS. The document was sent to 14 peer reviewers. The writing group evaluated the peer reviewers' comments and revised when appropriate. The current final document was approved by all members of the writing group except when relationships with industry precluded members from voting and by the governing bodies of the AHA. These guidelines use the American College of Cardiology/AHA 2015 Class of Recommendations and Level of Evidence and the new AHA guidelines format. Results- These guidelines detail prehospital care, urgent and emergency evaluation and treatment with intravenous and intra-arterial therapies, and in-hospital management, including secondary prevention measures that are appropriately instituted within the first 2 weeks. The guidelines support the overarching concept of stroke systems of care in both the prehospital and hospital settings. Conclusions- These guidelines provide general recommendations based on the currently available evidence to guide clinicians caring for adult patients with acute arterial ischemic stroke. In many instances, however, only limited data exist demonstrating the urgent need for continued research on treatment of acute ischemic stroke.
Collapse
|
19
|
The global burden of cerebral small vessel disease related to neurological deficit severity and clinical outcomes of acute ischemic stroke after IV rt-PA treatment. Neurol Sci 2019; 40:1157-1166. [DOI: 10.1007/s10072-019-03790-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Accepted: 02/22/2019] [Indexed: 12/18/2022]
|
20
|
Gao Y, Nie K, Duan Z, Wang S, Ma G, Zhang X, Li C, Zhang Y, Dai C, Wang L. A Follow-up Study of Cerebral Microbleeds in Patients Who Received Stents for Symptomatic Cerebral Artery Stenosis. Ann Vasc Surg 2019; 58:338-346. [PMID: 30769077 DOI: 10.1016/j.avsg.2018.11.031] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2018] [Revised: 11/19/2018] [Accepted: 11/25/2018] [Indexed: 12/26/2022]
Abstract
BACKGROUND The aims of this study were to explore (i) the dynamic changes in cerebral microbleeds (CMBs) in patients with symptomatic cerebral artery stenosis who received endovascular stent-assisted angioplasty and (ii) the risk factors associated with the new incidence of CMBs as well as whether CMBs increased the risk of vascular events in these patients. METHODS Clinical information and magnetic resonance images were collected on admission and 3 months after endovascular stent-assisted angioplasty. Based on susceptibility-weighted imaging, the patients were divided into groups with or without newly developed CMBs, and between-group differences in risk factors were compared. We also compared whether CMBs increased the risk of vascular events among those patients. RESULTS Seventy-three patients completed the relevant follow-up examinations. After an average follow-up period of 109 days, 7 (9.6%) patients showed new CMBs. A univariate analysis showed that the number of lacunar infarcts and the increase in systolic blood pressure were higher in patients with new CMBs than in those without new CMBs, and these differences were significant (P = 0.034, P = 0.001). Increased systolic blood pressure was an independent risk factor for developing new CMBs (P = 0.017). CONCLUSIONS CMBs may be a continuously progressing cerebral small-vessel disease. The newly developed CMBs in patients with intracranial and/or extracranial stents were associated with increased systolic blood pressure but not with the number of baseline CMBs.
Collapse
Affiliation(s)
- Yuyuan Gao
- Department of Neurology, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangdong Neuroscience Institute, Guangzhou, Guangdong Province, PR China
| | - Kun Nie
- Department of Neurology, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangdong Neuroscience Institute, Guangzhou, Guangdong Province, PR China
| | - Zhenpeng Duan
- Department of Neurology, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangdong Neuroscience Institute, Guangzhou, Guangdong Province, PR China
| | - Shuo Wang
- Department of Neurology, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangdong Neuroscience Institute, Guangzhou, Guangdong Province, PR China
| | - Guixian Ma
- Department of Neurology, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangdong Neuroscience Institute, Guangzhou, Guangdong Province, PR China
| | - Xiong Zhang
- Department of Neurology, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangdong Neuroscience Institute, Guangzhou, Guangdong Province, PR China
| | - Changmao Li
- Department of Neurology, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangdong Neuroscience Institute, Guangzhou, Guangdong Province, PR China
| | - Yuhu Zhang
- Department of Neurology, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangdong Neuroscience Institute, Guangzhou, Guangdong Province, PR China
| | - Chengbo Dai
- Department of Neurology, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangdong Neuroscience Institute, Guangzhou, Guangdong Province, PR China.
| | - Lijuan Wang
- Department of Neurology, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangdong Neuroscience Institute, Guangzhou, Guangdong Province, PR China.
| |
Collapse
|
21
|
Does High Cerebral Microbleed Burden Increase the Risk of Intracerebral Hemorrhage After Intravenous Tissue Plasminogen Activator for Acute Ischemic Stroke? Neurologist 2019; 24:40-43. [PMID: 30586035 DOI: 10.1097/nrl.0000000000000228] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND The risk of developing intracerebral hemorrhage (ICH) after the administration of intravenous tissue plasminogen activator for acute ischemic stroke is well established in the general population. However, the risk associated with stroke thrombolysis in patients with a history of cerebral microbleeds (CMBs) is undetermined. OBJECTIVE The main objective of this study was to critically assess current evidence with regard to the risk of development of ICH after the administration of intravenous tissue plasminogen activator for acute ischemic stroke in patients with CMBs. METHODS The objective was addressed through the development of a critically appraised topic that included a clinical scenario, structured question, literature search strategy, critical appraisal, assessment of results, evidence summary, commentary, and bottom-line conclusions. Participants included consultant and resident neurologists, a medical librarian, clinical epidemiologists, and content experts in the field of vascular and hospital neurology. RESULTS A recent individual patient data meta-analysis was selected for critical appraisal. Cohorts were analyzed with pretreatment magnetic resonance imaging to determine CMB burden and were followed-up to assess subsequent symptomatic ICH, hemorrhagic transformation, parenchymal hemorrhage (PH), and remote PH (PHr) following intravenous thrombolysis. Risk of symptomatic ICH, PH, and PHr was increased in the presence of CMBs, with PHr having the strongest association with increasing CMB burden. Only patients with >10 CMBs were found to have associations with poor outcome at 3 to 6 months, whereas there was no association with 3 to 6 months' mortality. CONCLUSIONS CMBs are associated with an increased risk of postthrombolysis ICH; however, the clinical implications have yet to be determined.
Collapse
|
22
|
Zand R, Shahjouei S, Tsivgoulis G, Singh M, McCormack M, Noorbakhsh-Sabet N, Goyal N, Alexandrov AV. Cerebral Microbleeds are Associated with Higher Mortality Among Ischemic Stroke Patients. J Stroke Cerebrovasc Dis 2018; 27:3036-3042. [DOI: 10.1016/j.jstrokecerebrovasdis.2018.06.037] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2017] [Revised: 06/22/2018] [Accepted: 06/26/2018] [Indexed: 01/31/2023] Open
|
23
|
Li L, Liu MS, Li GQ, Zheng Y, Guo TL, Kang X, Yuan MT. Susceptibility-weighted Imaging in Thrombolytic Therapy of Acute Ischemic Stroke. Chin Med J (Engl) 2018; 130:2489-2497. [PMID: 29052571 PMCID: PMC5684633 DOI: 10.4103/0366-6999.216401] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
Objective: To provide a comprehensive and latest overview of susceptibility-weighted imaging (SWI) in the application of thrombolysis in acute ischemic stroke, and to update the decision-making effect and clinical value of SWI on identifying stroke patients suitable for thrombolytic therapy and possible benefits and risks followed. Data Sources: Literatures referred to this review were collected from PubMed, Medline, and EMBASE published till May 2017, using the search terms including susceptibility-weighted imaging, gradient-echo, T2*, thrombolysis, recombinant tissue plasminogen activator (rt-PA), thrombolytic therapy, and stroke. Study Selection: Papers in English or with available English abstracts were considered, with no limitation of study design. References were also identified from the bibliographies of identified articles and the authors’ files. Results: SWI is of guiding significance for thrombolytic therapy in stroke patients, it can predict the location and length of thrombus and ischemic penumbra. It is worthy of noting that susceptibility vessel sign (SVS) on SWI can be used to predict recanalization after thrombolytic therapy and whether it is better to implement endovascular thrombolectomy in combination or alone. SWI is sensitive in detecting cerebral microbleed (CMB), and CMB might not be a contraindication for thrombolytic therapy, yet CMBs in multiple foci could possibly be related to intracranial hemorrhage (ICH) after thrombolysis. SVS and CMB on SWI sequence are of instructive value in performing antiplatelet therapy after thrombolytic therapy. Cerebral venous change on SWI is related to lower recanalization rate and poor outcome after thrombolysis. Conclusions: It seems that SWI can be applied to guide individualized thrombolytic therapies and assist clinicians in making better decisions by weighing benefits and risks. However, there still exist controversies about the relationship between signs on SWI and thrombolytic therapy.
Collapse
Affiliation(s)
- Lin Li
- Department of Neurology, The First Affiliated Hospital, Chongqing Medical University, Chongqing 400016, China
| | - Ming-Su Liu
- Department of Neurology, The First Affiliated Hospital, Chongqing Medical University, Chongqing 400016, China
| | - Guang-Qin Li
- Department of Neurology, The First Affiliated Hospital, Chongqing Medical University, Chongqing 400016, China
| | - Yang Zheng
- Department of Neurology, The First Affiliated Hospital, Chongqing Medical University, Chongqing 400016, China
| | - Tong-Li Guo
- Department of Neurology, The First Affiliated Hospital, Chongqing Medical University, Chongqing 400016, China
| | - Xin Kang
- Department of Neurology, The First Affiliated Hospital, Chongqing Medical University, Chongqing 400016, China
| | - Mao-Ting Yuan
- Department of Neurology, The First Affiliated Hospital, Chongqing Medical University, Chongqing 400016, China
| |
Collapse
|
24
|
Tsivgoulis G, Kargiotis O, Alexandrov AV. Intravenous thrombolysis for acute ischemic stroke: a bridge between two centuries. Expert Rev Neurother 2018. [PMID: 28644924 DOI: 10.1080/14737175.2017.1347039] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Intravenous tissue-plasminogen activator (tPA) remains the only approved systemic reperfusion therapy suitable for most patients presenting timely with acute ischemic stroke. Accumulating real-word experience for over 20 years regarding tPA safety and effectiveness led to re-appraisal of original contraindications for intravenous thrombolysis (IVT). Areas covered: This narrative review focuses on fast yet appropriate selection of patients for safe administration of tPA per recently expanded indications. Novel strategies for rapid patient assessment will be discussed. The potential for mobile stroke units (MSU) that shorten onset-to-needle time and increase tPA treatment rates is addressed. The use of IVT in the era of non-vitamin K antagonist oral anticoagulants (NOACs) is highlighted. The continuing role of IVT in large vessel occlusion (LVO) patients eligible for mechanical thrombectomy (MT) is discussed with regards to 'drip and ship' vs. 'mothership' treatment paradigms. Promising studies of penumbral imaging to extend IVT beyond the 4.5-hour window and in wake-up strokes are summarized. Expert commentary: This review provides an update on the role of IVT in specific conditions originally considered tPA contraindications. Novel practice challenges including NOAC's, MSU proliferation and bridging therapy (IVT&MT) for LVO patients, and the potential extension of IVT time-window using penumbral imaging are emerging as safe and potentially effective IVT applications.
Collapse
Affiliation(s)
- Georgios Tsivgoulis
- a Second Department of Neurology , National & Kapodistrian University of Athens, School of Medicine, "Attikon" University Hospital , Athens , Greece.,b Department of Neurology , University of Tennessee Health Science Center , Memphis , TN , USA
| | | | - Andrei V Alexandrov
- b Department of Neurology , University of Tennessee Health Science Center , Memphis , TN , USA
| |
Collapse
|
25
|
Chacon-Portillo MA, Llinas RH, Marsh EB. Cerebral microbleeds shouldn't dictate treatment of acute stroke: a retrospective cohort study evaluating risk of intracerebral hemorrhage. BMC Neurol 2018; 18:33. [PMID: 29587638 PMCID: PMC5870091 DOI: 10.1186/s12883-018-1029-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2017] [Accepted: 02/28/2018] [Indexed: 11/10/2022] Open
Abstract
Background Intravenous tissue plasminogen activator (IV tPA) after acute ischemic stroke carries the risk of symptomatic intracerebral hemorrhage (sICH). Cerebral microbleeds (CMBs) may indicate increased risk of hemorrhage and can be seen on magnetic resonance imaging (MRI). In this study, we examined the association between CMBs and sICH, focusing on the predictive value of their presence, burden, and location. Methods Records from all patients presenting to two academic stroke centers with acute ischemic stroke treated with IV tPA over a 5-year period were retrospectively reviewed. Demographic, medical, and imaging variables were evaluated. The presence, number, and location (lobar vs nonlobar) of CMBs were noted on gradient echo MRI sequences obtained during the admission. Univariable and multivariable statistical models were used to determine the relationship between CMBs and hemorrhagic (symptomatic and asymptomatic) transformation. Results Of 292 patients (mean age 62.8 years (SD 15.3), 49% African-American, 52% women), 21% (n = 62) had at least one CMB, 1% (n = 3) had > 10 CMBs, and 1% (n = 3) were diagnosed with probable cerebral amyloid angiopathy. After treatment, 16% (n = 46) developed hemorrhagic transformation, of which 6 (2%) were sICH. There was no association between CMB presence (p = .135) or location (p = .325) with sICH; however, those with a high CMB burden (> 10 CMB) were more likely to develop sICH (OR 37.8; 95% CI: 2.7–539.3; p = .007). Conclusions Our findings support prior findings that a high CMB burden (> 10) in patients with acute stroke treated with IV tPA are associated with a higher risk of sICH. However, the overall rate of sICH in the presence of CMB is very low, indicating that the presence of CMBs by itself should not dictate the decision to treat with thrombolytics.
Collapse
Affiliation(s)
- Martin A Chacon-Portillo
- Division of Congenital Heart Surgery, Texas Children's Hospital, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas, USA
| | - Rafael H Llinas
- Department of Neurology, Johns Hopkins University School of Medicine, 600 N Wolfe St, Phipps 446, Baltimore, MD, 21287, USA
| | - Elisabeth B Marsh
- Department of Neurology, Johns Hopkins University School of Medicine, 600 N Wolfe St, Phipps 446, Baltimore, MD, 21287, USA.
| |
Collapse
|
26
|
Zhu H, Li Z, Lv J, Zhao R. Effects of cerebral small vessel disease on the outcome of patients with ischemic stroke caused by large artery atherosclerosis. Neurol Res 2018. [PMID: 29543130 DOI: 10.1080/01616412.2018.1446283] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- Hui Zhu
- Medical College, Qingdao University, Qingdao, China
| | - Zhixing Li
- Medical College, Qingdao University, Qingdao, China
| | - Jinglei Lv
- Department of Neurology, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Renliang Zhao
- Department of Neurology, The Affiliated Hospital of Qingdao University, Qingdao, China
| |
Collapse
|
27
|
Zand R, Tsivgoulis G, Sadighi A, Singh M, McCormack M, Shahjouei S, Goyal N, Noorbakhsh-Sabet N, Alexandrov AW, Alexandrov AV. Safety of Intravenous Thrombolysis in Chronic Intracranial Hemorrhage: A Five-Year Multicenter Study. J Stroke Cerebrovasc Dis 2018; 27:620-624. [DOI: 10.1016/j.jstrokecerebrovasdis.2017.09.037] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2017] [Accepted: 09/24/2017] [Indexed: 12/16/2022] Open
|
28
|
Tsivgoulis G, Katsanos AH, Zand R. Letter by Tsivgoulis et al Regarding Article, “Microbleeds, Cerebral Hemorrhage, and Functional Outcome After Stroke Thrombolysis: Individual Patient Data Meta-Analysis”. Stroke 2017; 48:e331. [DOI: 10.1161/strokeaha.117.019002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Georgios Tsivgoulis
- Second Department of Neurology, “Attikon” Hospital, School of Medicine, National and Kapodistrian University of Athens, Greece
| | - Aristeidis H. Katsanos
- Second Department of Neurology, “Attikon” Hospital, School of Medicine, National and Kapodistrian University of Athens, Greece
| | - Ramin Zand
- Department of Neurology, University of Tennessee Health Science Center, Memphis
| |
Collapse
|
29
|
Werring DJ, Charidimou A. Response by Werring and Charidimou to Letter Regarding Article, "Microbleeds, Cerebral Hemorrhage, and Functional Outcome After Stroke Thrombolysis: Individual Patient Data Meta-Analysis". Stroke 2017; 48:e332. [PMID: 29030477 DOI: 10.1161/strokeaha.117.019038] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Affiliation(s)
- David J Werring
- Stroke Research Centre, Department of Brain Repair and Rehabilitation, UCL Institute of Neurology, London, United Kingdom
| | - Andreas Charidimou
- Hemorrhagic Stroke Research Group, Massachusetts General Hospital, Boston
| | | |
Collapse
|