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Wen H, Wang N, Lv M, Yang Y, Liu H. The early predictive value of platelet-to-lymphocyte ratio to hemorrhagic transformation of young acute ischemic stroke. ASIAN BIOMED 2023; 17:267-272. [PMID: 38161346 PMCID: PMC10754501 DOI: 10.2478/abm-2023-0069] [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] [Indexed: 01/03/2024]
Abstract
Background The increasing incidence of acute ischemic stroke (AIS) necessitates a comprehensive understanding of the related factors. Hemorrhagic transformation (HT), a severe complication of AIS, is influenced by platelet-induced inflammation and lymphocyte levels. Objective To measure the predictive value of platelet-to-lymphocyte ratio (PLR) in the occurrence of HT in young AIS patients. Methods Data of young AIS patients (n = 157) admitted to the hospital for the first time were retrospectively collected. The patients were divided into HT (63 patients) and non-HT groups (94 patients) on the basis of whether HT had occurred after admission. The National Institute of Health stroke scale (NIHSS) score was used to determine the severity of clinical symptoms. The relationship between PLR and HT and NIHSS scores was analyzed to evaluate the predictive value of PLR in the occurrence of HT using receiver operating characteristic (ROC) and area under the curve (AUC). Results Multivariate analysis showed that PLR and NIHSS are independent risk factors of HT. The PLR value of the observation group was positively associated with the NIHSS score (r = 0.8075, P < 0.0001). According to the PLR prediction about the occurrence of HT, an AUC of 0.713 (95% CI, 0.652-0.781), a cut-off value of 109.073, and a sensitivity and specificity of 0.806 and 0.674, respectively, were obtained. Conclusions PLR value can predict the possibility of HT in young AIS patients to a certain extent. To take effective measures to prevent HT in advance has crucial clinical significance according to PLR value.
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Affiliation(s)
- Huijun Wen
- Department of Neurology, Baoji Central Hospital, Baoji, Shaanxi721008, China
| | - Ning Wang
- Department of Neurology, Baoji Central Hospital, Baoji, Shaanxi721008, China
| | - Min Lv
- Department of Rehabilitation Medicine, Baoji Traditional Chinese Medicine Hospital, Baoji, Shaanxi721008, China
| | - Yue Yang
- Department of Cardiology, Shangluo Beikuanping Central Hospital, Shangluo, Shaanxi726000, China
| | - Hongmei Liu
- Department of Neurology, Baoji Central Hospital, Baoji, Shaanxi721008, China
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2
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Xu Y, Liu C, Li W, Nie X, Huang S, Li X, Wu Y, Jin WS, Jiang J, Dong J, Yang Y, Sun Z, Han W, Wang Y, Liu L, Zhang M. Efficacy and safety of early anticoagulation after endovascular treatment in patients with atrial fibrillation. Stroke Vasc Neurol 2023; 8:405-412. [PMID: 36972921 PMCID: PMC10647876 DOI: 10.1136/svn-2022-002082] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Accepted: 01/27/2023] [Indexed: 03/29/2023] Open
Abstract
BACKGROUND The timing for initiating anticoagulant therapy in acute ischaemic stroke (AIS) patients with atrial fibrillation who recanalised after endovascular treatment (EVT) is unclear. The objective of this study was to evaluate the effect of early anticoagulation after successful recanalisation in AIS patients with atrial fibrillation. METHODS Patients with anterior circulation large vessel occlusion and atrial fibrillation who were successfully recanalised by EVT within 24 hours after stroke in the Registration Study for Critical Care of Acute Ischemic Stroke after Recanalization registry were analysed. Early anticoagulation was defined as the initiation of unfractionated heparin (UFH) or low-molecular-weight heparin (LMWH) within 72 hours after EVT. Ultra-early anticoagulation was defined if it was initiated within 24 hours. The primary efficacy outcome was the score on the modified Rankin Scale (mRS) at day 90, and the primary safety outcome was symptomatic intracranial haemorrhage within 90 days. RESULTS Overall, 257 patients were enrolled, of whom 141 (54.9%) initiated anticoagulation within 72 hours after EVT, including 111 within 24 hours. A significant shift towards better mRS scores at day 90 was associated with early anticoagulation (adjusted common OR 2.08 (95% CI 1.27 to 3.41)). Symptomatic intracranial haemorrhage was comparable between patients treated with early and routine anticoagulation (adjusted OR 0.20 (95% CI 0.02 to 2.18)). Comparison of different early anticoagulation regimens showed that ultra-early anticoagulation was more significantly associated with favourable functional outcomes (adjusted common OR 2.03 (95% CI 1.20 to 3.44)) and reduced the incidence of asymptomatic intracranial haemorrhage (OR 0.37 (95% CI 0.14 to 0.94)). CONCLUSIONS In AIS patients with atrial fibrillation, early anticoagulation with UFH or LMWH after successful recanalisation is associated with favourable functional outcomes without increasing the risk of symptomatic intracranial haemorrhages. TRIAL REGISTRATION NUMBER ChiCTR1900022154.
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Affiliation(s)
- Yaning Xu
- Department of Neurology, Army Medical Center of PLA, Army Medical University, Chongqing, China
| | - Chengchun Liu
- Department of Neurology, Army Medical Center of PLA, Army Medical University, Chongqing, China
| | - Wei Li
- Department of Neurology, Army Medical Center of PLA, Army Medical University, Chongqing, China
| | - Ximing Nie
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Shuhan Huang
- Department of Neurology, Army Medical Center of PLA, Army Medical University, Chongqing, China
| | - Xiaoshu Li
- Department of Neurology, Army Medical Center of PLA, Army Medical University, Chongqing, China
| | - Ya Wu
- Department of Neurology, Army Medical Center of PLA, Army Medical University, Chongqing, China
| | - Wang-Sheng Jin
- Department of Neurology, Army Medical Center of PLA, Army Medical University, Chongqing, China
| | - Jiaojin Jiang
- Department of Neurology, Army Medical Center of PLA, Army Medical University, Chongqing, China
| | - Jun Dong
- Department of Neurology, Army Medical Center of PLA, Army Medical University, Chongqing, China
| | - Yi Yang
- Department of Neurology, Army Medical Center of PLA, Army Medical University, Chongqing, China
| | - Zhiqiang Sun
- Department of Neurology, Army Medical Center of PLA, Army Medical University, Chongqing, China
| | - Wenjun Han
- Department of Neurology, Army Medical Center of PLA, Army Medical University, Chongqing, China
| | - Yanjiang Wang
- Department of Neurology, Army Medical Center of PLA, Army Medical University, Chongqing, China
| | - Liping Liu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Meng Zhang
- Department of Neurology, Army Medical Center of PLA, Army Medical University, Chongqing, China
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3
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Kumar R, Sun LR, Rodriguez V, Sankar A, Sharma M, Meoded A, Brandão LR, Goldenberg NA. Hemostatic and Thrombotic Considerations in the Diagnosis and Management of Childhood Arterial Ischemic Stroke: A Narrative Review. Semin Pediatr Neurol 2022; 43:101003. [PMID: 36344025 DOI: 10.1016/j.spen.2022.101003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Revised: 09/12/2022] [Accepted: 09/26/2022] [Indexed: 11/06/2022]
Abstract
Although rare in children, arterial ischemic stroke (AIS) is associated with increased mortality and neurological morbidity. The incidence of AIS after the neonatal period is approximately 1-2/100,000/year, with an estimated mortality of 3-7%. A significant proportion of children surviving AIS experience life-long neurological deficits including hemiparesis, epilepsy, and cognitive delays. The low incidence of childhood AIS coupled with atypical clinical-presentation and lack of awareness contribute to delay in diagnosis and consequently, the early initiation of treatment. While randomized-clinical trials have demonstrated the efficacy and safety of reperfusion therapies including thrombolysis and endovascular thrombectomy in appropriately-selected adult patients, similar data for children are unavailable. Consequently, clinical decisions surrounding reperfusion therapy in childhood AIS are either extrapolated from adult data or based on local experience. The etiology of childhood AIS is multifactorial, often occurring in the setting of both acquired and congenital risk-factors including thrombophilia. While multiple studies have investigated the association of thrombophilia with incident childhood AIS, its impact on stroke recurrence and therefore duration and intensity of antithrombotic therapy is less clear. Despite these limitations, a significant progress has been made over the last decade in the management of childhood AIS. This progress can be attributed to international consortiums, and in selected cohorts to federally-funded clinical trials. In this narrative review, the authors have systematically appraised the literature and summarize the hemostatic and thrombotic considerations in the diagnosis and management of childhood AIS focusing on the evidence supporting reperfusion therapies, relevance of thrombophilia testing, and duration and drug choices for secondary-prophylaxis.
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Affiliation(s)
- Riten Kumar
- Dana Farber/Boston Children's Cancer and Blood Disorders Center, Boston, MA; Department of Pediatrics, Harvard Medical School, Boston, MA.
| | - Lisa R Sun
- Division of Pediatric Neurology, Johns Hopkins School of Medicine, Baltimore, MD; Division of Cerebrovascular Neurology, Johns Hopkins School of Medicine, Baltimore, MD
| | - Vilmarie Rodriguez
- Division of Pediatric Hematology/Oncology, Nationwide Children's Hospital, Columbus, OH; Department of Pediatrics, The Ohio State University, Columbus, OH
| | - Amanda Sankar
- Division of Pediatric Hematology/Oncology, Nationwide Children's Hospital, Columbus, OH; Department of Pediatrics, The Ohio State University, Columbus, OH
| | - Mukta Sharma
- Division of Hematology, Children's Mercy Hospital, Kansas City, MO
| | - Avner Meoded
- Edward B. Singleton, Department of Radiology, Texas Children's Hospital, Houston, TX
| | - Leonardo R Brandão
- Division of Hematology/Oncology, The Hospital for Sick Children, Toronto, ON; Dalla Lana School of Public Health, University of Toronto, Toronto, ON
| | - Neil A Goldenberg
- Institute for Clinical and Translational Research, Johns Hopkins All Children's Hospital, St. Petersburg, FL; Departments of Pediatrics and Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
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4
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Timing of anticoagulation after acute ischemic stroke in patients with atrial fibrillation. Neurol Sci 2022:1-12. [PMID: 35762354 DOI: 10.1017/cjn.2022.268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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5
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Nomogram to predict hemorrhagic transformation for acute ischemic stroke in Western China: a retrospective analysis. BMC Neurol 2022; 22:156. [PMID: 35468774 PMCID: PMC9040382 DOI: 10.1186/s12883-022-02678-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Accepted: 04/13/2022] [Indexed: 12/30/2022] Open
Abstract
Background and purpose Hemorrhagic transformation (HT) is the most alarming complication of acute ischemic stroke. We aimed to identify risk factors for HT in Chinese patients and attempted to develop a nomogram to predict individual cases. Methods A retrospective study was used to collect the demographic and clinical characteristics of ischemic stroke patients at the Second Affiliated Hospital of Chongqing Medical University (development cohort) and Chongqing Sanbo Changan Hospital (validation cohort) from October 2013 to August 2020. Univariate analysis and multivariate analysis were used to identify the risk factors of patients in the development cohort. The nomogram was generated, and internal validation was performed. We used the area under the receiver-operating characteristic curve (AUC-ROC) to assess the discrimination and used the Hosmer–Lemeshow test to calibrate the model. To further verify the predictability and accuracy of the model, we performed an external validation of the patients in the validation cohort. Results A total of 570 patients were used to generate the nomogram. After univariate analysis and multivariate logistic regression, the remaining 7 variables (diabetes mellitus, atrial fibrillation, total cholesterol, fibrous protein, cerebral infarction area, NIHSS score and onset-to-treatment) were independent predictors of HT and used to compose the nomogram. The area under the receiver-operating characteristic curve of the model was 0.889 (95% CI, 0.841–0.938), and the calibration was good (P = 0.487 for the Hosmer–Lemeshow test). The model was validated externally with an AUC-ROC value of 0.832 (95% CI, 0.727–0.938). Conclusions The nomogram prediction model in this study has good predictive ability, accuracy and discrimination, which can improve the diagnostic efficiency of HT in patients with acute ischemic stroke. Supplementary Information The online version contains supplementary material available at 10.1186/s12883-022-02678-2.
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6
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Li D, Li N, Chen X. The Relationship between Insomnia and Internal Carotid Artery Stenosis and Cognitive Dysfunction by Magnetic Sensitivity Weighted Imaging Based on Wireless Network Communication. JOURNAL OF HEALTHCARE ENGINEERING 2022; 2022:6056502. [PMID: 35463683 PMCID: PMC9023171 DOI: 10.1155/2022/6056502] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Revised: 03/28/2022] [Accepted: 03/30/2022] [Indexed: 11/18/2022]
Abstract
The paper analyzes the detection of insomnia and carotid artery stenosis by magnetic sensitivity weighted imaging (SWI) based on radio communication and its relationship with cognitive dysfunction. A total of 148 patients with carotid artery stenosis and insomnia admitted to our hospital from January 2020 to June 2021 are selected. According to different detection methods, wireless communication combined with SWI group and conventional group are established respectively, with 74 cases in each group. The conventional group applies CT angiography (CTA) is in line with the intervention mode of patients complaining of sleep at night. In the wireless communication combined with SWI group, the sleep monitoring system of wireless communication combined with SWI detection method is used to observe the imaging detection rate, insomnia detection rate and diagnostic efficiency of the two groups. The differences of PSG index parameters, sleep quality (PSQI) score and cognitive function (MoCA) score of patients with different disease degrees are compared. Pearson correlation coefficient is used to analyze the correlation between PSQI score and MoCA score. SWI sequence scan based on wireless network communication has high efficiency in the diagnosis of carotid artery stenosis, and the sleep status of patients can be better understood by real-time monitoring of patients, which is of great significance for the follow-up development of effective diagnosis and treatment plans and recovery of patients' cognitive function, and worthy of clinical application.
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Affiliation(s)
- Dan Li
- Second Department of Bone Surgery, Affiliated Hospital of BeiHua University, Jilin 132011, China
| | - Na Li
- Second Department of Neurology, Affiliated Hospital of BeiHua University, Jilin 132011, China
| | - Xi Chen
- Second Department of Neurology, Affiliated Hospital of BeiHua University, Jilin 132011, China
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7
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Jin Y, Shi P, Wang Y, Li J, Zhang J, Zhao X, Ge Y, Huang Y, Guo M, Wang F, Ci B, Xiao X, Gao X, Xu J, Dang B, Ji B, Ge WP, Jia JM. Precise control of embolic stroke with magnetized red blood cells in mice. Commun Biol 2022; 5:136. [PMID: 35173272 PMCID: PMC8850623 DOI: 10.1038/s42003-022-03082-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2021] [Accepted: 01/28/2022] [Indexed: 11/09/2022] Open
Abstract
Precise embolism control in immature brains can facilitate mechanistic studies of brain damage and repair after perinatal arterial ischemic stroke (PAIS), but it remains a technical challenge. Microhemorrhagic transformation is observed in one-third of infant patients who have suffered PAIS, but the underlying mechanism remains elusive. Building on an established approach that uses magnetic nanoparticles to induce PAIS, we develop a more advanced approach that utilizes magnetized erythrocytes to precisely manipulate de novo and in situ embolus formation and reperfusion in perinatal rodent brains. This approach grants spatiotemporal control of embolic stroke without any transarterial delivery of pre-formed emboli. Transmission electron microscopy revealed that erythrocytes rather than nanoparticles are the main material obstructing the vessels. Both approaches can induce microbleeds as an age-dependent complication; this complication can be prevented by microglia and macrophage depletion. Thus, this study provides an animal model mimicking perinatal embolic stroke and implies a potential therapeutic strategy for the treatment of perinatal stroke.
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Affiliation(s)
- Yuxiao Jin
- College of Life Sciences, Zhejiang University, Hangzhou, Zhejiang, 310058, China.,Key Laboratory of Growth Regulation and Translational Research of Zhejiang Province, School of Life Sciences, Westlake University, Hangzhou, 310024, China.,Westlake Laboratory of Life Sciences and Biomedicine, Hangzhou, 310024, China.,Laboratory of Neurovascular Biology, Institute of Basic Medical Sciences, Westlake Institute for Advanced Study, Hangzhou, 310024, China
| | - Peijun Shi
- Key Laboratory of 3D Micro/Nano Fabrication and Characterization of Zhejiang Province, Hangzhou, China.,School of Engineering, Westlake University and Institute of Advanced Technology, Westlake Institute for Advanced Study, Hangzhou, China
| | - Yu Wang
- Westlake Laboratory of Life Sciences and Biomedicine, Key Laboratory of Structural Biology of Zhejiang Province, School of Life Sciences, Westlake University, Hangzhou, Zhejiang, China
| | - Jinghang Li
- School of Engineering, Westlake University and Institute of Advanced Technology, Westlake Institute for Advanced Study, Hangzhou, China.,School of Materials Science and Engineering, Wuhan Institute of Technology, Wuhan, Hubei, China
| | - Jiachen Zhang
- School of Basic Medical Sciences, Wuhan University, Wuhan, China
| | - Xinxin Zhao
- Department of Radiology, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Yaping Ge
- Key Laboratory of Growth Regulation and Translational Research of Zhejiang Province, School of Life Sciences, Westlake University, Hangzhou, 310024, China.,Westlake Laboratory of Life Sciences and Biomedicine, Hangzhou, 310024, China.,Laboratory of Neurovascular Biology, Institute of Basic Medical Sciences, Westlake Institute for Advanced Study, Hangzhou, 310024, China
| | - Yanjie Huang
- Key Laboratory of Growth Regulation and Translational Research of Zhejiang Province, School of Life Sciences, Westlake University, Hangzhou, 310024, China
| | - Mengzhun Guo
- Westlake Laboratory of Life Sciences and Biomedicine, Key Laboratory of Structural Biology of Zhejiang Province, School of Life Sciences, Westlake University, Hangzhou, Zhejiang, China.,Institute of Biology, Westlake Institute for Advanced Study, Hangzhou, Zhejiang, China
| | - Feidi Wang
- Department of Anesthesiology & Center for Brain Science, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi Province, China
| | - Bo Ci
- Children's Medical Center Research Institute, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Xian Xiao
- Key Laboratory of Growth Regulation and Translational Research of Zhejiang Province, School of Life Sciences, Westlake University, Hangzhou, 310024, China.,Westlake Laboratory of Life Sciences and Biomedicine, Hangzhou, 310024, China
| | - Xiaofei Gao
- Key Laboratory of Growth Regulation and Translational Research of Zhejiang Province, School of Life Sciences, Westlake University, Hangzhou, 310024, China.,Westlake Laboratory of Life Sciences and Biomedicine, Hangzhou, 310024, China
| | - Jianrong Xu
- Department of Radiology, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Bobo Dang
- Westlake Laboratory of Life Sciences and Biomedicine, Key Laboratory of Structural Biology of Zhejiang Province, School of Life Sciences, Westlake University, Hangzhou, Zhejiang, China.,Institute of Biology, Westlake Institute for Advanced Study, Hangzhou, Zhejiang, China
| | - Botao Ji
- Key Laboratory of 3D Micro/Nano Fabrication and Characterization of Zhejiang Province, Hangzhou, China.,School of Engineering, Westlake University and Institute of Advanced Technology, Westlake Institute for Advanced Study, Hangzhou, China
| | - Woo-Ping Ge
- Chinese Institute for Brain Research, Beijing, China
| | - Jie-Min Jia
- Key Laboratory of Growth Regulation and Translational Research of Zhejiang Province, School of Life Sciences, Westlake University, Hangzhou, 310024, China. .,Westlake Laboratory of Life Sciences and Biomedicine, Hangzhou, 310024, China. .,Laboratory of Neurovascular Biology, Institute of Basic Medical Sciences, Westlake Institute for Advanced Study, Hangzhou, 310024, China.
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8
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A Review of Risk Factors and Predictors for Hemorrhagic Transformation in Patients with Acute Ischemic Stroke. Int J Vasc Med 2021; 2021:4244267. [PMID: 34912581 PMCID: PMC8668348 DOI: 10.1155/2021/4244267] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Revised: 11/15/2021] [Accepted: 11/17/2021] [Indexed: 12/26/2022] Open
Abstract
Acute ischemic strokes (AIS) and hemorrhagic strokes lead to disabling neuropsychiatric and cognitive deficits. A serious and fatal complication of AIS is the occurrence of hemorrhagic transformation (HT). HT is cerebral bleeding that occurs after an ischemic event in the infarcted areas. This review summarises how specific risk factors such as demographic factors like age, gender, and race/ethnicity, comorbidities including essential hypertension, atrial fibrillation, diabetes mellitus, congestive heart failure, and ischemic heart disease along with predictors like higher NIHSS score, larger infarction size, cardioembolic strokes, systolic blood pressure/pulse pressure variability, higher plasma glucose levels, and higher body temperature during ischemic event, lower low-density lipoprotein and total cholesterol, early ischemic changes on imaging modalities, and some rare causes make an individual more susceptible to developing HT. We also discuss few other risk factors such as the role of blood-brain barrier, increased arterial stiffness, and globulin levels in patients postreperfusion using thrombolysis and mechanical thrombectomy. In addition, we discuss the implications of dual antiplatelet therapy and the length of treatment in reference to the incidence of developing HT. Current research into inflammatory mediators and biomarkers such as Cyclooxygenase-2, matrix metalloproteinases, and soluble ST2 and their potential role as treatment options for HT is also briefly discussed. Finally, this review calls for more research into use of dual antiplatelet and the timing of antiplatelet and anticoagulant use in reference to hemorrhagic transformation.
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9
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Qiu K, Zhao LB, Xu XQ, Wang Y, Liu J, Liu S, Shi HB, Zu QQ. Non-negligible clinical relevance of haemorrhagic transformation after endovascular thrombectomy with successful reperfusion in acute ischaemic stroke. Clin Radiol 2021; 77:e99-e105. [PMID: 34756700 DOI: 10.1016/j.crad.2021.10.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Accepted: 10/06/2021] [Indexed: 12/01/2022]
Abstract
AIM To explore the association between haemorrhagic transformation (HT) subtypes and functional outcome in acute ischaemic stroke (AIS) patients with successful recanalization treated by endovascular thrombectomy (EVT). MATERIALS AND METHODS Consecutive patients with AIS due to large-vessel occlusion in the anterior circulation, who were treated between January 2015 and June 2019 and achieved successful EVT, were enrolled in this retrospective study. HT was categorized according to the Heidelberg Bleeding Classification. Functional outcome was evaluated using the 90-day modified Rankin Scale (mRS) after stroke onset. Ordinal logistic regression analysis was performed to determine the association of HT subtypes with functional outcomes. RESULTS A total of 243 patients were included for further analysis. Among them, 121 (49.8%) had HT. Ten (4.1%) patients were classified as haemorrhagic infarction (HI) subtype 1, 61 (25.1%) as HI subtype 2, 17 (7.0%) as parenchymal haematoma (PH) subtype 1, and 33 (13.6%) as PH subtype 2. Ordinal logistic regression analysis suggested that HI subtype 2 (adjusted common OR 0.357, 95% CI: 0.192-0.667), PH1 (adjusted common OR 0.254, 95% CI: 0.093-0.696) and PH subtype 2 (adjusted common OR 0.017, 95% CI: 0.006-0.051) were significantly associated with poor functional outcomes. CONCLUSION The present study shows that HI subtype 2, PH subtype 1, and PH subtype 2 are independently associated with poor clinical outcomes in AIS patients with successful recanalization after EVT.
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Affiliation(s)
- K Qiu
- Department of Interventional Radiology, The First Affiliated Hospital with Nanjing Medical University, Nanjing, 210029, China
| | - L-B Zhao
- Department of Interventional Radiology, The First Affiliated Hospital with Nanjing Medical University, Nanjing, 210029, China
| | - X-Q Xu
- Department of Radiology, The First Affiliated Hospital with Nanjing Medical University, Nanjing, 210029, China
| | - Y Wang
- Department of Emergency Center, The First Affiliated Hospital with Nanjing Medical University, Nanjing, 210029, China
| | - J Liu
- Department of Clinical Medicine Research Institution, The First Affiliated Hospital with Nanjing Medical University, Nanjing, 210029, China
| | - S Liu
- Department of Interventional Radiology, The First Affiliated Hospital with Nanjing Medical University, Nanjing, 210029, China
| | - H-B Shi
- Department of Interventional Radiology, The First Affiliated Hospital with Nanjing Medical University, Nanjing, 210029, China
| | - Q-Q Zu
- Department of Interventional Radiology, The First Affiliated Hospital with Nanjing Medical University, Nanjing, 210029, China.
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10
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Gusev VV, Lvova OA, Shamalov NA. Problems of selecting an anticoagulant for secondary stroke prevention in patients with atrial fibrillation. КАРДИОВАСКУЛЯРНАЯ ТЕРАПИЯ И ПРОФИЛАКТИКА 2021. [DOI: 10.15829/1728-8800-2021-3044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
The article describes the urgent problem of ischemic stroke prevention in patients with atrial fibrillation. It is proved that ischemic stroke in combination with AF is the most severe in terms of developing stable motor and speech disorders and disability. The frail older patients, as well as patients with swallowing disorders and reduced medical adherence present a special problem from this point of view. The most famous clinical studies on secondary prevention of cardioembolic stroke are RE-LY, ROCKET-AF, and ARISTOTLE. Based on subanalyses of randomized controlled trials, direct oral anticoagulants demonstrated a favorable efficacy profile in patients with atrial fibrillation and stroke/ transient ischemic attack, but the level of knowledge on each of them remained different. A number of advantages of rivaroxaban for primary and secondary prevention of stroke in patients with atrial fibrillation, including the elderly and patients with cognitive impairments and swallowing disorders, have been demonstrated.
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Affiliation(s)
- V. V. Gusev
- Central City Clinical Hospital № 23; Ural Federal University named after the First President of Russia B.N. Yeltsin; Ural State Medical University
| | - O. A. Lvova
- Ural Federal University named after the First President of Russia B.N. Yeltsin; Ural State Medical University
| | - N. A. Shamalov
- Institute of Cerebrovascular Pathology and Stroke, Federal Center of Brain Research and Neurotechnologies
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11
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D'Anna L, Filippidis FT, Harvey K, Marinescu M, Bentley P, Korompoki E, Veltkamp R. Extent of white matter lesion is associated with early hemorrhagic transformation in acute ischemic stroke related to atrial fibrillation. Brain Behav 2021; 11:e2250. [PMID: 34124834 PMCID: PMC8413731 DOI: 10.1002/brb3.2250] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Revised: 05/27/2021] [Accepted: 05/29/2021] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Hemorrhagic transformation (HT) after stroke, related to atrial fibrillation (AF), is a frequent complication, and it can be associated with a delay in the (re-)initiation of oral anticoagulation therapy. We investigated the effect of the presence and severity of white matter disease (WMD) on early HT after stroke related to AF. METHODS A consecutive series of patients with recent (<4 weeks) ischemic stroke and AF, treated at the Hyper Acute Stroke Unit of the Imperial College London between 2010 and 2017, were enrolled. Patients with brain MRI performed 24-72 h from stroke onset and not yet started on anticoagulant treatment were included. WMD was graded using the Fazekas score. RESULTS Among the 441 patients eligible for the analysis, 91 (20.6%) had any HT. Patients with and without HT showed similar clinical characteristics. Patients with HT had a larger diffusion-weighted imaging (DWI) infarct volume compared to patients without HT (p < .001) and significant difference in the distribution of the Fazekas score (p = .001). On multivariable analysis, HT was independently associated with increasing DWI infarct volume (odd ratio (OR), 1.03; 95% confidence interval (CI), 1.01-1.05; p < .001), higher Fazekas scores (OR, 1.94; 95% CI, 1.47-2.57; p < .001) and history of previous intracranial hemorrhage (OR, 4.80; 95% CI, 1.11-20.80; p = .036). CONCLUSIONS Presence and severity of WMD is associated with increased risk of development of early HT in patients with stroke and AF. Further evidence is needed to provide reliable radiological predictors of the risk of HT in cardioembolic stroke.
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Affiliation(s)
- Lucio D'Anna
- Department of Stroke and Neuroscience, Charing Cross Hospital, Imperial College London NHS Healthcare Trust, London, UK.,Department of Brain Sciences, Imperial College London, London, UK
| | - Filippos T Filippidis
- Department of Primary Care and Public Health, School of Public Health, Imperial College London, London, UK
| | - Kirsten Harvey
- Department of Brain Sciences, Imperial College London, London, UK
| | | | - Paul Bentley
- Department of Stroke and Neuroscience, Charing Cross Hospital, Imperial College London NHS Healthcare Trust, London, UK.,Department of Brain Sciences, Imperial College London, London, UK
| | - Eleni Korompoki
- Department of Brain Sciences, Imperial College London, London, UK
| | - Roland Veltkamp
- Department of Brain Sciences, Imperial College London, London, UK.,Department of Neurology, Alfried-Krupp Krankenhaus, Essen, Germany.,Department of Neurology, University Hospital Heidelberg, Heidelberg, Germany
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12
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Hindricks G, Potpara T, Dagres N, Arbelo E, Bax JJ, Blomström-Lundqvist C, Boriani G, Castella M, Dan GA, Dilaveris PE, Fauchier L, Filippatos G, Kalman JM, Meir ML, Lane DA, Lebeau JP, Lettino M, Lip GY, Pinto FJ, Neil Thomas G, Valgimigli M, Van Gelder IC, Van Putte BP, Watkins CL. Guía ESC 2020 sobre el diagnóstico y tratamiento de la fibrilación auricular, desarrollada en colaboración de la European Association of Cardio-Thoracic Surgery (EACTS). Rev Esp Cardiol 2021. [DOI: 10.1016/j.recesp.2020.10.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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13
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Risk of Early Bleeding with Dual Antiplatelet Therapy in Acute Stroke and Transient Ischemic Attack Regardless of NIHSS Admission. J Stroke Cerebrovasc Dis 2021; 30:105677. [DOI: 10.1016/j.jstrokecerebrovasdis.2021.105677] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Revised: 01/10/2021] [Accepted: 02/06/2021] [Indexed: 11/18/2022] Open
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14
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Hindricks G, Potpara T, Dagres N, Arbelo E, Bax JJ, Blomström-Lundqvist C, Boriani G, Castella M, Dan GA, Dilaveris PE, Fauchier L, Filippatos G, Kalman JM, La Meir M, Lane DA, Lebeau JP, Lettino M, Lip GYH, Pinto FJ, Thomas GN, Valgimigli M, Van Gelder IC, Van Putte BP, Watkins CL. 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS): The Task Force for the diagnosis and management of atrial fibrillation of the European Society of Cardiology (ESC) Developed with the special contribution of the European Heart Rhythm Association (EHRA) of the ESC. Eur Heart J 2021; 42:373-498. [PMID: 32860505 DOI: 10.1093/eurheartj/ehaa612] [Citation(s) in RCA: 5009] [Impact Index Per Article: 1669.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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15
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Wang X, Cao Q, Lai Y, Liu X, Zhou Y, Yang L, Zhang L. Association Between Plasma Total Homocysteine Levels and Risk of Early Hemorrhagic Transformation in Patients with Acute Ischemic Stroke: A Hospital-Based Study. J Stroke Cerebrovasc Dis 2020; 30:105538. [PMID: 33341563 DOI: 10.1016/j.jstrokecerebrovasdis.2020.105538] [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: 07/04/2020] [Revised: 11/28/2020] [Accepted: 12/06/2020] [Indexed: 11/25/2022] Open
Abstract
OBJECTS In this study, we investigated the association between plasma total homocysteine(tHcy) levels and the risk of early hemorrhagic transformation(HT) in patients with acute ischemic stroke(AIS). METHODS Consecutive hospitalized participants who met the inclusion criteria were enrolled and grouped according to plasma tHcy levels. Participants were divided into a low homocysteine level(L-tHcy) group (<12 µmol/L) and a high homocysteine level group(H-tHcy) (≥ 12 µmol/L). Baseline computed tomography (CT) examination was performed. HT was determined via CT or magnetic resonance imaging within 1 to 3 days after admission. RESULTS A total of 1858 patients were screened and 1378 patients completed the this study(797 patients in the H-tHcy group and 581 patients in the L-tHcy group). HT incidence was 5.2% (30/581,) in the L-tHcy group and 11.2% (90/797) in the H-tHcy group(P<0.05). Binary logistic regression analysis showed that initial NIHSS score, tHcy levels, treatment with recombinant tissue plasminogen activator thrombolysis, systolic blood pressure on admission, glucose level on admission, smoking status and estimated glomerular filtration rate were independent risk factors for HT. Receiver operating characteristic analysis showed that tHcy level was a moderately sensitive and specific index to predict the incidence of HT, and the optimal cutoff was 16.56 μmol/L (sensitivity 63.3%, specificity 41.3%). CONCLUSION Our study findings reveal that high plasma tHcy level is one independent risk factor associated with increased risk of early HT in patients with AIS.
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Affiliation(s)
- Xin Wang
- Department of Neurology, the Second Affiliated Hospital of Chengdu Medical College, (China National Nuclear Corporation 416 Hospital), Chengdu 610000, China
| | - Qiuju Cao
- Department of Neurology, the Second Affiliated Hospital of Chengdu Medical College, (China National Nuclear Corporation 416 Hospital), Chengdu 610000, China.
| | - Yali Lai
- Department of Neurology, the Second Affiliated Hospital of Chengdu Medical College, (China National Nuclear Corporation 416 Hospital), Chengdu 610000, China.
| | - Xindong Liu
- Department of Neurology, the Second Affiliated Hospital of Chengdu Medical College, (China National Nuclear Corporation 416 Hospital), Chengdu 610000, China
| | - Yi Zhou
- Department of Neurology, the Second Affiliated Hospital of Chengdu Medical College, (China National Nuclear Corporation 416 Hospital), Chengdu 610000, China.
| | - Le Yang
- Department of Neurology, the Second Affiliated Hospital of Chengdu Medical College, (China National Nuclear Corporation 416 Hospital), Chengdu 610000, China
| | - Lijuan Zhang
- Department of Neurology, the Second Affiliated Hospital of Chengdu Medical College, (China National Nuclear Corporation 416 Hospital), Chengdu 610000, China.
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16
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Świtońska M, Piekuś-Słomka N, Słomka A, Sokal P, Żekanowska E, Lattanzi S. Neutrophil-to-Lymphocyte Ratio and Symptomatic Hemorrhagic Transformation in Ischemic Stroke Patients Undergoing Revascularization. Brain Sci 2020; 10:brainsci10110771. [PMID: 33114150 PMCID: PMC7690817 DOI: 10.3390/brainsci10110771] [Citation(s) in RCA: 79] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Revised: 10/17/2020] [Accepted: 10/22/2020] [Indexed: 12/23/2022] Open
Abstract
Objectives: Symptomatic hemorrhagic transformation (sHT) is a life-threatening complication of acute ischemic stroke (AIS). The early identification of the patients at increased risk of sHT can have clinically relevant implications. The aim of this study was to explore the validity and accuracy of the neutrophil-to-lymphocyte ratio (NLR) in predicting sHT in patients with AIS undergoing revascularization. Methods: Consecutive patients hospitalized for AIS who underwent intravenous thrombolysis, mechanical thrombectomy or both were identified. The NLR values were estimated at admission. The study endpoint was the occurrence of sHT within 24 h from stroke treatment. Results: Fifty-one patients with AIS were included, with a median age of 67 (interquartile range, 55–78) years. sHT occurred in 10 (19.6%) patients. Patients who developed sHT had higher NLR at admission. NLR was an independent predictor of sHT and showed good discriminatory power (area under the curve 0.81). In a multivariable analysis, NLR and systolic blood pressure were independently associated with sHT. Conclusions: NLR at admission can accurately predict sHT in patients with AIS undergoing revascularization.
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Affiliation(s)
- Milena Świtońska
- Department of Neurosurgery and Neurology, Nicolaus Copernicus University in Toruń, Ludwik Rydygier Collegium Medicum, 85-168 Bydgoszcz, Poland;
- Correspondence: ; Tel.: +48-52-365-5565
| | - Natalia Piekuś-Słomka
- Department of Inorganic and Analytical Chemistry, Nicolaus Copernicus University in Toruń, Ludwik Rydygier Collegium Medicum, 85-089 Bydgoszcz, Poland;
| | - Artur Słomka
- Department of Pathophysiology, Nicolaus Copernicus University in Toruń, Ludwik Rydygier Collegium Medicum, 85-094 Bydgoszcz, Poland; (A.S.); (E.Ż.)
| | - Paweł Sokal
- Department of Neurosurgery and Neurology, Nicolaus Copernicus University in Toruń, Ludwik Rydygier Collegium Medicum, 85-168 Bydgoszcz, Poland;
| | - Ewa Żekanowska
- Department of Pathophysiology, Nicolaus Copernicus University in Toruń, Ludwik Rydygier Collegium Medicum, 85-094 Bydgoszcz, Poland; (A.S.); (E.Ż.)
| | - Simona Lattanzi
- Neurological Clinic, Department of Experimental and Clinical Medicine, Marche Polytechnic University, 60121 Ancona, Italy;
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17
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Early venous filling after reperfusion therapy in acute ischemic stroke. J Stroke Cerebrovasc Dis 2020; 29:104926. [DOI: 10.1016/j.jstrokecerebrovasdis.2020.104926] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Revised: 04/27/2020] [Accepted: 04/29/2020] [Indexed: 11/20/2022] Open
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18
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Boursier-Bossy V, Zuber M, Emmerich J. Ischemic stroke and non-valvular atrial fibrillation: When to introduce anticoagulant therapy? JOURNAL DE MEDECINE VASCULAIRE 2020; 45:72-80. [PMID: 32265018 DOI: 10.1016/j.jdmv.2020.01.153] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Accepted: 12/19/2019] [Indexed: 06/11/2023]
Abstract
About 20 to 30% of ischemic strokes are related to non-valvular atrial fibrillation. This type of situation is particularly at risk for both recurrence of the ischemic event and the hemorrhagic transformation of this stroke. The timing of the introduction or going back to the anticoagulant therapy in these patients remains a difficult issue, with a complex benefit-risk balance that needs to be assessed. Randomized controlled studies are lacking and current recommendations do not allow for clear decision making. The administration of a curative anticoagulant within 72 hours after the event is not recommended in the absence of demonstrated efficacy in preventing recurrence at this stage and because of the risk of intracerebral hemorrhage. This attitude can nevertheless be qualified by a transient accident or ischemic accident of very small size, and in the absence of any other risk factor for intra- or extra-cerebral hemorrhage. From the 4th day, after an appropriate case by case evaluation, the introduction of anticoagulant would be possible within a time which will remain at the appreciation of the medical teams. If the patient's risk of an intracerebral hemorrhage or general bleeding is transiently increased, it will be preferable to wait at least 2 weeks after the stroke. If this risk persists in the long term, the decision of the administration or not of an anticoagulant will have to be made with a multidisciplinary consultation. Vitamin K antagonists or direct oral anticoagulants may be prescribed as first-line therapy for the prevention of recurrence of ischemic stroke in a non-valvular atrial fibrillation patient. The choice will be based on the clinical and biological data of each patient. Direct oral anticoagulants have not shown superiority in the prevention of ischemic recurrence but open up new prospects for earlier treatment if their lesser risk of bleeding is confirmed after further studies.
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Affiliation(s)
- V Boursier-Bossy
- Department of Neurology and Neurovascular, Paris Saint-Joseph Hospital Group, 185, rue Raymond-Losserand, 75014 Paris, France.
| | - M Zuber
- Department of Neurology and Neurovascular, Paris Saint-Joseph Hospital Group, 185, rue Raymond-Losserand, 75014 Paris, France; Paris Descartes University, Paris, France
| | - J Emmerich
- Department of Vascular Medicine, Paris Saint-Joseph Hospital Group, 185, rue Raymond-Losserand, 75014 Paris, France; Paris Descartes University, Paris, France
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19
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Pande SD, Win MM, Khine AA, Zaw EM, Manoharraj N, Lolong L, Tin AS. Haemorrhagic transformation following ischaemic stroke: A retrospective study. Sci Rep 2020; 10:5319. [PMID: 32210323 PMCID: PMC7093519 DOI: 10.1038/s41598-020-62230-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Accepted: 03/05/2020] [Indexed: 11/09/2022] Open
Abstract
The aim of this study was to identify the prevalence of haemorrhagic transformation (HT) in patients with ischaemic stroke, and evaluate its association with medical comorbidities, stroke subtypes, premorbid medication, and long-term survival. To achieve this, we performed a retrospective analysis of 527 consecutive stroke rehabilitation patients. Of these, 102 (19.4%) developed HT. Older patients, and those with large artery strokes, had a higher risk of HT. Forty-one patients received alteplase (rtPA), of which 15 (36.6%) developed HT. A total of 129 (24.5%) patients were taking aspirin prior to their stroke and, of these, 39 (30.2%) developed HT. Twenty-three (4.36%) patients were taking vitamin k antagonists, prior to stroke, of which 14 (60.9%) developed HT. There were 102 patients (19.35%) with underlying atrial fibrillation, of whom 55 (53.9%) developed HT. Patients with known ischaemic heart disease had an increased risk of HT, and patients with HT had significantly lower total cholesterol levels (4.96 vs. 5.34) and lower LDL cholesterol levels (3.20 vs. 3.5). In conclusion, older age, atrial fibrillation, treatment with oral anticoagulants and antiplatelet medications prior to stroke, low total and LDL cholesterol, and rtPA use, are all associated with HT. Survival was not affected by the presence of HT.
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Affiliation(s)
- S D Pande
- Department of Rehabilitation medicine, Changi General Hospital, Singapore, Singapore.
| | - M M Win
- Department of Rehabilitation medicine, Changi General Hospital, Singapore, Singapore
| | - A A Khine
- Department of Rehabilitation medicine, Changi General Hospital, Singapore, Singapore
| | - E M Zaw
- Department of Rehabilitation medicine, Changi General Hospital, Singapore, Singapore
| | - N Manoharraj
- Department of Rehabilitation medicine, Changi General Hospital, Singapore, Singapore
| | - L Lolong
- Department of Rehabilitation medicine, Changi General Hospital, Singapore, Singapore
| | - A S Tin
- Clinical Trials and Research Unit, Changi General Hospital, Singapore, Singapore
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20
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Muscari A, Faccioli L, Lega MV, Lorusso A, Masetti M, Pastore Trossello M, Puddu GM, Spinardi L, Zoli M. Predicting hemorrhagic transformation and its timing from maximum cerebral lesion diameter in nonlacunar ischemic strokes. Brain Behav 2020; 10:e01497. [PMID: 31846215 PMCID: PMC6955832 DOI: 10.1002/brb3.1497] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Revised: 10/29/2019] [Accepted: 11/22/2019] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVES We performed this retrospective cohort study to establish which factors are mostly indicative of the appearance of hemorrhagic transformation (HT) and of its time course in a sample of nonlacunar ischemic strokes. MATERIALS AND METHODS In 402 patients with nonlacunar ischemic stroke (75.0 ± 12.7 years, 192 male), clinical, laboratory, and neuroimaging variables obtained during the first 3 days of hospitalization were compared between patients with and without HT at computer tomography scan. RESULTS HT was documented in 129 patients (32.1%), including 36 with parenchymal hematoma (PH), after a median time of 6 days (range 1-27). Many variables were univariately associated with HT, but only 5 of them were confirmed in Cox regression (Hazard Ratio, 95% Confidence Interval): maximum cerebral lesion diameter (CLD) in cm (1.12, 1.06-1.18; p = .0001), hemoglobin in g/dl (1.16, 1.06-1.27; p = .002), blood glucose in mmol/L (1.10, 1.03-1.18; p = .007), prior anticoagulant therapy (1.82, 1.10-3.03; p = .02), and edema with mass effect (1.72, 1.08-2.75; p = .02). Thus, the most significant predictor was CLD. The overall risk of HT was minimum for CLD < 2 cm (1.5%), intermediate for CLD ≥ 2 and < 5 cm (22%), and maximum for CLD ≥ 5 cm (58%). The residual probability of having HT decreased progressively over time, and a simple formula is proposed to predict, from CLD in cm, when the probability of HT falls below 10%. CONCLUSIONS The main determinant of HT was CLD, a simple quantitative parameter that could prove useful, in particular, in deciding the timing of anticoagulation in cardioembolic stroke patients.
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Affiliation(s)
- Antonio Muscari
- Stroke Unit, Medical Department of Continuity of Care and Disability, S.Orsola-Malpighi Hospital, Bologna, Italy.,Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Luca Faccioli
- Diagnostic and Interventional Neuroradiology Unit, S.Orsola-Malpighi Hospital, Bologna, Italy
| | - Maria Vittoria Lega
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Andrea Lorusso
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Marco Masetti
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Marco Pastore Trossello
- Diagnostic and Interventional Neuroradiology Unit, S.Orsola-Malpighi Hospital, Bologna, Italy
| | - Giovanni M Puddu
- Stroke Unit, Medical Department of Continuity of Care and Disability, S.Orsola-Malpighi Hospital, Bologna, Italy
| | - Luca Spinardi
- Diagnostic and Interventional Neuroradiology Unit, S.Orsola-Malpighi Hospital, Bologna, Italy
| | - Marco Zoli
- Stroke Unit, Medical Department of Continuity of Care and Disability, S.Orsola-Malpighi Hospital, Bologna, Italy.,Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
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21
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He W, Ruan Y, Yuan C, Cheng Q, Cheng H, Zeng Y, Chen Y, Huang G, Chen H, He J. High Neutrophil-to-Platelet Ratio Is Associated With Hemorrhagic Transformation in Patients With Acute Ischemic Stroke. Front Neurol 2019; 10:1310. [PMID: 31920933 PMCID: PMC6914868 DOI: 10.3389/fneur.2019.01310] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Accepted: 11/26/2019] [Indexed: 12/25/2022] Open
Abstract
Background: Hemorrhagic transformation (HT) is a complication that may cause neurological deterioration in patients with acute ischemic stroke. Both neutrophil and platelet have been associated with the stroke progression. The aim of this study was to explore the relationship between neutrophil-to-platelet ratio (NPR) and HT after acute ischemic stroke. Methods: A total of 279 stroke patients with HT were consecutively recruited. HT was diagnosed using magnetic resonance imaging (MRI) or computed tomography (CT) and classified into hemorrhagic infarction (HI) and parenchymal hematoma (PH). Blood samples for neutrophil and platelet counts were obtained at admission. Meanwhile, 270 age- and gender-matched controls without HT were included for comparison. Results: Among the patients with HT, 131 patients had PH and 148 patients had HI. NPR was higher in patients with PH than those with HI or non-HT [36.8 (23.7–49.2) vs. 26.6 (17.9–38.3) vs. 19.1 (14.8–24.8), P < 0.001]. After adjustment for potential confounders, high NPR remained independently associated with the increased risk of HT (OR = 2.000, 95% CI: 1.041–3.843, P = 0.037). NPR (>39.9) was independently associated with PH (OR = 2.641, 95% CI: 1.308–5.342, P = 0.007). Conclusions: High NPR was associated with the increased risk of HT especially PH in patients with acute ischemic stroke.
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Affiliation(s)
- Weilei He
- Department of Neurology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Yiting Ruan
- Department of Neurology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Chengxiang Yuan
- Department of Neurology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Qianqian Cheng
- Department of Mental Health, Mental Health School, Wenzhou Medical University, Wenzhou, China
| | - Haoran Cheng
- Department of Neurology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Yaying Zeng
- Department of Mental Health, Mental Health School, Wenzhou Medical University, Wenzhou, China
| | - Yunbin Chen
- Department of Neurology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Guiqian Huang
- Department of Neurology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Huijun Chen
- Department of Neurology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Jincai He
- Department of Neurology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
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22
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Torres-Aguila NP, Carrera C, Muiño E, Cullell N, Cárcel-Márquez J, Gallego-Fabrega C, González-Sánchez J, Bustamante A, Delgado P, Ibañez L, Heitsch L, Krupinski J, Montaner J, Martí-Fàbregas J, Cruchaga C, Lee JM, Fernandez-Cadenas I. Clinical Variables and Genetic Risk Factors Associated with the Acute Outcome of Ischemic Stroke: A Systematic Review. J Stroke 2019; 21:276-289. [PMID: 31590472 PMCID: PMC6780022 DOI: 10.5853/jos.2019.01522] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Accepted: 08/28/2019] [Indexed: 12/19/2022] Open
Abstract
Stroke is a complex disease and one of the main causes of morbidity and mortality among the adult population. A huge variety of factors is known to influence patient outcome, including demographic variables, comorbidities or genetics. In this review, we expound what is known about the influence of clinical variables and related genetic risk factors on ischemic stroke outcome, focusing on acute and subacute outcome (within 24 to 48 hours after stroke and until day 10, respectively), as they are the first indicators of stroke damage. We searched the PubMed data base for articles that investigated the interaction between clinical variables or genetic factors and acute or subacute stroke outcome. A total of 61 studies were finally included in this review. Regarding the data collected, the variables consistently associated with acute stroke outcome are: glucose levels, blood pressure, presence of atrial fibrillation, prior statin treatment, stroke severity, type of acute treatment performed, severe neurological complications, leukocyte levels, and genetic risk factors. Further research and international efforts are required in this field, which should include genome-wide association studies.
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Affiliation(s)
- Nuria P Torres-Aguila
- Stroke Pharmacogenomics and Genetics Laboratory, Sant Pau Research Institute, Barcelona, Spain.,Neurovascular Research Laboratory, Vall d'Hebron Research Institute (VHIR), Autonomous University of Barcelona, Barcelona, Spain
| | - Caty Carrera
- Stroke Pharmacogenomics and Genetics Laboratory, Sant Pau Research Institute, Barcelona, Spain.,Neurovascular Research Laboratory, Vall d'Hebron Research Institute (VHIR), Autonomous University of Barcelona, Barcelona, Spain
| | - Elena Muiño
- Stroke Pharmacogenomics and Genetics Laboratory, Sant Pau Research Institute, Barcelona, Spain
| | - Natalia Cullell
- Stroke Pharmacogenomics and Genetics Laboratory, Mutua Terrasa Foundation of Teaching and Research, Mutua Terrassa Hospital, Terrassa, Spain
| | - Jara Cárcel-Márquez
- Stroke Pharmacogenomics and Genetics Laboratory, Sant Pau Research Institute, Barcelona, Spain
| | - Cristina Gallego-Fabrega
- Stroke Pharmacogenomics and Genetics Laboratory, Sant Pau Research Institute, Barcelona, Spain.,Stroke Pharmacogenomics and Genetics Laboratory, Mutua Terrasa Foundation of Teaching and Research, Mutua Terrassa Hospital, Terrassa, Spain
| | - Jonathan González-Sánchez
- Stroke Pharmacogenomics and Genetics Laboratory, Sant Pau Research Institute, Barcelona, Spain.,Stroke Pharmacogenomics and Genetics Laboratory, Mutua Terrasa Foundation of Teaching and Research, Mutua Terrassa Hospital, Terrassa, Spain.,Health Care Science Department, The Manchester Metropolitan University of All Saints, Manchester, UK
| | - Alejandro Bustamante
- Neurovascular Research Laboratory, Vall d'Hebron Research Institute (VHIR), Autonomous University of Barcelona, Barcelona, Spain
| | - Pilar Delgado
- Neurovascular Research Laboratory, Vall d'Hebron Research Institute (VHIR), Autonomous University of Barcelona, Barcelona, Spain
| | - Laura Ibañez
- Department of Psychiatry, Washington University School of Medicine, St. Louis, MO, USA
| | - Laura Heitsch
- Division of Emergency Medicine, Washington University School of Medicine, St. Louis, MO, USA.,Department of Neurology, Washington University School of Medicine, St. Louis, MO, USA
| | - Jerzy Krupinski
- Stroke Pharmacogenomics and Genetics Laboratory, Mutua Terrasa Foundation of Teaching and Research, Mutua Terrassa Hospital, Terrassa, Spain.,Health Care Science Department, The Manchester Metropolitan University of All Saints, Manchester, UK
| | - Joan Montaner
- Department of Neurology, Virgin Rocío and Macarena Hospitals, Institute of Biomedicine of Seville (IBiS), Seville, Spain
| | - Joan Martí-Fàbregas
- Stroke Unit, Department of Neurology, Saint Cross and Saint Pau Hospital, Barcelona, Spain
| | - Carlos Cruchaga
- Department of Psychiatry, Washington University School of Medicine, St. Louis, MO, USA
| | - Jin-Moo Lee
- Department of Neurology, Washington University School of Medicine, St. Louis, MO, USA
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- Stroke Pharmacogenomics and Genetics Laboratory, Sant Pau Research Institute, Barcelona, Spain
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23
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Hutchinson ML, Beslow LA. Hemorrhagic Transformation of Arterial Ischemic and Venous Stroke in Children. Pediatr Neurol 2019; 95:26-33. [PMID: 30904397 DOI: 10.1016/j.pediatrneurol.2019.01.023] [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: 11/30/2018] [Revised: 01/30/2019] [Accepted: 01/31/2019] [Indexed: 11/28/2022]
Abstract
Hemorrhagic transformation can complicate both arterial ischemic stroke and cerebral sinus venous thrombosis. Risk factors for hemorrhagic transformation after adult arterial ischemic stroke include larger infarct volume, cardioembolic stroke, and anticoagulation in the acute period. Large hemorrhagic transformation in adults is associated with poor outcome. Therefore hemorrhagic transformation is used as a safety end point for most arterial ischemic stroke acute treatment and secondary prevention trials. Up to 30% of children with arterial ischemic stroke have hemorrhagic transformation, most of which are petechial. As in adults, large infarct size is the greatest predictor of hemorrhagic transformation, but in children, acute anticoagulation is not a clear predictor of hemorrhage. As use of acute endovascular interventions for arterial ischemic stroke has expanded in adults, these therapies have also been used in some teenagers and even younger children. More information, including safety data with end points like hemorrhagic transformation, is needed in the pediatric population. In adults with cerebral sinus venous thrombosis, including those with hemorrhagic transformation, acute anticoagulation is associated with better outcomes and is the standard of care. Some hemorrhagic transformation may be evident at baseline in over half of children and neonates with cerebral sinus venous thrombosis. Anticoagulation-associated hemorrhage in pediatric cerebral sinus venous thrombosis occurs in about 10% of children but is not clearly related to outcome, whereas lack of anticoagulation may be associated with clot propagation and worse outcomes. This review provides background on hemorrhagic transformation of ischemic stroke in adults and summarizes literature regarding hemorrhagic transformation of pediatric arterial ischemic stroke and cerebral sinus venous thrombosis, with a focus on implications for acute treatment and outcome.
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Affiliation(s)
- Melissa L Hutchinson
- Division of Neurology, Children's Hospital of Philadelphia, Departments of Neurology and Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Lauren A Beslow
- Division of Neurology, Children's Hospital of Philadelphia, Departments of Neurology and Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania.
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24
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Langel C, Popovic KS. Infarct-core CT perfusion parameters in predicting post-thrombolysis hemorrhagic transformation of acute ischemic stroke. Radiol Oncol 2019; 53:25-30. [PMID: 30864425 PMCID: PMC6411018 DOI: 10.2478/raon-2018-0048] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2018] [Accepted: 11/11/2018] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Intravenous thrombolysis (IVT) is the method of choice in reperfusion treatment of patients with signs and symptoms of acute ischemic stroke (AIS) lasting less than 4.5 hours. Hemorrhagic transformation (HT) of acute ischemic stroke is a serious complication of IVT and occurs in 4.5-68.0% of clinical cases. The aim of our study was to determine the infarct core CT perfusion parameter (CTPP) most predictive of HT. PATIENTS AND METHODS Seventy-five patients with AIS who had undergone CT perfusion (CTP) imaging and were treated with IVT were enrolled in this retrospective study. Patients with and without HT after IVT were defined as cases and controls, respectively. Controls were found by matching for time from AIS symptom onset to IVT ± 0.5 h. The following CTPPs were measured: cerebral blood flow (CBF), cerebral blood volume (CBV), mean transit time (MTT), relative CBF (rCBF) and relative CBV (rCBV). Receiver operating characteristic analysis curves of significant CTPPs determined cut-off values that best predict HT. RESULTS There was a significant difference between cases and controls for CBF (p = 0.004), CBV (p = 0.009), rCBF (p < 0.001) and rCBV (p = 0.001). Receiver operating characteristic analysis revealed that rCBF < 4.5% of the contralateral mean (area under the curve = 0.736) allowed prediction of HT with a sensitivity of 71.0% and specificity of 52.5%. CONCLUSIONS CTP imaging has a considerable role in HT prediction, assisting in selection of patients that are likely to benefit from IVT. rCBF proved to have the highest HT predictive value.
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Affiliation(s)
- Crt Langel
- Novo Mesto General Hospital, Novo MestoSlovenia
| | - Katarina Surlan Popovic
- Institute of Radiology, University Medical Centre Ljubljana, LjubljanaSlovenia
- Assoc. Prof. Šurlan Popović Katarina, M.D., Ph.D., Institute of Radiology, University Medical Centre Ljubljana, Zaloška cesta 7, SI-1000 Ljubljana, Slovenia. Phone: +386 1 522 85 30
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Seiffge DJ, Werring DJ, Paciaroni M, Dawson J, Warach S, Milling TJ, Engelter ST, Fischer U, Norrving B. Timing of anticoagulation after recent ischaemic stroke in patients with atrial fibrillation. Lancet Neurol 2019; 18:117-126. [PMID: 30415934 PMCID: PMC6524642 DOI: 10.1016/s1474-4422(18)30356-9] [Citation(s) in RCA: 135] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2018] [Revised: 08/12/2018] [Accepted: 09/17/2018] [Indexed: 01/01/2023]
Abstract
BACKGROUND About 13-26% of all acute ischaemic strokes are related to non-valvular atrial fibrillation, the most common cardiac arrhythmia globally. Deciding when to initiate oral anticoagulation in patients with non-valvular atrial fibrillation is a longstanding, common, and unresolved clinical challenge. Although the risk of early recurrent ischaemic stroke is high in this population, early oral anticoagulation is suspected to increase the risk of potentially harmful intracranial haemorrhage, including haemorrhagic transformation of the infarct. This assumption, and current treatment guidelines, are based on historical, mostly observational data from patients with ischaemic stroke and atrial fibrillation treated with heparins, heparinoids, or vitamin K antagonists (VKAs) to prevent recurrent ischaemic stroke. Randomised controlled trials have subsequently shown that direct oral anticoagulants (DOACs; ie, apixaban, dabigatran, edoxaban, and rivaroxaban) are at least as effective as VKAs in primary and secondary prevention of atrial fibrillation-related ischaemic stroke, with around half the risk of intracranial haemorrhage. However, none of these DOAC trials included patients who had experienced ischaemic stroke recently (within the first few weeks). Clinicians therefore remain uncertain regarding when to commence DOAC administration after acute ischaemic stroke in patients with atrial fibrillation. RECENT DEVELOPMENTS Prospective observational studies and two small randomised trials have investigated the risks and benefits of early DOAC-administration initiation (most with a median delay of 3-5 days) in mild-to-moderate atrial fibrillation-associated ischaemic stroke. These studies reported that early DOAC treatment was associated with a low frequency of clinically symptomatic intracranial haemorrhage or surrogate haemorrhagic lesions on MRI scans, whereas later DOAC-administration initiation (ie, >7 days or >14 days after index stroke) was associated with an increased frequency of recurrent ischaemic stroke. WHERE NEXT?: Adequately powered randomised controlled trials comparing early to later oral anticoagulation with DOACs in ischaemic stroke associated with atrial fibrillation are justified to confirm the acceptable safety and efficacy of this strategy. Four such randomised controlled trials (collectively planned to include around 9000 participants) are underway, either using single cutoff timepoints for early versus late DOAC-administration initiation, or selecting DOAC-administration timing according to the severity and imaging features of the ischaemic stroke. The results of these trials should help to establish the optimal timing to initiate DOAC administration after recent ischaemic stroke and whether the timing should differ according to stroke severity. Results of these trials are expected from 2021.
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Affiliation(s)
- David J Seiffge
- UCL Queen Square Institute of Neurology, National Hospital for Neurology and Neurosurgery, University College London, London, UK; Stroke Center and Department of Neurology, University Hospital, and Department of Clinical Research, University of Basel, Basel, Switzerland
| | - David J Werring
- UCL Queen Square Institute of Neurology, National Hospital for Neurology and Neurosurgery, University College London, London, UK.
| | - Maurizio Paciaroni
- Stroke Unit and Division of Cardiovascular Medicine, University of Perugia, Perugia, Italy
| | - Jesse Dawson
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Steven Warach
- Dell Medical School, The University of Texas Austin, TX, USA
| | | | - Stefan T Engelter
- Stroke Center and Department of Neurology, University Hospital, and Department of Clinical Research, University of Basel, Basel, Switzerland; Neurorehabilitation Unit, University Center for Medicine of Aging and Rehabilitation Basel, Felix Platter Hospital, University of Basel, Basel, Switzerland
| | - Urs Fischer
- Department of Neurology, University Hospital Bern and University of Bern, Bern, Switzerland
| | - Bo Norrving
- Department of Neurology, Lund University, Skane University Hospital, Lund, Sweden
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Yuan R, Tan S, Wang D, Wu S, Cao X, Zhang S, Wu B, Liu M. Predictive value of plasma matrix metalloproteinase-9 concentrations for spontaneous haemorrhagic transformation in patients with acute ischaemic stroke: A cohort study in Chinese patients. J Clin Neurosci 2018; 58:108-112. [DOI: 10.1016/j.jocn.2018.09.014] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2018] [Revised: 07/01/2018] [Accepted: 09/24/2018] [Indexed: 11/29/2022]
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Abstract
Given the need for early restoration of blood flow and preservation of partially damaged brain cells after ischemic stroke, the noninterventional treatment of stroke relies heavily on the speedy recognition and classification of the clinical syndrome. Initiation of systemic thrombolysis with careful observation of contraindications within the 3.0 (4.5)-hour time window is the approved therapy of choice. Management of hemorrhagic complications and resumption of oral anticoagulation if indicated are also discussed in this article.
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van Kranendonk KR, Treurniet KM, Boers AMM, Berkhemer OA, van den Berg LA, Chalos V, Lingsma HF, van Zwam WH, van der Lugt A, van Oostenbrugge RJ, Dippel DWJ, Roos YBWEM, Marquering HA, Majoie CBLM. Hemorrhagic transformation is associated with poor functional outcome in patients with acute ischemic stroke due to a large vessel occlusion. J Neurointerv Surg 2018; 11:464-468. [PMID: 30297537 DOI: 10.1136/neurintsurg-2018-014141] [Citation(s) in RCA: 82] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2018] [Revised: 08/20/2018] [Accepted: 08/22/2018] [Indexed: 11/04/2022]
Abstract
Background and purposeHemorrhagic transformation (HT) is a complication that may cause neurological deterioration in patients with acute ischemic stroke. Various radiological subtypes of HT can be distinguished. Their influence on functional outcome is currently unclear. The purpose of this study was to assess the associations between HT subtypes and functional outcome in acute ischemic stroke patients with proven large vessel occlusion included in the MR CLEAN trial (Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic stroke in The Netherlands).MethodsAll patients with follow-up imaging were included. HT was classified on follow-up CT scans according to the European Cooperative Acute Stroke Study II classification. Functional outcome was assessed using the modified Rankin Scale (mRS) 90 days after stroke onset. Ordinal logistic regression analysis with adjustment for potential confounders was used to determine the association of HT subtypes with functional outcome.ResultsOf 478 patients, 222 had HT. Of these, 76 (16%) patients were classified as hemorrhagic infarction type 1, 71 (15%) as hemorrhagic infarction type 2, 36 (8%) as parenchymal hematoma type 1, and 39 (8%) as parenchymal hematoma type 2. Hemorrhagic infarction type 2 (adjusted common OR (acOR) 0.54, 95% CI: 0.32 to 0.89) and parenchymal hematoma type 2 (acOR 0.37, 95% CI 0.17 to 0.78) were significantly associated with a worse functional outcome. Hemorrhagic infarction type 1 and parenchymal hematoma type 1 were not significantly associated, although their point estimates pointed in the direction of worse outcome.ConclusionThis study suggests that parenchymal hematoma type 2 is relevant for functional outcome after an acute ischemic stroke, and smaller HTs might also influence long term functional outcome.Trail registration numberISRCTN10888758.
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Affiliation(s)
- Katinka R van Kranendonk
- Department of Radiology and Nuclear Medicine, Academic Medical Center, Amsterdam, The Netherlands
| | - Kilian M Treurniet
- Department of Radiology and Nuclear Medicine, Academic Medical Center, Amsterdam, The Netherlands
| | - Anna M M Boers
- Department of Radiology and Nuclear Medicine, Academic Medical Center, Amsterdam, The Netherlands
- Department of Biomedical Engineering and Physics, Academic Medical Center, Amsterdam, The Netherlands
- Department of Robotics and Mechatronics, University of Twente, Enschede, The Netherlands
| | - Olvert A Berkhemer
- Department of Radiology and Nuclear Medicine, Academic Medical Center, Amsterdam, The Netherlands
- Department of Neurology, Erasmus MC-University Medical Rotterdam, Amsterdam, The Netherlands
- Department of Radiology and Nuclear Medicine, Erasmus MC-University Medical Center Rotterdam, Rotterdam, The Netherlands
| | | | - Vicky Chalos
- Department of Neurology, Erasmus MC-University Medical Rotterdam, Amsterdam, The Netherlands
- Department of Radiology and Nuclear Medicine, Erasmus MC-University Medical Center Rotterdam, Rotterdam, The Netherlands
- Department of Public Health, Center for Medical Decision Making, Erasmus MC-University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Hester F Lingsma
- Department of Public Health, Center for Medical Decision Making, Erasmus MC-University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Wim H van Zwam
- Department of Radiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, Maastricht, The Netherlands
| | - Aad van der Lugt
- Department of Radiology and Nuclear Medicine, Erasmus MC-University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Robert J van Oostenbrugge
- Department of Neurology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, Maastricht, The Netherlands
| | - Diederik W J Dippel
- Department of Neurology, Erasmus MC-University Medical Rotterdam, Amsterdam, The Netherlands
| | - Yvo B W E M Roos
- Department of Neurology, Academic Medical Center, Amsterdam, The Netherlands
| | - Henk A Marquering
- Department of Biomedical Engineering and Physics, Academic Medical Center, Amsterdam, The Netherlands
| | - Charles B L M Majoie
- Department of Radiology and Nuclear Medicine, Academic Medical Center, Amsterdam, The Netherlands
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Tan G, Yuan R, Wei C, Xu M, Liu M. Serum magnesium but not calcium was associated with hemorrhagic transformation in stroke overall and stroke subtypes: a case-control study in China. Neurol Sci 2018; 39:1437-1443. [PMID: 29804167 DOI: 10.1007/s10072-018-3445-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2017] [Accepted: 05/09/2018] [Indexed: 02/05/2023]
Abstract
Association between serum calcium and magnesium versus hemorrhagic transformation (HT) remains to be identified. A total of 1212 non-thrombolysis patients with serum calcium and magnesium collected within 24 h from stroke onset were enrolled. Backward stepwise multivariate logistic regression analysis was conducted to investigate association between calcium and magnesium versus HT. Calcium and magnesium were entered into logistic regression analysis in two models, separately: model 1, as continuous variable (per 1-mmol/L increase), and model 2, as four-categorized variable (being collapsed into quartiles). HT occurred in 140 patients (11.6%). Serum calcium was slightly lower in patients with HT than in patient without HT (P = 0.273). But serum magnesium was significantly lower in patients with HT than in patients without HT (P = 0.007). In logistic regression analysis, calcium displayed no association with HT. Magnesium, as either continuous or four-categorized variable, was independently and inversely associated with HT in stroke overall and stroke of large-artery atherosclerosis (LAA). The results demonstrated that serum calcium had no association with HT in patients without thrombolysis after acute ischemic stroke. Serum magnesium in low level was independently associated with increasing HT in stroke overall and particularly in stroke of LAA.
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Affiliation(s)
- Ge Tan
- Stroke Clinical Research Unit, Department of Neurology, West China Hospital, Sichuan University, No. 37, Guo Xue Xiang, Chengdu, 610041, Sichuan Province, China
| | - Ruozhen Yuan
- Stroke Clinical Research Unit, Department of Neurology, West China Hospital, Sichuan University, No. 37, Guo Xue Xiang, Chengdu, 610041, Sichuan Province, China
| | - ChenChen Wei
- Stroke Clinical Research Unit, Department of Neurology, West China Hospital, Sichuan University, No. 37, Guo Xue Xiang, Chengdu, 610041, Sichuan Province, China
| | - Mangmang Xu
- Stroke Clinical Research Unit, Department of Neurology, West China Hospital, Sichuan University, No. 37, Guo Xue Xiang, Chengdu, 610041, Sichuan Province, China
| | - Ming Liu
- Stroke Clinical Research Unit, Department of Neurology, West China Hospital, Sichuan University, No. 37, Guo Xue Xiang, Chengdu, 610041, Sichuan Province, China.
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El Amki M, Wegener S. Improving Cerebral Blood Flow after Arterial Recanalization: A Novel Therapeutic Strategy in Stroke. Int J Mol Sci 2017; 18:ijms18122669. [PMID: 29232823 PMCID: PMC5751271 DOI: 10.3390/ijms18122669] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2017] [Revised: 11/30/2017] [Accepted: 12/06/2017] [Indexed: 12/14/2022] Open
Abstract
Ischemic stroke is caused by a disruption in blood supply to a region of the brain. It induces dysfunction of brain cells and networks, resulting in sudden neurological deficits. The cause of stroke is vascular, but the consequences are neurological. Decades of research have focused on finding new strategies to reduce the neural damage after cerebral ischemia. However, despite the incredibly huge investment, all strategies targeting neuroprotection have failed to demonstrate clinical efficacy. Today, treatment for stroke consists of dealing with the cause, attempting to remove the occluding blood clot and recanalize the vessel. However, clinical evidence suggests that the beneficial effect of post-stroke recanalization may be hampered by the occurrence of microvascular reperfusion failure. In short: recanalization is not synonymous with reperfusion. Today, clinicians are confronted with several challenges in acute stroke therapy, even after successful recanalization: (1) induce reperfusion, (2) avoid hemorrhagic transformation (HT), and (3) avoid early or late vascular reocclusion. All these parameters impact the restoration of cerebral blood flow after stroke. Recent advances in understanding the molecular consequences of recanalization and reperfusion may lead to innovative therapeutic strategies for improving reperfusion after stroke. In this review, we will highlight the importance of restoring normal cerebral blood flow after stroke and outline molecular mechanisms involved in blood flow regulation.
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Affiliation(s)
- Mohamad El Amki
- Department of Neurology, University Hospital Zurich and University of Zurich, 8091 Zürich, Switzerland.
| | - Susanne Wegener
- Department of Neurology, University Hospital Zurich and University of Zurich, 8091 Zürich, Switzerland.
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31
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Kaesmacher J, Kaesmacher M, Maegerlein C, Zimmer C, Gersing AS, Wunderlich S, Friedrich B, Boeckh-Behrens T, Kleine JF. Hemorrhagic Transformations after Thrombectomy: Risk Factors and Clinical Relevance. Cerebrovasc Dis 2017; 43:294-304. [PMID: 28343220 DOI: 10.1159/000460265] [Citation(s) in RCA: 108] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2016] [Accepted: 01/28/2017] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Hemorrhagic transformation (HT) is a major complication of acute ischemic stroke, potentially associated with clinical deterioration. We attempted to identify risk factors and evaluated clinical relevance of minor and major HTs following endovascular thrombectomy (ET) in isolated middle cerebral artery (MCA) occlusions. METHODS This is a retrospective single-center analysis of 409 patients with isolated MCA occlusion treated with ET. Patients' and procedural characteristics, severity of HT according to the European Cooperative Acute Stroke Study criteria, and clinical outcomes were analyzed. Multivariate logistic regression models with standard retention criteria (p < 0.1) were used to determine risk factors and clinical relevance of HT. Results are shown as adjusted OR (aOR) and respective 95% CIs. Good neurologic short-term outcome was defined as National Institutes of Health Stroke Scale (NIHSS) score <5 at the day of discharge. RESULTS Of 299 patients included, hemorrhagic infarction (HI) was detected in 87 patients, while 13 patients developed parenchymal hematoma (PH). Higher age (aOR 0.970, 95% CI 0.947-0.993, p = 0.012), eligibility for intravenous recombinant tissue plasminogen activator (IV rtPA; aOR 0.512, 95% CI 0.267-0.982, p = 0.044), and complete recanalization (TICI 3, aOR 0.408, 95% CI 0.210-0.789, p = 0.008) were associated with a lower risk of HI. Risk factors for HI included higher admission NIHSS score (aOR 1.080, 95% CI 1.010-1.153, p = 0.024) and higher admission glucose levels (aOR 1.493, 95% CI 1.170-1.904, p = 0.001). Further, female sex tended to be associated with a lower risk of HI (aOR 0.601, 95% CI 0.316-1.143, p = 0.121), while a statistical trend was observable for proximal MCA occlusion (aOR 1.856, 95% CI 0.945-3.646, p = 0.073) and a history of hypertension (aOR 2.176, 95% CI 0.932-5.080, p = 0.072) to increase risk of HI. Longer intervals from symptom onset to first digital subtraction angiography runs (aOR 1.013, 95% CI 1.003-1.022, p = 0.009), lower preinterventional Alberta Stroke Program Early CT score (aOR 0.536, 95% CI 0.307-0.936, p = 0.028) and wake-up stroke (aOR 18.540, 95% CI 1.352-254.276, p = 0.029) were associated with PH. Both, PH and HI were independently associated with lower rates of good neurologic outcome (aOR 0.086, 95% CI 0.008-0.902, p = 0.041 and aOR 0.282, 95% CI 0.131-0.606, p = 0.001). CONCLUSION Risk of HI following MCA occlusion and subsequent ET is mainly determined by factors influencing infarct severity. Good recanalization results seem to be protective against subsequent HI. Our results support the notion that occurrence of PH after ET is time dependent and risk increases with more extensive early ischemic damage. Both, HI and PH do not seem to be facilitated by bridging therapy with IV rtPA or the use of oral anticoagulants, but were independently associated with more severe neurologic disability. These results support the notion that HI is not a "benign" imaging sign.
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Affiliation(s)
- Johannes Kaesmacher
- Department of Neuroradiology, Klinikum rechts der Isar, TU München, Munich, Germany
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Lin H, Li SN, Bai R, Wen SN, Liu N, Long DY, Yu RH, Tang RB, Sang CH, Du X, Dong JZ, Ma CS. Safety of catheter ablation for atrial fibrillation in patients with intracranial hemorrhage. Herz 2017; 43:169-176. [PMID: 28314875 DOI: 10.1007/s00059-017-4551-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2016] [Revised: 01/06/2017] [Accepted: 02/05/2017] [Indexed: 12/01/2022]
Abstract
BACKGROUND The safety of anticoagulation and radiofrequency catheter ablation (RFCA) in patients with atrial fibrillation (AF) and a history of intracranial hemorrhage (ICH) remains unclear. We investigated the risks and benefits of this approach in AF patients with a history of ICH. PATIENTS AND METHODS The ICH group included 45 AF patients with a history of ICH who underwent RFCA. Five of these patients were excluded because ICH occurred spontaneously after cerebral infarction. The control group included 80 individuals who presented for AF ablation and did not have a history of ICH. Two controls were matched for each study group patient in terms of sex, age (±2 years), type of AF, and procedure date. RESULTS Patients in the ICH group had higher CHADS2 (1.7 ± 1.3 vs. 1.1 ± 1.2, p < 0.05), CHA2DS2-VASc (2.6 ± 1.7 vs. 1.9 ± 1.6, p < 0.05), and HAS-BLED scores (2.5 ± 1.0 vs. 1.1 ± 1.0, p < 0.001). All participants in both groups underwent successful RFCA. The incidence of ICH during follow-up (1 vs. 0, p = 0.333) was similar between the ICH and control groups. AF-free survival between the two groups was not significant (log-rank p = 0.283) within the first 3 months, but was significant (log-rank p = 0.011) within 48 months of RFCA. History of ICH was the only independent predictor of AF recurrence according to univariate Cox regression analysis. CONCLUSION In AF patients with a history of ICH, AF ablation with a standard anticoagulation strategy is safe and does not seem to be associated with an increased risk of hemorrhage.
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Affiliation(s)
- H Lin
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, No. 2 Beijing Anzhen Road, Chaoyang District, 100029, Beijing, China
| | - S-N Li
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, No. 2 Beijing Anzhen Road, Chaoyang District, 100029, Beijing, China
| | - R Bai
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, No. 2 Beijing Anzhen Road, Chaoyang District, 100029, Beijing, China
| | - S-N Wen
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, No. 2 Beijing Anzhen Road, Chaoyang District, 100029, Beijing, China
| | - N Liu
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, No. 2 Beijing Anzhen Road, Chaoyang District, 100029, Beijing, China
| | - D-Y Long
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, No. 2 Beijing Anzhen Road, Chaoyang District, 100029, Beijing, China
| | - R-H Yu
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, No. 2 Beijing Anzhen Road, Chaoyang District, 100029, Beijing, China
| | - R-B Tang
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, No. 2 Beijing Anzhen Road, Chaoyang District, 100029, Beijing, China
| | - C-H Sang
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, No. 2 Beijing Anzhen Road, Chaoyang District, 100029, Beijing, China
| | - X Du
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, No. 2 Beijing Anzhen Road, Chaoyang District, 100029, Beijing, China
| | - J-Z Dong
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, No. 2 Beijing Anzhen Road, Chaoyang District, 100029, Beijing, China
| | - C-S Ma
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, No. 2 Beijing Anzhen Road, Chaoyang District, 100029, Beijing, China.
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Bhaskar S, Bivard A, Stanwell P, Parsons M, Attia JR, Nilsson M, Levi C. Baseline collateral status and infarct topography in post-ischaemic perilesional hyperperfusion: An arterial spin labelling study. J Cereb Blood Flow Metab 2017; 37:1148-1162. [PMID: 27256323 PMCID: PMC5363484 DOI: 10.1177/0271678x16653133] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Focal hyperperfusion after acute ischaemic stroke could be of prognostic value depending upon its spatial localisation and temporal dynamics. Factors associated with late stage (12-24 h) perilesional hyperperfusion, identified using arterial spin labelling, are poorly defined. A prospective cohort of acute ischaemic stroke patients presenting within 4.5 h of symptom onset were assessed with multi-modal computed tomography acutely and magnetic resonance imaging at 24 ± 8 h. Multivariate logistic regression analysis and receiver operating characteristics curves were used. One hundred and nineteen hemispheric acute ischaemic stroke patients (mean age = 71 ± 12 years) with 24 h arterial spin labelling imaging were included. Forty-two (35.3%) patients showed perilesional hyperperfusion on arterial spin labelling at 24 h. Several factors were independently associated with perilesional hyperperfusion: good collaterals (71% versus 29%, P < 0.0001; OR = 5, 95% CI = [1.6, 15.7], P = 0.005), major reperfusion (81% versus 48%, P = < 0.0001; OR = 7.5, 95% CI = [1.6, 35.1], P = 0.01), penumbral salvage (76.2% versus 47%, P = 0.002; OR = 6.6, 95% CI = [1.8, 24.5], P = 0.004), infarction in striatocapsular (OR = 9.5, 95% CI = [2.6, 34], P = 0.001) and in cortical superior division middle cerebral artery (OR = 4.7, 95% CI = [1.4, 15.7], P = 0.012) territory. The area under the receiver operating characteristic curve was 0.91. Our results demonstrate good arterial collaterals, major reperfusion, penumbral salvage, and infarct topographies involving cortical superior middle cerebral artery and striatocapsular are associated with perilesional hyperperfusion.
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Affiliation(s)
- Sonu Bhaskar
- 1 Department of Neurology, John Hunter Hospital, University of Newcastle, Newcastle, Australia.,2 Centre for Translational Neuroscience and Mental Health, School of Health Sciences and Hunter Medical Research Institute, University of Newcastle, Newcastle, Australia
| | - Andrew Bivard
- 1 Department of Neurology, John Hunter Hospital, University of Newcastle, Newcastle, Australia
| | - Peter Stanwell
- 2 Centre for Translational Neuroscience and Mental Health, School of Health Sciences and Hunter Medical Research Institute, University of Newcastle, Newcastle, Australia
| | - Mark Parsons
- 1 Department of Neurology, John Hunter Hospital, University of Newcastle, Newcastle, Australia.,2 Centre for Translational Neuroscience and Mental Health, School of Health Sciences and Hunter Medical Research Institute, University of Newcastle, Newcastle, Australia
| | - John R Attia
- 3 Centre for Clinical Epidemiology & Biostatistics, Hunter Medical Research Institute, University of Newcastle, Newcastle, Australia
| | - Michael Nilsson
- 2 Centre for Translational Neuroscience and Mental Health, School of Health Sciences and Hunter Medical Research Institute, University of Newcastle, Newcastle, Australia.,4 Centre for Brain Repair and Rehabilitation, Institute of Neuroscience and Physiology, Sahlgrenska University Hospital, University of Gothenburg, Gothenburg, Sweden
| | - Christopher Levi
- 1 Department of Neurology, John Hunter Hospital, University of Newcastle, Newcastle, Australia.,2 Centre for Translational Neuroscience and Mental Health, School of Health Sciences and Hunter Medical Research Institute, University of Newcastle, Newcastle, Australia
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Heit JJ, Iv M, Wintermark M. Imaging of Intracranial Hemorrhage. J Stroke 2016; 19:11-27. [PMID: 28030895 PMCID: PMC5307932 DOI: 10.5853/jos.2016.00563] [Citation(s) in RCA: 89] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2016] [Revised: 07/24/2016] [Accepted: 07/25/2016] [Indexed: 12/19/2022] Open
Abstract
Intracranial hemorrhage is common and is caused by diverse pathology, including trauma, hypertension, cerebral amyloid angiopathy, hemorrhagic conversion of ischemic infarction, cerebral aneurysms, cerebral arteriovenous malformations, dural arteriovenous fistula, vasculitis, and venous sinus thrombosis, among other causes. Neuroimaging is essential for the treating physician to identify the cause of hemorrhage and to understand the location and severity of hemorrhage, the risk of impending cerebral injury, and to guide often emergent patient treatment. We review CT and MRI evaluation of intracranial hemorrhage with the goal of providing a broad overview of the diverse causes and varied appearances of intracranial hemorrhage.
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Affiliation(s)
- Jeremy J Heit
- Stanford University Hospital, Department of Radiology, Neuroimaging and Neurointervention Division, CA, USA
| | - Michael Iv
- Stanford University Hospital, Department of Radiology, Neuroimaging and Neurointervention Division, CA, USA
| | - Max Wintermark
- Stanford University Hospital, Department of Radiology, Neuroimaging and Neurointervention Division, CA, USA
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Lipoic Acid Use and Functional Outcomes after Thrombolysis in Patients with Acute Ischemic Stroke and Diabetes. PLoS One 2016; 11:e0163484. [PMID: 27677185 PMCID: PMC5038972 DOI: 10.1371/journal.pone.0163484] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2016] [Accepted: 09/10/2016] [Indexed: 12/05/2022] Open
Abstract
Background Alpha-lipoic acid (aLA) is a strong antioxidant commonly used for treating diabetic polyneuropathy. Previously, we demonstrated the neurorestorative effects of aLA after cerebral ischemia in rats. However, its effects on patients with stroke remain unknown. We investigated whether patients treated with aLA have better functional outcomes after acute ischemic stroke (AIS) and reperfusion therapy than patients not receiving aLA. Methods In this retrospective study of 172 prospectively registered patients with diabetes and AIS treated with tissue plasminogen activator (tPA), we investigated the relationship between aLA use and functional outcome both after 3 months and after 1 year. The functional outcomes included occurrence of hemorrhagic transformation (HT), early neurological deterioration (END), and early clinical improvement (ECI). Favorable outcomes were defined as modified Rankin Scale (mRS) scores of 0–2. Results Of the 172 patients with AIS and diabetes, 47 (27.3%) used aLA. In the entire cohort, favorable outcomes occurred at significantly higher rates both at 3 months and at 1 year in those treated with aLA. The risks for END and HT were lower and the occurrence of ECI was higher in patients treated with aLA. In multivariable analysis, aLA use was associated with favorable outcomes both at 3 months and at 1 year. Age, HT, and increased National Institutes of Health Stroke Scale scores were negative predictors of a favorable outcome. Conclusions The use of aLA in patients with AIS and diabetes who are treated with tPA is associated with favorable outcomes. These results indicate that aLA could be a useful intervention for the treatment of AIS after reperfusion therapy.
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Severe Hemorrhagic Transformation after Thrombolysis for Acute Ischemic Stroke Prevents Early Neurological Improvement. J Stroke Cerebrovasc Dis 2016; 25:2232-6. [PMID: 27318653 DOI: 10.1016/j.jstrokecerebrovasdis.2016.04.020] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2016] [Accepted: 04/27/2016] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Intravenous thrombolysis can improve neurological outcomes after acute ischemic stroke (AIS), but hemorrhagic transformation (HT) of the infarct remains a risk. Current definitions for symptomatic intracerebral hemorrhage (ICH) all entail that there be some degree of associated neurological deterioration. However, early deleterious effects of secondary ICH might also be manifested as reduced neurological improvement. This study aims to investigate whether there are any independent associations between different radiological subtypes of HT and the degree of neurological improvement 24 hours after thrombolysis. METHODS This study is a retrospective analysis of a single-center database of consecutive thrombolysis cases for AIS. Multivariate regression analysis was undertaken to explore the relationship between different subtypes of HT with changes in National Institutes of Health Stroke Scale (NIHSS) score 24 hours after thrombolysis, after adjusting for potential confounders. RESULTS As compared to cases with no HT, occurrence of the parenchymal hematoma 2 (PH2) subtype of secondary ICH was independently associated with reduced improvement or worsening in the NIHSS score, with an average effect size of 7 points (95% confidence interval -10 to -4, P < .001). In the absence of PH2, thrombolysis for AIS was generally associated with an improvement in the neurological status at 24 hours. CONCLUSIONS The PH2 subtype of HT is associated with reduced neurological improvement or deterioration 24 hours after thrombolysis for AIS.
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Novel composite score to predict atrial Fibrillation in acute stroke patients. Int J Cardiol 2016; 209:184-9. [DOI: 10.1016/j.ijcard.2016.02.002] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2015] [Revised: 01/22/2016] [Accepted: 02/01/2016] [Indexed: 11/19/2022]
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Tong E, Komlosi P, Wintermark M. One-stop-shop stroke imaging with functional CT. Eur J Radiol 2015; 84:2425-31. [DOI: 10.1016/j.ejrad.2014.11.027] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2014] [Revised: 11/19/2014] [Accepted: 11/24/2014] [Indexed: 10/24/2022]
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Öcek L, Güner D, Uludağ İF, Tiftikçioğlu Bİ, Zorlu Y. Risk Factors for Hemorrhagic Transformation in Patients with Acute Middle Cerebral Artery Infarction. Noro Psikiyatr Ars 2015; 52:342-345. [PMID: 28360737 DOI: 10.5152/npa.2015.8792] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2014] [Accepted: 10/13/2014] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION Hemorrhagic transformation (HT) after acute ischemic stroke (AIS) can be seen at any time following ischemic stroke. Although HT usually occurs as a complication of antithrombotic, anticoagulant, or thrombolytic treatments, it can also occur spontaneously. We aimed to investigate the occurrence of early HT and its relevant risk factors in patients diagnosed with acute middle cerebral artery (MCA) infarction who were not treated with thrombolytic agents. METHODS We recruited 171 patients with acute MCA infarction between January 2011 and July 2012 who were not treated with thrombolytic agents and were suitable to our inclusion criteria. Controlled neuroimaging was performed immediately in patients with deterioration, otherwise on day 7 following stroke. All patients were investigated for AIS risk factors and biochemical analyses were performed. Patients with HT in controlled neuroimaging were grouped both clinically (i.e., symptomatic or asymptomatic) and radiologically, according to "European Cooperative Acute Stroke Radiological Study" (ECASS), and risk factors were examined. RESULTS We enrolled 171 patients [94 men (55%) and 77 women (45%)] in the study. HT developed in 37 patients (21.63%). In terms of risk factor analysis, the most frequent etiological factor was atherosclerosis in AIS patients (50.3%). National Institutes of Health Stroke Scale scores were significantly higher both in sHT patients according to asHT patients and in HT patients on day 7 compared with their initial scores. Serum low-density lipoprotein (LDL-C), triglycerides (TG), and total cholesterol (TC) levels were significantly lower in patients with HT (p<.001). CONCLUSION HT is a major complication in AIS that considerably increases the morbidity and mortality. To reduce the occurrence of HT, risk factors for each patient population should be determined. Acute thrombolytic therapy should be used cautiously in high-risk patients, and appropriate alternative therapies should be revised in them.
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Affiliation(s)
- Levent Öcek
- Clinic of Neurology, İzmir Tepecik Training and Research Hospital, İzmir, Turkey
| | - Derya Güner
- Clinic of Neurology, İzmir Tepecik Training and Research Hospital, İzmir, Turkey
| | - İrem Fatma Uludağ
- Clinic of Neurology, İzmir Tepecik Training and Research Hospital, İzmir, Turkey
| | | | - Yaşar Zorlu
- Clinic of Neurology, İzmir Tepecik Training and Research Hospital, İzmir, Turkey
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Jia W, Liao X, Pan Y, Wang Y, Cui T, Zhou L, Wang Y. Thrombolytic-Related Asymptomatic Hemorrhagic Transformation Does Not Deteriorate Clinical Outcome: Data from TIMS in China. PLoS One 2015; 10:e0142381. [PMID: 26619008 PMCID: PMC4664552 DOI: 10.1371/journal.pone.0142381] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2015] [Accepted: 10/21/2015] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE It has been unclear whether thrombolytic-related asymptomatic hemorrhagic transformation (AHT) affects the clinical outcome. To answer this question, we examined whether thrombolytic-related AHT affect short-term and long-term clinical outcome. METHODS All data were collected from the Thrombolysis Implementation and Monitor of Acute Ischemic Stroke in China (TIMS-China) registry. The patients were diagnosed as having AHT group and non- hemorrhagic transformation (HT) group based on clinical and imaging data. The patients with symptomatic hemorrhagic transformation were excluded from this study. Thrombolytic-related AHT was defined according to European-Australasian Acute Stroke Study (ECASS) II criteria. 90-day functional outcome, 7-day National Institutes of Health Stroke Scale (NIHSS) score, 7-day and 90-day mortalities were compared between two groups. Logistic regression analysis was used to evaluate the effects of AHT on a short-term and long-term clinical outcome. RESULTS 904 of all 1440 patients in TIMS-China registry were enrolled. 89 (9.6%) patients presented with AHT after thrombolysis within 24-36 h. These patients with AHT were more likely to be elder age, cardioembolic subtype, and to have higher National Institutes of Health Stroke Scale score before thrombolysis than patients without AHT. No significant difference was found on the odds of 7-day (95% CI:0.692 (0.218-2.195), (P = 0.532) or 90-day mortalities (95% CI:0.548 (0.237-1.268), P = 0.160) and modified Rankin Score(0-1) at 90-day (95% CI:0.798 (0.460-1.386), P = 0.423) or modified Rankin Score(0-2) at 90-day (95% CI:0.732 (0.429-1.253), P = 0.116) or modified Rankin Score(5-6) at 90-day (95% CI:0.375 (0.169-1.830), P = 0.116) between two groups. CONCLUSIONS Thrombolytic-related AHT does not deteriorate short-term and long-term clinical outcome.
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Affiliation(s)
- Weihua Jia
- Center of Stroke, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- National Clinical Research Center for Neurological Diseases, Beijing, China
- Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China
- Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
- Department of Neurology, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Xiaoling Liao
- Center of Stroke, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- National Clinical Research Center for Neurological Diseases, Beijing, China
- Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China
- Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Yuesong Pan
- Center of Stroke, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- National Clinical Research Center for Neurological Diseases, Beijing, China
- Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China
- Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Yilong Wang
- Center of Stroke, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- National Clinical Research Center for Neurological Diseases, Beijing, China
- Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China
- Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Tao Cui
- Center of Stroke, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Lichun Zhou
- Department of Neurology, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
- * E-mail: (YW); (LZ)
| | - Yongjun Wang
- Center of Stroke, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- National Clinical Research Center for Neurological Diseases, Beijing, China
- Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China
- Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
- * E-mail: (YW); (LZ)
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Jia W, Zhou L, Liao X, Pan Y, Wang Y. Postthrombolytic Antiplatelet Use for Patients with Intercerebral Hemorrhage without Extensive Parenchymal Involvement Does Not Worsen Outcome. J Clin Neurol 2015; 11:305-10. [PMID: 26424236 PMCID: PMC4596115 DOI: 10.3988/jcn.2015.11.4.305] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2014] [Revised: 10/01/2014] [Accepted: 10/01/2014] [Indexed: 11/29/2022] Open
Abstract
Background and Purpose It is unclear whether postthrombolytic antiplatelet (AP) therapy after thrombolytic-related hemorrhage without extensive parenchymal involvement (THEPI) affects the clinical outcome. This study explored whether AP administration in patients with THEPI affects short- and long-term outcomes. Methods All of the data for this study were collected from the Thrombolysis Implementation and Monitor of Acute Ischemic Stroke in China (TIMS-China) registry. Patients with THEPI were assigned to either the AP (AP therapy should be commenced 24 h after intravenous thrombolysis) or AP-naïve groups. THEPI was defined according to European-Australasian Acute Stroke Study II criteria. The 90-day functional outcome, 7-day National Institutes of Health Stroke Scale (NIHSS) score, and 7-day and 90-day mortalities were compared between the AP and AP-naïve groups. Logistic regression analysis was used to evaluate the effects of AP therapy on the short- and long-term clinical outcomes. Results Of the 928 patients enrolled from those in the TIMS-China registry (n=1,440), 89 (9.6%) had nonsymptomatic intracerebral hemorrhage (ICH) within 24-36 h after thrombolysis; 33 (37%) of these patients were given AP therapy (AP group) and 56 (63%) were not (AP-naïve group). No significant differences were found for the risk of 7-day aggravated ICH (p=0.998), 7-day NIHSS score (p=0.5491), 7-day mortality [odds ratio (OR)=3.427; 95% confidence interval (95% CI)=0.344-34.160; p=0.294], 90-day mortality (OR=0.788, 95% CI=0.154-4.040, p=0.775), or modified Rankin score 5 or 6 at 90-days (OR=1.108, 95% CI=0.249-4.928, p=0.893) between the AP and AP-naïve groups after THEPI. Conclusions Early administration of postthrombolytic AP therapy after THEPI does not worsen either the short- or long-term outcome. AP therapy may be a reasonable treatment option for patients with THEPI to reduce the risk of ischemic stroke recurrence.
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Affiliation(s)
- Weihua Jia
- Department of Neurology, Beijing Tian Tan Hospital, Capital Medical University, Beijing, China
| | - Lichun Zhou
- Department of Neurology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Xiaoling Liao
- Department of Neurology, Beijing Tian Tan Hospital, Capital Medical University, Beijing, China
| | - Yuesong Pan
- Department of Neurology, Beijing Tian Tan Hospital, Capital Medical University, Beijing, China
| | - Yongjun Wang
- Department of Neurology, Beijing Tian Tan Hospital, Capital Medical University, Beijing, China.
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Ibatullin MM, Kalinin MN, Curado AT, Khasanova DR. [Neurovisualisation predictors of malignant cerebral infarction and hemorrhagic transformation]. Zh Nevrol Psikhiatr Im S S Korsakova 2015; 115:3-11. [PMID: 26120991 DOI: 10.17116/jnevro2015115323-11] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Neuroimaging plays a central role in the assessment of patients with acute ischemic stroke. Within a few minutes, modern multimodal imaging protocols can provide one with comprehensive information about prognosis, management, and outcome of the disease, and may detect changes in the intracranial structures reflecting severity of the ischemic injury depicted by four Ps: parenchyma (of the brain), pipes (i.e., the cerebral blood vessels), penumbra, and permeability (of the blood brain barrier). In this article, we have reviewed neuroradiological predictors of malignant middle cerebral artery infarction and hemorrhagic transformation in light of the aforementioned four Ps.
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Affiliation(s)
| | | | - A T Curado
- Interregional Clinical Diagnostic Center, Kazan
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Sorabella RA, Han SM, Grbic M, Wu YS, Takyama H, Kurlansky P, Borger MA, Argenziano M, Gordon R, George I. Early Operation for Endocarditis Complicated by Preoperative Cerebral Emboli Is Not Associated With Worsened Outcomes. Ann Thorac Surg 2015; 100:501-8. [PMID: 26116483 DOI: 10.1016/j.athoracsur.2015.03.078] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2015] [Revised: 03/12/2015] [Accepted: 03/18/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND Valve operations for patients presenting with infective endocarditis (IE) complicated by stroke are thought to carry elevated risk of postoperative complications. Our aim was to compare outcomes of IE patients who undergo surgical intervention early after diagnosis of septic cerebral emboli with outcomes of patients without preoperative emboli. METHODS All patients undergoing operations for left-sided IE between 1996 and 2013 at our institution were reviewed. Patients undergoing operations more than 14 days after embolic stroke diagnosis (n = 11) and those with purely hemorrhagic lesions (n = 7) were excluded from the analysis. The study included 308 patients who were stratified according to the presence (STR, n = 54) or absence of a preoperative septic cerebral embolus (NoSTR, n = 254). Primary outcomes of interest were the development of a new postoperative stroke and 30-day mortality. RESULTS Mean time to surgical intervention from stroke onset was 6.0 ± 4.1 days. Staphylococcus aureus (39% STR vs 21% NoSTR, p = 0.004) infection and annular abscess at operation (52% STR vs 27% NoSTR, p < 0.001) were more prevalent in STR patients. There was no significant difference in 30-day mortality (9.3% STR vs 7.1% NoSTR, p = 0.57) or in the rate of new postoperative stroke (5 [9.4%] STR vs 12 [4.7%] NoSTR, p = 0.19) between groups. In addition, there was no difference in 10-year survival between groups (log-rank p = 0.74). CONCLUSIONS Early surgical intervention in patients with IE complicated by preoperative septic cerebral emboli does not lead to significantly worse postoperative outcomes. Early surgical intervention for IE after embolic stroke warrants consideration, particularly in patients with high-risk features such as S aureus or annular abscess, or both.
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Affiliation(s)
- Robert A Sorabella
- Division of Cardiothoracic Surgery, New York-Presbyterian Hospital, Columbia University College of Physicians and Surgeons, New York, New York
| | - Sang Myung Han
- Division of Cardiothoracic Surgery, New York-Presbyterian Hospital, Columbia University College of Physicians and Surgeons, New York, New York
| | - Mark Grbic
- Division of Cardiothoracic Surgery, New York-Presbyterian Hospital, Columbia University College of Physicians and Surgeons, New York, New York
| | - Yeu Sanz Wu
- Division of Cardiothoracic Surgery, New York-Presbyterian Hospital, Columbia University College of Physicians and Surgeons, New York, New York
| | - Hiroo Takyama
- Division of Cardiothoracic Surgery, New York-Presbyterian Hospital, Columbia University College of Physicians and Surgeons, New York, New York
| | - Paul Kurlansky
- Division of Cardiothoracic Surgery, New York-Presbyterian Hospital, Columbia University College of Physicians and Surgeons, New York, New York
| | - Michal A Borger
- Division of Cardiothoracic Surgery, New York-Presbyterian Hospital, Columbia University College of Physicians and Surgeons, New York, New York
| | - Michael Argenziano
- Division of Cardiothoracic Surgery, New York-Presbyterian Hospital, Columbia University College of Physicians and Surgeons, New York, New York
| | - Rachel Gordon
- Division of Infectious Diseases, New York-Presbyterian Hospital, Columbia University College of Physicians and Surgeons, New York, New York
| | - Isaac George
- Division of Cardiothoracic Surgery, New York-Presbyterian Hospital, Columbia University College of Physicians and Surgeons, New York, New York.
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Blood-brain barrier breakdown involves four distinct stages of vascular damage in various models of experimental focal cerebral ischemia. J Cereb Blood Flow Metab 2015; 35:292-303. [PMID: 25425076 PMCID: PMC4426746 DOI: 10.1038/jcbfm.2014.199] [Citation(s) in RCA: 151] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2014] [Revised: 10/16/2014] [Accepted: 10/17/2014] [Indexed: 12/18/2022]
Abstract
Ischemic stroke not only impairs neuronal function but also affects the cerebral vasculature as indicated by loss of blood-brain barrier (BBB) integrity. Therefore, therapeutical recanalization includes an enhanced risk for hemorrhagic transformation and bleeding, traditionally attributed to a 'reperfusion injury'. To investigate the mechanisms underlying ischemia-/reperfusion-related BBB opening, we applied multiple immunofluorescence labeling and electron microscopy in a rat model of thromboembolic stroke as well as mouse models of permanent and transient focal cerebral ischemia. In these models, areas exhibiting BBB breakdown were identified by extravasation of intravenously administered fluorescein isothiocyanate (FITC)-albumin. After 24 hours, expression of markers for tight and adherens junctions in areas of FITC-albumin leakage consistently remained unaltered in the applied models. However, lectin staining with isolectin B4 indicated structural alterations in the endothelium, which were confirmed by electron microscopy. While ultrastructural alterations in endothelial cells did not differ between the applied models including the reperfusion scenario, we regularly identified vascular alterations, which we propose to reflect four distinct stages of BBB breakdown with ultimate loss of endothelial cells. Therefore, our data strongly suggest that ischemia-related BBB failure is predominantly caused by endothelial degeneration. Thus, protecting endothelial cells may represent a promising therapeutical approach in addition to the established recanalizing strategies.
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Suzuki K, Aoki J, Kanzawa T, Nishiyama Y, Takayama Y, Kimura H, Takahashi S, Kano T, Akaji K, Tanizaki Y, Kimura K, Mihara B. Correlation between the Occlusion Site and Clinical Outcome after Acute Ischemic Stroke. Intern Med 2015; 54:3139-44. [PMID: 26666600 DOI: 10.2169/internalmedicine.54.4990] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
OBJECTIVE The significance of early mild clinical improvement after intravenous tissue plasminogen activator (IVtPA) treatment is unclear. Therefore, we examined whether the timing of clinical improvement after IVtPA predicted the clinical outcome at 3 months. METHODS Consecutive patients with acute cerebral infarction in the anterior circulation who received IVtPA treatment within 3 hours of the onset of symptoms were enrolled in the study. Patients were classified according to the timing of clinical improvement [early responder (ER), National Institutes of Health Stroke Scale (NIHSS) score improved ≥4 points or who had a score of 0 within 2 hours after IVtPA; late responder (LR), a similar improvement between 2 and 24 hours; and non-responder (NR)] and according to the arterial occlusion site (P group, internal carotid artery and proximal middle cerebral artery M1 region; and D group, distal M1 and M2). RESULTS Ninety-three patients [median age, 74 (67-79) years; 54 men (58%); median NIHSS score, 11 (7-16)] were enrolled in the study. The P group consisted of 48 (52%) patients and the D group consisted of 45 (48%) patients. Thirty-eight patients (41%) were classified as ERs, 20 (22%) as LRs, and 35 (38%) as NRs. On a multivariate regression analysis, the P group [odds ratio (OR), 3.24; 95% confidence interval (CI), 1.08-10.45; p=0.036] and NR (OR, 4.04; 95% CI, 1.29-14.27; p=0.016) were independent predictors of a poor outcome. ER (47%, p=0.01) and LR (45%, p=0.01) patients showed fewer poor outcomes than NR (77%) patients, but the rate did not differ significantly between the ER and LR patients. CONCLUSION Early mild clinical recovery did not predict a good outcome. The occlusion site was a stronger predictor of clinical improvement after IVtPA administration.
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Affiliation(s)
- Kentaro Suzuki
- Department of Neurological Science, Nippon Medical School, Japan
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Zhang J, Yang Y, Sun H, Xing Y. Hemorrhagic transformation after cerebral infarction: current concepts and challenges. ANNALS OF TRANSLATIONAL MEDICINE 2014; 2:81. [PMID: 25333056 DOI: 10.3978/j.issn.2305-5839.2014.08.08] [Citation(s) in RCA: 65] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 07/17/2014] [Accepted: 07/18/2014] [Indexed: 01/11/2023]
Abstract
Hemorrhagic transformation (HT) is a frequent complication of acute ischemic stroke that is especially common after thrombolytic therapy. The risk of HT limits the applicability of tissue plasminogen activator (tPA). Here, we sought to review the rate, classification, predictors, possible mechanism, and clinical outcomes of HT, as well as existing therapeutic approaches, in order to call attention to the current challenges in the treatment of this complication.
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Affiliation(s)
- Jie Zhang
- 1 Neuroscience Center, Department of Neurology, 2 Cadre Ward, The First Hospital of Jilin University, Jilin University, Changchun 130021, China
| | - Yi Yang
- 1 Neuroscience Center, Department of Neurology, 2 Cadre Ward, The First Hospital of Jilin University, Jilin University, Changchun 130021, China
| | - Huijie Sun
- 1 Neuroscience Center, Department of Neurology, 2 Cadre Ward, The First Hospital of Jilin University, Jilin University, Changchun 130021, China
| | - Yingqi Xing
- 1 Neuroscience Center, Department of Neurology, 2 Cadre Ward, The First Hospital of Jilin University, Jilin University, Changchun 130021, China
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Abstract
Neuroimaging has expanded beyond its traditional diagnostic role and become a critical tool in the evaluation and management of stroke. The objectives of imaging include prompt accurate diagnosis, treatment triage, prognosis prediction, and secondary preventative precautions. While capitalizing on the latest treatment options and expanding upon the "time is brain" doctrine, the ultimate goal of imaging is to maximize the number of treated patients and improve the outcome of one the most costly and morbid disease. A broad overview of comprehensive multimodal stroke imaging is presented here to affirm its utilization.
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Affiliation(s)
- Elizabeth Tong
- Neuroradiology Division, Department of Radiology, University of Virginia, Charlottesville, Virginia
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George AJ, Boehme AK, Dunn CR, Beasley T, Siegler JE, Albright KC, El Khoury R, Martin-Schild S. Trimming the fat in acute ischemic stroke: an assessment of 24-h CT scans in tPA patients. Int J Stroke 2014; 10:37-41. [PMID: 24894300 DOI: 10.1111/ijs.12293] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2014] [Accepted: 04/02/2014] [Indexed: 01/06/2023]
Abstract
BACKGROUND International management of acute ischemic stroke patients treated with intravenous tissue plasminogen activator frequently includes 24-h head imaging. These recommendations stem from the National Institute of Neurological Disorders and Stroke (NINDS) clinical trial protocol regarding the risk of intracerebral hemorrhage post-tissue plasminogen activator administration. Follow-up computed tomography scans on select patients, however, may not effect clinical management, resulting in unnecessary radiation exposure and healthcare costs. AIMS Our study questions the utility of routine 24-h computed tomography imaging and looks at the National Institute of Health Stroke Scale as a possible clinical screen for selecting candidates for 24-h imaging. Such a tool would result in decreased radiation exposure to the patient and decreased cost to the hospital. METHODS Consecutive patients with acute ischemic stroke given intravenous tissue plasminogen activator between June 2008 and December 2011 were retrospectively identified and dichotomized based on change in 24-h National Institute of Health Stroke Scale from baseline. Initial analysis compared patients with National Institute of Health Stroke Scale worsening to those without worsening. Subsequent analysis was limited to patients with a baseline National Institute of Health Stroke Scale ≤10. Baseline demographics and medical history, baseline and 24-h computed tomography findings, medical and/or surgical orders within six-hours of imaging, and antithrombotic administration within 24-48-h postintravenous tissue plasminogen activator were compared between the two groups. RESULTS Two-hundred patients met inclusion criteria: No 24-h National Institute of Health Stroke Scale worsening (n = 167) vs. 24-h National Institute of Health Stroke Scale worsening (n = 33). No baseline demographic or admission data differed significantly between the two groups. Patients without 24-h National Institute of Health Stroke Scale worsening had significantly lower incidence of hemorrhagic infarction (10·8% vs. 31·3%, P = 0·0014) on follow-up imaging. Less than 2% of all patients without 24-h National Institute of Health Stroke Scale worsening had a parenchymal hematoma. No patient with baseline National Institute of Health Stroke Scale ≤10 and without 24-h National Institute of Health Stroke Scale worsening had parenchymal hematoma. Patients with 24-h worsening were significantly less likely to receive timely antithrombotic therapy (60·6% vs. 77·8%, odds ratio 0·44, 95% confidence interval 0·20-0·96). CONCLUSIONS Our results demonstrate that routine 24-h computed tomography scan in patients without 24-h National Institute of Health Stroke Scale worsening (especially those with baseline National Institute of Health Stroke Scale ≤10) is less likely to yield information that results in a deviation from standard acute stroke care. No patient without worsening and baseline National Institute of Health Stroke Scale ≤10 had parenchymal hematoma on 24-h computed tomography. Application of the National Institute of Health Stroke Scale to distinguish patients who should have 24-h follow-up imaging from those who will not benefit is a potential avenue for improving utilization of resources and warrants further study.
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Affiliation(s)
- Alexander J George
- Stroke Program, Department of Neurology, Tulane University Hospital, New Orleans, LA, USA
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Ozkul-Wermester O, Guegan-Massardier E, Triquenot A, Borden A, Perot G, Gérardin E. Increased blood-brain barrier permeability on perfusion computed tomography predicts hemorrhagic transformation in acute ischemic stroke. Eur Neurol 2014; 72:45-53. [PMID: 24853726 DOI: 10.1159/000358297] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2013] [Accepted: 12/30/2013] [Indexed: 11/19/2022]
Abstract
BACKGROUND/PURPOSE Perfusion computed tomography (CT) is capable of measuring the permeability surface product (PS). PS reflects the permeability of the blood-brain barrier, involved in the pathophysiology of hemorrhagic transformation (HT) of ischemic stroke. The aim of our study was to determine if an increased PS can predict HT. METHODS A total of 86 patients with ischemic stroke were included. They underwent multimodality CT, including the measurement of PS. We compared the clinical and radiological characteristics of patients who developed HT to those who did not, using univariate analysis. Multivariate regression analyses were then used to determine HT predictors. RESULTS HT was observed in 27 patients (31%). Infarct PS was significantly associated with HT (p = 0.047), as were atrial fibrillation (p = 0.03), admission National Institute of Health Stroke Scale score (p = 0.02), infarct volume (p = 0.0004), presence of large-vessel occlusion (p = 0.0005) and a poorer collateral status (p = 0.003). Using logistic regression modeling, an infarct PS >0.84 ml/100 g/min was an independent predictor of HT (OR 28, 95% CI 1.75-452.98; p = 0.02). Other independent predictors of HT were infarct volume and a history of atrial fibrillation. CONCLUSIONS Our findings suggest that infarct PS can be a predictor of HT and may help clinicians to improve patient care around thrombolysis decisions in the acute phase of ischemic stroke.
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Canavero I, Cavallini A, Perrone P, Magoni M, Sacchi L, Quaglini S, Lanzola G, Micieli G. Clinical factors associated with statins prescription in acute ischemic stroke patients: findings from the Lombardia Stroke Registry. BMC Neurol 2014; 14:53. [PMID: 24650199 PMCID: PMC3994484 DOI: 10.1186/1471-2377-14-53] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2013] [Accepted: 03/17/2014] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Statins, due to their well-established pleiotropic effects, have noteworthy benefits in stroke prevention. Despite this, a significant proportion of high-risk patients still do not receive the recommended therapeutic regimens, and many others discontinue treatment after being started on them. The causes of non-adherence to current guidelines are multifactorial, and depend on both physicians and patients. The aim of this study is to identify the factors influencing statin prescription at Stroke Unit (SU) discharge. METHODS This study included 12,750 patients enrolled on the web-based Lombardia Stroke Registry (LRS) from July 2009 to April 2012 and discharged alive, with a diagnosis of ischemic stroke or transient ischemic attack (TIA) and without contra-indication to statin therapy. By logistic regression analysis and classification trees, we evaluated the impact of demographic data, risk factors, tPA treatment, in-hospital procedures and complications on statin prescription rate at discharge. RESULTS We observed a slight increase in statins prescription during the study period (from 39.1 to 43.9%). Lower age, lower stroke severity and prestroke disability, the presence of atherothrombotic/lacunar risk factors, a diagnosis of non-cardioembolic stroke, tPA treatment, the absence of in-hospital complications, with the sole exception of hypertensive fits and hyperglycemia, were the patient-related predictors of adherence to guidelines by physicians. Overall, dyslipidemia appears as the leading factor, while TOAST classification does not reach statistical significance. CONCLUSIONS In our region, Lombardia, adherence to guidelines in statin prescription at Stroke Unit discharge is very different from international goals. The presence of dyslipidemia remains the main factor influencing statin prescription, while the presence of well-defined atherosclerotic etiopathogenesis of stroke does not enhance statin prescription. Some uncertainties about the risk/benefit of statin therapy in stroke etiology subtypes (cardioembolism, other or undetermined causes) may partially justify the underuse of statin in ischemic stroke. The differences that exist between current international guidelines may prevent a more widespread use of statin and should be clarified in a consensus.
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Affiliation(s)
- Isabella Canavero
- Department of Emergency Neurology/Stroke Unit, National Neurologic Institute C. Mondino IRCCS, Pavia, Italy
| | - Anna Cavallini
- Department of Emergency Neurology/Stroke Unit, National Neurologic Institute C. Mondino IRCCS, Pavia, Italy
| | | | - Mauro Magoni
- Neurovascular Unit, ‘Spedali Civili’ Hospital, Brescia, Italy
| | - Lucia Sacchi
- Department of Electrical, Computer and Biomedical Engineering, University of Pavia, Pavia, Italy
| | - Silvana Quaglini
- Department of Electrical, Computer and Biomedical Engineering, University of Pavia, Pavia, Italy
| | - Giordano Lanzola
- Department of Electrical, Computer and Biomedical Engineering, University of Pavia, Pavia, Italy
| | - Giuseppe Micieli
- Department of Emergency Neurology/Stroke Unit, National Neurologic Institute C. Mondino IRCCS, Pavia, Italy
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