1
|
Ma F, Zeng Z, Chen J, Zhang J. A new score for predicting intracranial hemorrhage in patients using antiplatelet drugs. Ann Hematol 2024; 103:2511-2521. [PMID: 38630131 DOI: 10.1007/s00277-024-05734-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Accepted: 03/29/2024] [Indexed: 07/06/2024]
Abstract
Antiplatelet drugs in patients increase the risk of intracranial hemorrhage (ICH), which can seriously affect patients' quality of life and even endanger their lives. Currently, there is no specific score for predicting the risk of ICH caused by antiplatelet drugs. We aimed to identify factors associated with ICH in patients on antiplatelet drugs and to construct and validate a predictive model that would provide a validated tool for the clinic. Data were obtained from the patient medical records inpatient system. Prediction models were built by logistic regression, the area under the curve (AUC), and column line plots. Internal validation, analytical identification and calibration of the model using AUC, calibration curves and Hosmer-Lemeshow test. The registration number of this study is ChiCTR2000031909, and the ethical review number is 2020KY087. This single-center retrospective study enrolled 753 patients treated with antiplatelet drugs, including 527 in the development cohort. Multifactorial analysis showed that male, headache or vomiting, hypertension, cerebrovascular disease, CT-defined white matter hypodensity, abnormal GCS, fibrinogen and D-dimer were independent risk factors for ICH, and lipid-lowering drugs was a protective factor. The model was constructed using these nine factors with an AUC value of 0.949. In the validation cohort, the model showed good discriminatory power with an AUC value of 0.943 and good calibration (Hosmer-Lemeshow test P value of 0.818). Based on 9 factors, we derived and validated a predictive model for ICH with antiplatelet drugs in patients. The model has good predictive value and may be an effective tool to reduce the occurrence of ICH.
Collapse
Affiliation(s)
- Fuxin Ma
- Department of School, Fujian Medical University, Fuzhou, China
| | - Zhiwei Zeng
- Department of Pharmacy, College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Maternity and Child Health Hospital, Fujian Medical University, #18 Daoshan Road, Fuzhou, 350001, China
| | - Jiana Chen
- Department of Pharmacy, College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Maternity and Child Health Hospital, Fujian Medical University, #18 Daoshan Road, Fuzhou, 350001, China
| | - Jinhua Zhang
- Department of Pharmacy, College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Maternity and Child Health Hospital, Fujian Medical University, #18 Daoshan Road, Fuzhou, 350001, China.
| |
Collapse
|
2
|
Woodhouse LJ, Appleton JP, Christensen H, Dineen RA, England TJ, James M, Krishnan K, Montgomery AA, Ranta A, Robinson TG, Sprigg N, Bath PM. Bleeding with intensive versus guideline antiplatelet therapy in acute cerebral ischaemia. Sci Rep 2023; 13:11717. [PMID: 37474599 PMCID: PMC10359249 DOI: 10.1038/s41598-023-38474-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Accepted: 07/09/2023] [Indexed: 07/22/2023] Open
Abstract
Intensive antiplatelet therapy did not reduce recurrent stroke/transient ischaemic attack (TIA) events as compared with guideline treatment in the Triple Antiplatelets for Reducing Dependency after Ischaemic Stroke (TARDIS) trial, but did increase the frequency and severity of bleeding. In this pre-specified analysis, we investigated predictors of bleeding and the association of bleeding with outcome. TARDIS was an international prospective randomised open-label blinded-endpoint trial in participants with ischaemic stroke or TIA within 48 h of onset. Participants were randomised to 30 days of intensive antiplatelet therapy (aspirin, clopidogrel, dipyridamole) or guideline-based therapy (either clopidogrel alone or combined aspirin and dipyridamole). Bleeding was defined using the International Society on Thrombosis and Haemostasis five-level ordered categorical scale: fatal, major, moderate, minor, none. Of 3,096 participants, bleeding severity was: fatal 0.4%, major 1.5%, moderate 1.2%, minor 11.4%, none 85.5%. Major/fatal bleeding was increased with intensive as compared with guideline therapy: 39 vs. 17 participants, adjusted hazard ratio 2.21, 95% CI 1.24-3.93, p = 0.007. Bleeding events diverged between treatment groups in the 8-35 day period but not in the 0-7 or 36-90 day epochs. In multivariate analysis more, and more severe, bleeding events were seen with increasing age, female sex, pre-morbid dependency, increased time to randomisation, prior major bleed, prior antiplatelet therapy and in those randomised to triple vs guideline antiplatelet therapy. More severe bleeding was associated with worse clinical outcomes across multiple physical, emotional and quality of life domains.Trial registration ISRCTN47823388 .
Collapse
Affiliation(s)
- Lisa J Woodhouse
- Stroke Trials Unit, Mental Health and Clinical Neuroscience, School of Medicine, South Block D Floor, Queen's Medical Centre, University of Nottingham, Nottingham, NG7 2UH, UK
| | - Jason P Appleton
- Stroke Trials Unit, Mental Health and Clinical Neuroscience, School of Medicine, South Block D Floor, Queen's Medical Centre, University of Nottingham, Nottingham, NG7 2UH, UK
- Stroke, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, NG7 2UH, UK
| | - Hanne Christensen
- Bispebjerg and Frederiksberg Hospital, Department of Neurology, University of Copenhagen, Copenhagen, Denmark
| | - Rob A Dineen
- Radiological Sciences, Mental Health and Clinical Neuroscience, School of Medicine, Queens Medical Centre, University of Nottingham, Nottingham, NG7 2UH, UK
| | - Timothy J England
- Stroke Trials Unit, Mental Health and Clinical Neuroscience, School of Medicine, South Block D Floor, Queen's Medical Centre, University of Nottingham, Nottingham, NG7 2UH, UK
- Derby Stroke Centre, University Hospitals of Derby and Burton, Derby, DE22 3NE, UK
| | - Marilyn James
- Nottingham Clinical Trials Unit, Applied Health Research Building, School of Medicine, University of Nottingham, University Park, Nottingham, NG7 2RD, UK
| | - Kailash Krishnan
- Stroke Trials Unit, Mental Health and Clinical Neuroscience, School of Medicine, South Block D Floor, Queen's Medical Centre, University of Nottingham, Nottingham, NG7 2UH, UK
- Stroke, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, NG7 2UH, UK
| | - Alan A Montgomery
- Nottingham Clinical Trials Unit, Applied Health Research Building, School of Medicine, University of Nottingham, University Park, Nottingham, NG7 2RD, UK
| | - Anna Ranta
- Department of Medicine, University of Otago, Wellington, New Zealand
- Department of Neurology, Wellington Hospital, Wellington, New Zealand
| | - Thompson G Robinson
- Department of Cardiovascular Sciences and NIHR Leicester Biomedical Research Centre, University of Leicester, Leicester, UK
| | - Nikola Sprigg
- Stroke Trials Unit, Mental Health and Clinical Neuroscience, School of Medicine, South Block D Floor, Queen's Medical Centre, University of Nottingham, Nottingham, NG7 2UH, UK
- Stroke, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, NG7 2UH, UK
| | - Philip M Bath
- Stroke Trials Unit, Mental Health and Clinical Neuroscience, School of Medicine, South Block D Floor, Queen's Medical Centre, University of Nottingham, Nottingham, NG7 2UH, UK.
- Stroke, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, NG7 2UH, UK.
| |
Collapse
|
3
|
Castelijns MC, Hageman SHJ, Teraa M, van der Meer MG, Westerink J, Costa F, Ten Berg JM, Visseren FLJ. External validation of bleeding risk models for the prediction of long-term bleeding risk in patients with established cardiovascular disease. Am Heart J 2023; 260:72-81. [PMID: 36841319 DOI: 10.1016/j.ahj.2023.02.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Revised: 02/14/2023] [Accepted: 02/18/2023] [Indexed: 05/07/2023]
Abstract
OBJECTIVE The long-term predictive performance of existing bleeding risk models in patients with various manifestations of cardiovascular disease (CVD) is not well known. This study aims to assess and compare the performance of relevant existing bleeding risk models in estimating the long-term risk of major bleeding in a cohort of patients with established CVD. METHODS Seven existing bleeding risk models (PRECISE-DAPT, DAPT, Ducrocq et al, de Vries et al, S2TOP-BLEED, Intracranial B2LEED3S and HAS-BLED) were identified and externally validated in 7,249 patients with established CVD included in the Utrecht Cardiovascular Cohort-second manifestations of arterial disease study. Predictive performance was assessed in terms of discrimination and calibration, both at 10 years and the original prediction horizon of the models. Major bleeding was defined as Bleeding Academic Research Consortium type 3 or 5. RESULTS After a median follow-up of 8.4 years (interquartile range 4.5-12.5), a total of 233 (3.2%) major bleeding events occurred. C-statistics for discrimination at 10 years ranged from 0.53 (95%CI 0.49-0.57) to 0.64 (95%CI 0.60-0.68). Calibration plots after recalibration to 10 years showed best agreement between predicted and observed bleeding risk for De Vries et al, S2TOP-BLEED, DAPT and PRECISE-DAPT. CONCLUSIONS The performance of existing bleeding risk models to predict long-term bleeding in patients with CVD varied. Discrimination and calibration were best for the models of de Vries et al, S2TOP-BLEED, DAPT and PRECISE-DAPT. Of these, recalibrated models requiring the least predictors may be preferred for use to personalize prevention with antithrombotic therapy.
Collapse
Affiliation(s)
- Maria C Castelijns
- Department of Vascular Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Steven H J Hageman
- Department of Vascular Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Martin Teraa
- Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Manon G van der Meer
- Department of Cardiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Jan Westerink
- Department of Vascular Medicine, University Medical Center Utrecht, Utrecht, The Netherlands; Department of Internal Medicine, Isala Clinics Zwolle, Zwolle, The Netherlands
| | - Francesco Costa
- Department of Cardiology, G. Martino University Hospital Messina, Messina, Italy
| | - Jurriën M Ten Berg
- Department of Cardiology and Platelet Function Research, St. Antonius Hospital Nieuwegein, Nieuwegein, The Netherlands; Cardiovascular Research Institute Maastricht, Maastricht, The Netherlands
| | - Frank L J Visseren
- Department of Vascular Medicine, University Medical Center Utrecht, Utrecht, The Netherlands.
| |
Collapse
|
4
|
Xiang Q, Wang Z, Mu G, Xie Q, Liu Z, Zhou S, Zhang H, Wang Z, Hu K, Song H, Yuan D, Xia Q, Huang Y, Cui Y. PROK2, HRNR, and FIG4 as potential genetic biomarkers of high bleeding propensity in East Asian patients with acute coronary syndrome using ticagrelor. Pharmacotherapy 2022; 42:872-879. [PMID: 36263704 DOI: 10.1002/phar.2736] [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: 07/07/2022] [Revised: 09/26/2022] [Accepted: 10/01/2022] [Indexed: 12/13/2022]
Abstract
STUDY OBJECTIVE East Asians have a higher risk of bleeding than Europeans when treated with ticagrelor. This study aimed to explore genetic indicators related to the high bleeding propensity in East Asian patients with acute coronary syndrome (ACS) using ticagrelor. DESIGN A multicenter prospective cohort study. SETTING Four sub center hospitals participating the study. PATIENTS Between March 2018 and July 2021, 208 patients with ACS were administered ticagrelor and underwent genetic testing. INVERTENTION Patients were enrolled and followed up for bleeding events for 12 months. Single-nucleotide polymorphisms (SNPs) were detected using whole-exome sequencing. SNPs significantly associated with cumulative bleeding events within 1-, 6-, and 12-month follow-ups were selected (p < 0.01). Among these, SNPs showing a difference of ≥2 fold in their distribution frequency among East Asians and Europeans were selected. MEASUREMENTS AND MAIN RESULTS Among all patients, 96.60% received ticagrelor plus aspirin or cilostazol, and 42.3% suffered from bleeding events during 12-month follow-up. Furthermore, 22 SNPs of 15 genes were found to have a significant association with cumulative bleeding events within 1-, 6-, and 12-month follow-ups. Among these SNPs, FIG4 rs2295837 (A>T) variant had the strongest association with bleeding events within 1 month (p = 1.28 × 10-4 ), with an increased risk of bleeding in T allele carriers (odds ratio [OR]: 3.07, 95% confidence interval [CI]: 1.68-5.63). PROK2 rs3796224 (C>T) variant was most strongly associated with cumulative bleeding events within 6 months (p = 4.57 × 10-4 ) with an increased risk of bleeding in T allele carriers (OR: 2.16, 95% CI: 1.20-3.89). Moreover, HRNR rs6662450 (C>T) variant showed the strongest relation with cumulative bleeding events within 12 months (p = 4.86 × 10-4 ) with a reduced risk of bleeding in T allele carriers (OR: 0.48, 95% CI: 0.24-0.95). CONCLUSION Fifteen genes, including PROK2, HRNR, and FIG4, were potential biomarkers of high bleeding propensity in East Asian patients with ACS using ticagrelor.
Collapse
Affiliation(s)
- Qian Xiang
- Department of Pharmacy, Peking University First Hospital, Beijing, China
| | - Zhe Wang
- Department of Pharmacy, Peking University First Hospital, Beijing, China.,School of Pharmaceutical Sciences, Peking University Health Science Center, Beijing, China
| | - Guangyan Mu
- Department of Pharmacy, Peking University First Hospital, Beijing, China
| | - Qiufen Xie
- Department of Pharmacy, Peking University First Hospital, Beijing, China
| | - Zhiyan Liu
- Department of Pharmacy, Peking University First Hospital, Beijing, China
| | - Shuang Zhou
- Department of Pharmacy, Peking University First Hospital, Beijing, China.,School of Pharmaceutical Sciences, Peking University Health Science Center, Beijing, China
| | - Hanxu Zhang
- School of Pharmaceutical Sciences, Peking University Health Science Center, Beijing, China
| | - Zining Wang
- Department of Pharmacy, Peking University First Hospital, Beijing, China
| | - Kun Hu
- Department of Pharmacy, Peking University First Hospital, Beijing, China.,School of Pharmaceutical Sciences, Peking University Health Science Center, Beijing, China
| | - Hongtao Song
- Department of Pharmacy, 900 Hospital of the Joint Logistics Team, Fuzhou, China
| | - Dongdong Yuan
- Department of Pharmacy, Zhengzhou Seventh People's Hospital, Zhengzhou, China
| | - Quan Xia
- Department of Pharmacy, First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Yan Huang
- Department of Pharmacy, First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Yimin Cui
- Department of Pharmacy, Peking University First Hospital, Beijing, China.,School of Pharmaceutical Sciences, Peking University Health Science Center, Beijing, China.,Institute of Clinical Pharmacology, Peking University, Beijing, China
| |
Collapse
|
5
|
Zeng Z, Chen J, Chen M, Ma F, Lv M, Zhang J. Risk factors for antiplatelet drug–associated intracranial hemorrhage: a systematic review and meta-analysis. Neurol Sci 2022; 43:6761-6769. [DOI: 10.1007/s10072-022-06326-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Accepted: 08/05/2022] [Indexed: 10/15/2022]
|
6
|
Ha ACT, Bhatt DL, Rutka JT, Johnston SC, Mazer CD, Verma S. Intracranial Hemorrhage During Dual Antiplatelet Therapy: JACC Review Topic of the Week. J Am Coll Cardiol 2021; 78:1372-1384. [PMID: 34556323 DOI: 10.1016/j.jacc.2021.07.048] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Revised: 07/26/2021] [Accepted: 07/27/2021] [Indexed: 12/19/2022]
Abstract
Dual antiplatelet therapy (DAPT) with acetylsalicylic acid and a P2Y12 inhibitor is an established therapy for a broad spectrum of patients with cardiovascular disease. The ischemic benefit of DAPT is partially offset by its increased bleeding risk, with intracranial hemorrhage (ICH) being the most serious complication. Although uncommon (0.2%-0.3% annually), its cumulative burden can be substantial given the number of patients afflicted by cardiovascular disease worldwide. Patients with a history of stroke or transient ischemic attack harbor a particularly high risk for ICH when treated with DAPT. Prediction rules may assist clinicians when weighing the risk/benefit ratio of prescribing DAPT for patients with stroke/transient ischemic attack in the nonacute, ambulatory setting. Currently, there are no reversal agents that can rapidly and effectively reverse the effect of P2Y12 inhibitors in routine practice, although a reversal agent for ticagrelor is under clinical investigation.
Collapse
Affiliation(s)
- Andrew C T Ha
- University of Toronto, Toronto, Ontario, Canada; Peter Munk Cardiac Centre, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Deepak L Bhatt
- Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, Massachusetts, USA.
| | - James T Rutka
- University of Toronto, Toronto, Ontario, Canada; Division of Neurosurgery, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - S Claiborne Johnston
- The Dean's Office, Dell Medical School, University of Texas at Austin, Austin, Texas, USA
| | - C David Mazer
- University of Toronto, Toronto, Ontario, Canada; St Michael's Hospital, Unity Health Toronto, Toronto, Ontario, Canada
| | - Subodh Verma
- University of Toronto, Toronto, Ontario, Canada; St Michael's Hospital, Unity Health Toronto, Toronto, Ontario, Canada
| |
Collapse
|
7
|
Best JG, Ambler G, Wilson D, Lee KJ, Lim JS, Shiozawa M, Koga M, Li L, Lovelock C, Chabriat H, Hennerici M, Wong YK, Mak HKF, Prats-Sanchez L, Martínez-Domeño A, Inamura S, Yoshifuji K, Arsava EM, Horstmann S, Purrucker J, Lam BYK, Wong A, Kim YD, Song TJ, Lemmens R, Eppinger S, Gattringer T, Uysal E, Tanriverdi Z, Bornstein NM, Ben Assayag E, Hallevi H, Molad J, Nishihara M, Tanaka J, Coutts SB, Polymeris A, Wagner B, Seiffge DJ, Lyrer P, Algra A, Kappelle LJ, Al-Shahi Salman R, Jäger HR, Lip GYH, Fischer U, El-Koussy M, Mas JL, Legrand L, Karayiannis C, Phan T, Gunkel S, Christ N, Abrigo J, Leung T, Chu W, Chappell F, Makin S, Hayden D, Williams DJ, Mess WH, Nederkoorn PJ, Barbato C, Browning S, Wiegertjes K, Tuladhar AM, Maaijwee N, Guevarra AC, Yatawara C, Mendyk AM, Delmaire C, Köhler S, van Oostenbrugge R, Zhou Y, Xu C, Hilal S, Gyanwali B, Chen C, Lou M, Staals J, Bordet R, Kandiah N, de Leeuw FE, Simister R, Hendrikse J, Kelly PJ, Wardlaw J, Soo Y, Fluri F, Srikanth V, Calvet D, Jung S, Kwa VIH, Engelter ST, Peters N, Smith EE, Hara H, Yakushiji Y, Orken DN, Fazekas F, Thijs V, Heo JH, Mok V, Veltkamp R, Ay H, Imaizumi T, Gomez-Anson B, Lau KK, Jouvent E, Rothwell PM, Toyoda K, Bae HJ, Marti-Fabregas J, Werring DJ. Development of imaging-based risk scores for prediction of intracranial haemorrhage and ischaemic stroke in patients taking antithrombotic therapy after ischaemic stroke or transient ischaemic attack: a pooled analysis of individual patient data from cohort studies. Lancet Neurol 2021; 20:294-303. [PMID: 33743239 DOI: 10.1016/s1474-4422(21)00024-7] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Revised: 12/16/2020] [Accepted: 01/08/2021] [Indexed: 12/23/2022]
Abstract
BACKGROUND Balancing the risks of recurrent ischaemic stroke and intracranial haemorrhage is important for patients treated with antithrombotic therapy after ischaemic stroke or transient ischaemic attack. However, existing predictive models offer insufficient performance, particularly for assessing the risk of intracranial haemorrhage. We aimed to develop new risk scores incorporating clinical variables and cerebral microbleeds, an MRI biomarker of intracranial haemorrhage and ischaemic stroke risk. METHODS We did a pooled analysis of individual-patient data from the Microbleeds International Collaborative Network (MICON), which includes 38 hospital-based prospective cohort studies from 18 countries. All studies recruited participants with previous ischaemic stroke or transient ischaemic attack, acquired baseline MRI allowing quantification of cerebral microbleeds, and followed-up participants for ischaemic stroke and intracranial haemorrhage. Participants not taking antithrombotic drugs were excluded. We developed Cox regression models to predict the 5-year risks of intracranial haemorrhage and ischaemic stroke, selecting candidate predictors on biological relevance and simplifying models using backward elimination. We derived integer risk scores for clinical use. We assessed model performance in internal validation, adjusted for optimism using bootstrapping. The study is registered on PROSPERO, CRD42016036602. FINDINGS The included studies recruited participants between Aug 28, 2001, and Feb 4, 2018. 15 766 participants had follow-up for intracranial haemorrhage, and 15 784 for ischaemic stroke. Over a median follow-up of 2 years, 184 intracranial haemorrhages and 1048 ischaemic strokes were reported. The risk models we developed included cerebral microbleed burden and simple clinical variables. Optimism-adjusted c indices were 0·73 (95% CI 0·69-0·77) with a calibration slope of 0·94 (0·81-1·06) for the intracranial haemorrhage model and 0·63 (0·62-0·65) with a calibration slope of 0·97 (0·87-1·07) for the ischaemic stroke model. There was good agreement between predicted and observed risk for both models. INTERPRETATION The MICON risk scores, incorporating clinical variables and cerebral microbleeds, offer predictive value for the long-term risks of intracranial haemorrhage and ischaemic stroke in patients prescribed antithrombotic therapy for secondary stroke prevention; external validation is warranted. FUNDING British Heart Foundation and Stroke Association.
Collapse
Affiliation(s)
- Jonathan G Best
- UCL Stroke Research Centre, Department of Brain Repair and Rehabilitation, University College London Queen Square Institute of Neurology, London, UK
| | - Gareth Ambler
- Department of Statistical Science, University College London, Gower Street, London, UK
| | - Duncan Wilson
- UCL Stroke Research Centre, Department of Brain Repair and Rehabilitation, University College London Queen Square Institute of Neurology, London, UK; New Zealand Brain Research Institute, Christchurch, New Zealand
| | - Keon-Joo Lee
- Department of Neurology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, South Korea
| | - Jae-Sung Lim
- Department of Neurology, Hallym Neurological Institute, Hallym University College of Medicine, Hallym University Sacred Heart Hospital, Anyang, South Korea
| | - Masayuki Shiozawa
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Centre, Suita, Japan
| | - Masatoshi Koga
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Centre, Suita, Japan
| | - Linxin Li
- Wolfson Centre for Prevention of Stroke and Dementia, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Caroline Lovelock
- Wolfson Centre for Prevention of Stroke and Dementia, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Hugues Chabriat
- Assistance Publique - Hôpitaux de Paris, Lariboisière Hospital, Department of Neurology, Paris, France; Federation Hospitalo-Universitaire NeuroVasc, Université de Paris, Paris, France; INSERM U1141, Paris, France
| | - Michael Hennerici
- Department of Neurology, Universitätsmedizin Mannheim, University of Heidelberg, Mannheim, Germany
| | - Yuen Kwun Wong
- Division of Neurology, Department of Medicine, The University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Henry Ka Fung Mak
- Department of Diagnostic Radiology, The University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Luis Prats-Sanchez
- Department of Neurology, Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute, Barcelona, Spain
| | - Alejandro Martínez-Domeño
- Department of Neurology, Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute, Barcelona, Spain
| | - Shigeru Inamura
- Department of Neurosurgery, Kushiro City General Hospital, Kushiro, Japan
| | - Kazuhisa Yoshifuji
- Department of Neurosurgery, Kushiro City General Hospital, Kushiro, Japan
| | - Ethem Murat Arsava
- A A Martinos Center for Biomedial Imaging, Department of Neurology, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston MA, USA
| | - Solveig Horstmann
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Jan Purrucker
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Bonnie Yin Ka Lam
- Therese Pei Fong Chow Research Centre for Prevention of Dementia, Gerald Choa Neuroscience Centre, Lui Che Woo Institute of Innovative Medicine, Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Adrian Wong
- Therese Pei Fong Chow Research Centre for Prevention of Dementia, Gerald Choa Neuroscience Centre, Lui Che Woo Institute of Innovative Medicine, Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Young Dae Kim
- Department of Neurology, Yonsei University College of Medicine, Seoul, South Korea
| | - Tae-Jin Song
- Department of Neurology, Seoul Hospital, Ewha Womans University College of Medicine, Seoul, South Korea
| | - Robin Lemmens
- Experimental Neurology, Department of Neurosciences, Katholieke Universiteit Leuven, Leuven, Belgium; Vlaams Instituut voor Biotechnologie, Center for Brain & Disease Research; Department of Neurology, University Hospitals Leuven, Leuven, Belgium
| | | | | | - Ender Uysal
- Department of Radiology, Saglık Bilimleri University, Sisli Etfal Education and Research Hospital, Istanbul, Turkey
| | - Zeynep Tanriverdi
- Department of Neurology, İzmir Katip Çelebi University Atatürk Education and Research Hospital, İzmir Turkey
| | - Natan M Bornstein
- Department of Neurology, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel; Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Einor Ben Assayag
- Department of Neurology, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel; Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Hen Hallevi
- Department of Neurology, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel; Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Jeremy Molad
- Department of Neurology, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel; Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Masashi Nishihara
- Department of Radiology, Saga University Faculty of Medicine, Saga, Japan
| | - Jun Tanaka
- Division of Neurology, Department of Internal Medicine, Saga University Faculty of Medicine, Saga, Japan
| | - Shelagh B Coutts
- Calgary Stroke Program, Department of Clinical Neurosciences, Radiology and Community Health Sciences, Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
| | - Alexandros Polymeris
- Department of Neurology and Stroke Centre, University Hospital Basel and University of Basel, Switzerland
| | - Benjamin Wagner
- Department of Neurology and Stroke Centre, University Hospital Basel and University of Basel, Switzerland
| | - David J Seiffge
- UCL Stroke Research Centre, Department of Brain Repair and Rehabilitation, University College London Queen Square Institute of Neurology, London, UK; Department of Neurology and Stroke Centre, University Hospital Basel and University of Basel, Switzerland; Department of Neurology, University Hospital Inselspital Bern, University of Bern, Bern, Switzerland
| | - Philippe Lyrer
- Department of Neurology and Stroke Centre, University Hospital Basel and University of Basel, Switzerland
| | - Ale Algra
- Julius Centre for Health Sciences and Primary Care, Utrecht University, Utrecht, The Netherlands; Department of Neurology and Neurosurgery, Utrecht University, Utrecht, The Netherlands
| | - L Jaap Kappelle
- Department of Neurology and Neurosurgery, Utrecht University, Utrecht, The Netherlands
| | - Rustam Al-Shahi Salman
- Centre for Clinical Brain Sciences, School of Clinical Sciences, University of Edinburgh, Edinburgh, UK
| | - Hans R Jäger
- Lysholm Department of Neuroradiology and the Neuroradiological Academic Unit, Department of Brain Repair and Rehabilitation, University College London Institute of Neurology and the National Hospital for Neurology and Neurosurgery, London, UK
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool, UK; Liverpool Heart & Chest Hospital, Liverpool, UK; Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Urs Fischer
- Department of Neurology, University Hospital Inselspital Bern, University of Bern, Bern, Switzerland
| | - Marwan El-Koussy
- Department of Diagnostic and Interventional Neuroradiology, University Hospital Inselspital Bern, University of Bern, Bern, Switzerland
| | - Jean-Louis Mas
- Department of Neurology, Sainte-Anne Hospital, Institut de Psychiatrie et Neurosciences de Paris, INSERM, Université de Paris, Paris, France
| | - Laurence Legrand
- Department of Neuroradiology, Sainte-Anne Hospital, Institut de Psychiatrie et Neurosciences de Paris, INSERM, Université de Paris, Paris, France
| | | | - Thanh Phan
- Stroke and Ageing Research Group, School of Clinical Sciences at Monash Health, Monash University, Melbourne, Australia
| | - Sarah Gunkel
- Department of Neurology, University Hospital of Würzburg, Würzburg, Germany
| | - Nicolas Christ
- Department of Neurology, University Hospital of Würzburg, Würzburg, Germany
| | - Jill Abrigo
- Department of Imaging and Interventional Radiology, Prince of Wales Hospital, The Chinese University of Hong Kong, Special Administrative Region, China
| | - Thomas Leung
- Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Special Administrative Region, China
| | - Winnie Chu
- Department of Imaging and Interventional Radiology, Prince of Wales Hospital, The Chinese University of Hong Kong, Special Administrative Region, China
| | - Francesca Chappell
- Centre for Clinical Brain Sciences, Edinburgh Imaging, University of Edinburgh, Edinburgh, UK; UK Dementia Research Institute, University of Edinburgh, Edinburgh, UK
| | - Stephen Makin
- Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
| | - Derek Hayden
- The Neurovascular Research Unit and Health Research Board, Stroke Clinical Trials Network Ireland, University College Dublin, Dublin, Ireland; Department of Medical Gerontology, Trinity College Dublin, Dublin, Ireland
| | - David J Williams
- Department of Geriatric and Stroke Medicine, Royal College of Surgeons in Ireland, University of Medicine and Health Sciences Dublin, Ireland; Department of Geriatric and Stroke Medicine, Beaumont Hospital Dublin, Ireland
| | - Werner H Mess
- Department of Clinical Neurophysiology, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Paul J Nederkoorn
- Department of Neurology, Amsterdam University Medical Centres, Netherlands
| | - Carmen Barbato
- UCL Stroke Research Centre, Department of Brain Repair and Rehabilitation, University College London Queen Square Institute of Neurology, London, UK; Comprehensive Stroke Service, University College London Hospitals NHS Trust, London, UK
| | - Simone Browning
- UCL Stroke Research Centre, Department of Brain Repair and Rehabilitation, University College London Queen Square Institute of Neurology, London, UK; Comprehensive Stroke Service, University College London Hospitals NHS Trust, London, UK
| | - Kim Wiegertjes
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Donders Centre for Medical Neuroscience, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Anil M Tuladhar
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Donders Centre for Medical Neuroscience, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Noortje Maaijwee
- Department for Neurology and Neurorehabilitation, Neurocenter, Lucerne State Hospital, Lucerne, Switzerland
| | | | | | - Anne-Marie Mendyk
- Degenerative and vascular cognitive disorders, University of Lille, INSERM, Centre Hospitalier Universitaire de Lille, Lille, France
| | - Christine Delmaire
- Degenerative and vascular cognitive disorders, University of Lille, INSERM, Centre Hospitalier Universitaire de Lille, Lille, France; Department of Radiology, Fondation A de Rothschild, Paris, France
| | - Sebastian Köhler
- Department of Psychiatry and Neuropsychology, School for Mental Health and Neuroscience, Maastricht University Medical Centre, The Netherlands
| | - Robert van Oostenbrugge
- Department of Neurology, Cardiovascular Research Institute Maastricht, Maastricht University Medical Centre, The Netherlands
| | - Ying Zhou
- Department of Neurology, The 2nd affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China
| | - Chao Xu
- Department of Neurology, The 2nd affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China
| | - Saima Hilal
- Memory Aging & Cognition Centre, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Bibek Gyanwali
- Memory Aging & Cognition Centre, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Christopher Chen
- Memory Aging & Cognition Centre, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Min Lou
- Department of Neurology, The 2nd affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China
| | - Julie Staals
- Department of Neurology, Cardiovascular Research Institute Maastricht, Maastricht University Medical Centre, The Netherlands
| | - Régis Bordet
- Degenerative and vascular cognitive disorders, University of Lille, INSERM, Centre Hospitalier Universitaire de Lille, Lille, France
| | | | - Frank-Erik de Leeuw
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Donders Centre for Medical Neuroscience, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Robert Simister
- UCL Stroke Research Centre, Department of Brain Repair and Rehabilitation, University College London Queen Square Institute of Neurology, London, UK; Comprehensive Stroke Service, University College London Hospitals NHS Trust, London, UK
| | - Jeroen Hendrikse
- Department of Radiology, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Peter J Kelly
- The Neurovascular Research Unit and Health Research Board, Stroke Clinical Trials Network Ireland, University College Dublin, Dublin, Ireland
| | - Joanna Wardlaw
- Centre for Clinical Brain Sciences, Edinburgh Imaging, University of Edinburgh, Edinburgh, UK; UK Dementia Research Institute, University of Edinburgh, Edinburgh, UK
| | - Yannie Soo
- Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Special Administrative Region, China
| | - Felix Fluri
- Department of Neurology, University Hospital of Würzburg, Würzburg, Germany
| | - Velandai Srikanth
- Peninsula Clinical School, Peninsula Health, Monash University, Melbourne, Australia
| | - David Calvet
- Department of Neurology, Sainte-Anne Hospital, Institut de Psychiatrie et Neurosciences de Paris, INSERM, Université de Paris, Paris, France
| | - Simon Jung
- Department of Neurology, University Hospital Inselspital Bern, University of Bern, Bern, Switzerland
| | - Vincent I H Kwa
- Department of Neurology, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands
| | - Stefan T Engelter
- Department of Neurology and Stroke Centre, University Hospital Basel and University of Basel, Switzerland; Neurology and Neurorehabilitation, Department of Geriatric Medicine FELIX PLATTER, University of Basel, Switzerland
| | - Nils Peters
- Department of Neurology and Stroke Centre, University Hospital Basel and University of Basel, Switzerland; Neurology and Neurorehabilitation, Department of Geriatric Medicine FELIX PLATTER, University of Basel, Switzerland
| | - Eric E Smith
- Calgary Stroke Program, Department of Clinical Neurosciences, Radiology and Community Health Sciences, Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
| | - Hideo Hara
- Division of Neurology, Department of Internal Medicine, Saga University Faculty of Medicine, Saga, Japan
| | - Yusuke Yakushiji
- Division of Neurology, Department of Internal Medicine, Saga University Faculty of Medicine, Saga, Japan; Department of Neurology, Kansai Medical University, Osaka, Japan
| | | | - Franz Fazekas
- Department of Neurology, Medical University of Graz, Graz, Austria
| | - Vincent Thijs
- Stroke Division, Florey Institute of Neuroscience and Mental Health, University of Melbourne, Heidelberg, VIC, Australia; Department of Neurology, Austin Health, Heidelberg, VIC, Australia
| | - Ji Hoe Heo
- Department of Neurology, Yonsei University College of Medicine, Seoul, South Korea
| | - Vincent Mok
- Therese Pei Fong Chow Research Centre for Prevention of Dementia, Gerald Choa Neuroscience Centre, Lui Che Woo Institute of Innovative Medicine, Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Roland Veltkamp
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany; Department of Brain Sciences, Imperial College London, London, UK
| | - Hakan Ay
- A A Martinos Center for Biomedial Imaging, Department of Neurology, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston MA, USA; Takeda, Cambridge, MA, USA
| | - Toshio Imaizumi
- Department of Neurosurgery, Kushiro City General Hospital, Kushiro, Japan
| | - Beatriz Gomez-Anson
- Unit of Neuroradiology, Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute, Barcelona, Spain
| | - Kui Kai Lau
- Division of Neurology, Department of Medicine, The University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Eric Jouvent
- Assistance Publique - Hôpitaux de Paris, Lariboisière Hospital, Department of Neurology, Paris, France; Federation Hospitalo-Universitaire NeuroVasc, Université de Paris, Paris, France; INSERM U1141, Paris, France
| | - Peter M Rothwell
- Wolfson Centre for Prevention of Stroke and Dementia, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Kazunori Toyoda
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Centre, Suita, Japan
| | - Hee-Joon Bae
- Department of Neurology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, South Korea
| | - Joan Marti-Fabregas
- Department of Neurology, Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute, Barcelona, Spain
| | - David J Werring
- UCL Stroke Research Centre, Department of Brain Repair and Rehabilitation, University College London Queen Square Institute of Neurology, London, UK.
| |
Collapse
|
8
|
Mikulík R, Eckstein J, Pearce LA, Mundl H, Rudilosso S, Olavarría VV, Shoamanesh A, Chamorro Á, Martí-Fàbregas J, Veltkamp R, Öztürk Ş, Tatlisumak T, Peacock WF, Berkowitz SD, Connolly SJ, Hart RG. Frequency and Predictors of Major Bleeding in Patients With Embolic Strokes of Undetermined Source: NAVIGATE-ESUS Trial. Stroke 2020; 51:2139-2147. [PMID: 32517582 DOI: 10.1161/strokeaha.119.027995] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Risks, sites, and predictors of major bleeding during antithrombotic therapies have not been well defined for patients with recent embolic stroke of undetermined source. METHODS Exploratory analysis of major bleeds defined by International Society of Thrombosis and Hemostasis criteria occurring among 7213 participants in international NAVIGATE (New Approach Rivaroxaban Inhibition of Factor Xa in a Global Trial) embolic stroke of undetermined source randomized trial comparing rivaroxaban 15 mg daily with aspirin 100 mg daily. RESULTS During a median follow-up of 11 months, 85 major bleeds occurred. The most frequent site was gastrointestinal (38%), followed by intracranial (29%). Assignment to rivaroxaban (hazard ratio [HR], 2.7 [95% CI, 1.7-4.3]), East Asia region (HR, 2.5 [95% CI, 1.6-3.9]), systolic blood pressure ≥160 mm Hg (HR, 2.2 [95% CI, 1.2-3.8]), and reduced estimated glomerular filtration rate (HR, 1.2 per 10 mL/min per 1.73 m2 decrease, [95% CI, 1.0-1.3]) were independently associated with presence of major bleeds. Five (6%) were fatal. Among 15 patients with intracerebral hemorrhage, 2 (13%) were fatal. There was no evidence of an early high-risk period following initiation of rivaroxaban. The annualized rate of intracerebral hemorrhage was 6-fold higher among East Asian participants (0.67%) versus all other regions (0.11%; HR, 6.3 [95% CI, 2.2-18.0]). Distribution of bleeding sites was similar for rivaroxaban and aspirin. CONCLUSIONS Among embolic stroke of undetermined source patients participating in an international randomized trial, independent predictors of major bleeding were assignment to rivaroxaban, East Asia region, increased systolic blood pressure, and impaired renal function. East Asia as a region was strongly associated with risk of intracerebral hemorrhage. Estimated glomerular filtration rate should be a consideration for stratifying bleeding risk. Registration: URL: https://www.clinicaltrials.gov. Unique identifier: NCT02313909.
Collapse
Affiliation(s)
- Robert Mikulík
- International Clinical Research Center and Neurology Department, St. Anne's University Hospital and Masaryk University Brno, Czech Republic (R.M.)
| | - Jens Eckstein
- Department of Internal Medicine, University Hospital Basel, Switzerland (J.E.)
| | | | | | - Salvatore Rudilosso
- Comprehensive Stroke Center, Department of Neuroscience (S.R.), Hospital Clinic, Barcelona, Spain
| | - Veroníca V Olavarría
- Department of Neurology and Psychiatry, Faculty of Medicine, Universidad del Desarrollo, Clínica Alemana de Santiago, Santiago, Chile (V.V.O.)
| | - Ashkan Shoamanesh
- McMaster University/Population Health Research Institute, Hamilton Health Sciences, ON, Canada (A.S., S.J.C., R.G.H.)
| | - Ángel Chamorro
- Comprehensive Stroke Center, Department of Neuroscience (A.C.), Hospital Clinic, Barcelona, Spain
| | | | | | - Şerefnur Öztürk
- Department of Neurology, Selcuk University Faculty of Medicine, Turkey (S.O.)
| | - Turgut Tatlisumak
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Sweden (T.T.).,Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden (T.T.)
| | | | - Scott D Berkowitz
- Pharmaceuticals Clinical Development Thrombosis, Bayer U.S. LLC, Whippany, NJ (S.D.B.)
| | - Stuart J Connolly
- McMaster University/Population Health Research Institute, Hamilton Health Sciences, ON, Canada (A.S., S.J.C., R.G.H.)
| | - Robert G Hart
- McMaster University/Population Health Research Institute, Hamilton Health Sciences, ON, Canada (A.S., S.J.C., R.G.H.)
| |
Collapse
|
9
|
Hilkens NA, Li L, Rothwell PM, Algra A, Greving JP. Refining prediction of major bleeding on antiplatelet treatment after transient ischaemic attack or ischaemic stroke. Eur Stroke J 2020; 5:130-137. [PMID: 32637646 PMCID: PMC7309362 DOI: 10.1177/2396987319898064] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Accepted: 12/03/2019] [Indexed: 12/03/2022] Open
Abstract
Introduction Bleeding is the main safety concern of treatment with antiplatelet drugs. We aimed to refine prediction of major bleeding on antiplatelet treatment after a transient ischaemic attack (TIA) or stroke by assessing the added value of new predictors to the existing S2TOP-BLEED score. Patients and methods We used Cox regression analysis to study the association between candidate predictors and major bleeding among 2072 patients with a transient ischaemic attack or ischaemic stroke included in a population-based study (Oxford Vascular Study – OXVASC). An updated model was proposed and validated in 1094 patients with a myocardial infarction included in OXVASC. Models were compared with c-statistics, calibration plots, and net reclassification improvement. Results Independent predictors for major bleeding on top of S2TOP-BLEED variables were peptic ulcer (hazard ratio (HR): 1.72; 1.04–2.86), cancer (HR: 2.40; 1.57–3.68), anaemia (HR: 1.55; 0.99–2.44) and renal failure (HR: 2.20; 1.57–4.28). Addition of those variables improved discrimination from 0.69 (0.64–0.73) to 0.73 (0.69–0.78) in the TIA/stroke cohort (p = 0.01). Performance improved particularly for upper gastro-intestinal bleeds (0.70; 0.64–0.75 to 0.77; 0.72–0.82). Net reclassification improved over the entire range of the score (net reclassification improvement: 0.56; 0.36–0.76). In the validation cohort, discriminatory performance improved from 0.68 (0.62–0.74) to 0.70 (0.64–0.76). Discussion and Conclusion Peptic ulcer, cancer, anaemia and renal failure improve predictive performance of the S2TOP-BLEED score for major bleeding after stroke. Future external validation studies will be required to confirm the value of the STOP-BLEED+ score in transient ischaemic attack/stroke patients.
Collapse
Affiliation(s)
- Nina A Hilkens
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, the Netherlands
| | - Linxin Li
- Centre for Prevention of Stroke and Dementia, Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, UK
| | - Peter M Rothwell
- Centre for Prevention of Stroke and Dementia, Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, UK
| | - Ale Algra
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, the Netherlands
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht University, the Netherlands
| | - Jacoba P Greving
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, the Netherlands
| |
Collapse
|
10
|
Ungar L, Clare RM, Rodriguez F, Kolls BJ, Armstrong PW, Aylward P, Held C, Moliterno DJ, Strony J, Van de Werf F, Wallentin L, White HD, Tricoci P, Harrington RA, Mahaffey KW, Melloni C. Stroke Outcomes With Vorapaxar Versus Placebo in Patients With Acute Coronary Syndromes: Insights From the TRACER Trial. J Am Heart Assoc 2019; 7:e009609. [PMID: 30526198 PMCID: PMC6405615 DOI: 10.1161/jaha.118.009609] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Background Vorapaxar, a protease‐activated receptor‐1 antagonist, is approved for secondary prevention of cardiovascular events but is associated with increased intracranial hemorrhage. Methods and Results TRACER (Thrombin Receptor Antagonist for Clinical Event Reduction in Acute Coronary Syndrome) was a trial of vorapaxar versus placebo among patients with acute coronary syndrome. Strokes were adjudicated by a central events committee. Of 12 944 patients, 199 (1.5%) had ≥1 stroke during the study period (median follow‐up, 477 days). Four patients had a single stroke of unknown type; 195 patients had ≥1 stroke classified as hemorrhagic or nonhemorrhagic (165 nonhemorrhagic, 28 hemorrhagic, and 2 both). Strokes occurred in 96 of 6473 patients (1.5%) assigned vorapaxar and 103 of 6471 patients (1.6%) assigned placebo. Kaplan‐Meier incidence of stroke for vorapaxar versus placebo was higher for hemorrhagic stroke (0.45% versus 0.14% [hazard ratio, 2.74; 95% confidence interval, 1.22–6.15]), lower but not significantly different for nonhemorrhagic stroke (1.53% versus 1.98% at 2 years [hazard ratio, 0.79; 95% confidence interval, 0.58–1.07]), and similar for stroke overall (1.93% versus 2.13% at 2 years [hazard ratio, 0.94; 95% confidence interval, 0.71–1.24]). Conclusions Stroke occurred in <2% of patients. Vorapaxar‐assigned patients had increased hemorrhagic stroke but a nonsignificant trend toward lower nonhemorrhagic stroke. Overall stroke frequency was similar with vorapaxar versus placebo.
Collapse
Affiliation(s)
- Leo Ungar
- 1 Department of Cardiology University of California Irvine Medical Center Orange CA
| | - Robert M Clare
- 2 Department of Medicine Duke Clinical Research Institute Durham NC
| | - Fatima Rodriguez
- 3 Division of Cardiovascular Medicine Stanford University School of Medicine Stanford CA
| | - Bradley J Kolls
- 2 Department of Medicine Duke Clinical Research Institute Durham NC
| | | | - Philip Aylward
- 5 South Australian Health and Medical Research Institute Flinders University and Medical Centre Adelaide Australia
| | - Claes Held
- 6 Uppsala Clinical Research Center Uppsala University Uppsala Sweden
| | - David J Moliterno
- 7 Division of Cardiovascular Medicine Gill Heart Institute University of Kentucky Lexington KY
| | | | - Frans Van de Werf
- 9 Department of Cardiovascular Sciences University Hospitals Leuven Leuven Belgium
| | - Lars Wallentin
- 6 Uppsala Clinical Research Center Uppsala University Uppsala Sweden
| | - Harvey D White
- 10 Green Lane Cardiovascular Service Auckland City Hospital Auckland New Zealand
| | | | - Robert A Harrington
- 11 Department of Medicine Stanford University School of Medicine Stanford CA
| | - Kenneth W Mahaffey
- 11 Department of Medicine Stanford University School of Medicine Stanford CA
| | - Chiara Melloni
- 2 Department of Medicine Duke Clinical Research Institute Durham NC
| |
Collapse
|
11
|
Bleeding risk assessment for stroke patients on antithrombotic therapy. CLINICA E INVESTIGACION EN ARTERIOSCLEROSIS 2019; 31:282-288. [PMID: 31005341 DOI: 10.1016/j.arteri.2019.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Revised: 01/04/2019] [Accepted: 01/27/2019] [Indexed: 11/21/2022]
Abstract
INTRODUCTION After an ischemic cerebrovascular event the risk of new ischemic events is high, therefore antithrombotic therapy are indicated to prevent stroke recurrence. DISCUSSION Despite its clear benefit, these therapies increase the risk of bleeding. Therefore, it is essential to identify high hemorrhagic risk patients. There are different predictive models of hemorrhage, in particular of intracranial hemorrhage, associated with the use of antiaggregants in patients who have presented an ischemic stroke or TIA, such as the CCSC, intracranial scales -B2LEED3S score or S2TOP-BLEED. However, though main international guidelines recommend the use of scales, in particular, the HAS-BLED score, to assess the risk of bleeding in anticoagulated patients, there is no specific recommendation in the case of the use of antiplatelet drugs. CONCLUSIONS In this review we present the main models currently available for the prediction of bleeding of antithrombotic therapy in patients who have had a stroke or TIA.
Collapse
|
12
|
Sychev DA, Shprakh VV, Kitaeva EY, Mirzaev KB, Mickhalevich IM. Genetic and non-genetic factors of laboratory resistance to clopidogrel in patients with ischemic stroke. Zh Nevrol Psikhiatr Im S S Korsakova 2019; 119:45-52. [DOI: 10.17116/jnevro201911903245] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
|
13
|
Hilkens NA, Li L, Rothwell PM, Algra A, Greving JP. External Validation of Risk Scores for Major Bleeding in a Population-Based Cohort of Transient Ischemic Attack and Ischemic Stroke Patients. Stroke 2018; 49:601-606. [PMID: 29459399 PMCID: PMC5839707 DOI: 10.1161/strokeaha.117.019259] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2017] [Revised: 10/31/2017] [Accepted: 11/06/2017] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE The S2TOP-BLEED score may help to identify patients at high risk of bleeding on antiplatelet drugs after a transient ischemic attack or ischemic stroke. The score was derived on trial populations, and its performance in a real-world setting is unknown. We aimed to externally validate the S2TOP-BLEED score for major bleeding in a population-based cohort and to compare its performance with other risk scores for bleeding. METHODS We studied risk of bleeding in 2072 patients with a transient ischemic attack or ischemic stroke on antiplatelet agents in the population-based OXVASC (Oxford Vascular Study) according to 3 scores: S2TOP-BLEED, REACH, and Intracranial-B2LEED3S. Performance was assessed with C statistics and calibration plots. RESULTS During 8302 patient-years of follow-up, 117 patients had a major bleed. The S2TOP-BLEED score showed a C statistic of 0.69 (95% confidence interval [CI], 0.64-0.73) and accurate calibration for 3-year risk of major bleeding. The S2TOP-BLEED score was much more predictive of fatal bleeding than nonmajor bleeding (C statistics 0.77; 95% CI, 0.69-0.85 and 0.50; 95% CI, 0.44-0.58). The REACH score had a C statistic of 0.63 (95% CI, 0.58-0.69) for major bleeding and the Intracranial-B2LEED3S score a C statistic of 0.60 (95% CI, 0.51-0.70) for intracranial bleeding. The ratio of ischemic events versus bleeds decreased across risk groups of bleeding from 6.6:1 in the low-risk group to 1.8:1 in the high-risk group. CONCLUSIONS The S2TOP-BLEED score shows modest performance in a population-based cohort of patients with a transient ischemic attack or ischemic stroke. Although bleeding risks were associated with risks of ischemic events, risk stratification may still be useful to identify a subgroup of patients at particularly high risk of bleeding, in whom preventive measures are indicated.
Collapse
Affiliation(s)
- Nina A Hilkens
- From the Julius Center for Health Sciences and Primary Care (N.A.H., A.A., J.P.G.) and Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus (A.A.), University Medical Center Utrecht, Utrecht University, the Netherlands; and Nuffield Department of Clinical Neurosciences, University of Oxford, United Kingdom (L.L., P.M.R.).
| | - Linxin Li
- From the Julius Center for Health Sciences and Primary Care (N.A.H., A.A., J.P.G.) and Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus (A.A.), University Medical Center Utrecht, Utrecht University, the Netherlands; and Nuffield Department of Clinical Neurosciences, University of Oxford, United Kingdom (L.L., P.M.R.)
| | - Peter M Rothwell
- From the Julius Center for Health Sciences and Primary Care (N.A.H., A.A., J.P.G.) and Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus (A.A.), University Medical Center Utrecht, Utrecht University, the Netherlands; and Nuffield Department of Clinical Neurosciences, University of Oxford, United Kingdom (L.L., P.M.R.)
| | - Ale Algra
- From the Julius Center for Health Sciences and Primary Care (N.A.H., A.A., J.P.G.) and Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus (A.A.), University Medical Center Utrecht, Utrecht University, the Netherlands; and Nuffield Department of Clinical Neurosciences, University of Oxford, United Kingdom (L.L., P.M.R.)
| | - Jacoba P Greving
- From the Julius Center for Health Sciences and Primary Care (N.A.H., A.A., J.P.G.) and Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus (A.A.), University Medical Center Utrecht, Utrecht University, the Netherlands; and Nuffield Department of Clinical Neurosciences, University of Oxford, United Kingdom (L.L., P.M.R.)
| |
Collapse
|
14
|
Hilkens NA, Algra A, Diener HC, Reitsma JB, Bath PM, Csiba L, Hacke W, Kappelle LJ, Koudstaal PJ, Leys D, Mas JL, Sacco RL, Amarenco P, Sissani L, Greving JP. Predicting major bleeding in patients with noncardioembolic stroke on antiplatelets: S 2TOP-BLEED. Neurology 2017; 89:936-943. [PMID: 28768848 DOI: 10.1212/wnl.0000000000004289] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2016] [Accepted: 05/01/2017] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVE To develop and externally validate a prediction model for major bleeding in patients with a TIA or ischemic stroke on antiplatelet agents. METHODS We combined individual patient data from 6 randomized clinical trials (CAPRIE, ESPS-2, MATCH, CHARISMA, ESPRIT, and PRoFESS) investigating antiplatelet therapy after TIA or ischemic stroke. Cox regression analyses stratified by trial were performed to study the association between predictors and major bleeding. A risk prediction model was derived and validated in the PERFORM trial. Performance was assessed with the c statistic and calibration plots. RESULTS Major bleeding occurred in 1,530 of the 43,112 patients during 94,833 person-years of follow-up. The observed 3-year risk of major bleeding was 4.6% (95% confidence interval [CI] 4.4%-4.9%). Predictors were male sex, smoking, type of antiplatelet agents (aspirin-clopidogrel), outcome on modified Rankin Scale ≥3, prior stroke, high blood pressure, lower body mass index, elderly, Asian ethnicity, and diabetes (S2TOP-BLEED). The S2TOP-BLEED score had a c statistic of 0.63 (95% CI 0.60-0.64) and showed good calibration in the development data. Major bleeding risk ranged from 2% in patients aged 45-54 years without additional risk factors to more than 10% in patients aged 75-84 years with multiple risk factors. In external validation, the model had a c statistic of 0.61 (95% CI 0.59-0.63) and slightly underestimated major bleeding risk. CONCLUSIONS The S2TOP-BLEED score can be used to estimate 3-year major bleeding risk in patients with a TIA or ischemic stroke who use antiplatelet agents, based on readily available characteristics. The discriminatory performance may be improved by identifying stronger predictors of major bleeding.
Collapse
Affiliation(s)
- Nina A Hilkens
- From the Julius Center for Health Sciences and Primary Care (N.A.H., A.A., J.B.R., J.P.G.) and Department of Neurology and Neurosurgery (A.A., L.J.K.), Brain Center Rudolf Magnus, University Medical Center Utrecht, the Netherlands; Department of Neurology (H.-C.D.), University Hospital Essen, Germany; Stroke Trials Unit (P.M.B.), Division of Clinical Neuroscience, University of Nottingham, UK; Department of Neurology (L.C.), University of Debrecen Medical and Health Science Center, Hungary; Department of Neurology (W.H.), University of Heidelberg, Germany; Department of Neurology (P.J.K.), Erasmus Medical Center, Rotterdam, the Netherlands; Department of Neurology (D.L.), Roger Salengro Hospital, Lille, France; Department of Neurology (J.-L.M.), Hôpital Sainte-Anne, Université Paris Descartes, France; Department of Neurology (R.L.S.), Miller School of Medicine, University of Miami, FL; and Department of Neurology and Stroke Center (P.A., L.S.), Bichat University Hospital, Paris, France.
| | - Ale Algra
- From the Julius Center for Health Sciences and Primary Care (N.A.H., A.A., J.B.R., J.P.G.) and Department of Neurology and Neurosurgery (A.A., L.J.K.), Brain Center Rudolf Magnus, University Medical Center Utrecht, the Netherlands; Department of Neurology (H.-C.D.), University Hospital Essen, Germany; Stroke Trials Unit (P.M.B.), Division of Clinical Neuroscience, University of Nottingham, UK; Department of Neurology (L.C.), University of Debrecen Medical and Health Science Center, Hungary; Department of Neurology (W.H.), University of Heidelberg, Germany; Department of Neurology (P.J.K.), Erasmus Medical Center, Rotterdam, the Netherlands; Department of Neurology (D.L.), Roger Salengro Hospital, Lille, France; Department of Neurology (J.-L.M.), Hôpital Sainte-Anne, Université Paris Descartes, France; Department of Neurology (R.L.S.), Miller School of Medicine, University of Miami, FL; and Department of Neurology and Stroke Center (P.A., L.S.), Bichat University Hospital, Paris, France
| | - Hans-Christoph Diener
- From the Julius Center for Health Sciences and Primary Care (N.A.H., A.A., J.B.R., J.P.G.) and Department of Neurology and Neurosurgery (A.A., L.J.K.), Brain Center Rudolf Magnus, University Medical Center Utrecht, the Netherlands; Department of Neurology (H.-C.D.), University Hospital Essen, Germany; Stroke Trials Unit (P.M.B.), Division of Clinical Neuroscience, University of Nottingham, UK; Department of Neurology (L.C.), University of Debrecen Medical and Health Science Center, Hungary; Department of Neurology (W.H.), University of Heidelberg, Germany; Department of Neurology (P.J.K.), Erasmus Medical Center, Rotterdam, the Netherlands; Department of Neurology (D.L.), Roger Salengro Hospital, Lille, France; Department of Neurology (J.-L.M.), Hôpital Sainte-Anne, Université Paris Descartes, France; Department of Neurology (R.L.S.), Miller School of Medicine, University of Miami, FL; and Department of Neurology and Stroke Center (P.A., L.S.), Bichat University Hospital, Paris, France
| | - Johannes B Reitsma
- From the Julius Center for Health Sciences and Primary Care (N.A.H., A.A., J.B.R., J.P.G.) and Department of Neurology and Neurosurgery (A.A., L.J.K.), Brain Center Rudolf Magnus, University Medical Center Utrecht, the Netherlands; Department of Neurology (H.-C.D.), University Hospital Essen, Germany; Stroke Trials Unit (P.M.B.), Division of Clinical Neuroscience, University of Nottingham, UK; Department of Neurology (L.C.), University of Debrecen Medical and Health Science Center, Hungary; Department of Neurology (W.H.), University of Heidelberg, Germany; Department of Neurology (P.J.K.), Erasmus Medical Center, Rotterdam, the Netherlands; Department of Neurology (D.L.), Roger Salengro Hospital, Lille, France; Department of Neurology (J.-L.M.), Hôpital Sainte-Anne, Université Paris Descartes, France; Department of Neurology (R.L.S.), Miller School of Medicine, University of Miami, FL; and Department of Neurology and Stroke Center (P.A., L.S.), Bichat University Hospital, Paris, France
| | - Philip M Bath
- From the Julius Center for Health Sciences and Primary Care (N.A.H., A.A., J.B.R., J.P.G.) and Department of Neurology and Neurosurgery (A.A., L.J.K.), Brain Center Rudolf Magnus, University Medical Center Utrecht, the Netherlands; Department of Neurology (H.-C.D.), University Hospital Essen, Germany; Stroke Trials Unit (P.M.B.), Division of Clinical Neuroscience, University of Nottingham, UK; Department of Neurology (L.C.), University of Debrecen Medical and Health Science Center, Hungary; Department of Neurology (W.H.), University of Heidelberg, Germany; Department of Neurology (P.J.K.), Erasmus Medical Center, Rotterdam, the Netherlands; Department of Neurology (D.L.), Roger Salengro Hospital, Lille, France; Department of Neurology (J.-L.M.), Hôpital Sainte-Anne, Université Paris Descartes, France; Department of Neurology (R.L.S.), Miller School of Medicine, University of Miami, FL; and Department of Neurology and Stroke Center (P.A., L.S.), Bichat University Hospital, Paris, France
| | - Laszlo Csiba
- From the Julius Center for Health Sciences and Primary Care (N.A.H., A.A., J.B.R., J.P.G.) and Department of Neurology and Neurosurgery (A.A., L.J.K.), Brain Center Rudolf Magnus, University Medical Center Utrecht, the Netherlands; Department of Neurology (H.-C.D.), University Hospital Essen, Germany; Stroke Trials Unit (P.M.B.), Division of Clinical Neuroscience, University of Nottingham, UK; Department of Neurology (L.C.), University of Debrecen Medical and Health Science Center, Hungary; Department of Neurology (W.H.), University of Heidelberg, Germany; Department of Neurology (P.J.K.), Erasmus Medical Center, Rotterdam, the Netherlands; Department of Neurology (D.L.), Roger Salengro Hospital, Lille, France; Department of Neurology (J.-L.M.), Hôpital Sainte-Anne, Université Paris Descartes, France; Department of Neurology (R.L.S.), Miller School of Medicine, University of Miami, FL; and Department of Neurology and Stroke Center (P.A., L.S.), Bichat University Hospital, Paris, France
| | - Werner Hacke
- From the Julius Center for Health Sciences and Primary Care (N.A.H., A.A., J.B.R., J.P.G.) and Department of Neurology and Neurosurgery (A.A., L.J.K.), Brain Center Rudolf Magnus, University Medical Center Utrecht, the Netherlands; Department of Neurology (H.-C.D.), University Hospital Essen, Germany; Stroke Trials Unit (P.M.B.), Division of Clinical Neuroscience, University of Nottingham, UK; Department of Neurology (L.C.), University of Debrecen Medical and Health Science Center, Hungary; Department of Neurology (W.H.), University of Heidelberg, Germany; Department of Neurology (P.J.K.), Erasmus Medical Center, Rotterdam, the Netherlands; Department of Neurology (D.L.), Roger Salengro Hospital, Lille, France; Department of Neurology (J.-L.M.), Hôpital Sainte-Anne, Université Paris Descartes, France; Department of Neurology (R.L.S.), Miller School of Medicine, University of Miami, FL; and Department of Neurology and Stroke Center (P.A., L.S.), Bichat University Hospital, Paris, France
| | - L Jaap Kappelle
- From the Julius Center for Health Sciences and Primary Care (N.A.H., A.A., J.B.R., J.P.G.) and Department of Neurology and Neurosurgery (A.A., L.J.K.), Brain Center Rudolf Magnus, University Medical Center Utrecht, the Netherlands; Department of Neurology (H.-C.D.), University Hospital Essen, Germany; Stroke Trials Unit (P.M.B.), Division of Clinical Neuroscience, University of Nottingham, UK; Department of Neurology (L.C.), University of Debrecen Medical and Health Science Center, Hungary; Department of Neurology (W.H.), University of Heidelberg, Germany; Department of Neurology (P.J.K.), Erasmus Medical Center, Rotterdam, the Netherlands; Department of Neurology (D.L.), Roger Salengro Hospital, Lille, France; Department of Neurology (J.-L.M.), Hôpital Sainte-Anne, Université Paris Descartes, France; Department of Neurology (R.L.S.), Miller School of Medicine, University of Miami, FL; and Department of Neurology and Stroke Center (P.A., L.S.), Bichat University Hospital, Paris, France
| | - Peter J Koudstaal
- From the Julius Center for Health Sciences and Primary Care (N.A.H., A.A., J.B.R., J.P.G.) and Department of Neurology and Neurosurgery (A.A., L.J.K.), Brain Center Rudolf Magnus, University Medical Center Utrecht, the Netherlands; Department of Neurology (H.-C.D.), University Hospital Essen, Germany; Stroke Trials Unit (P.M.B.), Division of Clinical Neuroscience, University of Nottingham, UK; Department of Neurology (L.C.), University of Debrecen Medical and Health Science Center, Hungary; Department of Neurology (W.H.), University of Heidelberg, Germany; Department of Neurology (P.J.K.), Erasmus Medical Center, Rotterdam, the Netherlands; Department of Neurology (D.L.), Roger Salengro Hospital, Lille, France; Department of Neurology (J.-L.M.), Hôpital Sainte-Anne, Université Paris Descartes, France; Department of Neurology (R.L.S.), Miller School of Medicine, University of Miami, FL; and Department of Neurology and Stroke Center (P.A., L.S.), Bichat University Hospital, Paris, France
| | - Didier Leys
- From the Julius Center for Health Sciences and Primary Care (N.A.H., A.A., J.B.R., J.P.G.) and Department of Neurology and Neurosurgery (A.A., L.J.K.), Brain Center Rudolf Magnus, University Medical Center Utrecht, the Netherlands; Department of Neurology (H.-C.D.), University Hospital Essen, Germany; Stroke Trials Unit (P.M.B.), Division of Clinical Neuroscience, University of Nottingham, UK; Department of Neurology (L.C.), University of Debrecen Medical and Health Science Center, Hungary; Department of Neurology (W.H.), University of Heidelberg, Germany; Department of Neurology (P.J.K.), Erasmus Medical Center, Rotterdam, the Netherlands; Department of Neurology (D.L.), Roger Salengro Hospital, Lille, France; Department of Neurology (J.-L.M.), Hôpital Sainte-Anne, Université Paris Descartes, France; Department of Neurology (R.L.S.), Miller School of Medicine, University of Miami, FL; and Department of Neurology and Stroke Center (P.A., L.S.), Bichat University Hospital, Paris, France
| | - Jean-Louis Mas
- From the Julius Center for Health Sciences and Primary Care (N.A.H., A.A., J.B.R., J.P.G.) and Department of Neurology and Neurosurgery (A.A., L.J.K.), Brain Center Rudolf Magnus, University Medical Center Utrecht, the Netherlands; Department of Neurology (H.-C.D.), University Hospital Essen, Germany; Stroke Trials Unit (P.M.B.), Division of Clinical Neuroscience, University of Nottingham, UK; Department of Neurology (L.C.), University of Debrecen Medical and Health Science Center, Hungary; Department of Neurology (W.H.), University of Heidelberg, Germany; Department of Neurology (P.J.K.), Erasmus Medical Center, Rotterdam, the Netherlands; Department of Neurology (D.L.), Roger Salengro Hospital, Lille, France; Department of Neurology (J.-L.M.), Hôpital Sainte-Anne, Université Paris Descartes, France; Department of Neurology (R.L.S.), Miller School of Medicine, University of Miami, FL; and Department of Neurology and Stroke Center (P.A., L.S.), Bichat University Hospital, Paris, France
| | - Ralph L Sacco
- From the Julius Center for Health Sciences and Primary Care (N.A.H., A.A., J.B.R., J.P.G.) and Department of Neurology and Neurosurgery (A.A., L.J.K.), Brain Center Rudolf Magnus, University Medical Center Utrecht, the Netherlands; Department of Neurology (H.-C.D.), University Hospital Essen, Germany; Stroke Trials Unit (P.M.B.), Division of Clinical Neuroscience, University of Nottingham, UK; Department of Neurology (L.C.), University of Debrecen Medical and Health Science Center, Hungary; Department of Neurology (W.H.), University of Heidelberg, Germany; Department of Neurology (P.J.K.), Erasmus Medical Center, Rotterdam, the Netherlands; Department of Neurology (D.L.), Roger Salengro Hospital, Lille, France; Department of Neurology (J.-L.M.), Hôpital Sainte-Anne, Université Paris Descartes, France; Department of Neurology (R.L.S.), Miller School of Medicine, University of Miami, FL; and Department of Neurology and Stroke Center (P.A., L.S.), Bichat University Hospital, Paris, France
| | - Pierre Amarenco
- From the Julius Center for Health Sciences and Primary Care (N.A.H., A.A., J.B.R., J.P.G.) and Department of Neurology and Neurosurgery (A.A., L.J.K.), Brain Center Rudolf Magnus, University Medical Center Utrecht, the Netherlands; Department of Neurology (H.-C.D.), University Hospital Essen, Germany; Stroke Trials Unit (P.M.B.), Division of Clinical Neuroscience, University of Nottingham, UK; Department of Neurology (L.C.), University of Debrecen Medical and Health Science Center, Hungary; Department of Neurology (W.H.), University of Heidelberg, Germany; Department of Neurology (P.J.K.), Erasmus Medical Center, Rotterdam, the Netherlands; Department of Neurology (D.L.), Roger Salengro Hospital, Lille, France; Department of Neurology (J.-L.M.), Hôpital Sainte-Anne, Université Paris Descartes, France; Department of Neurology (R.L.S.), Miller School of Medicine, University of Miami, FL; and Department of Neurology and Stroke Center (P.A., L.S.), Bichat University Hospital, Paris, France
| | - Leila Sissani
- From the Julius Center for Health Sciences and Primary Care (N.A.H., A.A., J.B.R., J.P.G.) and Department of Neurology and Neurosurgery (A.A., L.J.K.), Brain Center Rudolf Magnus, University Medical Center Utrecht, the Netherlands; Department of Neurology (H.-C.D.), University Hospital Essen, Germany; Stroke Trials Unit (P.M.B.), Division of Clinical Neuroscience, University of Nottingham, UK; Department of Neurology (L.C.), University of Debrecen Medical and Health Science Center, Hungary; Department of Neurology (W.H.), University of Heidelberg, Germany; Department of Neurology (P.J.K.), Erasmus Medical Center, Rotterdam, the Netherlands; Department of Neurology (D.L.), Roger Salengro Hospital, Lille, France; Department of Neurology (J.-L.M.), Hôpital Sainte-Anne, Université Paris Descartes, France; Department of Neurology (R.L.S.), Miller School of Medicine, University of Miami, FL; and Department of Neurology and Stroke Center (P.A., L.S.), Bichat University Hospital, Paris, France
| | - Jacoba P Greving
- From the Julius Center for Health Sciences and Primary Care (N.A.H., A.A., J.B.R., J.P.G.) and Department of Neurology and Neurosurgery (A.A., L.J.K.), Brain Center Rudolf Magnus, University Medical Center Utrecht, the Netherlands; Department of Neurology (H.-C.D.), University Hospital Essen, Germany; Stroke Trials Unit (P.M.B.), Division of Clinical Neuroscience, University of Nottingham, UK; Department of Neurology (L.C.), University of Debrecen Medical and Health Science Center, Hungary; Department of Neurology (W.H.), University of Heidelberg, Germany; Department of Neurology (P.J.K.), Erasmus Medical Center, Rotterdam, the Netherlands; Department of Neurology (D.L.), Roger Salengro Hospital, Lille, France; Department of Neurology (J.-L.M.), Hôpital Sainte-Anne, Université Paris Descartes, France; Department of Neurology (R.L.S.), Miller School of Medicine, University of Miami, FL; and Department of Neurology and Stroke Center (P.A., L.S.), Bichat University Hospital, Paris, France
| | | |
Collapse
|
15
|
Hennerici MG. Update in Intracerebral Hemorrhages - Part 2: Patients at Risk Associated with Vascular Lesions. Cerebrovasc Dis 2017; 43:I-II. [PMID: 28531890 DOI: 10.1159/000477194] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
|
16
|
|