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McKinnie CM, Effron MB. More Potent Antiplatelet Therapy in Acute Coronary Syndrome Patients With Prior Stroke: Proceed With Caution? Mayo Clin Proc 2023; 98:1590-1592. [PMID: 37923516 DOI: 10.1016/j.mayocp.2023.09.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Accepted: 09/22/2023] [Indexed: 11/07/2023]
Affiliation(s)
| | - Mark B Effron
- John Ochsner Heart and Vascular Institute, Ochsner Medical Center, New Orleans, LA; University of Queensland-Ochsner Clinical School, New Orleans, LA.
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2
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Broocks G, McDonough R, Bechstein M, Hanning U, Brekenfeld C, Flottmann F, Kniep H, Nawka MT, Deb-Chatterji M, Thomalla G, Sporns P, Yeo LL, Tan BY, Gopinathan A, Kastrup A, Politi M, Papanagiotou P, Kemmling A, Fiehler J, Meyer L. Benefit and risk of intravenous alteplase in patients with acute large vessel occlusion stroke and low ASPECTS. J Neurointerv Surg 2023; 15:8-13. [PMID: 35078927 DOI: 10.1136/neurintsurg-2021-017986] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Accepted: 12/10/2021] [Indexed: 12/16/2022]
Abstract
BACKGROUND The benefit of best medical treatment including intravenous alteplase (IVT) before mechanical thrombectomy (MT) in patients with acute ischemic stroke and extensive early ischemic changes on baseline CT remains uncertain. The purpose of this study was to evaluate the benefit of IVT for patients with low ASPECTS (Alberta Stroke Programme Early CT Score) compared with patients with or without MT. METHODS This multicenter study pooled consecutive patients with anterior circulation acute stroke and ASPECTS≤5 to analyze the impact of IVT on functional outcome, and to compare bridging IVT with direct MT. Functional endpoints were the rates of good (modified Rankin Scale (mRS) score ≤2) and very poor (mRS ≥5) outcome at day 90. Safety endpoint was the occurrence of symptomatic intracranial hemorrhage (sICH). RESULTS 429 patients were included. 290 (68%) received IVT and 168 (39%) underwent MT. The rate of good functional outcome was 14.4% (95% CI 7.1% to 21.8%) for patients who received bridging IVT and 24.4% (95% CI 16.5% to 32.2%) for those who underwent direct MT. The rate of sICH was significantly higher in patients with bridging IVT compared with direct MT (17.8% vs 6.4%, p=0.004). In multivariable logistic regression analysis, IVT was significantly associated with very poor outcome (OR 2.22, 95% CI 1.05 to 4.73, p=0.04) and sICH (OR 3.44, 95% CI 1.18 to 10.07, p=0.02). Successful recanalization, age, and ASPECTS were associated with good functional outcome. CONCLUSIONS Bridging IVT in patients with low ASPECTS was associated with very poor functional outcome and an increased risk of sICH. The benefit of this treatment should therefore be carefully weighed in such scenarios. Further randomized controlled trials are required to validate our findings.
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Affiliation(s)
- Gabriel Broocks
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Rosalie McDonough
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Matthias Bechstein
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Uta Hanning
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Caspar Brekenfeld
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Fabian Flottmann
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Helge Kniep
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Marie Teresa Nawka
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Milani Deb-Chatterji
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Götz Thomalla
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Peter Sporns
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,Department of Diagnostic and Interventional Neuroradiology, University Hospital Basel, Basel, Switzerland
| | - Leonard Ll Yeo
- National University Health System and Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Benjamin Yq Tan
- National University Health System and Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Anil Gopinathan
- National University Health System and Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Andreas Kastrup
- Department of Neurology, Klinikum Bremen-Mitte gGmbH, Bremen, Germany
| | - Maria Politi
- Department of Neuroradiology, Klinikum Bremen-Mitte GmbH, Bremen, Germany
| | - Panagiotis Papanagiotou
- Department of Neuroradiology, Klinikum Bremen-Mitte GmbH, Bremen, Germany.,National and Kapodistrian University of Athens, Aretaiio Hospital, Athens, Greece
| | | | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Lukas Meyer
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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3
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Das AS, Gökçal E, Regenhardt RW, Warren AD, Biffi A, Goldstein JN, Kimberly WT, Viswanathan A, Schwamm LH, Rosand J, Greenberg SM, Gurol ME. Clinical and neuroimaging risk factors associated with the development of intracerebral hemorrhage while taking direct oral anticoagulants. J Neurol 2022; 269:6589-6596. [PMID: 35997817 PMCID: PMC10947801 DOI: 10.1007/s00415-022-11333-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Revised: 08/06/2022] [Accepted: 08/09/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND AND AIMS Intracerebral hemorrhage (ICH) associated with direct oral anticoagulant (DOAC) usage confers significant mortality/disability. We aimed to understand the clinical and neuroimaging features associated with developing ICH among DOAC users. METHODS Clinical and radiological data were collected from consecutive DOAC users with ICH (DOAC-ICH) and age-matched controls without ICH from a single referral center. The frequency/distribution of MRI markers of hemorrhage risk were assessed. Baseline demographics and neuroimaging markers were compared in univariate tests. Significant associations (p < 0.1) were entered into a multivariable regression model to determine predictors of ICH. RESULTS 86 DOAC-ICH and 94 ICH-free patients were included. Diabetes, coronary artery disease, prior ischemic stroke, smoking history, and antiplatelet usage were more common in ICH patients than ICH-free DOAC users. In the neuroimaging analyses, severe white matter hyperintensities (WMHs), lacunes, cortical superficial siderosis (cSS), and cerebral microbleeds (CMBs) were more common in the ICH cohort than the ICH-free cohort. In the multivariable regression, diabetes [OR 3.53 95% CI (1.05-11.87)], prior ischemic stroke [OR 14.80 95% CI (3.33-65.77)], smoking history [OR 3.08 95% CI (1.05-9.01)], CMBs [OR 4.07 95% CI (1.45-11.39)], and cSS [OR 39.73 95% CI (3.43-460.24)] were independently associated with ICH. CONCLUSIONS Risk factors including diabetes, prior stroke, and smoking history as well as MRI biomarkers including CMBs and cSS are associated with ICH in DOAC users. Although screening MRIs are not typically performed prior to initiating DOAC therapy, these data suggest that patients of high-hemorrhagic risk may be identified.
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Affiliation(s)
- Alvin S Das
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, 175 Cambridge Street, Suite 300, Boston, MA, 02114, USA
| | - Elif Gökçal
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, 175 Cambridge Street, Suite 300, Boston, MA, 02114, USA
| | - Robert W Regenhardt
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, 175 Cambridge Street, Suite 300, Boston, MA, 02114, USA
| | - Andrew D Warren
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, 175 Cambridge Street, Suite 300, Boston, MA, 02114, USA
| | - Alessandro Biffi
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, 175 Cambridge Street, Suite 300, Boston, MA, 02114, USA
- Henry and Allison McCance Center for Brain Health, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Joshua N Goldstein
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - W Taylor Kimberly
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, 175 Cambridge Street, Suite 300, Boston, MA, 02114, USA
| | - Anand Viswanathan
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, 175 Cambridge Street, Suite 300, Boston, MA, 02114, USA
| | - Lee H Schwamm
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, 175 Cambridge Street, Suite 300, Boston, MA, 02114, USA
| | - Jonathan Rosand
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, 175 Cambridge Street, Suite 300, Boston, MA, 02114, USA
- Henry and Allison McCance Center for Brain Health, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Steven M Greenberg
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, 175 Cambridge Street, Suite 300, Boston, MA, 02114, USA
| | - M Edip Gurol
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, 175 Cambridge Street, Suite 300, Boston, MA, 02114, USA.
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4
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Polymeris AA, Zietz A, Schaub F, Meya L, Traenka C, Thilemann S, Wagner B, Hert L, Altersberger VL, Seiffge DJ, Lyrer F, Dittrich T, Piot I, Kaufmann J, Barone L, Dahlheim L, Flammer S, Avramiotis NS, Peters N, De Marchis GM, Bonati LH, Gensicke H, Engelter ST, Lyrer PA. Once versus twice daily direct oral anticoagulants in patients with recent stroke and atrial fibrillation. Eur Stroke J 2022; 7:221-229. [PMID: 36082252 PMCID: PMC9446322 DOI: 10.1177/23969873221099477] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Accepted: 04/20/2022] [Indexed: 06/26/2024] Open
Abstract
BACKGROUND Data on the safety and effectiveness of once-daily (QD) versus twice-daily (BID) direct oral anticoagulants (DOAC) in comparison to vitamin K antagonists (VKA) and to one another in patients with atrial fibrillation (AF) and recent stroke are scarce. PATIENTS AND METHODS Based on prospectively obtained data from the observational registry Novel-Oral-Anticoagulants-in-Ischemic-Stroke-Patients(NOACISP)-LONGTERM (NCT03826927) from Basel, Switzerland, we compared the occurrence of the primary outcome - the composite of recurrent ischemic stroke, major bleeding, and all-cause death - among consecutive AF patients treated with either VKA, QD DOAC, or BID DOAC following a recent stroke using Cox proportional hazards regression including adjustment for potential confounders. RESULTS We analyzed 956 patients (median age 80 years, 46% female), of whom 128 received VKA (13.4%), 264 QD DOAC (27.6%), and 564 BID DOAC (59%). Over a total follow-up of 1596 patient-years, both QD DOAC and BID DOAC showed a lower hazard for the composite outcome compared to VKA (adjusted HR [95% CI] 0.69 [0.48, 1.01] and 0.66 [0.47, 0.91], respectively). Upon direct comparison, the hazard for the composite outcome did not differ between patients treated with QD versus BID DOAC (adjusted HR [95% CI] 0.94 [0.70, 1.26]). Secondary analyses focusing on the individual components of the composite outcome revealed no clear differences in the risk-benefit profile of QD versus BID DOAC. DISCUSSION AND CONCLUSION The overall benefit of DOAC over VKA seems to apply to both QD and BID DOAC in AF patients with a recent stroke, without clear evidence that one DOAC dosing regimen is more advantageous than the other.
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Affiliation(s)
- Alexandros A Polymeris
- Department of Neurology and Stroke
Center, University Hospital Basel and University of Basel, Basel, Switzerland
- Neurology and Neurorehabilitation,
University Department of Geriatric Medicine Felix Platter, University of Basel,
Basel, Switzerland
| | - Annaelle Zietz
- Department of Neurology and Stroke
Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Fabian Schaub
- Department of Neurology and Stroke
Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Louisa Meya
- Department of Neurology and Stroke
Center, University Hospital Basel and University of Basel, Basel, Switzerland
- Neurology and Neurorehabilitation,
University Department of Geriatric Medicine Felix Platter, University of Basel,
Basel, Switzerland
| | - Christopher Traenka
- Department of Neurology and Stroke
Center, University Hospital Basel and University of Basel, Basel, Switzerland
- Neurology and Neurorehabilitation,
University Department of Geriatric Medicine Felix Platter, University of Basel,
Basel, Switzerland
| | - Sebastian Thilemann
- Department of Neurology and Stroke
Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Benjamin Wagner
- Department of Neurology and Stroke
Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Lisa Hert
- Department of Intensive Care Medicine,
University Hospital Basel and University of Basel, Basel, Switzerland
| | - Valerian L Altersberger
- Department of Neurology and Stroke
Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - David J Seiffge
- Department of Neurology, Inselspital,
University Hospital and University of Bern, Bern, Switzerland
| | - Flurina Lyrer
- Department of Neurology and Stroke
Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Tolga Dittrich
- Department of Neurology and Stroke
Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Ines Piot
- Department of Neurology and Stroke
Center, University Hospital Basel and University of Basel, Basel, Switzerland
- Neurology and Neurorehabilitation,
University Department of Geriatric Medicine Felix Platter, University of Basel,
Basel, Switzerland
| | - Josefin Kaufmann
- Department of Neurology and Stroke
Center, University Hospital Basel and University of Basel, Basel, Switzerland
- Neurology and Neurorehabilitation,
University Department of Geriatric Medicine Felix Platter, University of Basel,
Basel, Switzerland
| | - Lea Barone
- Department of Neurology and Stroke
Center, University Hospital Basel and University of Basel, Basel, Switzerland
- Neurology and Neurorehabilitation,
University Department of Geriatric Medicine Felix Platter, University of Basel,
Basel, Switzerland
| | | | - Sophie Flammer
- Medical Faculty, University of Basel,
Basel, Switzerland
| | - Nikolaos S Avramiotis
- Department of Neurology and Stroke
Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Nils Peters
- Department of Neurology and Stroke
Center, University Hospital Basel and University of Basel, Basel, Switzerland
- Neurology and Neurorehabilitation,
University Department of Geriatric Medicine Felix Platter, University of Basel,
Basel, Switzerland
- Stroke Center, Klinik Hirslanden
Zurich, Zurich, Switzerland
| | - Gian Marco De Marchis
- Department of Neurology and Stroke
Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Leo H Bonati
- Department of Neurology and Stroke
Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Henrik Gensicke
- Department of Neurology and Stroke
Center, University Hospital Basel and University of Basel, Basel, Switzerland
- Neurology and Neurorehabilitation,
University Department of Geriatric Medicine Felix Platter, University of Basel,
Basel, Switzerland
| | - Stefan T Engelter
- Department of Neurology and Stroke
Center, University Hospital Basel and University of Basel, Basel, Switzerland
- Neurology and Neurorehabilitation,
University Department of Geriatric Medicine Felix Platter, University of Basel,
Basel, Switzerland
| | - Philippe A Lyrer
- Department of Neurology and Stroke
Center, University Hospital Basel and University of Basel, Basel, Switzerland
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5
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Abstract
OBJECTIVE To investigate the safety and effectiveness of direct oral anticoagulants (DOAC) versus vitamin K antagonists (VKA) after recent stroke in patients with atrial fibrillation (AF) aged ≥85 years. METHODS Individual patient data analysis from seven prospective stroke cohorts. We compared DOAC versus VKA treatment among patients with AF and recent stroke (<3 months) aged ≥85 versus <85 years. Primary outcome was the composite of recurrent stroke, intracranial hemorrhage (ICH) and all-cause death. We used simple, adjusted, and weighted Cox regression to account for confounders. We calculated the net benefit of DOAC versus VKA by balancing stroke reduction against the weighted ICH risk. RESULTS In total, 5,984 of 6,267 (95.5%) patients were eligible for analysis. Of those, 1,380 (23%) were aged ≥85 years and 3,688 (62%) received a DOAC. During 6,874 patient-years follow-up, the impact of anticoagulant type (DOAC versus VKA) on the hazard for the composite outcome did not differ between patients aged ≥85 (HR≥85y = 0.65, 95%-CI [0.52, 0.81]) and < 85 years (HR<85y = 0.79, 95%-CI [0.66, 0.95]) in simple (pinteraction = 0.129), adjusted (pinteraction = 0.094) or weighted (pinteraction = 0.512) models. Analyses on recurrent stroke, ICH and death separately were consistent with the primary analysis, as were sensitivity analyses using age dichotomized at 90 years and as a continuous variable. DOAC had a similar net clinical benefit in patients aged ≥85 (+1.73 to +2.66) and < 85 years (+1.90 to +3.36 events/100 patient-years for ICH-weights 1.5 to 3.1). INTERPRETATION The favorable profile of DOAC over VKA in patients with AF and recent stroke was maintained in the oldest old. ANN NEUROL 2021.
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Cell Therapy of Stroke: Do the Intra-Arterially Transplanted Mesenchymal Stem Cells Cross the Blood-Brain Barrier? Cells 2021; 10:cells10112997. [PMID: 34831220 PMCID: PMC8616541 DOI: 10.3390/cells10112997] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Revised: 10/31/2021] [Accepted: 11/01/2021] [Indexed: 02/07/2023] Open
Abstract
Animal model studies and first clinical trials have demonstrated the safety and efficacy of the mesenchymal stem cells' (MSCs) transplantation in stroke. Intra-arterial (IA) administration looks especially promising, since it provides targeted cell delivery to the ischemic brain, is highly effective, and can be safe as long as the infusion is conducted appropriately. However, wider clinical application of the IA MSCs transplantation will only be possible after a better understanding of the mechanism of their therapeutic action is achieved. On the way to achieve this goal, the study of transplanted cells' fate and their interactions with the blood-brain barrier (BBB) structures could be one of the key factors. In this review, we analyze the available data concerning one of the most important aspects of the transplanted MSCs' action-the ability of cells to cross the blood-brain barrier (BBB) in vitro and in vivo after IA administration into animals with experimental stroke. The collected data show that some of the transplanted MSCs temporarily attach to the walls of the cerebral vessels and then return to the bloodstream or penetrate the BBB and either undergo homing in the perivascular space or penetrate deeper into the parenchyma. Transmigration across the BBB is not necessary for the induction of therapeutic effects, which can be incited through a paracrine mechanism even by cells located inside the blood vessels.
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7
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Chen X, Huang W, Sun A, Wang L, Mo F, Guo W. Bleeding risks with novel oral anticoagulants especially rivaroxaban versus aspirin: a meta-analysis. Thromb J 2021; 19:69. [PMID: 34600549 PMCID: PMC8487538 DOI: 10.1186/s12959-021-00322-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Accepted: 09/19/2021] [Indexed: 11/23/2022] Open
Abstract
Background This pairwise meta-analysis determines the difference in bleeding risks associated with the use of novel oral anticoagulants (NOACs) and aspirin. Methods PubMed, the Cochrane Library database, clinicaltrial.gov, and related studies were searched for randomized control trials (RCTs) comparing NOAC and aspirin published between January 1, 2000 and May 10, 2021. The primary endpoint was intracranial hemorrhage (ICH). Results Eleven studies involving 57,645 patients were included. Compared to aspirin, rivaroxaban (5 mg/day) had a similar risk of ICH, major bleeding, and fatal bleeding; rivaroxaban (10 mg/day) had higher risks of gastrointestinal hemorrhage (OR: 1.41; 95% CI: 1.03–1.94; P = 0.032; I2 = 0%) and a similar risk of ICH, major bleeding, and fatal bleeding; and rivaroxaban (15–20 mg/day) had higher risks of ICH (OR: 3.21; 95% CI: 1.36–7.60; P = 0.008; I2 = 0%), major bleeding (OR: 2.64; 95% CI: 1.68–4.16; P < 0.001; I2 = 0%), and fatal bleeding (OR: 2.26; 95% CI: 1.25–4.08; P = 0.007; I2 = 0%) and a similar risk of gastrointestinal hemorrhage. Bleeding outcomes between other NOACs (apixaban and dabigatran etexilate) and aspirin were not different. Conclusions The bleeding risks associated with NOACs depend on drug type and dosage. For ≥15 mg/day of rivaroxaban, the risk of ICH was significantly higher than that with aspirin. However, further studies comparing dabigatran etexilate and apixaban versus aspirin are warranted to draw a definite conclusion. Supplementary Information The online version contains supplementary material available at 10.1186/s12959-021-00322-6.
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Affiliation(s)
- Xiehui Chen
- Department of Cardiology, Shenzhen Longhua District Central Hospital, No. 187, Guanlan Road, Longhua District, Shenzhen, China.
| | - Weichao Huang
- Department of Cardiology, Fuwai Hospital Chinese Academy of Medical Sciences, No. 12, Langshan Road, Nanshan District, Shenzhen, China
| | - Aimei Sun
- Department of Cardiology, Fuwai Hospital Chinese Academy of Medical Sciences, No. 12, Langshan Road, Nanshan District, Shenzhen, China
| | - Lili Wang
- Department of Cardiology, Fuwai Hospital Chinese Academy of Medical Sciences, No. 12, Langshan Road, Nanshan District, Shenzhen, China
| | - Fanrui Mo
- Department of Cardiology, Fuwai Hospital Chinese Academy of Medical Sciences, No. 12, Langshan Road, Nanshan District, Shenzhen, China
| | - Wenqin Guo
- Department of Cardiology, Fuwai Hospital Chinese Academy of Medical Sciences, No. 12, Langshan Road, Nanshan District, Shenzhen, China.
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Bernardo-Castro S, Sousa JA, Brás A, Cecília C, Rodrigues B, Almendra L, Machado C, Santo G, Silva F, Ferreira L, Santana I, Sargento-Freitas J. Pathophysiology of Blood-Brain Barrier Permeability Throughout the Different Stages of Ischemic Stroke and Its Implication on Hemorrhagic Transformation and Recovery. Front Neurol 2020; 11:594672. [PMID: 33362697 PMCID: PMC7756029 DOI: 10.3389/fneur.2020.594672] [Citation(s) in RCA: 179] [Impact Index Per Article: 44.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Accepted: 11/09/2020] [Indexed: 12/25/2022] Open
Abstract
The blood–brain barrier (BBB) is a dynamic interface responsible for maintaining the central nervous system homeostasis. Its unique characteristics allow protecting the brain from unwanted compounds, but its impairment is involved in a vast number of pathological conditions. Disruption of the BBB and increase in its permeability are key in the development of several neurological diseases and have been extensively studied in stroke. Ischemic stroke is the most prevalent type of stroke and is characterized by a myriad of pathological events triggered by an arterial occlusion that can eventually lead to fatal outcomes such as hemorrhagic transformation (HT). BBB permeability seems to follow a multiphasic pattern throughout the different stroke stages that have been associated with distinct biological substrates. In the hyperacute stage, sudden hypoxia damages the BBB, leading to cytotoxic edema and increased permeability; in the acute stage, the neuroinflammatory response aggravates the BBB injury, leading to higher permeability and a consequent risk of HT that can be motivated by reperfusion therapy; in the subacute stage (1–3 weeks), repair mechanisms take place, especially neoangiogenesis. Immature vessels show leaky BBB, but this permeability has been associated with improved clinical recovery. In the chronic stage (>6 weeks), an increase of BBB restoration factors leads the barrier to start decreasing its permeability. Nonetheless, permeability will persist to some degree several weeks after injury. Understanding the mechanisms behind BBB dysregulation and HT pathophysiology could potentially help guide acute stroke care decisions and the development of new therapeutic targets; however, effective translation into clinical practice is still lacking. In this review, we will address the different pathological and physiological repair mechanisms involved in BBB permeability through the different stages of ischemic stroke and their role in the development of HT and stroke recovery.
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Affiliation(s)
| | - João André Sousa
- Stroke Unit, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Ana Brás
- Stroke Unit, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Carla Cecília
- Stroke Unit, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Bruno Rodrigues
- Stroke Unit, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Luciano Almendra
- Stroke Unit, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Cristina Machado
- Stroke Unit, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Gustavo Santo
- Stroke Unit, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Fernando Silva
- Stroke Unit, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Lino Ferreira
- Faculdade de Medicina da Universidade de Coimbra, Coimbra, Portugal
| | - Isabel Santana
- Stroke Unit, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal.,Faculdade de Medicina da Universidade de Coimbra, Coimbra, Portugal
| | - João Sargento-Freitas
- Stroke Unit, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal.,Faculdade de Medicina da Universidade de Coimbra, Coimbra, Portugal
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9
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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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Huang WY, Singer DE, Wu YL, Chiang CE, Weng HH, Lee M, Ovbiagele B. Association of Intracranial Hemorrhage Risk With Non-Vitamin K Antagonist Oral Anticoagulant Use vs Aspirin Use: A Systematic Review and Meta-analysis. JAMA Neurol 2019; 75:1511-1518. [PMID: 30105396 DOI: 10.1001/jamaneurol.2018.2215] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Non-vitamin K antagonist oral anticoagulants (NOACs) might be an attractive choice for stroke prevention in people without atrial fibrillation who may harbor a potential source of cardiac emboli, but not if certain individual NOACs carry risks of intracranial hemorrhage that are heightened relative to aspirin. Objective To conduct a systematic review and meta-analysis of randomized clinical trials to assess the risk of intracranial hemorrhage with individual NOACs vs aspirin across all indications. Data Sources We searched PubMed, Embase, CENTRAL, and ClinicalTrials.gov from inception to May 28, 2018, with the terms novel oral anticoagulants, non-vitamin K antagonist oral anticoagulants, direct oral anticoagulants, dabigatran, rivaroxaban, apixaban, edoxaban, warfarin, Coumadin, vitamin K antagonist, aspirin, acetylsalicylic acid, or ASA, and major bleeding, fatal bleeding, or intracranial hemorrhage. We restricted our search to clinical trials on humans. There were no language restrictions. Study Selection Randomized clinical trials of 3 months or longer that included a comparison of the outcomes of NOAC use vs use of aspirin. Data Extraction and Synthesis Two investigators independently abstracted data from eligible studies. We computed a fixed-effect estimate based on the Mantel-Haenszel method. Main Outcomes and Measures Odds ratios (ORs) with 95% CI were used as a measure of the association of individual NOAC vs aspirin with the risk of intracranial hemorrhage. The hypothesis that intracranial hemorrhage risk would be higher with NOACs than aspirin was formulated during data collection. Results Our principal analysis included 5 randomized clinical trials comparing 1 or more NOACs with aspirin, with 39 398 individuals enrolled. Pooling the results from the fixed-effects model showed that a dose of 15 to 20 mg of rivaroxaban once daily was associated with an increased risk of intracranial hemorrhage (2 trials; OR, 3.31 [95% CI, 1.42 to 7.72]) compared with aspirin, while a 10-mg dose of rivaroxaban once daily or a 5-mg dose twice daily (3 trials; OR, 1.43 [95% CI, 0.93 to 2.21]) and a 5-mg dose of apixaban twice daily (1 trial; OR, 0.84 [95% CI, 0.38 to 1.88]) were not. Conclusions and Relevance A 15-mg to 20-mg dose of rivaroxaban once daily is associated with substantially increased risks of intracranial hemorrhage, while smaller daily doses of rivaroxaban and apixaban were not, implying that risk increase is dose dependent. It may be worthwhile to conduct randomized clinical trials comparing specific NOACs in specific doses (eg, apixaban, 5 mg twice daily) and aspirin in patients without atrial fibrillation, but with potential sources of cardiac emboli that could cause stroke.
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Affiliation(s)
- Wen-Yi Huang
- Department of Neurology, Chang Gung University College of Medicine, Chang Gung Memorial Hospital, Keelung Branch, Taiwan
| | - Daniel E Singer
- Division of General Internal Medicine, Massachusetts General Hospital, and Harvard Medical School, Boston
| | - Yi-Ling Wu
- Institute of Population Health Sciences, National Health Research Institutes, Miaoli County, Taiwan
| | - Chern-En Chiang
- General Clinical Research Center, Division of Cardiology, Taipei Veterans General Hospital and National Yang-Ming University, Taipei, Taiwan
| | - Hsu-Huei Weng
- Department of Radiology, Chang Gung University College of Medicine, Chang Gung Memorial Hospital, Chiayi Branch, Taiwan
| | - Meng Lee
- Department of Neurology, Chang Gung University College of Medicine, Chang Gung Memorial Hospital, Chiayi Branch, Taiwan
| | - Bruce Ovbiagele
- Department of Neurology, Medical University of South Carolina, Charleston.,Now with Department of Neurology, University of California, San Francisco
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11
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Ögren J, Irewall AL, Söderström L, Mooe T. Serious hemorrhages after ischemic stroke or TIA - Incidence, mortality, and predictors. PLoS One 2018; 13:e0195324. [PMID: 29621285 PMCID: PMC5886551 DOI: 10.1371/journal.pone.0195324] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2017] [Accepted: 03/20/2018] [Indexed: 11/26/2022] Open
Abstract
Background Data are lacking on the risk and impact of a serious hemorrhage on the prognosis after ischemic stroke (IS) or transient ischemic attack (TIA). We aimed to estimate the incidence of serious hemorrhage, analyze the impact on mortality, and identify predictors of hemorrhage after discharge from IS or TIA. Methods and findings All patients admitted to Östersund Hospital for an IS or TIA in 2010–2013 were included (n = 1528, mean age: 75.1 years). Serious hemorrhages were identified until 31st December 2015. Incidence rates were calculated. The impact on mortality (stratified by functional level) was determined with Kaplan-Meier analysis. Non-parametric estimation under the assumption of competing risk was performed to assess the cumulative incidence and predictors of serious hemorrhages. The incidence rates of serious (n = 113) and intracranial hemorrhages (n = 45) after discharge from IS and TIA were 2.48% and 0.96% per year at risk, respectively. Patients with modified Rankin Scale (mRS) scores of 3–5 exhibited 58.9% mortality during follow-up and those with mRS scores of 0–2 exhibited 18.4% mortality. A serious hemorrhage did not affect mortality in patients with impaired functional status, but it increased the risk of death in patients with mRS scores of 0–2. Hypertension was associated with increased risk of serious hemorrhage. Conclusions We found that, after discharge from an IS or TIA, serious hemorrhages were fairly common. Impairments in function were associated with high mortality, but serious hemorrhages only increased the risk of mortality in patients with no or slight disability. Improved hypertension treatment may decrease the risk of serious hemorrhage, but in patients with low functional status, poor survival makes secondary prevention challenging.
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Affiliation(s)
- Joachim Ögren
- Department of Public Health and Clinical Medicine, Östersund, Umeå University, Sweden
- * E-mail:
| | - Anna-Lotta Irewall
- Department of Public Health and Clinical Medicine, Östersund, Umeå University, Sweden
| | - Lars Söderström
- Unit of Research, Development and Education, Östersund, Sweden
| | - Thomas Mooe
- Department of Public Health and Clinical Medicine, Östersund, Umeå University, Sweden
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12
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Mehta T, Hussain M, Sheth K, Ding Y, McCullough LD. Risk of hemorrhagic transformation after ischemic stroke in patients with antiphospholipid antibody syndrome. Neurol Res 2017; 39:477-483. [PMID: 28475479 DOI: 10.1080/01616412.2017.1323382] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND AND PURPOSE Several rheumatologic conditions including systemic lupus erythematosus, antiphospholipid antibody (APS) syndrome, rheumatoid arthritis, and scleroderma are known risk factors for stroke. The risk of hemorrhagic transformation after an acute ischemic stroke (AIS) in these patients is not known. METHODS We queried the Nationwide Inpatient Sample (NIS) data between 2010 and 2012 with ICD 9 diagnostic codes for AIS. The primary outcome was the development of hemorrhagic transformation. Multivariate predictors for hemorrhagic transformation were identified with a logistic regression model. Using SAS 9.2, Survey procedures were used to accommodate for hierarchical two stage cluster design of NIS. RESULTS APS (OR 2.57, 95% CI 1.14-5.81, p = 0.0228) independently predicted risk of hemorrhagic transformation in multivariate regression analysis. Similarly, in multivariate regression models for the outcome variables of total charges of the hospitalization and length of stay (LOS), patients with APS had the highest charges ($56,286, p = 0.0228) and LOS (3.87 days, p = 0.0164) compared to other co-variates. Univariate analysis showed increased mortality in the APS compared to the non-APS group (11.68% vs. 7.16%, p = 0.0024). CONCLUSION APS is an independent risk factor for hemorrhagic transformation in both thrombolytic and non-thrombolytic treated patients. APS is also associated with longer length and cost of hospital stay. Further research is warranted to identify the unique risk factors in these patients to identify strategies to reduce the risk of hemorrhagic transformation in this subgroup of the population.
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Affiliation(s)
- Tapan Mehta
- a Department of Neurology , University of Connecticut Health Center-Hartford Hospital , Hartford , CT , USA
| | - Mohammed Hussain
- a Department of Neurology , University of Connecticut Health Center-Hartford Hospital , Hartford , CT , USA
| | - Khushboo Sheth
- b Department of Internal Medicine , University of Connecticut , Farmington , CT , USA
| | - Yuchuan Ding
- c Department of Neurosurgery , Wayne State University , Detroit , MI , USA
| | - Louise D McCullough
- d Department of Neurology , McGovern Medical School, University of Texas Health Science Center , Houston , TX , USA
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