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Ferreira JRP, Sucupira ID, Carvalho GMC, Paiva FF, Pimentel-Coelho PM, Rosado-de-Castro PH, Mourão PAS, Fonseca RJC. A Combination of Ex Vivo and In Vivo Strategies for Evaluating How Much New Oral Anticoagulants Exacerbate Experimental Intracerebral Bleeding. TH OPEN 2023; 7:e195-e205. [PMID: 37435564 PMCID: PMC10332909 DOI: 10.1055/s-0043-1770782] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Accepted: 05/22/2023] [Indexed: 07/13/2023] Open
Abstract
Background Intracerebral hemorrhage is the most serious complication of anticoagulant therapy but the effects of different types of oral anticoagulants on the expansion of these hemorrhages are still unclear. Clinical studies have revealed controversial results; more robust and long-term clinical evaluations are necessary to define their outcomes. An alternative is to test the effect of these drugs in experimental models of intracerebral bleeding induced in animals. Aims To test new oral anticoagulants (dabigatran etexilate, rivaroxaban, and apixaban) in an experimental model of intracerebral hemorrhage induced by collagenase injection into the brain striatum of rats. Warfarin was used for comparison. Methods Ex vivo anticoagulant assays and an experimental model of venous thrombosis were employed to determine the doses and periods of time required for the anticoagulants to achieve their maximum effects. Subsequently, volumes of brain hematoma were evaluated after administration of the anticoagulants, using these same parameters. Volumes of brain hematoma were evaluated by magnetic resonance imaging, H&E (hematoxylin and eosin) staining, and Evans blue extravasation. Neuromotor function was assessed by the elevated body swing test. Results and Conclusions The new oral anticoagulants did not increase intracranial bleeding compared with control animals, while warfarin markedly favored expansion of the hematomas, as revealed by magnetic resonance imaging and H&E staining. Dabigatran etexilate caused a modest but statistically significant increase in Evans blue extravasation. We did not observe significant differences in elevated body swing tests among the experimental groups. The new oral anticoagulants may provide a better control over a brain hemorrhage than warfarin.
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Affiliation(s)
- Juliana R. P. Ferreira
- Laboratório de Tecido Conjuntivo, Hospital Universitário Clementino Fraga Filho and Programa de Glicobiologia, Instituto de Bioquímica Médica Leopoldo de Meis, Centro de Ciências da Saúde, Universidade Federal do Rio de Janeiro, Rio de Janeiro, RJ, Brazil
| | - Isabela D. Sucupira
- Laboratório de Tecido Conjuntivo, Hospital Universitário Clementino Fraga Filho and Programa de Glicobiologia, Instituto de Bioquímica Médica Leopoldo de Meis, Centro de Ciências da Saúde, Universidade Federal do Rio de Janeiro, Rio de Janeiro, RJ, Brazil
| | - Gabriella M. C. Carvalho
- Laboratório de Coagulação e Trombose, Hospital Universitário Clementino Fraga Filho, Instituto de Ciências Biomédicas, Centro de Ciências da Saúde, Universidade Federal do Rio de Janeiro, Rio de Janeiro, RJ, Brazil
| | - Fernando F. Paiva
- Centro de Imagens e Espectroscopia por Ressonância Magnética (CIERMag). Departamento de Física e Ciência Interdisciplinar. Instituto de Física de São Carlos, Universidade de São Paulo, São Carlos, Brazil
| | - Pedro M. Pimentel-Coelho
- Laboratório Intermediário de Neuropatologia Experimental. Instituto de Biofísica Carlos Chagas Filho, Centro de Ciências da Saúde, Universidade Federal do Rio de Janeiro, Rio de Janeiro, RJ, Brazil
- Laboratório Intermediário de Neuropatologia Experimental. Instituto Nacional de Ciência e Tecnologia em Medicina Regenerativa, Rio de Janeiro, Brazil
| | - Paulo H. Rosado-de-Castro
- Laboratório de Coagulação e Trombose, Hospital Universitário Clementino Fraga Filho, Instituto de Ciências Biomédicas, Centro de Ciências da Saúde, Universidade Federal do Rio de Janeiro, Rio de Janeiro, RJ, Brazil
- Laboratório Intermediário de Neuropatologia Experimental. Instituto Nacional de Ciência e Tecnologia em Medicina Regenerativa, Rio de Janeiro, Brazil
| | - Paulo A. S. Mourão
- Laboratório de Tecido Conjuntivo, Hospital Universitário Clementino Fraga Filho and Programa de Glicobiologia, Instituto de Bioquímica Médica Leopoldo de Meis, Centro de Ciências da Saúde, Universidade Federal do Rio de Janeiro, Rio de Janeiro, RJ, Brazil
| | - Roberto J. C. Fonseca
- Laboratório de Coagulação e Trombose, Hospital Universitário Clementino Fraga Filho, Instituto de Ciências Biomédicas, Centro de Ciências da Saúde, Universidade Federal do Rio de Janeiro, Rio de Janeiro, RJ, Brazil
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2
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Paiva WS, Zippo E, Miranda C, Brasil S, Godoy DA, De Andrade AF, Neville I, Patriota GC, Domingues R, Teixeira MJ. Animal models for the study of intracranial hematomas (Review). Exp Ther Med 2022; 25:20. [PMID: 36561628 PMCID: PMC9748783 DOI: 10.3892/etm.2022.11719] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Accepted: 09/26/2022] [Indexed: 11/23/2022] Open
Abstract
Intracranial hematomas (ICH) are a frequent condition in neurosurgical and neurological practices, with several mechanisms of primary and secondary injury. Experimental research has been fundamental for the understanding of the pathophysiology implicated with ICH and the development of therapeutic interventions. To date, a variety of different animal approaches have been described that consider, for example, the ICH evolutive phase, molecular implications and hemodynamic changes. Therefore, choosing a test protocol should consider the scope of each particular study. The present review summarized investigational protocols in experimental research on the subject of ICH. With this subject, injection of autologous blood or bacterial collagenase, inflation of intracranial balloon and avulsion of cerebral vessels were the models identified. Rodents (mice) and swine were the most frequent species used. These different models allowed improvements on the understanding of intracranial hypertension establishment, neuroinflammation, immunology, brain hemodynamics and served to the development of therapeutic strategies.
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Affiliation(s)
- Wellingson Silva Paiva
- Department of Neurology, Division of Neurosurgery, School of Medicine, University of São Paulo, 05403000 São Paulo, Brazil,Medical Research Laboratory 62, Department of Neurology, School of Medicine, University of São Paulo, 05403000 São Paulo, Brazil
| | - Emanuele Zippo
- Department of Neurology, Division of Neurosurgery, School of Medicine, University of São Paulo, 05403000 São Paulo, Brazil
| | - Carolina Miranda
- Neurology Center, Samaritan Hospital, 01232010 São Paulo, Brazil
| | - Sérgio Brasil
- Department of Neurology, Division of Neurosurgery, School of Medicine, University of São Paulo, 05403000 São Paulo, Brazil,Medical Research Laboratory 62, Department of Neurology, School of Medicine, University of São Paulo, 05403000 São Paulo, Brazil,Correspondence to: Dr Sérgio Brasil, Department of Neurology, Division of Neurosurgery, School of Medicine, University of São Paulo, 255 Enéas Aguiar Street, 05403 São Paulo, Brazil
| | - Daniel Augustin Godoy
- Department of Intensive Care, Neurointensive Care Unit, Pasteur Hospital, 4700 Catamarca, Argentina
| | - Almir Ferreira De Andrade
- Department of Neurology, Division of Neurosurgery, School of Medicine, University of São Paulo, 05403000 São Paulo, Brazil,Medical Research Laboratory 62, Department of Neurology, School of Medicine, University of São Paulo, 05403000 São Paulo, Brazil
| | - Iuri Neville
- Department of Neurology, Division of Neurosurgery, School of Medicine, University of São Paulo, 05403000 São Paulo, Brazil
| | | | - Renan Domingues
- Neurology Center, Samaritan Hospital, 01232010 São Paulo, Brazil
| | - Manoel Jacobsen Teixeira
- Department of Neurology, Division of Neurosurgery, School of Medicine, University of São Paulo, 05403000 São Paulo, Brazil,Medical Research Laboratory 62, Department of Neurology, School of Medicine, University of São Paulo, 05403000 São Paulo, Brazil
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3
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Zhang Y, Zhang X, Wee Yong V, Xue M. Vildagliptin improves neurological function by inhibiting apoptosis and ferroptosis following intracerebral hemorrhage in mice. Neurosci Lett 2022; 776:136579. [PMID: 35304193 DOI: 10.1016/j.neulet.2022.136579] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2022] [Revised: 03/07/2022] [Accepted: 03/13/2022] [Indexed: 02/07/2023]
Abstract
Intracerebral hemorrhage (ICH) is a fatal health problem which lacks effective treatment. The apoptosis caused by hematoma constituents, and the ferroptosis due to iron overload, are prominent contributors of neurologic impairment after ICH. Targeting cell death pathways may thus be a therapeutic strategy for neuroprotection and functional recovery in ICH. Vildagliptin (Vilda), a dipeptidyl peptidase (DPP)-4 inhibitor, has been reported to have potent anti-apoptosis and anti-ferroptotic capacity. However, it is not clear whether Vilda has anti-cell death efficacy in ICH. In the present study, the potential neuroprotective effect of Vilda in ICH mice was investigated. Mice were randomly divided into three groups: sham, ICH + saline or ICH + Vilda. ICH was induced by collagenase type VII micro-injection into the right basal ganglia. Vilda (50 mg/kg/day; gavage) daily treatment for 3 days after ICH improved neurological deficit scores, reduced hematoma volume, and inhibited degeneration of neurons. The activation of microglia/macrophages and infiltration of neutrophil were restrained by Vilda. Moreover, Vilda attenuated brain cell apoptosis as determined by TUNEL staining, raised Bcl-2 protein level, and simultaneously suppressed Bax as validated by western blots. In addition, Vilda reduced malondialdehyde level, elevated glutathione peroxidase brain content, and alleviated iron deposition at 3 days after ICH in mice. In conclusion, Vilda exerts neuroprotective effects in ICH, at least in part by inhibiting neuroinflammation, and preventing neuronal apoptosis and ferroptosis following ICH.
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Affiliation(s)
- Yan Zhang
- Departments of Cerebrovascular Diseases, The Second Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China; Academy of Medical Science, Zhengzhou University, Zhengzhou, Henan, China
| | - Xiangyu Zhang
- Departments of Cerebrovascular Diseases, The Second Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China; Academy of Medical Science, Zhengzhou University, Zhengzhou, Henan, China
| | - V Wee Yong
- Hotchkiss Brain Institute and Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada.
| | - Mengzhou Xue
- Departments of Cerebrovascular Diseases, The Second Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China; Academy of Medical Science, Zhengzhou University, Zhengzhou, Henan, China.
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4
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Novel targets, treatments, and advanced models for intracerebral haemorrhage. EBioMedicine 2022; 76:103880. [PMID: 35158309 PMCID: PMC8850756 DOI: 10.1016/j.ebiom.2022.103880] [Citation(s) in RCA: 45] [Impact Index Per Article: 22.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Revised: 01/17/2022] [Accepted: 01/28/2022] [Indexed: 12/20/2022] Open
Abstract
Intracerebral haemorrhage (ICH) is the second most common type of stroke and a major cause of mortality and disability worldwide. Despite advances in surgical interventions and acute ICH management, there is currently no effective therapy to improve functional outcomes in patients. Recently, there has been tremendous progress uncovering new pathophysiological mechanisms underlying ICH that may pave the way for the development of therapeutic interventions. Here, we highlight emerging targets, but also existing gaps in preclinical animal modelling that prevent their exploitation. We particularly focus on (1) ICH aetiology, (2) the haematoma, (3) inflammation, and (4) post-ICH pathology. It is important to recognize that beyond neurons and the brain, other cell types and organs are crucially involved in ICH pathophysiology and successful interventions likely will need to address the entire organism. This review will spur the development of successful therapeutic interventions for ICH and advanced animal models that better reflect its aetiology and pathophysiology.
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5
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Li Z, Li Y, Han J, Zhu Z, Li M, Liu Q, Wang Y, Shi FD. Formyl peptide receptor 1 signaling potentiates inflammatory brain injury. Sci Transl Med 2021; 13:13/605/eabe9890. [PMID: 34349037 DOI: 10.1126/scitranslmed.abe9890] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2020] [Accepted: 04/02/2021] [Indexed: 12/26/2022]
Abstract
Acute brain insults elicit pronounced inflammation that amplifies brain damage in intracerebral hemorrhage (ICH). We profiled perihematomal tissue from patients with ICH, generating a molecular landscape of the injured brain, and identified formyl peptide receptor 1 (FPR1) as the most abundantly increased damage-associated molecular pattern (DAMP) receptor, predominantly expressed by microglia. Circulating mitochondrial N-formyl peptides, endogenous ligands of FPR1, were augmented and correlated with the magnitude of brain edema in patients with ICH. Interactions of formyl peptides with FPR1 activated microglia, boosted neutrophil recruitment, and aggravated neurological deficits in two mouse models of ICH. We created an FPR1 antagonist T-0080 that can penetrate the brain and bind both human and murine FPR1. T-0080 attenuated brain edema and improved neurological outcomes in ICH models. Thus, FPR1 orchestrates brain inflammation after ICH and could be targeted to improve clinical outcome in patients.
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Affiliation(s)
- Zhiguo Li
- China National Clinical Research Center for Neurological Diseases, Advanced Innovation Center for Human Brain Protection, Beijing Tiantan Hospital, Capital Medical University, Beijing 100070, China.,Department of Neurology, Tianjin Neurological Institute, Tianjin Medical University General Hospital, Tianjin 300052, China
| | - Yulin Li
- Department of Neurology, Tianjin Neurological Institute, Tianjin Medical University General Hospital, Tianjin 300052, China
| | - Jinrui Han
- Department of Neurology, Tianjin Neurological Institute, Tianjin Medical University General Hospital, Tianjin 300052, China
| | - Zilong Zhu
- Department of Neurology, Tianjin Huanhu Hospital, Tianjin 300350, China
| | - Minshu Li
- China National Clinical Research Center for Neurological Diseases, Advanced Innovation Center for Human Brain Protection, Beijing Tiantan Hospital, Capital Medical University, Beijing 100070, China.,Department of Neurology, Tianjin Neurological Institute, Tianjin Medical University General Hospital, Tianjin 300052, China
| | - Qiang Liu
- Department of Neurology, Tianjin Neurological Institute, Tianjin Medical University General Hospital, Tianjin 300052, China
| | - Yongjun Wang
- China National Clinical Research Center for Neurological Diseases, Advanced Innovation Center for Human Brain Protection, Beijing Tiantan Hospital, Capital Medical University, Beijing 100070, China.
| | - Fu-Dong Shi
- China National Clinical Research Center for Neurological Diseases, Advanced Innovation Center for Human Brain Protection, Beijing Tiantan Hospital, Capital Medical University, Beijing 100070, China. .,Department of Neurology, Tianjin Neurological Institute, Tianjin Medical University General Hospital, Tianjin 300052, China
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6
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van Veluw SJ, Frosch MP, Scherlek AA, Lee D, Greenberg SM, Bacskai BJ. In vivo characterization of spontaneous microhemorrhage formation in mice with cerebral amyloid angiopathy. J Cereb Blood Flow Metab 2021; 41:82-91. [PMID: 31987010 PMCID: PMC7747164 DOI: 10.1177/0271678x19899377] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The pathophysiology of microhemorrhages in the context of cerebral amyloid angiopathy (CAA) remains poorly understood. Here we used in vivo two-photon microscopy in aged APP/PS1 mice with mild-to-moderate CAA to assess the formation of microhemorrhages and their spatial relationship with vascular Aβ depositions in the surrounding microvascular network. Mice with chronic cranial windows were intravenously injected with fluorescent dextran to visualize the vessels and a fluorescently labeled anti-fibrin antibody to visualize microhemorrhages. Focal vessel irradiations resulted in extravascular fibrin-positive clots at individual rupture sites that remained visible for weeks. Spontaneous extravascular fibrin-positive clots were more often observed in 19-month-old transgenic APP/PS1 mice compared to their wild-type littermate controls (p = 0.039), after heparin administration. In the transgenic mice, these spontaneous leakage sites frequently occurred at arteriolar segments without CAA at bifurcations or vessel bends. These findings suggest that the presence of vascular Aβ per se does not directly predispose vessels to leak, but that complex flow dynamics within CAA-affected vascular networks likely play a role. Our in vivo approach for the detection of individual spontaneous leakage sites may be used in longitudinal studies aimed to assess structural and functional alterations at the single-vessel level leading up to microhemorrhage formation.
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Affiliation(s)
- Susanne J van Veluw
- MassGeneral Institute for Neurodegenerative Disease, Massachusetts General Hospital and Harvard Medical School, Charlestown Navy Yard, MA, USA.,J. Philip Kistler Stroke Research Center, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Matthew P Frosch
- Neuropathology Service, C.S. Kubik Laboratory for Neuropathology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Ashley A Scherlek
- MassGeneral Institute for Neurodegenerative Disease, Massachusetts General Hospital and Harvard Medical School, Charlestown Navy Yard, MA, USA
| | - Daniel Lee
- MassGeneral Institute for Neurodegenerative Disease, Massachusetts General Hospital and Harvard Medical School, Charlestown Navy Yard, MA, USA
| | - Steven M Greenberg
- J. Philip Kistler Stroke Research Center, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Brian J Bacskai
- MassGeneral Institute for Neurodegenerative Disease, Massachusetts General Hospital and Harvard Medical School, Charlestown Navy Yard, MA, USA
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7
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Ye F, Garton HJL, Hua Y, Keep RF, Xi G. The Role of Thrombin in Brain Injury After Hemorrhagic and Ischemic Stroke. Transl Stroke Res 2020; 12:496-511. [PMID: 32989665 DOI: 10.1007/s12975-020-00855-4] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Revised: 09/22/2020] [Accepted: 09/23/2020] [Indexed: 02/06/2023]
Abstract
Thrombin is increased in the brain after hemorrhagic and ischemic stroke primarily due to the prothrombin entry from blood either with a hemorrhage or following blood-brain barrier disruption. Increasing evidence indicates that thrombin and its receptors (protease-activated receptors (PARs)) play a major role in brain pathology following ischemic and hemorrhagic stroke (including intracerebral, intraventricular, and subarachnoid hemorrhage). Thrombin and PARs affect brain injury via multiple mechanisms that can be detrimental or protective. The cleavage of prothrombin into thrombin is the key step of hemostasis and thrombosis which takes place in every stroke and subsequent brain injury. The extravascular effects and direct cellular interactions of thrombin are mediated by PARs (PAR-1, PAR-3, and PAR-4) and their downstream signaling in multiple brain cell types. Such effects include inducing blood-brain-barrier disruption, brain edema, neuroinflammation, and neuronal death, although low thrombin concentrations can promote cell survival. Also, thrombin directly links the coagulation system to the immune system by activating interleukin-1α. Such effects of thrombin can result in both short-term brain injury and long-term functional deficits, making extravascular thrombin an understudied therapeutic target for stroke. This review examines the role of thrombin and PARs in brain injury following hemorrhagic and ischemic stroke and the potential treatment strategies which are complicated by their role in both hemostasis and brain.
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Affiliation(s)
- Fenghui Ye
- Department of Neurosurgery, University of Michigan, R5018 Biomedical Science Research Building, 109 Zina Pitcher Place, Ann Arbor, MI, 48109-2200, USA
| | - Hugh J L Garton
- Department of Neurosurgery, University of Michigan, R5018 Biomedical Science Research Building, 109 Zina Pitcher Place, Ann Arbor, MI, 48109-2200, USA
| | - Ya Hua
- Department of Neurosurgery, University of Michigan, R5018 Biomedical Science Research Building, 109 Zina Pitcher Place, Ann Arbor, MI, 48109-2200, USA
| | - Richard F Keep
- Department of Neurosurgery, University of Michigan, R5018 Biomedical Science Research Building, 109 Zina Pitcher Place, Ann Arbor, MI, 48109-2200, USA
| | - Guohua Xi
- Department of Neurosurgery, University of Michigan, R5018 Biomedical Science Research Building, 109 Zina Pitcher Place, Ann Arbor, MI, 48109-2200, USA.
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8
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Miller MM, Lowe J, Khan M, Azeem MU, Muehlschlegel S, Jun-O'Connell AH, Goddeau RP, Moonis M, Gritters D, Silver B, Henninger N. Clinical and Radiological Characteristics of Vitamin K Versus Non-Vitamin K Antagonist Oral Anticoagulation-Related Intracerebral Hemorrhage. Neurocrit Care 2020; 31:56-65. [PMID: 30690686 DOI: 10.1007/s12028-019-00671-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
BACKGROUND/OBJECTIVE Recent studies indicated that functional outcome after intracranial hemorrhage (ICH) related to direct oral anticoagulation (DOAC-ICH) is similar, if not better, than vitamin K antagonist (VKA)-related ICH (VKA-ICH) due to a smaller initial hematoma volume (HV). However, the association with hematoma expansion (HE) and location is not well understood. METHODS We retrospectively analyzed 102 consecutive patients with acute non-traumatic ICH on oral anticoagulation therapy to determine HV and HE stratified by hematoma location, and the relation to the 90-day outcome. RESULTS DOAC-ICH (n = 25) and VKA-ICH (n = 77) had a similar admission HV and HE (unadjusted p > 0.05, each). Targeted reversal strategies were used in 93.5% of VKA-ICH versus 8% of DOAC-ICH. After adjustment, an unfavorable 90-day functional outcome (modified Rankin scale score 4-6) was independently associated with a lower admission Glasgow Coma Scale score (OR 1.63; 95% CI 1.26-2.10; p < 0.001) and greater HV (OR 1.03; 95% confidence interval (CI) 1.00-1.05; p = 0.046). After exclusion of patients without follow-up head computed tomography to allow for adjustment by occurrence of HE, VKA-ICH was associated with an approximately 3.5 times greater odds for a poor 90-day outcome (OR 3.64; 95% CI 1.01-13.09; p = 0.048). However, there was no significant association of the oral anticoagulant strategy with 90-day outcome in the entire cohort (OR 2.85; 95% CI 0.69-11.86; p = 0.15). CONCLUSIONS DOAC use did not relate to worse HE, HV, and functional outcome after ICH, adding to the notion that DOAC is a safe alternative to VKA even in the absence of access to targeted reversal strategies (which are still not universally available).
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Affiliation(s)
- Małgorzata M Miller
- Department of Neurology, University of Massachusetts Medical School, Worcester, MA, USA.
| | - Jessica Lowe
- Division of Neurology, Neuroscience Institute, Spectrum Health, Grand Rapids, MI, USA
| | - Muhib Khan
- Division of Neurology, Neuroscience Institute, Spectrum Health, Grand Rapids, MI, USA
| | - Muhammad U Azeem
- Department of Neurology, University of Massachusetts Medical School, Worcester, MA, USA
| | - Susanne Muehlschlegel
- Department of Neurology, University of Massachusetts Medical School, Worcester, MA, USA.,Department of Surgery, University of Massachusetts Medical School, Worcester, MA, USA.,Department of Anesthesia and Critical Care, University of Massachusetts Medical School, Worcester, MA, USA
| | | | - Richard P Goddeau
- Department of Neurology, University of Massachusetts Medical School, Worcester, MA, USA
| | - Majaz Moonis
- Department of Neurology, University of Massachusetts Medical School, Worcester, MA, USA
| | - Danielle Gritters
- Spectrum Health Office of Research, Spectrum Health, Grand Rapids, MI, USA
| | - Brian Silver
- Department of Neurology, University of Massachusetts Medical School, Worcester, MA, USA
| | - Nils Henninger
- Department of Neurology, University of Massachusetts Medical School, Worcester, MA, USA.,Department of Psychiatry, University of Massachusetts Medical School, Worcester, MA, USA
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9
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Sun ZG, Yang-Liu, Zhang JM, Cui SC, Zhang ZG, Zhu HL. The Research Progress of Direct Thrombin Inhibitors. Mini Rev Med Chem 2019; 20:1574-1585. [PMID: 31644402 DOI: 10.2174/1389557519666191015201125] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2018] [Revised: 03/18/2019] [Accepted: 05/19/2019] [Indexed: 11/22/2022]
Abstract
Blood coagulation is the process of changing the blood from the flowing state to the gel state. It is an important part of the hemostatic function. Coagulation is a process by which a series of coagulation factors are sequentially activated, and finally thrombin is formed to form fibrin clot. Direct thrombin inhibitors are important anticoagulant drug. These drugs can selectively bind to the active site of thrombin, inhibit thrombin activity, have strong action and high specificity, and have important significance in the clinical treatment of thrombus diseases. Some of them come from natural products of animals or plants, and many of them have been applied in the clinic. The other part is derived from the design, synthesis and activity studies of small molecule inhibitors. This review discusses the progress of direct thrombin inhibitors in recent years.
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Affiliation(s)
- Zhi-Gang Sun
- Central Laboratory, Linyi Central Hospital, No.17 Jiankang Road, Linyi 276400, China,State Key Laboratory of Pharmaceutical Biotechnology, School of Life Sciences, Nanjing University, No.163 Xianlin Road, Nanjing 210023, China
| | - Yang-Liu
- Central Laboratory, Linyi Central Hospital, No.17 Jiankang Road, Linyi 276400, China
| | - Jin-Mai Zhang
- Room 205, BIO-X white house, Shanghai Jiao Tong University, No.1954 Huashan Road, Shanghai 200030,China
| | - Shi-Chang Cui
- Central Laboratory, Linyi Central Hospital, No.17 Jiankang Road, Linyi 276400, China
| | - Zhi-Gang Zhang
- Department of Cardiovascular Medicine, Linyi Central Hospital, No.17 Jiankang Road, Linyi 276400, China
| | - Hai-Liang Zhu
- State Key Laboratory of Pharmaceutical Biotechnology, School of Life Sciences, Nanjing University, No.163 Xianlin Road, Nanjing 210023, China
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10
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Schlunk F, Böhm M, Boulouis G, Qin T, Arbel M, Tamim I, Fischer P, Bacskai BJ, Frosch MP, Endres M, Greenberg SM, Ayata C. Secondary Bleeding During Acute Experimental Intracerebral Hemorrhage. Stroke 2019; 50:1210-1215. [PMID: 31009358 PMCID: PMC6478448 DOI: 10.1161/strokeaha.118.021732] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Background and Purpose- Mechanisms contributing to acute hematoma growth in intracerebral hemorrhage are not well understood. Neuropathological studies suggest that the initial hematoma may create mass effect that can tear vessels in the vicinity by shearing, causing further bleeding and hematoma growth. Methods- To test this in mice, we simulated initial intracerebral hemorrhage by intrastriatal injection of a liquid polymer that coagulates upon contact with tissue and measured the presence and volume of bleeding secondary to the mass effect using Hemoglobin ELISA 15 minutes after injection. Results- Secondary hemorrhage occurred in a volume-dependent (4, 7.5, or 15 μL of polymer) and rate-dependent (0.05, 0.5, or 5 μL/s) manner. Anticoagulation (warfarin or dabigatran) exacerbated the secondary hemorrhage volume. In a second model of hematoma expansion, we confirmed that intrastriatal whole blood injection (15 μL, 0.5 μL/s) also caused secondary bleeding, using acute Evans blue extravasation as a surrogate. Anticoagulation once again exacerbated secondary hemorrhage after intrastriatal whole blood injection. Secondary hemorrhage directly and significantly correlated with arterial blood pressures in both nonanticoagulated and anticoagulated mice, when modulated by phenylephrine or labetalol. Conclusions- Our study provides the first proof of concept for secondary vessel rupture and bleeding as a potential mechanism for intracerebral hematoma growth.
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Affiliation(s)
- Frieder Schlunk
- Neurovascular Research Laboratory, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Charlestown, MA
- Stroke Research Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA
- Center for Stroke Research Berlin (CSB), Charité Universitätsmedizin, Berlin, Germany
- Department of Neurology, Charité Universitätsmedizin, Berlin, Germany
| | - Maximilian Böhm
- Neurovascular Research Laboratory, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Charlestown, MA
- Center for Stroke Research Berlin (CSB), Charité Universitätsmedizin, Berlin, Germany
| | - Gregoire Boulouis
- Stroke Research Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Tao Qin
- Neurovascular Research Laboratory, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Charlestown, MA
| | - Michal Arbel
- Alzheimer’s Disease Research Laboratory, Massachusetts General Hospital, Harvard Medical School, Charlestown, MA
| | - Isra Tamim
- Neurovascular Research Laboratory, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Charlestown, MA
- Center for Stroke Research Berlin (CSB), Charité Universitätsmedizin, Berlin, Germany
| | - Paul Fischer
- Neurovascular Research Laboratory, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Charlestown, MA
- Center for Stroke Research Berlin (CSB), Charité Universitätsmedizin, Berlin, Germany
| | - Brian J. Bacskai
- Alzheimer’s Disease Research Laboratory, Massachusetts General Hospital, Harvard Medical School, Charlestown, MA
| | - Matthew P. Frosch
- Alzheimer’s Disease Research Laboratory, Massachusetts General Hospital, Harvard Medical School, Charlestown, MA
| | - Matthias Endres
- Center for Stroke Research Berlin (CSB), Charité Universitätsmedizin, Berlin, Germany
- Department of Neurology, Charité Universitätsmedizin, Berlin, Germany
| | - Steven M. Greenberg
- Stroke Research Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA
- Alzheimer’s Disease Research Laboratory, Massachusetts General Hospital, Harvard Medical School, Charlestown, MA
| | - Cenk Ayata
- Neurovascular Research Laboratory, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Charlestown, MA
- Stroke Service, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
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11
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Foerch C, Lo EH, van Leyen K, Lauer A, Schaefer JH. Intracerebral Hemorrhage Formation Under Direct Oral Anticoagulants. Stroke 2019; 50:1034-1042. [PMID: 30869572 DOI: 10.1161/strokeaha.118.023722] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Affiliation(s)
- Christian Foerch
- From the Department of Neurology (C.F., J.H.S.), Goethe University, Frankfurt am Main, Germany
| | - Eng H Lo
- Neuroprotection Research Laboratory, Massachusetts General Hospital, Harvard Medical School, Charlestown (E.H.L., K.v.L.)
| | - Klaus van Leyen
- Neuroprotection Research Laboratory, Massachusetts General Hospital, Harvard Medical School, Charlestown (E.H.L., K.v.L.)
| | - Arne Lauer
- Institute of Neuroradiology (A.L.), Goethe University, Frankfurt am Main, Germany
| | - Jan Hendrik Schaefer
- From the Department of Neurology (C.F., J.H.S.), Goethe University, Frankfurt am Main, Germany
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12
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Pétrault M, Casolla B, Ouk T, Cordonnier C, Bérézowski V. Cerebral microbleeds: Beyond the macroscope. Int J Stroke 2019; 14:468-475. [DOI: 10.1177/1747493019830594] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
While being increasingly recognized in clinical routine, brain microbleeds remain a puzzling finding for physicians. These small dot-like lesions are thought to be old perivascular collections of hemosiderin deposits. They can be found in different neurological settings such as cerebrovascular or neurodegenerative diseases. While their microscopic size would suggest considering these lesions as anecdotal, they are now regarded as biomarkers of severity of an underlying cerebrovascular disease. Their natural history and the interactions with surrounding brain cells remain unknown. However, their presence may impact therapeutic decisions. Deciphering the biological mechanisms leading to, or following microbleeds would enable us to address a key question: do microbleeds arise and impact the surrounding parenchyma like a miniature version of intracerebral hemorrhages or do they represent a different kind of injury? We hereby discuss, based on both clinical and experimental literature, the gap between the definition of microbleeds coming from neuroimaging and the pathophysiological hypotheses raised from histopathological and experimental data. Our analysis supports the need for a convergent effort from clinicians and basic scientists to go beyond the current “macro” view and disclose the cellular and molecular insights of these cerebral hemorrhagic microlesions.
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Affiliation(s)
- Maud Pétrault
- Department of Medical Pharmacology, Univ Lille, Inserm U1171-Degenerative and Vascular Cognitive Disorders, CHU Lille, Lille, France
| | - Barbara Casolla
- Department of Neurology, Univ Lille, Inserm U1171-Degenerative and Vascular Cognitive Disorders, CHU Lille, Lille, France
| | - Thavarak Ouk
- Department of Medical Pharmacology, Univ Lille, Inserm U1171-Degenerative and Vascular Cognitive Disorders, CHU Lille, Lille, France
| | - Charlotte Cordonnier
- Department of Neurology, Univ Lille, Inserm U1171-Degenerative and Vascular Cognitive Disorders, CHU Lille, Lille, France
| | - Vincent Bérézowski
- Department of Medical Pharmacology, Univ Lille, Inserm U1171-Degenerative and Vascular Cognitive Disorders, CHU Lille, Lille, France
- Univ Artois, Lens, France
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13
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Chan S, Brophy M, Nishimura N, Schaffer CB. Aspirin treatment does not increase microhemorrhage size in young or aged mice. PLoS One 2019; 14:e0204295. [PMID: 30608925 PMCID: PMC6319729 DOI: 10.1371/journal.pone.0204295] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Accepted: 12/17/2018] [Indexed: 11/25/2022] Open
Abstract
Microhemorrhages are common in the aging brain and are thought to contribute to cognitive decline and the development of neurodegenerative diseases, such as Alzheimer’s disease. Chronic aspirin therapy is widespread in older individuals and decreases the risk of coronary artery occlusions and stroke. There remains a concern that such aspirin usage may prolong bleeding after a vessel rupture in the brain, leading to larger bleeds that cause more damage to the surrounding tissue. Here, we aimed to understand the influence of aspirin usage on the size of cortical microhemorrhages and explored the impact of age. We used femtosecond laser ablation to rupture arterioles in the cortex of both young (2–5 months old) and aged (18–29 months old) mice dosed on aspirin in their drinking water and measured the extent of penetration of both red blood cells and blood plasma into the surrounding tissue. We found no difference in microhemorrhage size for both young and aged mice dosed on aspirin, as compared to controls (hematoma diameter = 104 +/- 39 (97 +/- 38) μm in controls and 109 +/- 25 (101 +/- 28) μm in aspirin-treated young (aged) mice; mean +/- SD). In contrast, young mice treated with intravenous heparin had an increased hematoma diameter of 136 +/- 44 μm. These data suggest that aspirin does not increase the size of microhemorrhages, supporting the safety of aspirin usage.
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Affiliation(s)
- Sandy Chan
- Meinig School of Biomedical Engineering, Cornell University, Ithaca, New York, United States of America
| | - Morgan Brophy
- Meinig School of Biomedical Engineering, Cornell University, Ithaca, New York, United States of America
| | - Nozomi Nishimura
- Meinig School of Biomedical Engineering, Cornell University, Ithaca, New York, United States of America
| | - Chris B. Schaffer
- Meinig School of Biomedical Engineering, Cornell University, Ithaca, New York, United States of America
- * E-mail:
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14
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Burchell SR, Tang J, Zhang JH. Hematoma Expansion Following Intracerebral Hemorrhage: Mechanisms Targeting the Coagulation Cascade and Platelet Activation. Curr Drug Targets 2018; 18:1329-1344. [PMID: 28378693 DOI: 10.2174/1389450118666170329152305] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2015] [Revised: 07/20/2016] [Accepted: 03/14/2017] [Indexed: 01/04/2023]
Abstract
Hematoma expansion (HE), defined as a greater than 33% increase in intracerebral hemorrhage (ICH) volume within the first 24 hours, results in significant neurological deficits, and enhancement of ICH-induced primary and secondary brain injury. An escalation in the use of oral anticoagulants has led to a surge in the incidences of oral anticoagulation-associated ICH (OAT-ICH), which has been associated with a greater risk for HE and worse functional outcomes following ICH. The oral anticoagulants in use include vitamin K antagonists, and direct thrombin and factor Xa inhibitors. Fibrinolytic agents are also frequently administered. These all act via differing mechanisms and thus have varying degrees of impact on HE and ICH outcome. Additionally, antiplatelet medications have also been increasingly prescribed, and result in increased bleeding risks and worse outcomes after ICH. Aspirin, thienopyridines, and GPIIb/IIIa receptor blockers are some of the most common agents in use clinically, and also have different effects on ICH and hemorrhage growth, based on their mechanisms of action. Recent studies have found that reduced platelet activity may be more effective in predicting ICH risk, hemorrhage expansion, and outcomes, than antiplatelet agents, and activating platelets may thus be a novel target for ICH therapy. This review explores how dysfunctions or alterations in the coagulation and platelet cascades can lead to, and/or exacerbate, hematoma expansion following intracerebral hemorrhage, and describe the mechanisms behind these effects and the drugs that induce them. We also discuss potential future therapy aimed at increasing platelet activity after ICH.
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Affiliation(s)
- Sherrefa R Burchell
- Department of Physiology, Loma Linda University School of Medicine, Loma Linda CA, USA.,Center for Neuroscience Research, Loma Linda University School of Medicine, Loma Linda, CA, USA
| | - Jiping Tang
- Department of Physiology, Loma Linda University School of Medicine, Loma Linda CA, USA.,Center for Neuroscience Research, Loma Linda University School of Medicine, Loma Linda, CA, USA
| | - John H Zhang
- Department of Physiology, Loma Linda University School of Medicine, Loma Linda CA, USA.,Center for Neuroscience Research, Loma Linda University School of Medicine, Loma Linda, CA, USA.,Department of Anesthesiology, Loma Linda University School of Medicine, Loma Linda CA, USA
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15
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Choi HJ, Kim NE, Kim J, An S, Yang SH, Ha J, Cho S, Kwon I, Kim YD, Nam HS, Heo JH. Dabigatran reduces endothelial permeability through inhibition of thrombin-induced cytoskeleton reorganization. Thromb Res 2018; 167:S0049-3848(18)30324-4. [PMID: 29735342 DOI: 10.1016/j.thromres.2018.04.019] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Revised: 03/28/2018] [Accepted: 04/18/2018] [Indexed: 11/23/2022]
Abstract
Dabigatran etexilate (DE), a new oral anti-coagulant, is a direct thrombin inhibitor. Clinical trials showed the favorable benefit-to-risk profile of DE compared to warfarin for the prevention of ischemic stroke in patients with atrial fibrillation. Remarkably, patients treated with dabigatran showed reduced rates of intracerebral hemorrhage compared to warfarin. As the breakdown of endothelial barrier integrity is associated with hemorrhagic events and as thrombin increases endothelial permeability, we hypothesized that dabigatran preserves the endothelial barrier by inhibiting thrombin-induced permeability. We assessed leakage of fluorescein isothiocyanate (FITC)-dextran through the endothelial monolayer and measured trans-endothelial electrical resistance of the endothelial monolayer after treatment of thrombin or thrombin pre-incubated with dabigatran. Thrombin increased the permeability of endothelial cells. Dabigatran effectively blocked the ability of thrombin to increase permeability. Dabigatran inhibited the formation of actin stress fibers induced by thrombin and inhibited consequent destabilization of junctional protein complexes and intercellular gap formation. The interaction of thrombin with protease activated receptor-1 activates the Rho A guanosine triphosphate (GTP)ase-myosin light chain (MLC) phosphorylation signaling axis, leading to actin cytoskeleton changes. This signaling pathway was effectively inhibited by dabigatran in endothelial cells. Consistently, the number of phosphorylated MLC-positive cells was significantly decreased in ischemic tissue of rat brains. These results indicate dabigatran blocks the ability of thrombin to induce vascular permeability and the resulting underlying signaling cascade in endothelial cells. Our findings provide evidence that dabigatran may confer a lower risk of intracerebral hemorrhage by preserving endothelial barrier integrity.
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Affiliation(s)
- Hyun-Jung Choi
- Severance Integrative Research Institute for Cerebral & Cardiovascular Diseases, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Na-Eun Kim
- Severance Integrative Research Institute for Cerebral & Cardiovascular Diseases, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jayoung Kim
- Severance Integrative Research Institute for Cerebral & Cardiovascular Diseases, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Sunho An
- Severance Integrative Research Institute for Cerebral & Cardiovascular Diseases, Yonsei University College of Medicine, Seoul, Republic of Korea; Brain Korea 21 Plus Project for Medical Science, Yonsei University, Seoul 03722, Republic of Korea
| | - Seung-Hee Yang
- Severance Integrative Research Institute for Cerebral & Cardiovascular Diseases, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jimin Ha
- Severance Integrative Research Institute for Cerebral & Cardiovascular Diseases, Yonsei University College of Medicine, Seoul, Republic of Korea; Brain Korea 21 Plus Project for Medical Science, Yonsei University, Seoul 03722, Republic of Korea
| | - Sunghee Cho
- The Burke-Cornell Medical Research Institute, White Plains, NY 10605, United States; Feil Family Brain and Mind Research Institute, Weill Cornell Medical College, New York, NY 10021, United States
| | - Il Kwon
- Severance Integrative Research Institute for Cerebral & Cardiovascular Diseases, Yonsei University College of Medicine, Seoul, Republic of Korea; Severance Biomedical Science Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Young Dae Kim
- Severance Integrative Research Institute for Cerebral & Cardiovascular Diseases, Yonsei University College of Medicine, Seoul, Republic of Korea; Department of Neurology, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Hyo Suk Nam
- Severance Integrative Research Institute for Cerebral & Cardiovascular Diseases, Yonsei University College of Medicine, Seoul, Republic of Korea; Department of Neurology, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Ji Hoe Heo
- Severance Integrative Research Institute for Cerebral & Cardiovascular Diseases, Yonsei University College of Medicine, Seoul, Republic of Korea; Department of Neurology, Yonsei University College of Medicine, Seoul, Republic of Korea; Severance Biomedical Science Institute, Yonsei University College of Medicine, Seoul, Republic of Korea; Brain Korea 21 Plus Project for Medical Science, Yonsei University, Seoul 03722, Republic of Korea.
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16
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Kurogi R, Nishimura K, Nakai M, Kada A, Kamitani S, Nakagawara J, Toyoda K, Ogasawara K, Ono J, Shiokawa Y, Aruga T, Miyachi S, Nagata I, Matsuda S, Yoshimura S, Okuchi K, Suzuki A, Nakamura F, Onozuka D, Ido K, Kurogi A, Mukae N, Nishimura A, Arimura K, Kitazono T, Hagihara A, Iihara K. Comparing intracerebral hemorrhages associated with direct oral anticoagulants or warfarin. Neurology 2018; 90:e1143-e1149. [PMID: 29490916 PMCID: PMC5880631 DOI: 10.1212/wnl.0000000000005207] [Citation(s) in RCA: 57] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2017] [Accepted: 12/27/2017] [Indexed: 01/16/2023] Open
Abstract
OBJECTIVES This cross-sectional survey explored the characteristics and outcomes of direct oral anticoagulant (DOAC)-associated nontraumatic intracerebral hemorrhages (ICHs) by analyzing a large nationwide Japanese discharge database. METHODS We analyzed data from 2,245 patients who experienced ICHs while taking anticoagulants (DOAC: 227; warfarin: 2,018) and were urgently hospitalized at 621 institutions in Japan between April 2010 and March 2015. We compared the DOAC- and warfarin-treated patients based on their backgrounds, ICH severities, antiplatelet therapies at admission, hematoma removal surgeries, reversal agents, mortality rates, and modified Rankin Scale scores at discharge. RESULTS DOAC-associated ICHs were less likely to cause moderately or severely impaired consciousness (DOAC-associated ICHs: 31.3%; warfarin-associated ICHs: 39.4%; p = 0.002) or require surgical removal (DOAC-associated ICHs: 5.3%; warfarin-associated ICHs: 9.9%; p = 0.024) in the univariate analysis. Propensity score analysis revealed that patients with DOAC-associated ICHs also exhibited lower mortality rates within 1 day (odds ratio [OR] 4.96, p = 0.005), within 7 days (OR 2.29, p = 0.037), and during hospitalization (OR 1.96, p = 0.039). CONCLUSIONS This nationwide study revealed that DOAC-treated patients had less severe ICHs and lower mortality rates than did warfarin-treated patients, probably due to milder hemorrhages at admission and lower hematoma expansion frequencies.
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Affiliation(s)
- Ryota Kurogi
- From the Departments of Neurosurgery (R.K., K. Ido, A. Kurogi, N.M., A.N., K.A., K. Iihara), Health Communication (D.O., A.H.), and Medicine and Clinical Science (T.K.), Graduate School of Medical Sciences, Kyushu University; Department of Neuroendovascular Surgery (R.K.), National Hospital Organization, Clinical Research Institute, Kyushu Medical Center, Fukuoka; Department of Statistics and Data Analysis, Center for Cerebral and Cardiovascular Disease Information (K.N., M.N.), Integrative Stroke Imaging Centre (J.N.), and Department of Cerebrovascular Medicine (K.T.), National Cerebral and Cardiovascular Center, Suita; Department of Clinical Trials and Research (A. Kada), National Hospital Organization, Nagoya Medical Center; Division of Health Services Research (S.K.), Center for Cancer Control and Information Services, National Cancer Center, Tokyo; Department of Neurosurgery (K. Ogasawara), Iwate Medical University, Morioka; Department of Neurosurgery (J.O.), Sanmu Medical Center; Department of Neurosurgery (Y.S.), Kyorin University, Mitaka; Department of Emergency and Critical Care Medicine (T.A.), Showa University Hospital, Shinagawa; Department of Neurosurgery (S. Miyachi), Osaka Medical College, Takatsuki; Department of Neurosurgery (I.N.), Kokura Memorial Hospital; Department of Preventive Medicine and Community Health (S. Matsuda), School of Medicine, University of Occupational and Environmental Health, Kitakyushu; Department of Neurosurgery (S.Y.), Hyogo College of Medicine, Nishinomiya; Department of Emergency and Critical Care Medicine (K. Okuchi), Nara Medical University, Kashihara; Department of Surgical Neurology (A.S.), Research Institute for Brain and Blood Vessels, Akita; and Division of Data Management Center for Cardiovascular Disease Information (F.N.), National Cerebral Cardiovascular Disease Information, Suita, Japan
| | - Kunihiro Nishimura
- From the Departments of Neurosurgery (R.K., K. Ido, A. Kurogi, N.M., A.N., K.A., K. Iihara), Health Communication (D.O., A.H.), and Medicine and Clinical Science (T.K.), Graduate School of Medical Sciences, Kyushu University; Department of Neuroendovascular Surgery (R.K.), National Hospital Organization, Clinical Research Institute, Kyushu Medical Center, Fukuoka; Department of Statistics and Data Analysis, Center for Cerebral and Cardiovascular Disease Information (K.N., M.N.), Integrative Stroke Imaging Centre (J.N.), and Department of Cerebrovascular Medicine (K.T.), National Cerebral and Cardiovascular Center, Suita; Department of Clinical Trials and Research (A. Kada), National Hospital Organization, Nagoya Medical Center; Division of Health Services Research (S.K.), Center for Cancer Control and Information Services, National Cancer Center, Tokyo; Department of Neurosurgery (K. Ogasawara), Iwate Medical University, Morioka; Department of Neurosurgery (J.O.), Sanmu Medical Center; Department of Neurosurgery (Y.S.), Kyorin University, Mitaka; Department of Emergency and Critical Care Medicine (T.A.), Showa University Hospital, Shinagawa; Department of Neurosurgery (S. Miyachi), Osaka Medical College, Takatsuki; Department of Neurosurgery (I.N.), Kokura Memorial Hospital; Department of Preventive Medicine and Community Health (S. Matsuda), School of Medicine, University of Occupational and Environmental Health, Kitakyushu; Department of Neurosurgery (S.Y.), Hyogo College of Medicine, Nishinomiya; Department of Emergency and Critical Care Medicine (K. Okuchi), Nara Medical University, Kashihara; Department of Surgical Neurology (A.S.), Research Institute for Brain and Blood Vessels, Akita; and Division of Data Management Center for Cardiovascular Disease Information (F.N.), National Cerebral Cardiovascular Disease Information, Suita, Japan
| | - Michikazu Nakai
- From the Departments of Neurosurgery (R.K., K. Ido, A. Kurogi, N.M., A.N., K.A., K. Iihara), Health Communication (D.O., A.H.), and Medicine and Clinical Science (T.K.), Graduate School of Medical Sciences, Kyushu University; Department of Neuroendovascular Surgery (R.K.), National Hospital Organization, Clinical Research Institute, Kyushu Medical Center, Fukuoka; Department of Statistics and Data Analysis, Center for Cerebral and Cardiovascular Disease Information (K.N., M.N.), Integrative Stroke Imaging Centre (J.N.), and Department of Cerebrovascular Medicine (K.T.), National Cerebral and Cardiovascular Center, Suita; Department of Clinical Trials and Research (A. Kada), National Hospital Organization, Nagoya Medical Center; Division of Health Services Research (S.K.), Center for Cancer Control and Information Services, National Cancer Center, Tokyo; Department of Neurosurgery (K. Ogasawara), Iwate Medical University, Morioka; Department of Neurosurgery (J.O.), Sanmu Medical Center; Department of Neurosurgery (Y.S.), Kyorin University, Mitaka; Department of Emergency and Critical Care Medicine (T.A.), Showa University Hospital, Shinagawa; Department of Neurosurgery (S. Miyachi), Osaka Medical College, Takatsuki; Department of Neurosurgery (I.N.), Kokura Memorial Hospital; Department of Preventive Medicine and Community Health (S. Matsuda), School of Medicine, University of Occupational and Environmental Health, Kitakyushu; Department of Neurosurgery (S.Y.), Hyogo College of Medicine, Nishinomiya; Department of Emergency and Critical Care Medicine (K. Okuchi), Nara Medical University, Kashihara; Department of Surgical Neurology (A.S.), Research Institute for Brain and Blood Vessels, Akita; and Division of Data Management Center for Cardiovascular Disease Information (F.N.), National Cerebral Cardiovascular Disease Information, Suita, Japan
| | - Akiko Kada
- From the Departments of Neurosurgery (R.K., K. Ido, A. Kurogi, N.M., A.N., K.A., K. Iihara), Health Communication (D.O., A.H.), and Medicine and Clinical Science (T.K.), Graduate School of Medical Sciences, Kyushu University; Department of Neuroendovascular Surgery (R.K.), National Hospital Organization, Clinical Research Institute, Kyushu Medical Center, Fukuoka; Department of Statistics and Data Analysis, Center for Cerebral and Cardiovascular Disease Information (K.N., M.N.), Integrative Stroke Imaging Centre (J.N.), and Department of Cerebrovascular Medicine (K.T.), National Cerebral and Cardiovascular Center, Suita; Department of Clinical Trials and Research (A. Kada), National Hospital Organization, Nagoya Medical Center; Division of Health Services Research (S.K.), Center for Cancer Control and Information Services, National Cancer Center, Tokyo; Department of Neurosurgery (K. Ogasawara), Iwate Medical University, Morioka; Department of Neurosurgery (J.O.), Sanmu Medical Center; Department of Neurosurgery (Y.S.), Kyorin University, Mitaka; Department of Emergency and Critical Care Medicine (T.A.), Showa University Hospital, Shinagawa; Department of Neurosurgery (S. Miyachi), Osaka Medical College, Takatsuki; Department of Neurosurgery (I.N.), Kokura Memorial Hospital; Department of Preventive Medicine and Community Health (S. Matsuda), School of Medicine, University of Occupational and Environmental Health, Kitakyushu; Department of Neurosurgery (S.Y.), Hyogo College of Medicine, Nishinomiya; Department of Emergency and Critical Care Medicine (K. Okuchi), Nara Medical University, Kashihara; Department of Surgical Neurology (A.S.), Research Institute for Brain and Blood Vessels, Akita; and Division of Data Management Center for Cardiovascular Disease Information (F.N.), National Cerebral Cardiovascular Disease Information, Suita, Japan
| | - Satoru Kamitani
- From the Departments of Neurosurgery (R.K., K. Ido, A. Kurogi, N.M., A.N., K.A., K. Iihara), Health Communication (D.O., A.H.), and Medicine and Clinical Science (T.K.), Graduate School of Medical Sciences, Kyushu University; Department of Neuroendovascular Surgery (R.K.), National Hospital Organization, Clinical Research Institute, Kyushu Medical Center, Fukuoka; Department of Statistics and Data Analysis, Center for Cerebral and Cardiovascular Disease Information (K.N., M.N.), Integrative Stroke Imaging Centre (J.N.), and Department of Cerebrovascular Medicine (K.T.), National Cerebral and Cardiovascular Center, Suita; Department of Clinical Trials and Research (A. Kada), National Hospital Organization, Nagoya Medical Center; Division of Health Services Research (S.K.), Center for Cancer Control and Information Services, National Cancer Center, Tokyo; Department of Neurosurgery (K. Ogasawara), Iwate Medical University, Morioka; Department of Neurosurgery (J.O.), Sanmu Medical Center; Department of Neurosurgery (Y.S.), Kyorin University, Mitaka; Department of Emergency and Critical Care Medicine (T.A.), Showa University Hospital, Shinagawa; Department of Neurosurgery (S. Miyachi), Osaka Medical College, Takatsuki; Department of Neurosurgery (I.N.), Kokura Memorial Hospital; Department of Preventive Medicine and Community Health (S. Matsuda), School of Medicine, University of Occupational and Environmental Health, Kitakyushu; Department of Neurosurgery (S.Y.), Hyogo College of Medicine, Nishinomiya; Department of Emergency and Critical Care Medicine (K. Okuchi), Nara Medical University, Kashihara; Department of Surgical Neurology (A.S.), Research Institute for Brain and Blood Vessels, Akita; and Division of Data Management Center for Cardiovascular Disease Information (F.N.), National Cerebral Cardiovascular Disease Information, Suita, Japan
| | - Jyoji Nakagawara
- From the Departments of Neurosurgery (R.K., K. Ido, A. Kurogi, N.M., A.N., K.A., K. Iihara), Health Communication (D.O., A.H.), and Medicine and Clinical Science (T.K.), Graduate School of Medical Sciences, Kyushu University; Department of Neuroendovascular Surgery (R.K.), National Hospital Organization, Clinical Research Institute, Kyushu Medical Center, Fukuoka; Department of Statistics and Data Analysis, Center for Cerebral and Cardiovascular Disease Information (K.N., M.N.), Integrative Stroke Imaging Centre (J.N.), and Department of Cerebrovascular Medicine (K.T.), National Cerebral and Cardiovascular Center, Suita; Department of Clinical Trials and Research (A. Kada), National Hospital Organization, Nagoya Medical Center; Division of Health Services Research (S.K.), Center for Cancer Control and Information Services, National Cancer Center, Tokyo; Department of Neurosurgery (K. Ogasawara), Iwate Medical University, Morioka; Department of Neurosurgery (J.O.), Sanmu Medical Center; Department of Neurosurgery (Y.S.), Kyorin University, Mitaka; Department of Emergency and Critical Care Medicine (T.A.), Showa University Hospital, Shinagawa; Department of Neurosurgery (S. Miyachi), Osaka Medical College, Takatsuki; Department of Neurosurgery (I.N.), Kokura Memorial Hospital; Department of Preventive Medicine and Community Health (S. Matsuda), School of Medicine, University of Occupational and Environmental Health, Kitakyushu; Department of Neurosurgery (S.Y.), Hyogo College of Medicine, Nishinomiya; Department of Emergency and Critical Care Medicine (K. Okuchi), Nara Medical University, Kashihara; Department of Surgical Neurology (A.S.), Research Institute for Brain and Blood Vessels, Akita; and Division of Data Management Center for Cardiovascular Disease Information (F.N.), National Cerebral Cardiovascular Disease Information, Suita, Japan
| | - Kazunori Toyoda
- From the Departments of Neurosurgery (R.K., K. Ido, A. Kurogi, N.M., A.N., K.A., K. Iihara), Health Communication (D.O., A.H.), and Medicine and Clinical Science (T.K.), Graduate School of Medical Sciences, Kyushu University; Department of Neuroendovascular Surgery (R.K.), National Hospital Organization, Clinical Research Institute, Kyushu Medical Center, Fukuoka; Department of Statistics and Data Analysis, Center for Cerebral and Cardiovascular Disease Information (K.N., M.N.), Integrative Stroke Imaging Centre (J.N.), and Department of Cerebrovascular Medicine (K.T.), National Cerebral and Cardiovascular Center, Suita; Department of Clinical Trials and Research (A. Kada), National Hospital Organization, Nagoya Medical Center; Division of Health Services Research (S.K.), Center for Cancer Control and Information Services, National Cancer Center, Tokyo; Department of Neurosurgery (K. Ogasawara), Iwate Medical University, Morioka; Department of Neurosurgery (J.O.), Sanmu Medical Center; Department of Neurosurgery (Y.S.), Kyorin University, Mitaka; Department of Emergency and Critical Care Medicine (T.A.), Showa University Hospital, Shinagawa; Department of Neurosurgery (S. Miyachi), Osaka Medical College, Takatsuki; Department of Neurosurgery (I.N.), Kokura Memorial Hospital; Department of Preventive Medicine and Community Health (S. Matsuda), School of Medicine, University of Occupational and Environmental Health, Kitakyushu; Department of Neurosurgery (S.Y.), Hyogo College of Medicine, Nishinomiya; Department of Emergency and Critical Care Medicine (K. Okuchi), Nara Medical University, Kashihara; Department of Surgical Neurology (A.S.), Research Institute for Brain and Blood Vessels, Akita; and Division of Data Management Center for Cardiovascular Disease Information (F.N.), National Cerebral Cardiovascular Disease Information, Suita, Japan
| | - Kuniaki Ogasawara
- From the Departments of Neurosurgery (R.K., K. Ido, A. Kurogi, N.M., A.N., K.A., K. Iihara), Health Communication (D.O., A.H.), and Medicine and Clinical Science (T.K.), Graduate School of Medical Sciences, Kyushu University; Department of Neuroendovascular Surgery (R.K.), National Hospital Organization, Clinical Research Institute, Kyushu Medical Center, Fukuoka; Department of Statistics and Data Analysis, Center for Cerebral and Cardiovascular Disease Information (K.N., M.N.), Integrative Stroke Imaging Centre (J.N.), and Department of Cerebrovascular Medicine (K.T.), National Cerebral and Cardiovascular Center, Suita; Department of Clinical Trials and Research (A. Kada), National Hospital Organization, Nagoya Medical Center; Division of Health Services Research (S.K.), Center for Cancer Control and Information Services, National Cancer Center, Tokyo; Department of Neurosurgery (K. Ogasawara), Iwate Medical University, Morioka; Department of Neurosurgery (J.O.), Sanmu Medical Center; Department of Neurosurgery (Y.S.), Kyorin University, Mitaka; Department of Emergency and Critical Care Medicine (T.A.), Showa University Hospital, Shinagawa; Department of Neurosurgery (S. Miyachi), Osaka Medical College, Takatsuki; Department of Neurosurgery (I.N.), Kokura Memorial Hospital; Department of Preventive Medicine and Community Health (S. Matsuda), School of Medicine, University of Occupational and Environmental Health, Kitakyushu; Department of Neurosurgery (S.Y.), Hyogo College of Medicine, Nishinomiya; Department of Emergency and Critical Care Medicine (K. Okuchi), Nara Medical University, Kashihara; Department of Surgical Neurology (A.S.), Research Institute for Brain and Blood Vessels, Akita; and Division of Data Management Center for Cardiovascular Disease Information (F.N.), National Cerebral Cardiovascular Disease Information, Suita, Japan
| | - Junichi Ono
- From the Departments of Neurosurgery (R.K., K. Ido, A. Kurogi, N.M., A.N., K.A., K. Iihara), Health Communication (D.O., A.H.), and Medicine and Clinical Science (T.K.), Graduate School of Medical Sciences, Kyushu University; Department of Neuroendovascular Surgery (R.K.), National Hospital Organization, Clinical Research Institute, Kyushu Medical Center, Fukuoka; Department of Statistics and Data Analysis, Center for Cerebral and Cardiovascular Disease Information (K.N., M.N.), Integrative Stroke Imaging Centre (J.N.), and Department of Cerebrovascular Medicine (K.T.), National Cerebral and Cardiovascular Center, Suita; Department of Clinical Trials and Research (A. Kada), National Hospital Organization, Nagoya Medical Center; Division of Health Services Research (S.K.), Center for Cancer Control and Information Services, National Cancer Center, Tokyo; Department of Neurosurgery (K. Ogasawara), Iwate Medical University, Morioka; Department of Neurosurgery (J.O.), Sanmu Medical Center; Department of Neurosurgery (Y.S.), Kyorin University, Mitaka; Department of Emergency and Critical Care Medicine (T.A.), Showa University Hospital, Shinagawa; Department of Neurosurgery (S. Miyachi), Osaka Medical College, Takatsuki; Department of Neurosurgery (I.N.), Kokura Memorial Hospital; Department of Preventive Medicine and Community Health (S. Matsuda), School of Medicine, University of Occupational and Environmental Health, Kitakyushu; Department of Neurosurgery (S.Y.), Hyogo College of Medicine, Nishinomiya; Department of Emergency and Critical Care Medicine (K. Okuchi), Nara Medical University, Kashihara; Department of Surgical Neurology (A.S.), Research Institute for Brain and Blood Vessels, Akita; and Division of Data Management Center for Cardiovascular Disease Information (F.N.), National Cerebral Cardiovascular Disease Information, Suita, Japan
| | - Yoshiaki Shiokawa
- From the Departments of Neurosurgery (R.K., K. Ido, A. Kurogi, N.M., A.N., K.A., K. Iihara), Health Communication (D.O., A.H.), and Medicine and Clinical Science (T.K.), Graduate School of Medical Sciences, Kyushu University; Department of Neuroendovascular Surgery (R.K.), National Hospital Organization, Clinical Research Institute, Kyushu Medical Center, Fukuoka; Department of Statistics and Data Analysis, Center for Cerebral and Cardiovascular Disease Information (K.N., M.N.), Integrative Stroke Imaging Centre (J.N.), and Department of Cerebrovascular Medicine (K.T.), National Cerebral and Cardiovascular Center, Suita; Department of Clinical Trials and Research (A. Kada), National Hospital Organization, Nagoya Medical Center; Division of Health Services Research (S.K.), Center for Cancer Control and Information Services, National Cancer Center, Tokyo; Department of Neurosurgery (K. Ogasawara), Iwate Medical University, Morioka; Department of Neurosurgery (J.O.), Sanmu Medical Center; Department of Neurosurgery (Y.S.), Kyorin University, Mitaka; Department of Emergency and Critical Care Medicine (T.A.), Showa University Hospital, Shinagawa; Department of Neurosurgery (S. Miyachi), Osaka Medical College, Takatsuki; Department of Neurosurgery (I.N.), Kokura Memorial Hospital; Department of Preventive Medicine and Community Health (S. Matsuda), School of Medicine, University of Occupational and Environmental Health, Kitakyushu; Department of Neurosurgery (S.Y.), Hyogo College of Medicine, Nishinomiya; Department of Emergency and Critical Care Medicine (K. Okuchi), Nara Medical University, Kashihara; Department of Surgical Neurology (A.S.), Research Institute for Brain and Blood Vessels, Akita; and Division of Data Management Center for Cardiovascular Disease Information (F.N.), National Cerebral Cardiovascular Disease Information, Suita, Japan
| | - Toru Aruga
- From the Departments of Neurosurgery (R.K., K. Ido, A. Kurogi, N.M., A.N., K.A., K. Iihara), Health Communication (D.O., A.H.), and Medicine and Clinical Science (T.K.), Graduate School of Medical Sciences, Kyushu University; Department of Neuroendovascular Surgery (R.K.), National Hospital Organization, Clinical Research Institute, Kyushu Medical Center, Fukuoka; Department of Statistics and Data Analysis, Center for Cerebral and Cardiovascular Disease Information (K.N., M.N.), Integrative Stroke Imaging Centre (J.N.), and Department of Cerebrovascular Medicine (K.T.), National Cerebral and Cardiovascular Center, Suita; Department of Clinical Trials and Research (A. Kada), National Hospital Organization, Nagoya Medical Center; Division of Health Services Research (S.K.), Center for Cancer Control and Information Services, National Cancer Center, Tokyo; Department of Neurosurgery (K. Ogasawara), Iwate Medical University, Morioka; Department of Neurosurgery (J.O.), Sanmu Medical Center; Department of Neurosurgery (Y.S.), Kyorin University, Mitaka; Department of Emergency and Critical Care Medicine (T.A.), Showa University Hospital, Shinagawa; Department of Neurosurgery (S. Miyachi), Osaka Medical College, Takatsuki; Department of Neurosurgery (I.N.), Kokura Memorial Hospital; Department of Preventive Medicine and Community Health (S. Matsuda), School of Medicine, University of Occupational and Environmental Health, Kitakyushu; Department of Neurosurgery (S.Y.), Hyogo College of Medicine, Nishinomiya; Department of Emergency and Critical Care Medicine (K. Okuchi), Nara Medical University, Kashihara; Department of Surgical Neurology (A.S.), Research Institute for Brain and Blood Vessels, Akita; and Division of Data Management Center for Cardiovascular Disease Information (F.N.), National Cerebral Cardiovascular Disease Information, Suita, Japan
| | - Shigeru Miyachi
- From the Departments of Neurosurgery (R.K., K. Ido, A. Kurogi, N.M., A.N., K.A., K. Iihara), Health Communication (D.O., A.H.), and Medicine and Clinical Science (T.K.), Graduate School of Medical Sciences, Kyushu University; Department of Neuroendovascular Surgery (R.K.), National Hospital Organization, Clinical Research Institute, Kyushu Medical Center, Fukuoka; Department of Statistics and Data Analysis, Center for Cerebral and Cardiovascular Disease Information (K.N., M.N.), Integrative Stroke Imaging Centre (J.N.), and Department of Cerebrovascular Medicine (K.T.), National Cerebral and Cardiovascular Center, Suita; Department of Clinical Trials and Research (A. Kada), National Hospital Organization, Nagoya Medical Center; Division of Health Services Research (S.K.), Center for Cancer Control and Information Services, National Cancer Center, Tokyo; Department of Neurosurgery (K. Ogasawara), Iwate Medical University, Morioka; Department of Neurosurgery (J.O.), Sanmu Medical Center; Department of Neurosurgery (Y.S.), Kyorin University, Mitaka; Department of Emergency and Critical Care Medicine (T.A.), Showa University Hospital, Shinagawa; Department of Neurosurgery (S. Miyachi), Osaka Medical College, Takatsuki; Department of Neurosurgery (I.N.), Kokura Memorial Hospital; Department of Preventive Medicine and Community Health (S. Matsuda), School of Medicine, University of Occupational and Environmental Health, Kitakyushu; Department of Neurosurgery (S.Y.), Hyogo College of Medicine, Nishinomiya; Department of Emergency and Critical Care Medicine (K. Okuchi), Nara Medical University, Kashihara; Department of Surgical Neurology (A.S.), Research Institute for Brain and Blood Vessels, Akita; and Division of Data Management Center for Cardiovascular Disease Information (F.N.), National Cerebral Cardiovascular Disease Information, Suita, Japan
| | - Izumi Nagata
- From the Departments of Neurosurgery (R.K., K. Ido, A. Kurogi, N.M., A.N., K.A., K. Iihara), Health Communication (D.O., A.H.), and Medicine and Clinical Science (T.K.), Graduate School of Medical Sciences, Kyushu University; Department of Neuroendovascular Surgery (R.K.), National Hospital Organization, Clinical Research Institute, Kyushu Medical Center, Fukuoka; Department of Statistics and Data Analysis, Center for Cerebral and Cardiovascular Disease Information (K.N., M.N.), Integrative Stroke Imaging Centre (J.N.), and Department of Cerebrovascular Medicine (K.T.), National Cerebral and Cardiovascular Center, Suita; Department of Clinical Trials and Research (A. Kada), National Hospital Organization, Nagoya Medical Center; Division of Health Services Research (S.K.), Center for Cancer Control and Information Services, National Cancer Center, Tokyo; Department of Neurosurgery (K. Ogasawara), Iwate Medical University, Morioka; Department of Neurosurgery (J.O.), Sanmu Medical Center; Department of Neurosurgery (Y.S.), Kyorin University, Mitaka; Department of Emergency and Critical Care Medicine (T.A.), Showa University Hospital, Shinagawa; Department of Neurosurgery (S. Miyachi), Osaka Medical College, Takatsuki; Department of Neurosurgery (I.N.), Kokura Memorial Hospital; Department of Preventive Medicine and Community Health (S. Matsuda), School of Medicine, University of Occupational and Environmental Health, Kitakyushu; Department of Neurosurgery (S.Y.), Hyogo College of Medicine, Nishinomiya; Department of Emergency and Critical Care Medicine (K. Okuchi), Nara Medical University, Kashihara; Department of Surgical Neurology (A.S.), Research Institute for Brain and Blood Vessels, Akita; and Division of Data Management Center for Cardiovascular Disease Information (F.N.), National Cerebral Cardiovascular Disease Information, Suita, Japan
| | - Shinya Matsuda
- From the Departments of Neurosurgery (R.K., K. Ido, A. Kurogi, N.M., A.N., K.A., K. Iihara), Health Communication (D.O., A.H.), and Medicine and Clinical Science (T.K.), Graduate School of Medical Sciences, Kyushu University; Department of Neuroendovascular Surgery (R.K.), National Hospital Organization, Clinical Research Institute, Kyushu Medical Center, Fukuoka; Department of Statistics and Data Analysis, Center for Cerebral and Cardiovascular Disease Information (K.N., M.N.), Integrative Stroke Imaging Centre (J.N.), and Department of Cerebrovascular Medicine (K.T.), National Cerebral and Cardiovascular Center, Suita; Department of Clinical Trials and Research (A. Kada), National Hospital Organization, Nagoya Medical Center; Division of Health Services Research (S.K.), Center for Cancer Control and Information Services, National Cancer Center, Tokyo; Department of Neurosurgery (K. Ogasawara), Iwate Medical University, Morioka; Department of Neurosurgery (J.O.), Sanmu Medical Center; Department of Neurosurgery (Y.S.), Kyorin University, Mitaka; Department of Emergency and Critical Care Medicine (T.A.), Showa University Hospital, Shinagawa; Department of Neurosurgery (S. Miyachi), Osaka Medical College, Takatsuki; Department of Neurosurgery (I.N.), Kokura Memorial Hospital; Department of Preventive Medicine and Community Health (S. Matsuda), School of Medicine, University of Occupational and Environmental Health, Kitakyushu; Department of Neurosurgery (S.Y.), Hyogo College of Medicine, Nishinomiya; Department of Emergency and Critical Care Medicine (K. Okuchi), Nara Medical University, Kashihara; Department of Surgical Neurology (A.S.), Research Institute for Brain and Blood Vessels, Akita; and Division of Data Management Center for Cardiovascular Disease Information (F.N.), National Cerebral Cardiovascular Disease Information, Suita, Japan
| | - Shinichi Yoshimura
- From the Departments of Neurosurgery (R.K., K. Ido, A. Kurogi, N.M., A.N., K.A., K. Iihara), Health Communication (D.O., A.H.), and Medicine and Clinical Science (T.K.), Graduate School of Medical Sciences, Kyushu University; Department of Neuroendovascular Surgery (R.K.), National Hospital Organization, Clinical Research Institute, Kyushu Medical Center, Fukuoka; Department of Statistics and Data Analysis, Center for Cerebral and Cardiovascular Disease Information (K.N., M.N.), Integrative Stroke Imaging Centre (J.N.), and Department of Cerebrovascular Medicine (K.T.), National Cerebral and Cardiovascular Center, Suita; Department of Clinical Trials and Research (A. Kada), National Hospital Organization, Nagoya Medical Center; Division of Health Services Research (S.K.), Center for Cancer Control and Information Services, National Cancer Center, Tokyo; Department of Neurosurgery (K. Ogasawara), Iwate Medical University, Morioka; Department of Neurosurgery (J.O.), Sanmu Medical Center; Department of Neurosurgery (Y.S.), Kyorin University, Mitaka; Department of Emergency and Critical Care Medicine (T.A.), Showa University Hospital, Shinagawa; Department of Neurosurgery (S. Miyachi), Osaka Medical College, Takatsuki; Department of Neurosurgery (I.N.), Kokura Memorial Hospital; Department of Preventive Medicine and Community Health (S. Matsuda), School of Medicine, University of Occupational and Environmental Health, Kitakyushu; Department of Neurosurgery (S.Y.), Hyogo College of Medicine, Nishinomiya; Department of Emergency and Critical Care Medicine (K. Okuchi), Nara Medical University, Kashihara; Department of Surgical Neurology (A.S.), Research Institute for Brain and Blood Vessels, Akita; and Division of Data Management Center for Cardiovascular Disease Information (F.N.), National Cerebral Cardiovascular Disease Information, Suita, Japan
| | - Kazuo Okuchi
- From the Departments of Neurosurgery (R.K., K. Ido, A. Kurogi, N.M., A.N., K.A., K. Iihara), Health Communication (D.O., A.H.), and Medicine and Clinical Science (T.K.), Graduate School of Medical Sciences, Kyushu University; Department of Neuroendovascular Surgery (R.K.), National Hospital Organization, Clinical Research Institute, Kyushu Medical Center, Fukuoka; Department of Statistics and Data Analysis, Center for Cerebral and Cardiovascular Disease Information (K.N., M.N.), Integrative Stroke Imaging Centre (J.N.), and Department of Cerebrovascular Medicine (K.T.), National Cerebral and Cardiovascular Center, Suita; Department of Clinical Trials and Research (A. Kada), National Hospital Organization, Nagoya Medical Center; Division of Health Services Research (S.K.), Center for Cancer Control and Information Services, National Cancer Center, Tokyo; Department of Neurosurgery (K. Ogasawara), Iwate Medical University, Morioka; Department of Neurosurgery (J.O.), Sanmu Medical Center; Department of Neurosurgery (Y.S.), Kyorin University, Mitaka; Department of Emergency and Critical Care Medicine (T.A.), Showa University Hospital, Shinagawa; Department of Neurosurgery (S. Miyachi), Osaka Medical College, Takatsuki; Department of Neurosurgery (I.N.), Kokura Memorial Hospital; Department of Preventive Medicine and Community Health (S. Matsuda), School of Medicine, University of Occupational and Environmental Health, Kitakyushu; Department of Neurosurgery (S.Y.), Hyogo College of Medicine, Nishinomiya; Department of Emergency and Critical Care Medicine (K. Okuchi), Nara Medical University, Kashihara; Department of Surgical Neurology (A.S.), Research Institute for Brain and Blood Vessels, Akita; and Division of Data Management Center for Cardiovascular Disease Information (F.N.), National Cerebral Cardiovascular Disease Information, Suita, Japan
| | - Akifumi Suzuki
- From the Departments of Neurosurgery (R.K., K. Ido, A. Kurogi, N.M., A.N., K.A., K. Iihara), Health Communication (D.O., A.H.), and Medicine and Clinical Science (T.K.), Graduate School of Medical Sciences, Kyushu University; Department of Neuroendovascular Surgery (R.K.), National Hospital Organization, Clinical Research Institute, Kyushu Medical Center, Fukuoka; Department of Statistics and Data Analysis, Center for Cerebral and Cardiovascular Disease Information (K.N., M.N.), Integrative Stroke Imaging Centre (J.N.), and Department of Cerebrovascular Medicine (K.T.), National Cerebral and Cardiovascular Center, Suita; Department of Clinical Trials and Research (A. Kada), National Hospital Organization, Nagoya Medical Center; Division of Health Services Research (S.K.), Center for Cancer Control and Information Services, National Cancer Center, Tokyo; Department of Neurosurgery (K. Ogasawara), Iwate Medical University, Morioka; Department of Neurosurgery (J.O.), Sanmu Medical Center; Department of Neurosurgery (Y.S.), Kyorin University, Mitaka; Department of Emergency and Critical Care Medicine (T.A.), Showa University Hospital, Shinagawa; Department of Neurosurgery (S. Miyachi), Osaka Medical College, Takatsuki; Department of Neurosurgery (I.N.), Kokura Memorial Hospital; Department of Preventive Medicine and Community Health (S. Matsuda), School of Medicine, University of Occupational and Environmental Health, Kitakyushu; Department of Neurosurgery (S.Y.), Hyogo College of Medicine, Nishinomiya; Department of Emergency and Critical Care Medicine (K. Okuchi), Nara Medical University, Kashihara; Department of Surgical Neurology (A.S.), Research Institute for Brain and Blood Vessels, Akita; and Division of Data Management Center for Cardiovascular Disease Information (F.N.), National Cerebral Cardiovascular Disease Information, Suita, Japan
| | - Fumiaki Nakamura
- From the Departments of Neurosurgery (R.K., K. Ido, A. Kurogi, N.M., A.N., K.A., K. Iihara), Health Communication (D.O., A.H.), and Medicine and Clinical Science (T.K.), Graduate School of Medical Sciences, Kyushu University; Department of Neuroendovascular Surgery (R.K.), National Hospital Organization, Clinical Research Institute, Kyushu Medical Center, Fukuoka; Department of Statistics and Data Analysis, Center for Cerebral and Cardiovascular Disease Information (K.N., M.N.), Integrative Stroke Imaging Centre (J.N.), and Department of Cerebrovascular Medicine (K.T.), National Cerebral and Cardiovascular Center, Suita; Department of Clinical Trials and Research (A. Kada), National Hospital Organization, Nagoya Medical Center; Division of Health Services Research (S.K.), Center for Cancer Control and Information Services, National Cancer Center, Tokyo; Department of Neurosurgery (K. Ogasawara), Iwate Medical University, Morioka; Department of Neurosurgery (J.O.), Sanmu Medical Center; Department of Neurosurgery (Y.S.), Kyorin University, Mitaka; Department of Emergency and Critical Care Medicine (T.A.), Showa University Hospital, Shinagawa; Department of Neurosurgery (S. Miyachi), Osaka Medical College, Takatsuki; Department of Neurosurgery (I.N.), Kokura Memorial Hospital; Department of Preventive Medicine and Community Health (S. Matsuda), School of Medicine, University of Occupational and Environmental Health, Kitakyushu; Department of Neurosurgery (S.Y.), Hyogo College of Medicine, Nishinomiya; Department of Emergency and Critical Care Medicine (K. Okuchi), Nara Medical University, Kashihara; Department of Surgical Neurology (A.S.), Research Institute for Brain and Blood Vessels, Akita; and Division of Data Management Center for Cardiovascular Disease Information (F.N.), National Cerebral Cardiovascular Disease Information, Suita, Japan
| | - Daisuke Onozuka
- From the Departments of Neurosurgery (R.K., K. Ido, A. Kurogi, N.M., A.N., K.A., K. Iihara), Health Communication (D.O., A.H.), and Medicine and Clinical Science (T.K.), Graduate School of Medical Sciences, Kyushu University; Department of Neuroendovascular Surgery (R.K.), National Hospital Organization, Clinical Research Institute, Kyushu Medical Center, Fukuoka; Department of Statistics and Data Analysis, Center for Cerebral and Cardiovascular Disease Information (K.N., M.N.), Integrative Stroke Imaging Centre (J.N.), and Department of Cerebrovascular Medicine (K.T.), National Cerebral and Cardiovascular Center, Suita; Department of Clinical Trials and Research (A. Kada), National Hospital Organization, Nagoya Medical Center; Division of Health Services Research (S.K.), Center for Cancer Control and Information Services, National Cancer Center, Tokyo; Department of Neurosurgery (K. Ogasawara), Iwate Medical University, Morioka; Department of Neurosurgery (J.O.), Sanmu Medical Center; Department of Neurosurgery (Y.S.), Kyorin University, Mitaka; Department of Emergency and Critical Care Medicine (T.A.), Showa University Hospital, Shinagawa; Department of Neurosurgery (S. Miyachi), Osaka Medical College, Takatsuki; Department of Neurosurgery (I.N.), Kokura Memorial Hospital; Department of Preventive Medicine and Community Health (S. Matsuda), School of Medicine, University of Occupational and Environmental Health, Kitakyushu; Department of Neurosurgery (S.Y.), Hyogo College of Medicine, Nishinomiya; Department of Emergency and Critical Care Medicine (K. Okuchi), Nara Medical University, Kashihara; Department of Surgical Neurology (A.S.), Research Institute for Brain and Blood Vessels, Akita; and Division of Data Management Center for Cardiovascular Disease Information (F.N.), National Cerebral Cardiovascular Disease Information, Suita, Japan
| | - Keisuke Ido
- From the Departments of Neurosurgery (R.K., K. Ido, A. Kurogi, N.M., A.N., K.A., K. Iihara), Health Communication (D.O., A.H.), and Medicine and Clinical Science (T.K.), Graduate School of Medical Sciences, Kyushu University; Department of Neuroendovascular Surgery (R.K.), National Hospital Organization, Clinical Research Institute, Kyushu Medical Center, Fukuoka; Department of Statistics and Data Analysis, Center for Cerebral and Cardiovascular Disease Information (K.N., M.N.), Integrative Stroke Imaging Centre (J.N.), and Department of Cerebrovascular Medicine (K.T.), National Cerebral and Cardiovascular Center, Suita; Department of Clinical Trials and Research (A. Kada), National Hospital Organization, Nagoya Medical Center; Division of Health Services Research (S.K.), Center for Cancer Control and Information Services, National Cancer Center, Tokyo; Department of Neurosurgery (K. Ogasawara), Iwate Medical University, Morioka; Department of Neurosurgery (J.O.), Sanmu Medical Center; Department of Neurosurgery (Y.S.), Kyorin University, Mitaka; Department of Emergency and Critical Care Medicine (T.A.), Showa University Hospital, Shinagawa; Department of Neurosurgery (S. Miyachi), Osaka Medical College, Takatsuki; Department of Neurosurgery (I.N.), Kokura Memorial Hospital; Department of Preventive Medicine and Community Health (S. Matsuda), School of Medicine, University of Occupational and Environmental Health, Kitakyushu; Department of Neurosurgery (S.Y.), Hyogo College of Medicine, Nishinomiya; Department of Emergency and Critical Care Medicine (K. Okuchi), Nara Medical University, Kashihara; Department of Surgical Neurology (A.S.), Research Institute for Brain and Blood Vessels, Akita; and Division of Data Management Center for Cardiovascular Disease Information (F.N.), National Cerebral Cardiovascular Disease Information, Suita, Japan
| | - Ai Kurogi
- From the Departments of Neurosurgery (R.K., K. Ido, A. Kurogi, N.M., A.N., K.A., K. Iihara), Health Communication (D.O., A.H.), and Medicine and Clinical Science (T.K.), Graduate School of Medical Sciences, Kyushu University; Department of Neuroendovascular Surgery (R.K.), National Hospital Organization, Clinical Research Institute, Kyushu Medical Center, Fukuoka; Department of Statistics and Data Analysis, Center for Cerebral and Cardiovascular Disease Information (K.N., M.N.), Integrative Stroke Imaging Centre (J.N.), and Department of Cerebrovascular Medicine (K.T.), National Cerebral and Cardiovascular Center, Suita; Department of Clinical Trials and Research (A. Kada), National Hospital Organization, Nagoya Medical Center; Division of Health Services Research (S.K.), Center for Cancer Control and Information Services, National Cancer Center, Tokyo; Department of Neurosurgery (K. Ogasawara), Iwate Medical University, Morioka; Department of Neurosurgery (J.O.), Sanmu Medical Center; Department of Neurosurgery (Y.S.), Kyorin University, Mitaka; Department of Emergency and Critical Care Medicine (T.A.), Showa University Hospital, Shinagawa; Department of Neurosurgery (S. Miyachi), Osaka Medical College, Takatsuki; Department of Neurosurgery (I.N.), Kokura Memorial Hospital; Department of Preventive Medicine and Community Health (S. Matsuda), School of Medicine, University of Occupational and Environmental Health, Kitakyushu; Department of Neurosurgery (S.Y.), Hyogo College of Medicine, Nishinomiya; Department of Emergency and Critical Care Medicine (K. Okuchi), Nara Medical University, Kashihara; Department of Surgical Neurology (A.S.), Research Institute for Brain and Blood Vessels, Akita; and Division of Data Management Center for Cardiovascular Disease Information (F.N.), National Cerebral Cardiovascular Disease Information, Suita, Japan
| | - Nobutaka Mukae
- From the Departments of Neurosurgery (R.K., K. Ido, A. Kurogi, N.M., A.N., K.A., K. Iihara), Health Communication (D.O., A.H.), and Medicine and Clinical Science (T.K.), Graduate School of Medical Sciences, Kyushu University; Department of Neuroendovascular Surgery (R.K.), National Hospital Organization, Clinical Research Institute, Kyushu Medical Center, Fukuoka; Department of Statistics and Data Analysis, Center for Cerebral and Cardiovascular Disease Information (K.N., M.N.), Integrative Stroke Imaging Centre (J.N.), and Department of Cerebrovascular Medicine (K.T.), National Cerebral and Cardiovascular Center, Suita; Department of Clinical Trials and Research (A. Kada), National Hospital Organization, Nagoya Medical Center; Division of Health Services Research (S.K.), Center for Cancer Control and Information Services, National Cancer Center, Tokyo; Department of Neurosurgery (K. Ogasawara), Iwate Medical University, Morioka; Department of Neurosurgery (J.O.), Sanmu Medical Center; Department of Neurosurgery (Y.S.), Kyorin University, Mitaka; Department of Emergency and Critical Care Medicine (T.A.), Showa University Hospital, Shinagawa; Department of Neurosurgery (S. Miyachi), Osaka Medical College, Takatsuki; Department of Neurosurgery (I.N.), Kokura Memorial Hospital; Department of Preventive Medicine and Community Health (S. Matsuda), School of Medicine, University of Occupational and Environmental Health, Kitakyushu; Department of Neurosurgery (S.Y.), Hyogo College of Medicine, Nishinomiya; Department of Emergency and Critical Care Medicine (K. Okuchi), Nara Medical University, Kashihara; Department of Surgical Neurology (A.S.), Research Institute for Brain and Blood Vessels, Akita; and Division of Data Management Center for Cardiovascular Disease Information (F.N.), National Cerebral Cardiovascular Disease Information, Suita, Japan
| | - Ataru Nishimura
- From the Departments of Neurosurgery (R.K., K. Ido, A. Kurogi, N.M., A.N., K.A., K. Iihara), Health Communication (D.O., A.H.), and Medicine and Clinical Science (T.K.), Graduate School of Medical Sciences, Kyushu University; Department of Neuroendovascular Surgery (R.K.), National Hospital Organization, Clinical Research Institute, Kyushu Medical Center, Fukuoka; Department of Statistics and Data Analysis, Center for Cerebral and Cardiovascular Disease Information (K.N., M.N.), Integrative Stroke Imaging Centre (J.N.), and Department of Cerebrovascular Medicine (K.T.), National Cerebral and Cardiovascular Center, Suita; Department of Clinical Trials and Research (A. Kada), National Hospital Organization, Nagoya Medical Center; Division of Health Services Research (S.K.), Center for Cancer Control and Information Services, National Cancer Center, Tokyo; Department of Neurosurgery (K. Ogasawara), Iwate Medical University, Morioka; Department of Neurosurgery (J.O.), Sanmu Medical Center; Department of Neurosurgery (Y.S.), Kyorin University, Mitaka; Department of Emergency and Critical Care Medicine (T.A.), Showa University Hospital, Shinagawa; Department of Neurosurgery (S. Miyachi), Osaka Medical College, Takatsuki; Department of Neurosurgery (I.N.), Kokura Memorial Hospital; Department of Preventive Medicine and Community Health (S. Matsuda), School of Medicine, University of Occupational and Environmental Health, Kitakyushu; Department of Neurosurgery (S.Y.), Hyogo College of Medicine, Nishinomiya; Department of Emergency and Critical Care Medicine (K. Okuchi), Nara Medical University, Kashihara; Department of Surgical Neurology (A.S.), Research Institute for Brain and Blood Vessels, Akita; and Division of Data Management Center for Cardiovascular Disease Information (F.N.), National Cerebral Cardiovascular Disease Information, Suita, Japan
| | - Koichi Arimura
- From the Departments of Neurosurgery (R.K., K. Ido, A. Kurogi, N.M., A.N., K.A., K. Iihara), Health Communication (D.O., A.H.), and Medicine and Clinical Science (T.K.), Graduate School of Medical Sciences, Kyushu University; Department of Neuroendovascular Surgery (R.K.), National Hospital Organization, Clinical Research Institute, Kyushu Medical Center, Fukuoka; Department of Statistics and Data Analysis, Center for Cerebral and Cardiovascular Disease Information (K.N., M.N.), Integrative Stroke Imaging Centre (J.N.), and Department of Cerebrovascular Medicine (K.T.), National Cerebral and Cardiovascular Center, Suita; Department of Clinical Trials and Research (A. Kada), National Hospital Organization, Nagoya Medical Center; Division of Health Services Research (S.K.), Center for Cancer Control and Information Services, National Cancer Center, Tokyo; Department of Neurosurgery (K. Ogasawara), Iwate Medical University, Morioka; Department of Neurosurgery (J.O.), Sanmu Medical Center; Department of Neurosurgery (Y.S.), Kyorin University, Mitaka; Department of Emergency and Critical Care Medicine (T.A.), Showa University Hospital, Shinagawa; Department of Neurosurgery (S. Miyachi), Osaka Medical College, Takatsuki; Department of Neurosurgery (I.N.), Kokura Memorial Hospital; Department of Preventive Medicine and Community Health (S. Matsuda), School of Medicine, University of Occupational and Environmental Health, Kitakyushu; Department of Neurosurgery (S.Y.), Hyogo College of Medicine, Nishinomiya; Department of Emergency and Critical Care Medicine (K. Okuchi), Nara Medical University, Kashihara; Department of Surgical Neurology (A.S.), Research Institute for Brain and Blood Vessels, Akita; and Division of Data Management Center for Cardiovascular Disease Information (F.N.), National Cerebral Cardiovascular Disease Information, Suita, Japan
| | - Takanari Kitazono
- From the Departments of Neurosurgery (R.K., K. Ido, A. Kurogi, N.M., A.N., K.A., K. Iihara), Health Communication (D.O., A.H.), and Medicine and Clinical Science (T.K.), Graduate School of Medical Sciences, Kyushu University; Department of Neuroendovascular Surgery (R.K.), National Hospital Organization, Clinical Research Institute, Kyushu Medical Center, Fukuoka; Department of Statistics and Data Analysis, Center for Cerebral and Cardiovascular Disease Information (K.N., M.N.), Integrative Stroke Imaging Centre (J.N.), and Department of Cerebrovascular Medicine (K.T.), National Cerebral and Cardiovascular Center, Suita; Department of Clinical Trials and Research (A. Kada), National Hospital Organization, Nagoya Medical Center; Division of Health Services Research (S.K.), Center for Cancer Control and Information Services, National Cancer Center, Tokyo; Department of Neurosurgery (K. Ogasawara), Iwate Medical University, Morioka; Department of Neurosurgery (J.O.), Sanmu Medical Center; Department of Neurosurgery (Y.S.), Kyorin University, Mitaka; Department of Emergency and Critical Care Medicine (T.A.), Showa University Hospital, Shinagawa; Department of Neurosurgery (S. Miyachi), Osaka Medical College, Takatsuki; Department of Neurosurgery (I.N.), Kokura Memorial Hospital; Department of Preventive Medicine and Community Health (S. Matsuda), School of Medicine, University of Occupational and Environmental Health, Kitakyushu; Department of Neurosurgery (S.Y.), Hyogo College of Medicine, Nishinomiya; Department of Emergency and Critical Care Medicine (K. Okuchi), Nara Medical University, Kashihara; Department of Surgical Neurology (A.S.), Research Institute for Brain and Blood Vessels, Akita; and Division of Data Management Center for Cardiovascular Disease Information (F.N.), National Cerebral Cardiovascular Disease Information, Suita, Japan
| | - Akihito Hagihara
- From the Departments of Neurosurgery (R.K., K. Ido, A. Kurogi, N.M., A.N., K.A., K. Iihara), Health Communication (D.O., A.H.), and Medicine and Clinical Science (T.K.), Graduate School of Medical Sciences, Kyushu University; Department of Neuroendovascular Surgery (R.K.), National Hospital Organization, Clinical Research Institute, Kyushu Medical Center, Fukuoka; Department of Statistics and Data Analysis, Center for Cerebral and Cardiovascular Disease Information (K.N., M.N.), Integrative Stroke Imaging Centre (J.N.), and Department of Cerebrovascular Medicine (K.T.), National Cerebral and Cardiovascular Center, Suita; Department of Clinical Trials and Research (A. Kada), National Hospital Organization, Nagoya Medical Center; Division of Health Services Research (S.K.), Center for Cancer Control and Information Services, National Cancer Center, Tokyo; Department of Neurosurgery (K. Ogasawara), Iwate Medical University, Morioka; Department of Neurosurgery (J.O.), Sanmu Medical Center; Department of Neurosurgery (Y.S.), Kyorin University, Mitaka; Department of Emergency and Critical Care Medicine (T.A.), Showa University Hospital, Shinagawa; Department of Neurosurgery (S. Miyachi), Osaka Medical College, Takatsuki; Department of Neurosurgery (I.N.), Kokura Memorial Hospital; Department of Preventive Medicine and Community Health (S. Matsuda), School of Medicine, University of Occupational and Environmental Health, Kitakyushu; Department of Neurosurgery (S.Y.), Hyogo College of Medicine, Nishinomiya; Department of Emergency and Critical Care Medicine (K. Okuchi), Nara Medical University, Kashihara; Department of Surgical Neurology (A.S.), Research Institute for Brain and Blood Vessels, Akita; and Division of Data Management Center for Cardiovascular Disease Information (F.N.), National Cerebral Cardiovascular Disease Information, Suita, Japan
| | - Koji Iihara
- From the Departments of Neurosurgery (R.K., K. Ido, A. Kurogi, N.M., A.N., K.A., K. Iihara), Health Communication (D.O., A.H.), and Medicine and Clinical Science (T.K.), Graduate School of Medical Sciences, Kyushu University; Department of Neuroendovascular Surgery (R.K.), National Hospital Organization, Clinical Research Institute, Kyushu Medical Center, Fukuoka; Department of Statistics and Data Analysis, Center for Cerebral and Cardiovascular Disease Information (K.N., M.N.), Integrative Stroke Imaging Centre (J.N.), and Department of Cerebrovascular Medicine (K.T.), National Cerebral and Cardiovascular Center, Suita; Department of Clinical Trials and Research (A. Kada), National Hospital Organization, Nagoya Medical Center; Division of Health Services Research (S.K.), Center for Cancer Control and Information Services, National Cancer Center, Tokyo; Department of Neurosurgery (K. Ogasawara), Iwate Medical University, Morioka; Department of Neurosurgery (J.O.), Sanmu Medical Center; Department of Neurosurgery (Y.S.), Kyorin University, Mitaka; Department of Emergency and Critical Care Medicine (T.A.), Showa University Hospital, Shinagawa; Department of Neurosurgery (S. Miyachi), Osaka Medical College, Takatsuki; Department of Neurosurgery (I.N.), Kokura Memorial Hospital; Department of Preventive Medicine and Community Health (S. Matsuda), School of Medicine, University of Occupational and Environmental Health, Kitakyushu; Department of Neurosurgery (S.Y.), Hyogo College of Medicine, Nishinomiya; Department of Emergency and Critical Care Medicine (K. Okuchi), Nara Medical University, Kashihara; Department of Surgical Neurology (A.S.), Research Institute for Brain and Blood Vessels, Akita; and Division of Data Management Center for Cardiovascular Disease Information (F.N.), National Cerebral Cardiovascular Disease Information, Suita, Japan.
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Anticoagulants inhibit proteolytic clearance of plasma amyloid beta. Oncotarget 2017; 9:5614-5626. [PMID: 29464022 PMCID: PMC5814162 DOI: 10.18632/oncotarget.23718] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2017] [Accepted: 12/22/2017] [Indexed: 01/30/2023] Open
Abstract
We recently discovered a plasma proteolysis pathway, termed the FXII-FVII pathway which is composed of coagulation proteases, and found it to be mainly responsible for the clearance of Aβ42 in the plasma in mice. Aβ42 and Aβ40 are the main Aβ forms in Alzheimer’s disease (AD). In the present study, in vitro assays, wild type (WT) mice and J20 mice (a transgenic AD model) are used to assess the degradation of Aβ40 and Aβ42 by the FXII-FVII pathway and the impact of anticoagulants on such degradation. Four clinically available and mechanistically distinct anticoagulants are evaluated, including dabigatran, enoxaparin (EP), rivaroxaban and warfarin. Each anticoagulant significantly elevates plasma level of synthetic Aβ42 in WT mice, among which EP is the most effective. The differential efficacies of the anticoagulants in elevating plasma Aβ42 level match closely with their inhibitory mechanisms towards the FXII-FVII pathway. Plasma Aβ40 is also degraded by the FXII-FVII pathway and is protected by EP. Moreover, the FXII-FVII pathway is significantly activated in J20 mice, but EP inhibits the activation and significantly elevates plasma levels of both Aβ40 and Aβ42. Taken together, our results shed new light on Aβ metabolism, reveal a novel function of anticoagulants, and suggest a novel approach to potentially developing plasma Aβ as an AD biomarker.
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18
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Garton T, Hua Y, Xiang J, Xi G, Keep RF. Challenges for intraventricular hemorrhage research and emerging therapeutic targets. Expert Opin Ther Targets 2017; 21:1111-1122. [PMID: 29067856 PMCID: PMC6097191 DOI: 10.1080/14728222.2017.1397628] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Intraventricular hemorrhage (IVH) affects both premature infants and adults. In both demographics, it has high mortality and morbidity. There is no FDA approved therapy that improves neurological outcome in either population highlighting the need for additional focus on therapeutic targets and treatments emerging from preclinical studies. Areas covered: IVH induces both initial injury linked to the physical effects of the blood (mass effect) and secondary injury linked to the brain response to the hemorrhage. Preclinical studies have identified multiple secondary injury mechanisms following IVH, and particularly the role of blood components (e.g. hemoglobin, iron, thrombin). This review, with an emphasis on pre-clinical IVH research, highlights therapeutic targets and treatments that may be of use in prevention, acute care, or repair of damage. Expert opinion: An IVH is a potentially devastating event. Progress has been made in elucidating injury mechanisms, but this has still to translate to the clinic. Some pathways involved in injury also have beneficial effects (coagulation cascade/inflammation). A greater understanding of the downstream pathways involved in those pathways may allow therapeutic development. Iron chelation (deferoxamine) is in clinical trial for intracerebral hemorrhage and preclinical data suggest it may be a potential treatment for IVH.
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Affiliation(s)
- Thomas Garton
- a Department of Neurosurgery , University of Michigan , Ann Arbor , MI , USA
| | - Ya Hua
- a Department of Neurosurgery , University of Michigan , Ann Arbor , MI , USA
| | - Jianming Xiang
- a Department of Neurosurgery , University of Michigan , Ann Arbor , MI , USA
| | - Guohua Xi
- a Department of Neurosurgery , University of Michigan , Ann Arbor , MI , USA
| | - Richard F Keep
- a Department of Neurosurgery , University of Michigan , Ann Arbor , MI , USA
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19
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Tatsumi K, Antoniak S, Subramaniam S, Gondouin B, Neidich SD, Beck MA, Mickelson J, Monroe DM, Bastarache JA, Mackman N. Anticoagulation increases alveolar hemorrhage in mice infected with influenza A. Physiol Rep 2017; 4:4/24/e13071. [PMID: 28003564 PMCID: PMC5210384 DOI: 10.14814/phy2.13071] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2016] [Revised: 11/11/2016] [Accepted: 11/16/2016] [Indexed: 12/23/2022] Open
Abstract
Influenza A virus infection is a common respiratory tract infection. Alveolar hemorrhage has been reported in patients with influenza pneumonia and in mice infected with influenza A. In this study, we investigated the effect of two anticoagulants on alveolar hemorrhage after influenza A virus (IAV) infection of wild‐type mice. Wild‐type mice were anticoagulated with either warfarin or the direct thrombin inhibitor dabigatran etexilate and then infected with a mouse‐adapted influenza virus (A/Puerto Rico/8/34 H1N1). Alveolar hemorrhage was assessed by measuring hemoglobin levels in the bronchoalveolar lavage fluid (BALF). We also measured vascular permeability and viral genomes in the lung, as well as white blood cells, inflammatory mediators, and protein in BALF. Survival and body weight were monitored for 14 days after influenza A infection. In infected mice receiving either warfarin or dabigatran etexilate we observed decreased activation of coagulation in the BALF and increased alveolar hemorrhage. Warfarin but not dabigatran etexilate increased vascular permeability and mortality of influenza A‐infected mice. Anticoagulation did not affect levels of influenza A genomes, white blood cells, inflammatory mediators, or protein in the BALF. Our study indicates that systemic anticoagulation increases alveolar hemorrhage in influenza A‐infected mice.
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Affiliation(s)
- Kohei Tatsumi
- Department of Medicine, Division of Hematology and Oncology, UNC McAllister Heart Institute, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Silvio Antoniak
- Department of Medicine, Division of Hematology and Oncology, UNC McAllister Heart Institute, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.,Department of Pathology and Laboratory Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Saravanan Subramaniam
- Department of Medicine, Division of Hematology and Oncology, UNC McAllister Heart Institute, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.,Department of Pathology and Laboratory Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Bertrand Gondouin
- Department of Medicine, Division of Hematology and Oncology, UNC McAllister Heart Institute, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Scott D Neidich
- Department of Nutrition, UNC Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Melinda A Beck
- Department of Nutrition, UNC Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Jacqueline Mickelson
- Department of Medicine, Division of Hematology and Oncology, UNC McAllister Heart Institute, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Dougald M Monroe
- Department of Medicine, Division of Hematology and Oncology, UNC McAllister Heart Institute, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Julie A Bastarache
- Department of Medicine, Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Nigel Mackman
- Department of Medicine, Division of Hematology and Oncology, UNC McAllister Heart Institute, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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Klebe D, Flores JJ, McBride DW, Krafft PR, Rolland WB, Lekic T, Zhang JH. Dabigatran ameliorates post-haemorrhagic hydrocephalus development after germinal matrix haemorrhage in neonatal rat pups. J Cereb Blood Flow Metab 2017; 37:3135-3149. [PMID: 28155585 PMCID: PMC5584693 DOI: 10.1177/0271678x16684355] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
We aim to determine if direct thrombin inhibition by dabigatran will improve long-term brain morphological and neurofunctional outcomes and if potential therapeutic effects are dependent upon reduced PAR-1 stimulation and consequent mTOR activation. Germinal matrix haemorrhage was induced by stereotaxically injecting 0.3 U type VII-S collagenase into the germinal matrix of P7 rat pups. Animals were divided into five groups: sham, vehicle (5% DMSO), dabigatran intraperitoneal, dabigatran intraperitoneal + TFLLR-NH2 (PAR-1 agonist) intranasal, SCH79797 (PAR-1 antagonist) intraperitoneal, and dabigatran intranasal. Neurofunctional outcomes were determined by Morris water maze, rotarod, and foot fault evaluations at three weeks. Brain morphological outcomes were determined by histological Nissl staining at four weeks. Expression levels of p-mTOR/p-p70s6k at three days and vitronectin/fibronectin at 28 days were quantified. Intranasal and intraperitoneal dabigatran promoted long-term neurofunctional recovery, improved brain morphological outcomes, and reduced intracranial pressure at four weeks after GMH. PAR-1 stimulation tended to reverse dabigatran's effects on post-haemorrhagic hydrocephalus development. Dabigatran also reduced expression of short-term p-mTOR and long-term extracellular matrix proteins, which tended to be reversed by PAR-1 agonist co-administration. PAR-1 inhibition alone, however, did not achieve the same therapeutic effects as dabigatran administration.
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Affiliation(s)
- Damon Klebe
- 1 Department of Physiology and Pharmacology, Loma Linda University School of Medicine, Loma Linda, CA, USA
| | - Jerry J Flores
- 1 Department of Physiology and Pharmacology, Loma Linda University School of Medicine, Loma Linda, CA, USA
| | - Devin W McBride
- 1 Department of Physiology and Pharmacology, Loma Linda University School of Medicine, Loma Linda, CA, USA
| | - Paul R Krafft
- 1 Department of Physiology and Pharmacology, Loma Linda University School of Medicine, Loma Linda, CA, USA
| | - William B Rolland
- 1 Department of Physiology and Pharmacology, Loma Linda University School of Medicine, Loma Linda, CA, USA
| | - Tim Lekic
- 1 Department of Physiology and Pharmacology, Loma Linda University School of Medicine, Loma Linda, CA, USA
| | - John H Zhang
- 1 Department of Physiology and Pharmacology, Loma Linda University School of Medicine, Loma Linda, CA, USA.,2 Department of Anaesthesiology and Neurosurgery, Loma Linda University School of Medicine, Loma Linda, CA, USA
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21
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The Severity of Intracranial Hemorrhages Measured by Free Hemoglobin in the Brain Depends on the Anticoagulant Class: Experimental Data. Stroke Res Treat 2017; 2017:6516401. [PMID: 28808596 PMCID: PMC5541810 DOI: 10.1155/2017/6516401] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2017] [Revised: 04/26/2017] [Accepted: 05/23/2017] [Indexed: 11/28/2022] Open
Abstract
Background and Purpose. Anticoagulant therapy is broadly used to prevent thromboembolic events. Intracranial hemorrhages are serious complications of anticoagulation, especially with warfarin. Direct oral anticoagulants reduce but do not eliminate the risk of intracranial hemorrhages. The aim of this study is to determine the degree of intracranial hemorrhage after application of anticoagulants without additional triggers. Methods. Rats were treated with different anticoagulant classes (vitamin K antagonists, heparin, direct thrombin inhibitor, and factor Xa inhibitor). Brain hemorrhages were assessed by the free hemoglobin concentration in the brain parenchyma. Results. Vitamin K antagonists (warfarin and brodifacoum) significantly increased free hemoglobin in the brain. Among direct oral anticoagulants, thrombin inhibitor dabigatran also significantly increased free hemoglobin in the brain, whereas treatment with factor Xa inhibitor rivaroxaban did not have significant effect on the free hemoglobin concentration. Conclusions. Our data indicates that the severity of brain hemorrhages depends on the anticoagulant class and it is more pronounced with vitamin K antagonists.
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Direct Oral Anticoagulants Form Thrombus Different From Warfarin in a Microchip Flow Chamber System. Sci Rep 2017; 7:7399. [PMID: 28785005 PMCID: PMC5547037 DOI: 10.1038/s41598-017-07939-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2016] [Accepted: 07/05/2017] [Indexed: 01/24/2023] Open
Abstract
Direct oral anticoagulants (DOACs) have low risk of intracranial hemorrhage compared to warfarin. We sought to clarify the different mechanisms responsible for suppression of bleeding events using the Total Thrombus-formation Analysis System (T-TAS), a flow-microchip chamber with thrombogenic surfaces. Blood samples were obtained at Off- and On-anticoagulant (trough) from 120 consecutive patients with atrial fibrillation (warfarin; n = 29, dabigatran; n = 19, rivaroxaban; n = 47, apixaban; n = 25), which were used for T-TAS to compute the area under the curve (AUC) (AR10-AUC30) in the AR chip, and to measure plasma concentrations of DOACs at On-anticoagulant. In addition, the two-dimensional area covered by thrombi (%) in the capillary was analyzed every 3 minutes after sample applications. The AR10-AUC30 correlated weakly and negatively with plasma concentrations of DOACs, and the levels at On-anticoagulant were lower in all groups than at Off-anticoagulant. AR10-AUC30 levels at Off- and On-anticoagulant were identical among the groups. The thrombi areas in early phase were significantly larger in rivaroxaban and apixaban than warfarin and dabigatran groups. The findings suggested that visual analysis of the AR-chip can identify the differential inhibitory patterns of warfarin and DOACs on thrombus formation under flow condition.
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23
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Wilson D, Seiffge DJ, Traenka C, Basir G, Purrucker JC, Rizos T, Sobowale OA, Sallinen H, Yeh SJ, Wu TY, Ferrigno M, Houben R, Schreuder FHBM, Perry LA, Tanaka J, Boulanger M, Al-Shahi Salman R, Jäger HR, Ambler G, Shakeshaft C, Yakushiji Y, Choi PMC, Staals J, Cordonnier C, Jeng JS, Veltkamp R, Dowlatshahi D, Engelter ST, Parry-Jones AR, Meretoja A, Werring DJ. Outcome of intracerebral hemorrhage associated with different oral anticoagulants. Neurology 2017; 88:1693-1700. [PMID: 28381513 PMCID: PMC5409844 DOI: 10.1212/wnl.0000000000003886] [Citation(s) in RCA: 117] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2016] [Accepted: 01/18/2017] [Indexed: 11/15/2022] Open
Abstract
Objective: In an international collaborative multicenter pooled analysis, we compared mortality, functional outcome, intracerebral hemorrhage (ICH) volume, and hematoma expansion (HE) between non–vitamin K antagonist oral anticoagulation–related ICH (NOAC-ICH) and vitamin K antagonist–associated ICH (VKA-ICH). Methods: We compared all-cause mortality within 90 days for NOAC-ICH and VKA-ICH using a Cox proportional hazards model adjusted for age; sex; baseline Glasgow Coma Scale score, ICH location, and log volume; intraventricular hemorrhage volume; and intracranial surgery. We addressed heterogeneity using a shared frailty term. Good functional outcome was defined as discharge modified Rankin Scale score ≤2 and investigated in multivariable logistic regression. ICH volume was measured by ABC/2 or a semiautomated planimetric method. HE was defined as an ICH volume increase >33% or >6 mL from baseline within 72 hours. Results: We included 500 patients (97 NOAC-ICH and 403 VKA-ICH). Median baseline ICH volume was 14.4 mL (interquartile range [IQR] 3.6–38.4) for NOAC-ICH vs 10.6 mL (IQR 4.0–27.9) for VKA-ICH (p = 0.78). We did not find any difference between NOAC-ICH and VKA-ICH for all-cause mortality within 90 days (33% for NOAC-ICH vs 31% for VKA-ICH [p = 0.64]; adjusted Cox hazard ratio (for NOAC-ICH vs VKA-ICH) 0.93 [95% confidence interval (CI) 0.52–1.64] [p = 0.79]), the rate of HE (NOAC-ICH n = 29/48 [40%] vs VKA-ICH n = 93/140 [34%] [p = 0.45]), or functional outcome at hospital discharge (NOAC-ICH vs VKA-ICH odds ratio 0.47; 95% CI 0.18–1.19 [p = 0.11]). Conclusions: In our international collaborative multicenter pooled analysis, baseline ICH volume, hematoma expansion, 90-day mortality, and functional outcome were similar following NOAC-ICH and VKA-ICH.
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Affiliation(s)
- Duncan Wilson
- From the Stroke Research Center (D.W., C.S., D.J.W.) and Neuroradiological Academic Unit (H.R.J.), Department of Brain Repair and Rehabilitation, Institute of Neurology, and Department of Statistical Science (G.A.), UCL, London, UK; Stroke Center and Neurology (D.J.S., C.T., S.T.E.), University Hospital Basel, University of Basel, Switzerland; Ottawa Hospital Research Institute and University of Ottawa (G.B., D.D.), Canada; Department of Neurology (J.C.P., T.R.), Heidelberg University Hospital, Germany; Manchester Academic Health Sciences Center (O.A.S., A.R.P.-J.), Salford Royal NHS Foundation Trust, UK; Department of Neurology (H.S., A.M.), Helsinki University Hospital, Finland; Stroke Center & Department of Neurology (S.-J.Y., J.-S.J.), Department of Neurology, National Taiwan University Hospital, Taipei; Department of Medicine and neurology at the Royal Melbourne Hospital (T.Y.W., A.M.), University of Melbourne, Parkville, Australia; U1171-Degenerative & Vascular Cognitive Disorders (M.F., C.C.), Univ Lille, Inserm, CHU Lille, France; Department of Neurology (R.H., F.H.B.M.S., J.S.), Maastricht University Medical Center, the Netherlands; Department of Neurosciences (J.A.P., P.M.C.C.), Eastern Health, Melbourne, Australia; Division of Neurology, Department of Internal Medicine (J.T., Y.Y.), Saga University Faculty of Medicine, Japan; Division of Clinical Neurosciences (M.B., R.A.-S.S.), Center for Clinical Brain Sciences, School of Clinical Sciences, University of Edinburgh; Department of Stroke Medicine, Division of Brain Sciences (R.V.), Imperial College London, UK; and Neurorehabilitation Unit (S.T.E.), University of Basel and University Center for Medicine of Aging, Felix Platter Hospital, Switzerland
| | - David J Seiffge
- From the Stroke Research Center (D.W., C.S., D.J.W.) and Neuroradiological Academic Unit (H.R.J.), Department of Brain Repair and Rehabilitation, Institute of Neurology, and Department of Statistical Science (G.A.), UCL, London, UK; Stroke Center and Neurology (D.J.S., C.T., S.T.E.), University Hospital Basel, University of Basel, Switzerland; Ottawa Hospital Research Institute and University of Ottawa (G.B., D.D.), Canada; Department of Neurology (J.C.P., T.R.), Heidelberg University Hospital, Germany; Manchester Academic Health Sciences Center (O.A.S., A.R.P.-J.), Salford Royal NHS Foundation Trust, UK; Department of Neurology (H.S., A.M.), Helsinki University Hospital, Finland; Stroke Center & Department of Neurology (S.-J.Y., J.-S.J.), Department of Neurology, National Taiwan University Hospital, Taipei; Department of Medicine and neurology at the Royal Melbourne Hospital (T.Y.W., A.M.), University of Melbourne, Parkville, Australia; U1171-Degenerative & Vascular Cognitive Disorders (M.F., C.C.), Univ Lille, Inserm, CHU Lille, France; Department of Neurology (R.H., F.H.B.M.S., J.S.), Maastricht University Medical Center, the Netherlands; Department of Neurosciences (J.A.P., P.M.C.C.), Eastern Health, Melbourne, Australia; Division of Neurology, Department of Internal Medicine (J.T., Y.Y.), Saga University Faculty of Medicine, Japan; Division of Clinical Neurosciences (M.B., R.A.-S.S.), Center for Clinical Brain Sciences, School of Clinical Sciences, University of Edinburgh; Department of Stroke Medicine, Division of Brain Sciences (R.V.), Imperial College London, UK; and Neurorehabilitation Unit (S.T.E.), University of Basel and University Center for Medicine of Aging, Felix Platter Hospital, Switzerland
| | - Christopher Traenka
- From the Stroke Research Center (D.W., C.S., D.J.W.) and Neuroradiological Academic Unit (H.R.J.), Department of Brain Repair and Rehabilitation, Institute of Neurology, and Department of Statistical Science (G.A.), UCL, London, UK; Stroke Center and Neurology (D.J.S., C.T., S.T.E.), University Hospital Basel, University of Basel, Switzerland; Ottawa Hospital Research Institute and University of Ottawa (G.B., D.D.), Canada; Department of Neurology (J.C.P., T.R.), Heidelberg University Hospital, Germany; Manchester Academic Health Sciences Center (O.A.S., A.R.P.-J.), Salford Royal NHS Foundation Trust, UK; Department of Neurology (H.S., A.M.), Helsinki University Hospital, Finland; Stroke Center & Department of Neurology (S.-J.Y., J.-S.J.), Department of Neurology, National Taiwan University Hospital, Taipei; Department of Medicine and neurology at the Royal Melbourne Hospital (T.Y.W., A.M.), University of Melbourne, Parkville, Australia; U1171-Degenerative & Vascular Cognitive Disorders (M.F., C.C.), Univ Lille, Inserm, CHU Lille, France; Department of Neurology (R.H., F.H.B.M.S., J.S.), Maastricht University Medical Center, the Netherlands; Department of Neurosciences (J.A.P., P.M.C.C.), Eastern Health, Melbourne, Australia; Division of Neurology, Department of Internal Medicine (J.T., Y.Y.), Saga University Faculty of Medicine, Japan; Division of Clinical Neurosciences (M.B., R.A.-S.S.), Center for Clinical Brain Sciences, School of Clinical Sciences, University of Edinburgh; Department of Stroke Medicine, Division of Brain Sciences (R.V.), Imperial College London, UK; and Neurorehabilitation Unit (S.T.E.), University of Basel and University Center for Medicine of Aging, Felix Platter Hospital, Switzerland
| | - Ghazala Basir
- From the Stroke Research Center (D.W., C.S., D.J.W.) and Neuroradiological Academic Unit (H.R.J.), Department of Brain Repair and Rehabilitation, Institute of Neurology, and Department of Statistical Science (G.A.), UCL, London, UK; Stroke Center and Neurology (D.J.S., C.T., S.T.E.), University Hospital Basel, University of Basel, Switzerland; Ottawa Hospital Research Institute and University of Ottawa (G.B., D.D.), Canada; Department of Neurology (J.C.P., T.R.), Heidelberg University Hospital, Germany; Manchester Academic Health Sciences Center (O.A.S., A.R.P.-J.), Salford Royal NHS Foundation Trust, UK; Department of Neurology (H.S., A.M.), Helsinki University Hospital, Finland; Stroke Center & Department of Neurology (S.-J.Y., J.-S.J.), Department of Neurology, National Taiwan University Hospital, Taipei; Department of Medicine and neurology at the Royal Melbourne Hospital (T.Y.W., A.M.), University of Melbourne, Parkville, Australia; U1171-Degenerative & Vascular Cognitive Disorders (M.F., C.C.), Univ Lille, Inserm, CHU Lille, France; Department of Neurology (R.H., F.H.B.M.S., J.S.), Maastricht University Medical Center, the Netherlands; Department of Neurosciences (J.A.P., P.M.C.C.), Eastern Health, Melbourne, Australia; Division of Neurology, Department of Internal Medicine (J.T., Y.Y.), Saga University Faculty of Medicine, Japan; Division of Clinical Neurosciences (M.B., R.A.-S.S.), Center for Clinical Brain Sciences, School of Clinical Sciences, University of Edinburgh; Department of Stroke Medicine, Division of Brain Sciences (R.V.), Imperial College London, UK; and Neurorehabilitation Unit (S.T.E.), University of Basel and University Center for Medicine of Aging, Felix Platter Hospital, Switzerland
| | - Jan C Purrucker
- From the Stroke Research Center (D.W., C.S., D.J.W.) and Neuroradiological Academic Unit (H.R.J.), Department of Brain Repair and Rehabilitation, Institute of Neurology, and Department of Statistical Science (G.A.), UCL, London, UK; Stroke Center and Neurology (D.J.S., C.T., S.T.E.), University Hospital Basel, University of Basel, Switzerland; Ottawa Hospital Research Institute and University of Ottawa (G.B., D.D.), Canada; Department of Neurology (J.C.P., T.R.), Heidelberg University Hospital, Germany; Manchester Academic Health Sciences Center (O.A.S., A.R.P.-J.), Salford Royal NHS Foundation Trust, UK; Department of Neurology (H.S., A.M.), Helsinki University Hospital, Finland; Stroke Center & Department of Neurology (S.-J.Y., J.-S.J.), Department of Neurology, National Taiwan University Hospital, Taipei; Department of Medicine and neurology at the Royal Melbourne Hospital (T.Y.W., A.M.), University of Melbourne, Parkville, Australia; U1171-Degenerative & Vascular Cognitive Disorders (M.F., C.C.), Univ Lille, Inserm, CHU Lille, France; Department of Neurology (R.H., F.H.B.M.S., J.S.), Maastricht University Medical Center, the Netherlands; Department of Neurosciences (J.A.P., P.M.C.C.), Eastern Health, Melbourne, Australia; Division of Neurology, Department of Internal Medicine (J.T., Y.Y.), Saga University Faculty of Medicine, Japan; Division of Clinical Neurosciences (M.B., R.A.-S.S.), Center for Clinical Brain Sciences, School of Clinical Sciences, University of Edinburgh; Department of Stroke Medicine, Division of Brain Sciences (R.V.), Imperial College London, UK; and Neurorehabilitation Unit (S.T.E.), University of Basel and University Center for Medicine of Aging, Felix Platter Hospital, Switzerland
| | - Timolaos Rizos
- From the Stroke Research Center (D.W., C.S., D.J.W.) and Neuroradiological Academic Unit (H.R.J.), Department of Brain Repair and Rehabilitation, Institute of Neurology, and Department of Statistical Science (G.A.), UCL, London, UK; Stroke Center and Neurology (D.J.S., C.T., S.T.E.), University Hospital Basel, University of Basel, Switzerland; Ottawa Hospital Research Institute and University of Ottawa (G.B., D.D.), Canada; Department of Neurology (J.C.P., T.R.), Heidelberg University Hospital, Germany; Manchester Academic Health Sciences Center (O.A.S., A.R.P.-J.), Salford Royal NHS Foundation Trust, UK; Department of Neurology (H.S., A.M.), Helsinki University Hospital, Finland; Stroke Center & Department of Neurology (S.-J.Y., J.-S.J.), Department of Neurology, National Taiwan University Hospital, Taipei; Department of Medicine and neurology at the Royal Melbourne Hospital (T.Y.W., A.M.), University of Melbourne, Parkville, Australia; U1171-Degenerative & Vascular Cognitive Disorders (M.F., C.C.), Univ Lille, Inserm, CHU Lille, France; Department of Neurology (R.H., F.H.B.M.S., J.S.), Maastricht University Medical Center, the Netherlands; Department of Neurosciences (J.A.P., P.M.C.C.), Eastern Health, Melbourne, Australia; Division of Neurology, Department of Internal Medicine (J.T., Y.Y.), Saga University Faculty of Medicine, Japan; Division of Clinical Neurosciences (M.B., R.A.-S.S.), Center for Clinical Brain Sciences, School of Clinical Sciences, University of Edinburgh; Department of Stroke Medicine, Division of Brain Sciences (R.V.), Imperial College London, UK; and Neurorehabilitation Unit (S.T.E.), University of Basel and University Center for Medicine of Aging, Felix Platter Hospital, Switzerland
| | - Oluwaseun A Sobowale
- From the Stroke Research Center (D.W., C.S., D.J.W.) and Neuroradiological Academic Unit (H.R.J.), Department of Brain Repair and Rehabilitation, Institute of Neurology, and Department of Statistical Science (G.A.), UCL, London, UK; Stroke Center and Neurology (D.J.S., C.T., S.T.E.), University Hospital Basel, University of Basel, Switzerland; Ottawa Hospital Research Institute and University of Ottawa (G.B., D.D.), Canada; Department of Neurology (J.C.P., T.R.), Heidelberg University Hospital, Germany; Manchester Academic Health Sciences Center (O.A.S., A.R.P.-J.), Salford Royal NHS Foundation Trust, UK; Department of Neurology (H.S., A.M.), Helsinki University Hospital, Finland; Stroke Center & Department of Neurology (S.-J.Y., J.-S.J.), Department of Neurology, National Taiwan University Hospital, Taipei; Department of Medicine and neurology at the Royal Melbourne Hospital (T.Y.W., A.M.), University of Melbourne, Parkville, Australia; U1171-Degenerative & Vascular Cognitive Disorders (M.F., C.C.), Univ Lille, Inserm, CHU Lille, France; Department of Neurology (R.H., F.H.B.M.S., J.S.), Maastricht University Medical Center, the Netherlands; Department of Neurosciences (J.A.P., P.M.C.C.), Eastern Health, Melbourne, Australia; Division of Neurology, Department of Internal Medicine (J.T., Y.Y.), Saga University Faculty of Medicine, Japan; Division of Clinical Neurosciences (M.B., R.A.-S.S.), Center for Clinical Brain Sciences, School of Clinical Sciences, University of Edinburgh; Department of Stroke Medicine, Division of Brain Sciences (R.V.), Imperial College London, UK; and Neurorehabilitation Unit (S.T.E.), University of Basel and University Center for Medicine of Aging, Felix Platter Hospital, Switzerland
| | - Hanne Sallinen
- From the Stroke Research Center (D.W., C.S., D.J.W.) and Neuroradiological Academic Unit (H.R.J.), Department of Brain Repair and Rehabilitation, Institute of Neurology, and Department of Statistical Science (G.A.), UCL, London, UK; Stroke Center and Neurology (D.J.S., C.T., S.T.E.), University Hospital Basel, University of Basel, Switzerland; Ottawa Hospital Research Institute and University of Ottawa (G.B., D.D.), Canada; Department of Neurology (J.C.P., T.R.), Heidelberg University Hospital, Germany; Manchester Academic Health Sciences Center (O.A.S., A.R.P.-J.), Salford Royal NHS Foundation Trust, UK; Department of Neurology (H.S., A.M.), Helsinki University Hospital, Finland; Stroke Center & Department of Neurology (S.-J.Y., J.-S.J.), Department of Neurology, National Taiwan University Hospital, Taipei; Department of Medicine and neurology at the Royal Melbourne Hospital (T.Y.W., A.M.), University of Melbourne, Parkville, Australia; U1171-Degenerative & Vascular Cognitive Disorders (M.F., C.C.), Univ Lille, Inserm, CHU Lille, France; Department of Neurology (R.H., F.H.B.M.S., J.S.), Maastricht University Medical Center, the Netherlands; Department of Neurosciences (J.A.P., P.M.C.C.), Eastern Health, Melbourne, Australia; Division of Neurology, Department of Internal Medicine (J.T., Y.Y.), Saga University Faculty of Medicine, Japan; Division of Clinical Neurosciences (M.B., R.A.-S.S.), Center for Clinical Brain Sciences, School of Clinical Sciences, University of Edinburgh; Department of Stroke Medicine, Division of Brain Sciences (R.V.), Imperial College London, UK; and Neurorehabilitation Unit (S.T.E.), University of Basel and University Center for Medicine of Aging, Felix Platter Hospital, Switzerland
| | - Shin-Joe Yeh
- From the Stroke Research Center (D.W., C.S., D.J.W.) and Neuroradiological Academic Unit (H.R.J.), Department of Brain Repair and Rehabilitation, Institute of Neurology, and Department of Statistical Science (G.A.), UCL, London, UK; Stroke Center and Neurology (D.J.S., C.T., S.T.E.), University Hospital Basel, University of Basel, Switzerland; Ottawa Hospital Research Institute and University of Ottawa (G.B., D.D.), Canada; Department of Neurology (J.C.P., T.R.), Heidelberg University Hospital, Germany; Manchester Academic Health Sciences Center (O.A.S., A.R.P.-J.), Salford Royal NHS Foundation Trust, UK; Department of Neurology (H.S., A.M.), Helsinki University Hospital, Finland; Stroke Center & Department of Neurology (S.-J.Y., J.-S.J.), Department of Neurology, National Taiwan University Hospital, Taipei; Department of Medicine and neurology at the Royal Melbourne Hospital (T.Y.W., A.M.), University of Melbourne, Parkville, Australia; U1171-Degenerative & Vascular Cognitive Disorders (M.F., C.C.), Univ Lille, Inserm, CHU Lille, France; Department of Neurology (R.H., F.H.B.M.S., J.S.), Maastricht University Medical Center, the Netherlands; Department of Neurosciences (J.A.P., P.M.C.C.), Eastern Health, Melbourne, Australia; Division of Neurology, Department of Internal Medicine (J.T., Y.Y.), Saga University Faculty of Medicine, Japan; Division of Clinical Neurosciences (M.B., R.A.-S.S.), Center for Clinical Brain Sciences, School of Clinical Sciences, University of Edinburgh; Department of Stroke Medicine, Division of Brain Sciences (R.V.), Imperial College London, UK; and Neurorehabilitation Unit (S.T.E.), University of Basel and University Center for Medicine of Aging, Felix Platter Hospital, Switzerland
| | - Teddy Y Wu
- From the Stroke Research Center (D.W., C.S., D.J.W.) and Neuroradiological Academic Unit (H.R.J.), Department of Brain Repair and Rehabilitation, Institute of Neurology, and Department of Statistical Science (G.A.), UCL, London, UK; Stroke Center and Neurology (D.J.S., C.T., S.T.E.), University Hospital Basel, University of Basel, Switzerland; Ottawa Hospital Research Institute and University of Ottawa (G.B., D.D.), Canada; Department of Neurology (J.C.P., T.R.), Heidelberg University Hospital, Germany; Manchester Academic Health Sciences Center (O.A.S., A.R.P.-J.), Salford Royal NHS Foundation Trust, UK; Department of Neurology (H.S., A.M.), Helsinki University Hospital, Finland; Stroke Center & Department of Neurology (S.-J.Y., J.-S.J.), Department of Neurology, National Taiwan University Hospital, Taipei; Department of Medicine and neurology at the Royal Melbourne Hospital (T.Y.W., A.M.), University of Melbourne, Parkville, Australia; U1171-Degenerative & Vascular Cognitive Disorders (M.F., C.C.), Univ Lille, Inserm, CHU Lille, France; Department of Neurology (R.H., F.H.B.M.S., J.S.), Maastricht University Medical Center, the Netherlands; Department of Neurosciences (J.A.P., P.M.C.C.), Eastern Health, Melbourne, Australia; Division of Neurology, Department of Internal Medicine (J.T., Y.Y.), Saga University Faculty of Medicine, Japan; Division of Clinical Neurosciences (M.B., R.A.-S.S.), Center for Clinical Brain Sciences, School of Clinical Sciences, University of Edinburgh; Department of Stroke Medicine, Division of Brain Sciences (R.V.), Imperial College London, UK; and Neurorehabilitation Unit (S.T.E.), University of Basel and University Center for Medicine of Aging, Felix Platter Hospital, Switzerland
| | - Marc Ferrigno
- From the Stroke Research Center (D.W., C.S., D.J.W.) and Neuroradiological Academic Unit (H.R.J.), Department of Brain Repair and Rehabilitation, Institute of Neurology, and Department of Statistical Science (G.A.), UCL, London, UK; Stroke Center and Neurology (D.J.S., C.T., S.T.E.), University Hospital Basel, University of Basel, Switzerland; Ottawa Hospital Research Institute and University of Ottawa (G.B., D.D.), Canada; Department of Neurology (J.C.P., T.R.), Heidelberg University Hospital, Germany; Manchester Academic Health Sciences Center (O.A.S., A.R.P.-J.), Salford Royal NHS Foundation Trust, UK; Department of Neurology (H.S., A.M.), Helsinki University Hospital, Finland; Stroke Center & Department of Neurology (S.-J.Y., J.-S.J.), Department of Neurology, National Taiwan University Hospital, Taipei; Department of Medicine and neurology at the Royal Melbourne Hospital (T.Y.W., A.M.), University of Melbourne, Parkville, Australia; U1171-Degenerative & Vascular Cognitive Disorders (M.F., C.C.), Univ Lille, Inserm, CHU Lille, France; Department of Neurology (R.H., F.H.B.M.S., J.S.), Maastricht University Medical Center, the Netherlands; Department of Neurosciences (J.A.P., P.M.C.C.), Eastern Health, Melbourne, Australia; Division of Neurology, Department of Internal Medicine (J.T., Y.Y.), Saga University Faculty of Medicine, Japan; Division of Clinical Neurosciences (M.B., R.A.-S.S.), Center for Clinical Brain Sciences, School of Clinical Sciences, University of Edinburgh; Department of Stroke Medicine, Division of Brain Sciences (R.V.), Imperial College London, UK; and Neurorehabilitation Unit (S.T.E.), University of Basel and University Center for Medicine of Aging, Felix Platter Hospital, Switzerland
| | - Rik Houben
- From the Stroke Research Center (D.W., C.S., D.J.W.) and Neuroradiological Academic Unit (H.R.J.), Department of Brain Repair and Rehabilitation, Institute of Neurology, and Department of Statistical Science (G.A.), UCL, London, UK; Stroke Center and Neurology (D.J.S., C.T., S.T.E.), University Hospital Basel, University of Basel, Switzerland; Ottawa Hospital Research Institute and University of Ottawa (G.B., D.D.), Canada; Department of Neurology (J.C.P., T.R.), Heidelberg University Hospital, Germany; Manchester Academic Health Sciences Center (O.A.S., A.R.P.-J.), Salford Royal NHS Foundation Trust, UK; Department of Neurology (H.S., A.M.), Helsinki University Hospital, Finland; Stroke Center & Department of Neurology (S.-J.Y., J.-S.J.), Department of Neurology, National Taiwan University Hospital, Taipei; Department of Medicine and neurology at the Royal Melbourne Hospital (T.Y.W., A.M.), University of Melbourne, Parkville, Australia; U1171-Degenerative & Vascular Cognitive Disorders (M.F., C.C.), Univ Lille, Inserm, CHU Lille, France; Department of Neurology (R.H., F.H.B.M.S., J.S.), Maastricht University Medical Center, the Netherlands; Department of Neurosciences (J.A.P., P.M.C.C.), Eastern Health, Melbourne, Australia; Division of Neurology, Department of Internal Medicine (J.T., Y.Y.), Saga University Faculty of Medicine, Japan; Division of Clinical Neurosciences (M.B., R.A.-S.S.), Center for Clinical Brain Sciences, School of Clinical Sciences, University of Edinburgh; Department of Stroke Medicine, Division of Brain Sciences (R.V.), Imperial College London, UK; and Neurorehabilitation Unit (S.T.E.), University of Basel and University Center for Medicine of Aging, Felix Platter Hospital, Switzerland
| | - Floris H B M Schreuder
- From the Stroke Research Center (D.W., C.S., D.J.W.) and Neuroradiological Academic Unit (H.R.J.), Department of Brain Repair and Rehabilitation, Institute of Neurology, and Department of Statistical Science (G.A.), UCL, London, UK; Stroke Center and Neurology (D.J.S., C.T., S.T.E.), University Hospital Basel, University of Basel, Switzerland; Ottawa Hospital Research Institute and University of Ottawa (G.B., D.D.), Canada; Department of Neurology (J.C.P., T.R.), Heidelberg University Hospital, Germany; Manchester Academic Health Sciences Center (O.A.S., A.R.P.-J.), Salford Royal NHS Foundation Trust, UK; Department of Neurology (H.S., A.M.), Helsinki University Hospital, Finland; Stroke Center & Department of Neurology (S.-J.Y., J.-S.J.), Department of Neurology, National Taiwan University Hospital, Taipei; Department of Medicine and neurology at the Royal Melbourne Hospital (T.Y.W., A.M.), University of Melbourne, Parkville, Australia; U1171-Degenerative & Vascular Cognitive Disorders (M.F., C.C.), Univ Lille, Inserm, CHU Lille, France; Department of Neurology (R.H., F.H.B.M.S., J.S.), Maastricht University Medical Center, the Netherlands; Department of Neurosciences (J.A.P., P.M.C.C.), Eastern Health, Melbourne, Australia; Division of Neurology, Department of Internal Medicine (J.T., Y.Y.), Saga University Faculty of Medicine, Japan; Division of Clinical Neurosciences (M.B., R.A.-S.S.), Center for Clinical Brain Sciences, School of Clinical Sciences, University of Edinburgh; Department of Stroke Medicine, Division of Brain Sciences (R.V.), Imperial College London, UK; and Neurorehabilitation Unit (S.T.E.), University of Basel and University Center for Medicine of Aging, Felix Platter Hospital, Switzerland
| | - Luke A Perry
- From the Stroke Research Center (D.W., C.S., D.J.W.) and Neuroradiological Academic Unit (H.R.J.), Department of Brain Repair and Rehabilitation, Institute of Neurology, and Department of Statistical Science (G.A.), UCL, London, UK; Stroke Center and Neurology (D.J.S., C.T., S.T.E.), University Hospital Basel, University of Basel, Switzerland; Ottawa Hospital Research Institute and University of Ottawa (G.B., D.D.), Canada; Department of Neurology (J.C.P., T.R.), Heidelberg University Hospital, Germany; Manchester Academic Health Sciences Center (O.A.S., A.R.P.-J.), Salford Royal NHS Foundation Trust, UK; Department of Neurology (H.S., A.M.), Helsinki University Hospital, Finland; Stroke Center & Department of Neurology (S.-J.Y., J.-S.J.), Department of Neurology, National Taiwan University Hospital, Taipei; Department of Medicine and neurology at the Royal Melbourne Hospital (T.Y.W., A.M.), University of Melbourne, Parkville, Australia; U1171-Degenerative & Vascular Cognitive Disorders (M.F., C.C.), Univ Lille, Inserm, CHU Lille, France; Department of Neurology (R.H., F.H.B.M.S., J.S.), Maastricht University Medical Center, the Netherlands; Department of Neurosciences (J.A.P., P.M.C.C.), Eastern Health, Melbourne, Australia; Division of Neurology, Department of Internal Medicine (J.T., Y.Y.), Saga University Faculty of Medicine, Japan; Division of Clinical Neurosciences (M.B., R.A.-S.S.), Center for Clinical Brain Sciences, School of Clinical Sciences, University of Edinburgh; Department of Stroke Medicine, Division of Brain Sciences (R.V.), Imperial College London, UK; and Neurorehabilitation Unit (S.T.E.), University of Basel and University Center for Medicine of Aging, Felix Platter Hospital, Switzerland
| | - Jun Tanaka
- From the Stroke Research Center (D.W., C.S., D.J.W.) and Neuroradiological Academic Unit (H.R.J.), Department of Brain Repair and Rehabilitation, Institute of Neurology, and Department of Statistical Science (G.A.), UCL, London, UK; Stroke Center and Neurology (D.J.S., C.T., S.T.E.), University Hospital Basel, University of Basel, Switzerland; Ottawa Hospital Research Institute and University of Ottawa (G.B., D.D.), Canada; Department of Neurology (J.C.P., T.R.), Heidelberg University Hospital, Germany; Manchester Academic Health Sciences Center (O.A.S., A.R.P.-J.), Salford Royal NHS Foundation Trust, UK; Department of Neurology (H.S., A.M.), Helsinki University Hospital, Finland; Stroke Center & Department of Neurology (S.-J.Y., J.-S.J.), Department of Neurology, National Taiwan University Hospital, Taipei; Department of Medicine and neurology at the Royal Melbourne Hospital (T.Y.W., A.M.), University of Melbourne, Parkville, Australia; U1171-Degenerative & Vascular Cognitive Disorders (M.F., C.C.), Univ Lille, Inserm, CHU Lille, France; Department of Neurology (R.H., F.H.B.M.S., J.S.), Maastricht University Medical Center, the Netherlands; Department of Neurosciences (J.A.P., P.M.C.C.), Eastern Health, Melbourne, Australia; Division of Neurology, Department of Internal Medicine (J.T., Y.Y.), Saga University Faculty of Medicine, Japan; Division of Clinical Neurosciences (M.B., R.A.-S.S.), Center for Clinical Brain Sciences, School of Clinical Sciences, University of Edinburgh; Department of Stroke Medicine, Division of Brain Sciences (R.V.), Imperial College London, UK; and Neurorehabilitation Unit (S.T.E.), University of Basel and University Center for Medicine of Aging, Felix Platter Hospital, Switzerland
| | - Marion Boulanger
- From the Stroke Research Center (D.W., C.S., D.J.W.) and Neuroradiological Academic Unit (H.R.J.), Department of Brain Repair and Rehabilitation, Institute of Neurology, and Department of Statistical Science (G.A.), UCL, London, UK; Stroke Center and Neurology (D.J.S., C.T., S.T.E.), University Hospital Basel, University of Basel, Switzerland; Ottawa Hospital Research Institute and University of Ottawa (G.B., D.D.), Canada; Department of Neurology (J.C.P., T.R.), Heidelberg University Hospital, Germany; Manchester Academic Health Sciences Center (O.A.S., A.R.P.-J.), Salford Royal NHS Foundation Trust, UK; Department of Neurology (H.S., A.M.), Helsinki University Hospital, Finland; Stroke Center & Department of Neurology (S.-J.Y., J.-S.J.), Department of Neurology, National Taiwan University Hospital, Taipei; Department of Medicine and neurology at the Royal Melbourne Hospital (T.Y.W., A.M.), University of Melbourne, Parkville, Australia; U1171-Degenerative & Vascular Cognitive Disorders (M.F., C.C.), Univ Lille, Inserm, CHU Lille, France; Department of Neurology (R.H., F.H.B.M.S., J.S.), Maastricht University Medical Center, the Netherlands; Department of Neurosciences (J.A.P., P.M.C.C.), Eastern Health, Melbourne, Australia; Division of Neurology, Department of Internal Medicine (J.T., Y.Y.), Saga University Faculty of Medicine, Japan; Division of Clinical Neurosciences (M.B., R.A.-S.S.), Center for Clinical Brain Sciences, School of Clinical Sciences, University of Edinburgh; Department of Stroke Medicine, Division of Brain Sciences (R.V.), Imperial College London, UK; and Neurorehabilitation Unit (S.T.E.), University of Basel and University Center for Medicine of Aging, Felix Platter Hospital, Switzerland
| | - Rustam Al-Shahi Salman
- From the Stroke Research Center (D.W., C.S., D.J.W.) and Neuroradiological Academic Unit (H.R.J.), Department of Brain Repair and Rehabilitation, Institute of Neurology, and Department of Statistical Science (G.A.), UCL, London, UK; Stroke Center and Neurology (D.J.S., C.T., S.T.E.), University Hospital Basel, University of Basel, Switzerland; Ottawa Hospital Research Institute and University of Ottawa (G.B., D.D.), Canada; Department of Neurology (J.C.P., T.R.), Heidelberg University Hospital, Germany; Manchester Academic Health Sciences Center (O.A.S., A.R.P.-J.), Salford Royal NHS Foundation Trust, UK; Department of Neurology (H.S., A.M.), Helsinki University Hospital, Finland; Stroke Center & Department of Neurology (S.-J.Y., J.-S.J.), Department of Neurology, National Taiwan University Hospital, Taipei; Department of Medicine and neurology at the Royal Melbourne Hospital (T.Y.W., A.M.), University of Melbourne, Parkville, Australia; U1171-Degenerative & Vascular Cognitive Disorders (M.F., C.C.), Univ Lille, Inserm, CHU Lille, France; Department of Neurology (R.H., F.H.B.M.S., J.S.), Maastricht University Medical Center, the Netherlands; Department of Neurosciences (J.A.P., P.M.C.C.), Eastern Health, Melbourne, Australia; Division of Neurology, Department of Internal Medicine (J.T., Y.Y.), Saga University Faculty of Medicine, Japan; Division of Clinical Neurosciences (M.B., R.A.-S.S.), Center for Clinical Brain Sciences, School of Clinical Sciences, University of Edinburgh; Department of Stroke Medicine, Division of Brain Sciences (R.V.), Imperial College London, UK; and Neurorehabilitation Unit (S.T.E.), University of Basel and University Center for Medicine of Aging, Felix Platter Hospital, Switzerland
| | - Hans R Jäger
- From the Stroke Research Center (D.W., C.S., D.J.W.) and Neuroradiological Academic Unit (H.R.J.), Department of Brain Repair and Rehabilitation, Institute of Neurology, and Department of Statistical Science (G.A.), UCL, London, UK; Stroke Center and Neurology (D.J.S., C.T., S.T.E.), University Hospital Basel, University of Basel, Switzerland; Ottawa Hospital Research Institute and University of Ottawa (G.B., D.D.), Canada; Department of Neurology (J.C.P., T.R.), Heidelberg University Hospital, Germany; Manchester Academic Health Sciences Center (O.A.S., A.R.P.-J.), Salford Royal NHS Foundation Trust, UK; Department of Neurology (H.S., A.M.), Helsinki University Hospital, Finland; Stroke Center & Department of Neurology (S.-J.Y., J.-S.J.), Department of Neurology, National Taiwan University Hospital, Taipei; Department of Medicine and neurology at the Royal Melbourne Hospital (T.Y.W., A.M.), University of Melbourne, Parkville, Australia; U1171-Degenerative & Vascular Cognitive Disorders (M.F., C.C.), Univ Lille, Inserm, CHU Lille, France; Department of Neurology (R.H., F.H.B.M.S., J.S.), Maastricht University Medical Center, the Netherlands; Department of Neurosciences (J.A.P., P.M.C.C.), Eastern Health, Melbourne, Australia; Division of Neurology, Department of Internal Medicine (J.T., Y.Y.), Saga University Faculty of Medicine, Japan; Division of Clinical Neurosciences (M.B., R.A.-S.S.), Center for Clinical Brain Sciences, School of Clinical Sciences, University of Edinburgh; Department of Stroke Medicine, Division of Brain Sciences (R.V.), Imperial College London, UK; and Neurorehabilitation Unit (S.T.E.), University of Basel and University Center for Medicine of Aging, Felix Platter Hospital, Switzerland
| | - Gareth Ambler
- From the Stroke Research Center (D.W., C.S., D.J.W.) and Neuroradiological Academic Unit (H.R.J.), Department of Brain Repair and Rehabilitation, Institute of Neurology, and Department of Statistical Science (G.A.), UCL, London, UK; Stroke Center and Neurology (D.J.S., C.T., S.T.E.), University Hospital Basel, University of Basel, Switzerland; Ottawa Hospital Research Institute and University of Ottawa (G.B., D.D.), Canada; Department of Neurology (J.C.P., T.R.), Heidelberg University Hospital, Germany; Manchester Academic Health Sciences Center (O.A.S., A.R.P.-J.), Salford Royal NHS Foundation Trust, UK; Department of Neurology (H.S., A.M.), Helsinki University Hospital, Finland; Stroke Center & Department of Neurology (S.-J.Y., J.-S.J.), Department of Neurology, National Taiwan University Hospital, Taipei; Department of Medicine and neurology at the Royal Melbourne Hospital (T.Y.W., A.M.), University of Melbourne, Parkville, Australia; U1171-Degenerative & Vascular Cognitive Disorders (M.F., C.C.), Univ Lille, Inserm, CHU Lille, France; Department of Neurology (R.H., F.H.B.M.S., J.S.), Maastricht University Medical Center, the Netherlands; Department of Neurosciences (J.A.P., P.M.C.C.), Eastern Health, Melbourne, Australia; Division of Neurology, Department of Internal Medicine (J.T., Y.Y.), Saga University Faculty of Medicine, Japan; Division of Clinical Neurosciences (M.B., R.A.-S.S.), Center for Clinical Brain Sciences, School of Clinical Sciences, University of Edinburgh; Department of Stroke Medicine, Division of Brain Sciences (R.V.), Imperial College London, UK; and Neurorehabilitation Unit (S.T.E.), University of Basel and University Center for Medicine of Aging, Felix Platter Hospital, Switzerland
| | - Clare Shakeshaft
- From the Stroke Research Center (D.W., C.S., D.J.W.) and Neuroradiological Academic Unit (H.R.J.), Department of Brain Repair and Rehabilitation, Institute of Neurology, and Department of Statistical Science (G.A.), UCL, London, UK; Stroke Center and Neurology (D.J.S., C.T., S.T.E.), University Hospital Basel, University of Basel, Switzerland; Ottawa Hospital Research Institute and University of Ottawa (G.B., D.D.), Canada; Department of Neurology (J.C.P., T.R.), Heidelberg University Hospital, Germany; Manchester Academic Health Sciences Center (O.A.S., A.R.P.-J.), Salford Royal NHS Foundation Trust, UK; Department of Neurology (H.S., A.M.), Helsinki University Hospital, Finland; Stroke Center & Department of Neurology (S.-J.Y., J.-S.J.), Department of Neurology, National Taiwan University Hospital, Taipei; Department of Medicine and neurology at the Royal Melbourne Hospital (T.Y.W., A.M.), University of Melbourne, Parkville, Australia; U1171-Degenerative & Vascular Cognitive Disorders (M.F., C.C.), Univ Lille, Inserm, CHU Lille, France; Department of Neurology (R.H., F.H.B.M.S., J.S.), Maastricht University Medical Center, the Netherlands; Department of Neurosciences (J.A.P., P.M.C.C.), Eastern Health, Melbourne, Australia; Division of Neurology, Department of Internal Medicine (J.T., Y.Y.), Saga University Faculty of Medicine, Japan; Division of Clinical Neurosciences (M.B., R.A.-S.S.), Center for Clinical Brain Sciences, School of Clinical Sciences, University of Edinburgh; Department of Stroke Medicine, Division of Brain Sciences (R.V.), Imperial College London, UK; and Neurorehabilitation Unit (S.T.E.), University of Basel and University Center for Medicine of Aging, Felix Platter Hospital, Switzerland
| | - Yusuke Yakushiji
- From the Stroke Research Center (D.W., C.S., D.J.W.) and Neuroradiological Academic Unit (H.R.J.), Department of Brain Repair and Rehabilitation, Institute of Neurology, and Department of Statistical Science (G.A.), UCL, London, UK; Stroke Center and Neurology (D.J.S., C.T., S.T.E.), University Hospital Basel, University of Basel, Switzerland; Ottawa Hospital Research Institute and University of Ottawa (G.B., D.D.), Canada; Department of Neurology (J.C.P., T.R.), Heidelberg University Hospital, Germany; Manchester Academic Health Sciences Center (O.A.S., A.R.P.-J.), Salford Royal NHS Foundation Trust, UK; Department of Neurology (H.S., A.M.), Helsinki University Hospital, Finland; Stroke Center & Department of Neurology (S.-J.Y., J.-S.J.), Department of Neurology, National Taiwan University Hospital, Taipei; Department of Medicine and neurology at the Royal Melbourne Hospital (T.Y.W., A.M.), University of Melbourne, Parkville, Australia; U1171-Degenerative & Vascular Cognitive Disorders (M.F., C.C.), Univ Lille, Inserm, CHU Lille, France; Department of Neurology (R.H., F.H.B.M.S., J.S.), Maastricht University Medical Center, the Netherlands; Department of Neurosciences (J.A.P., P.M.C.C.), Eastern Health, Melbourne, Australia; Division of Neurology, Department of Internal Medicine (J.T., Y.Y.), Saga University Faculty of Medicine, Japan; Division of Clinical Neurosciences (M.B., R.A.-S.S.), Center for Clinical Brain Sciences, School of Clinical Sciences, University of Edinburgh; Department of Stroke Medicine, Division of Brain Sciences (R.V.), Imperial College London, UK; and Neurorehabilitation Unit (S.T.E.), University of Basel and University Center for Medicine of Aging, Felix Platter Hospital, Switzerland
| | - Philip M C Choi
- From the Stroke Research Center (D.W., C.S., D.J.W.) and Neuroradiological Academic Unit (H.R.J.), Department of Brain Repair and Rehabilitation, Institute of Neurology, and Department of Statistical Science (G.A.), UCL, London, UK; Stroke Center and Neurology (D.J.S., C.T., S.T.E.), University Hospital Basel, University of Basel, Switzerland; Ottawa Hospital Research Institute and University of Ottawa (G.B., D.D.), Canada; Department of Neurology (J.C.P., T.R.), Heidelberg University Hospital, Germany; Manchester Academic Health Sciences Center (O.A.S., A.R.P.-J.), Salford Royal NHS Foundation Trust, UK; Department of Neurology (H.S., A.M.), Helsinki University Hospital, Finland; Stroke Center & Department of Neurology (S.-J.Y., J.-S.J.), Department of Neurology, National Taiwan University Hospital, Taipei; Department of Medicine and neurology at the Royal Melbourne Hospital (T.Y.W., A.M.), University of Melbourne, Parkville, Australia; U1171-Degenerative & Vascular Cognitive Disorders (M.F., C.C.), Univ Lille, Inserm, CHU Lille, France; Department of Neurology (R.H., F.H.B.M.S., J.S.), Maastricht University Medical Center, the Netherlands; Department of Neurosciences (J.A.P., P.M.C.C.), Eastern Health, Melbourne, Australia; Division of Neurology, Department of Internal Medicine (J.T., Y.Y.), Saga University Faculty of Medicine, Japan; Division of Clinical Neurosciences (M.B., R.A.-S.S.), Center for Clinical Brain Sciences, School of Clinical Sciences, University of Edinburgh; Department of Stroke Medicine, Division of Brain Sciences (R.V.), Imperial College London, UK; and Neurorehabilitation Unit (S.T.E.), University of Basel and University Center for Medicine of Aging, Felix Platter Hospital, Switzerland
| | - Julie Staals
- From the Stroke Research Center (D.W., C.S., D.J.W.) and Neuroradiological Academic Unit (H.R.J.), Department of Brain Repair and Rehabilitation, Institute of Neurology, and Department of Statistical Science (G.A.), UCL, London, UK; Stroke Center and Neurology (D.J.S., C.T., S.T.E.), University Hospital Basel, University of Basel, Switzerland; Ottawa Hospital Research Institute and University of Ottawa (G.B., D.D.), Canada; Department of Neurology (J.C.P., T.R.), Heidelberg University Hospital, Germany; Manchester Academic Health Sciences Center (O.A.S., A.R.P.-J.), Salford Royal NHS Foundation Trust, UK; Department of Neurology (H.S., A.M.), Helsinki University Hospital, Finland; Stroke Center & Department of Neurology (S.-J.Y., J.-S.J.), Department of Neurology, National Taiwan University Hospital, Taipei; Department of Medicine and neurology at the Royal Melbourne Hospital (T.Y.W., A.M.), University of Melbourne, Parkville, Australia; U1171-Degenerative & Vascular Cognitive Disorders (M.F., C.C.), Univ Lille, Inserm, CHU Lille, France; Department of Neurology (R.H., F.H.B.M.S., J.S.), Maastricht University Medical Center, the Netherlands; Department of Neurosciences (J.A.P., P.M.C.C.), Eastern Health, Melbourne, Australia; Division of Neurology, Department of Internal Medicine (J.T., Y.Y.), Saga University Faculty of Medicine, Japan; Division of Clinical Neurosciences (M.B., R.A.-S.S.), Center for Clinical Brain Sciences, School of Clinical Sciences, University of Edinburgh; Department of Stroke Medicine, Division of Brain Sciences (R.V.), Imperial College London, UK; and Neurorehabilitation Unit (S.T.E.), University of Basel and University Center for Medicine of Aging, Felix Platter Hospital, Switzerland
| | - Charlotte Cordonnier
- From the Stroke Research Center (D.W., C.S., D.J.W.) and Neuroradiological Academic Unit (H.R.J.), Department of Brain Repair and Rehabilitation, Institute of Neurology, and Department of Statistical Science (G.A.), UCL, London, UK; Stroke Center and Neurology (D.J.S., C.T., S.T.E.), University Hospital Basel, University of Basel, Switzerland; Ottawa Hospital Research Institute and University of Ottawa (G.B., D.D.), Canada; Department of Neurology (J.C.P., T.R.), Heidelberg University Hospital, Germany; Manchester Academic Health Sciences Center (O.A.S., A.R.P.-J.), Salford Royal NHS Foundation Trust, UK; Department of Neurology (H.S., A.M.), Helsinki University Hospital, Finland; Stroke Center & Department of Neurology (S.-J.Y., J.-S.J.), Department of Neurology, National Taiwan University Hospital, Taipei; Department of Medicine and neurology at the Royal Melbourne Hospital (T.Y.W., A.M.), University of Melbourne, Parkville, Australia; U1171-Degenerative & Vascular Cognitive Disorders (M.F., C.C.), Univ Lille, Inserm, CHU Lille, France; Department of Neurology (R.H., F.H.B.M.S., J.S.), Maastricht University Medical Center, the Netherlands; Department of Neurosciences (J.A.P., P.M.C.C.), Eastern Health, Melbourne, Australia; Division of Neurology, Department of Internal Medicine (J.T., Y.Y.), Saga University Faculty of Medicine, Japan; Division of Clinical Neurosciences (M.B., R.A.-S.S.), Center for Clinical Brain Sciences, School of Clinical Sciences, University of Edinburgh; Department of Stroke Medicine, Division of Brain Sciences (R.V.), Imperial College London, UK; and Neurorehabilitation Unit (S.T.E.), University of Basel and University Center for Medicine of Aging, Felix Platter Hospital, Switzerland
| | - Jiann-Shing Jeng
- From the Stroke Research Center (D.W., C.S., D.J.W.) and Neuroradiological Academic Unit (H.R.J.), Department of Brain Repair and Rehabilitation, Institute of Neurology, and Department of Statistical Science (G.A.), UCL, London, UK; Stroke Center and Neurology (D.J.S., C.T., S.T.E.), University Hospital Basel, University of Basel, Switzerland; Ottawa Hospital Research Institute and University of Ottawa (G.B., D.D.), Canada; Department of Neurology (J.C.P., T.R.), Heidelberg University Hospital, Germany; Manchester Academic Health Sciences Center (O.A.S., A.R.P.-J.), Salford Royal NHS Foundation Trust, UK; Department of Neurology (H.S., A.M.), Helsinki University Hospital, Finland; Stroke Center & Department of Neurology (S.-J.Y., J.-S.J.), Department of Neurology, National Taiwan University Hospital, Taipei; Department of Medicine and neurology at the Royal Melbourne Hospital (T.Y.W., A.M.), University of Melbourne, Parkville, Australia; U1171-Degenerative & Vascular Cognitive Disorders (M.F., C.C.), Univ Lille, Inserm, CHU Lille, France; Department of Neurology (R.H., F.H.B.M.S., J.S.), Maastricht University Medical Center, the Netherlands; Department of Neurosciences (J.A.P., P.M.C.C.), Eastern Health, Melbourne, Australia; Division of Neurology, Department of Internal Medicine (J.T., Y.Y.), Saga University Faculty of Medicine, Japan; Division of Clinical Neurosciences (M.B., R.A.-S.S.), Center for Clinical Brain Sciences, School of Clinical Sciences, University of Edinburgh; Department of Stroke Medicine, Division of Brain Sciences (R.V.), Imperial College London, UK; and Neurorehabilitation Unit (S.T.E.), University of Basel and University Center for Medicine of Aging, Felix Platter Hospital, Switzerland
| | - Roland Veltkamp
- From the Stroke Research Center (D.W., C.S., D.J.W.) and Neuroradiological Academic Unit (H.R.J.), Department of Brain Repair and Rehabilitation, Institute of Neurology, and Department of Statistical Science (G.A.), UCL, London, UK; Stroke Center and Neurology (D.J.S., C.T., S.T.E.), University Hospital Basel, University of Basel, Switzerland; Ottawa Hospital Research Institute and University of Ottawa (G.B., D.D.), Canada; Department of Neurology (J.C.P., T.R.), Heidelberg University Hospital, Germany; Manchester Academic Health Sciences Center (O.A.S., A.R.P.-J.), Salford Royal NHS Foundation Trust, UK; Department of Neurology (H.S., A.M.), Helsinki University Hospital, Finland; Stroke Center & Department of Neurology (S.-J.Y., J.-S.J.), Department of Neurology, National Taiwan University Hospital, Taipei; Department of Medicine and neurology at the Royal Melbourne Hospital (T.Y.W., A.M.), University of Melbourne, Parkville, Australia; U1171-Degenerative & Vascular Cognitive Disorders (M.F., C.C.), Univ Lille, Inserm, CHU Lille, France; Department of Neurology (R.H., F.H.B.M.S., J.S.), Maastricht University Medical Center, the Netherlands; Department of Neurosciences (J.A.P., P.M.C.C.), Eastern Health, Melbourne, Australia; Division of Neurology, Department of Internal Medicine (J.T., Y.Y.), Saga University Faculty of Medicine, Japan; Division of Clinical Neurosciences (M.B., R.A.-S.S.), Center for Clinical Brain Sciences, School of Clinical Sciences, University of Edinburgh; Department of Stroke Medicine, Division of Brain Sciences (R.V.), Imperial College London, UK; and Neurorehabilitation Unit (S.T.E.), University of Basel and University Center for Medicine of Aging, Felix Platter Hospital, Switzerland
| | - Dar Dowlatshahi
- From the Stroke Research Center (D.W., C.S., D.J.W.) and Neuroradiological Academic Unit (H.R.J.), Department of Brain Repair and Rehabilitation, Institute of Neurology, and Department of Statistical Science (G.A.), UCL, London, UK; Stroke Center and Neurology (D.J.S., C.T., S.T.E.), University Hospital Basel, University of Basel, Switzerland; Ottawa Hospital Research Institute and University of Ottawa (G.B., D.D.), Canada; Department of Neurology (J.C.P., T.R.), Heidelberg University Hospital, Germany; Manchester Academic Health Sciences Center (O.A.S., A.R.P.-J.), Salford Royal NHS Foundation Trust, UK; Department of Neurology (H.S., A.M.), Helsinki University Hospital, Finland; Stroke Center & Department of Neurology (S.-J.Y., J.-S.J.), Department of Neurology, National Taiwan University Hospital, Taipei; Department of Medicine and neurology at the Royal Melbourne Hospital (T.Y.W., A.M.), University of Melbourne, Parkville, Australia; U1171-Degenerative & Vascular Cognitive Disorders (M.F., C.C.), Univ Lille, Inserm, CHU Lille, France; Department of Neurology (R.H., F.H.B.M.S., J.S.), Maastricht University Medical Center, the Netherlands; Department of Neurosciences (J.A.P., P.M.C.C.), Eastern Health, Melbourne, Australia; Division of Neurology, Department of Internal Medicine (J.T., Y.Y.), Saga University Faculty of Medicine, Japan; Division of Clinical Neurosciences (M.B., R.A.-S.S.), Center for Clinical Brain Sciences, School of Clinical Sciences, University of Edinburgh; Department of Stroke Medicine, Division of Brain Sciences (R.V.), Imperial College London, UK; and Neurorehabilitation Unit (S.T.E.), University of Basel and University Center for Medicine of Aging, Felix Platter Hospital, Switzerland
| | - Stefan T Engelter
- From the Stroke Research Center (D.W., C.S., D.J.W.) and Neuroradiological Academic Unit (H.R.J.), Department of Brain Repair and Rehabilitation, Institute of Neurology, and Department of Statistical Science (G.A.), UCL, London, UK; Stroke Center and Neurology (D.J.S., C.T., S.T.E.), University Hospital Basel, University of Basel, Switzerland; Ottawa Hospital Research Institute and University of Ottawa (G.B., D.D.), Canada; Department of Neurology (J.C.P., T.R.), Heidelberg University Hospital, Germany; Manchester Academic Health Sciences Center (O.A.S., A.R.P.-J.), Salford Royal NHS Foundation Trust, UK; Department of Neurology (H.S., A.M.), Helsinki University Hospital, Finland; Stroke Center & Department of Neurology (S.-J.Y., J.-S.J.), Department of Neurology, National Taiwan University Hospital, Taipei; Department of Medicine and neurology at the Royal Melbourne Hospital (T.Y.W., A.M.), University of Melbourne, Parkville, Australia; U1171-Degenerative & Vascular Cognitive Disorders (M.F., C.C.), Univ Lille, Inserm, CHU Lille, France; Department of Neurology (R.H., F.H.B.M.S., J.S.), Maastricht University Medical Center, the Netherlands; Department of Neurosciences (J.A.P., P.M.C.C.), Eastern Health, Melbourne, Australia; Division of Neurology, Department of Internal Medicine (J.T., Y.Y.), Saga University Faculty of Medicine, Japan; Division of Clinical Neurosciences (M.B., R.A.-S.S.), Center for Clinical Brain Sciences, School of Clinical Sciences, University of Edinburgh; Department of Stroke Medicine, Division of Brain Sciences (R.V.), Imperial College London, UK; and Neurorehabilitation Unit (S.T.E.), University of Basel and University Center for Medicine of Aging, Felix Platter Hospital, Switzerland
| | - Adrian R Parry-Jones
- From the Stroke Research Center (D.W., C.S., D.J.W.) and Neuroradiological Academic Unit (H.R.J.), Department of Brain Repair and Rehabilitation, Institute of Neurology, and Department of Statistical Science (G.A.), UCL, London, UK; Stroke Center and Neurology (D.J.S., C.T., S.T.E.), University Hospital Basel, University of Basel, Switzerland; Ottawa Hospital Research Institute and University of Ottawa (G.B., D.D.), Canada; Department of Neurology (J.C.P., T.R.), Heidelberg University Hospital, Germany; Manchester Academic Health Sciences Center (O.A.S., A.R.P.-J.), Salford Royal NHS Foundation Trust, UK; Department of Neurology (H.S., A.M.), Helsinki University Hospital, Finland; Stroke Center & Department of Neurology (S.-J.Y., J.-S.J.), Department of Neurology, National Taiwan University Hospital, Taipei; Department of Medicine and neurology at the Royal Melbourne Hospital (T.Y.W., A.M.), University of Melbourne, Parkville, Australia; U1171-Degenerative & Vascular Cognitive Disorders (M.F., C.C.), Univ Lille, Inserm, CHU Lille, France; Department of Neurology (R.H., F.H.B.M.S., J.S.), Maastricht University Medical Center, the Netherlands; Department of Neurosciences (J.A.P., P.M.C.C.), Eastern Health, Melbourne, Australia; Division of Neurology, Department of Internal Medicine (J.T., Y.Y.), Saga University Faculty of Medicine, Japan; Division of Clinical Neurosciences (M.B., R.A.-S.S.), Center for Clinical Brain Sciences, School of Clinical Sciences, University of Edinburgh; Department of Stroke Medicine, Division of Brain Sciences (R.V.), Imperial College London, UK; and Neurorehabilitation Unit (S.T.E.), University of Basel and University Center for Medicine of Aging, Felix Platter Hospital, Switzerland
| | - Atte Meretoja
- From the Stroke Research Center (D.W., C.S., D.J.W.) and Neuroradiological Academic Unit (H.R.J.), Department of Brain Repair and Rehabilitation, Institute of Neurology, and Department of Statistical Science (G.A.), UCL, London, UK; Stroke Center and Neurology (D.J.S., C.T., S.T.E.), University Hospital Basel, University of Basel, Switzerland; Ottawa Hospital Research Institute and University of Ottawa (G.B., D.D.), Canada; Department of Neurology (J.C.P., T.R.), Heidelberg University Hospital, Germany; Manchester Academic Health Sciences Center (O.A.S., A.R.P.-J.), Salford Royal NHS Foundation Trust, UK; Department of Neurology (H.S., A.M.), Helsinki University Hospital, Finland; Stroke Center & Department of Neurology (S.-J.Y., J.-S.J.), Department of Neurology, National Taiwan University Hospital, Taipei; Department of Medicine and neurology at the Royal Melbourne Hospital (T.Y.W., A.M.), University of Melbourne, Parkville, Australia; U1171-Degenerative & Vascular Cognitive Disorders (M.F., C.C.), Univ Lille, Inserm, CHU Lille, France; Department of Neurology (R.H., F.H.B.M.S., J.S.), Maastricht University Medical Center, the Netherlands; Department of Neurosciences (J.A.P., P.M.C.C.), Eastern Health, Melbourne, Australia; Division of Neurology, Department of Internal Medicine (J.T., Y.Y.), Saga University Faculty of Medicine, Japan; Division of Clinical Neurosciences (M.B., R.A.-S.S.), Center for Clinical Brain Sciences, School of Clinical Sciences, University of Edinburgh; Department of Stroke Medicine, Division of Brain Sciences (R.V.), Imperial College London, UK; and Neurorehabilitation Unit (S.T.E.), University of Basel and University Center for Medicine of Aging, Felix Platter Hospital, Switzerland
| | - David J Werring
- From the Stroke Research Center (D.W., C.S., D.J.W.) and Neuroradiological Academic Unit (H.R.J.), Department of Brain Repair and Rehabilitation, Institute of Neurology, and Department of Statistical Science (G.A.), UCL, London, UK; Stroke Center and Neurology (D.J.S., C.T., S.T.E.), University Hospital Basel, University of Basel, Switzerland; Ottawa Hospital Research Institute and University of Ottawa (G.B., D.D.), Canada; Department of Neurology (J.C.P., T.R.), Heidelberg University Hospital, Germany; Manchester Academic Health Sciences Center (O.A.S., A.R.P.-J.), Salford Royal NHS Foundation Trust, UK; Department of Neurology (H.S., A.M.), Helsinki University Hospital, Finland; Stroke Center & Department of Neurology (S.-J.Y., J.-S.J.), Department of Neurology, National Taiwan University Hospital, Taipei; Department of Medicine and neurology at the Royal Melbourne Hospital (T.Y.W., A.M.), University of Melbourne, Parkville, Australia; U1171-Degenerative & Vascular Cognitive Disorders (M.F., C.C.), Univ Lille, Inserm, CHU Lille, France; Department of Neurology (R.H., F.H.B.M.S., J.S.), Maastricht University Medical Center, the Netherlands; Department of Neurosciences (J.A.P., P.M.C.C.), Eastern Health, Melbourne, Australia; Division of Neurology, Department of Internal Medicine (J.T., Y.Y.), Saga University Faculty of Medicine, Japan; Division of Clinical Neurosciences (M.B., R.A.-S.S.), Center for Clinical Brain Sciences, School of Clinical Sciences, University of Edinburgh; Department of Stroke Medicine, Division of Brain Sciences (R.V.), Imperial College London, UK; and Neurorehabilitation Unit (S.T.E.), University of Basel and University Center for Medicine of Aging, Felix Platter Hospital, Switzerland.
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Adachi T, Hoshino H, Takagi M, Fujioka S. Volume and Characteristics of Intracerebral Hemorrhage with Direct Oral Anticoagulants in Comparison with Warfarin
. Cerebrovasc Dis Extra 2017; 7:62-71. [PMID: 28376486 PMCID: PMC5425761 DOI: 10.1159/000462985] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2016] [Accepted: 02/08/2017] [Indexed: 12/25/2022] Open
Abstract
Background Patients undergoing anticoagulation therapy often experience intracerebral hemorrhages (ICHs), and warfarin in particular is known to increase hematoma expansion in ICHs, which results in a poor outcome. Recent studies reported that, in comparison with warfarin, direct oral anticoagulants (DOACs) cause fewer ICHs with better functional outcome. However, since it is still unknown whether DOACs are associated with a smaller hematoma volume of ICHs, we aimed to compare the volume, hematoma expansion, and outcomes associated with ICHs treated with DOACs and warfarin. Methods We performed a prospective multicenter cross-sectional study. The subjects included patients with acute ICHs who received either DOACs or warfarin. We evaluated the clinical characteristics, and measured initial and follow-up ICH volumes. The volume of ICHs and hematoma expansion were compared between the DOAC and warfarin groups. Mortality and modified Rankin score at discharge were evaluated as outcomes. Results There were 18 patients in the DOAC group and 71 in the warfarin group. The baseline characteristics were similar between the 2 groups. Initial median hematoma volume of ICHs in the DOAC group was significantly lower than that in the warfarin group (6.2 vs. 24.2 mL, respectively; p = 0.04). In cases involving follow-up computed tomography scanning, the median hematoma volume of ICHs at follow-up was lower in the DOAC group than in the warfarin group (initial: DOACs 4.4 vs. warfarin 13.5 mL; follow-up: 5.0 vs. 18.4 mL, respectively; p = 0.05). Further, the hematoma in ICHs associated with DOACs did not expand. Although the mortality of ICHs associated with DOACs (11%) was lower than that associated with warfarin (24%), this difference was not statistically significant. The univariate analysis showed that the anticoagulant type (DOACs vs. warfarin) and sex (male vs. female) were associated with ICH volume. The multivariable linear regression showed that the use of DOACs (compared to warfarin; β: −0.23, p = 0.03) and female sex (compared to male; β: −0.25, p = 0.02) were associated with a small hematoma volume. Conclusions Based on the results of the present study, in terms of the risks associated with ICHs, the use of DOACs appears to be safer than warfarin for anticoagulation therapy. Further studies are required to validate these findings.
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Affiliation(s)
- Tomohide Adachi
- Department of Neurology, Tokyo Saiseikai Central Hospital, Tokyo, Japan
| | - Haruhiko Hoshino
- Department of Neurology, Tokyo Saiseikai Central Hospital, Tokyo, Japan
| | - Makoto Takagi
- Department of Neurology, Tokyo Saiseikai Central Hospital, Tokyo, Japan
| | - Shodo Fujioka
- Department of Neurosurgery, Saiseikai Misumi Hospital, Uki-city, Japan
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Pfeilschifter W, Steinstraesser T, Paulus P, Zeiner PS, Bohmann F, Theisen A, Lindhoff-Last E, Penski C, Wagner M, Mittelbronn M, Foerch C. Risk of long-term anticoagulation under sustained severe arterial hypertension: A translational study comparing warfarin and the new oral anticoagulant apixaban. J Cereb Blood Flow Metab 2017; 37:855-865. [PMID: 27189904 PMCID: PMC5363464 DOI: 10.1177/0271678x16642443] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
New oral anticoagulants for the prevention of stroke and systemic embolism in patients with atrial fibrillation have recently been introduced. In this translational study, we explored the risk of long-term anticoagulation on intracerebral hemorrhage under sustained severe arterial hypertension. We initiated anticoagulation with warfarin or apixaban in spontaneously hypertensive rats prone to develop severe hypertension and subsequent intracerebral bleeding complications. A non-anticoagulated group served as control. During an 11-week-study period, blood pressure, anticoagulation parameters, and clinical status were determined regularly. The incidence of histopathologically proven intracerebral hemorrhage was defined as the primary endpoint. Both warfarin and apixaban anticoagulation was fairly stable during the study period, and all rats developed severe hypertension. Intracerebral hemorrhage was determined in 29% (4/14) of warfarin rats and in 10% (1/10) of apixaban rats. Controls did not show cerebral bleeding complications (chi-square not significant). Mortality rate at study termination was 33% (2/6) in controls, 43% (6/14) in the warfarin group, and 60% (6/10) in the apixaban group. Animals died from extracerebral complications in most cases. Our study describes an experimental intracerebral hemorrhage model in the context of sustained hypertension and long-term anticoagulation. Extracerebral bleeding complications occurred more often in warfarin-treated animals compared with apixaban and control rats.
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Affiliation(s)
| | | | - Patrick Paulus
- 2 Department of Anesthesiology and Operative Intensive Care Medicine, Kepler University Hospital, Linz, Austria
| | - Pia Susan Zeiner
- 1 Department of Neurology, Goethe-University, Frankfurt am Main, Germany
| | - Ferdinand Bohmann
- 1 Department of Neurology, Goethe-University, Frankfurt am Main, Germany
| | - Alf Theisen
- 3 Zentrale Forschungseinheit, Goethe-University, Frankfurt am Main, Germany
| | - Edelgard Lindhoff-Last
- 4 Department of Internal Medicine, Goethe-University, Frankfurt am Main, Germany.,5 CCB Coagulation Research Center, Bethanien Hospital, Frankfurt am Main, Germany
| | - Cornelia Penski
- 6 Neurological Institute (Edinger Institute), Goethe-University, Frankfurt am Main, Germany
| | - Marlies Wagner
- 7 Institute of Neuroradiology, Goethe-University, Frankfurt am Main, Germany
| | - Michel Mittelbronn
- 6 Neurological Institute (Edinger Institute), Goethe-University, Frankfurt am Main, Germany
| | - Christian Foerch
- 1 Department of Neurology, Goethe-University, Frankfurt am Main, Germany
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Foerch C, Schäfer JH, Pfeilschifter W, Bohmann F. [Direct oral anticoagulants and acute stroke : Insights into translational research studies]. DER NERVENARZT 2017; 88:642-651. [PMID: 28188404 DOI: 10.1007/s00115-017-0282-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
In recent years a considerable number of translational research studies on intracerebral hemorrhage and ischemic stroke have been published, which are characterized by a particular proximity to practical clinical questions. Animal research has provided insights into the pathophysiological processes and therapy effects, which have so far only been insufficiently investigated in clinical studies. This includes the effectiveness of a rapid reversal of anticoagulation in cases of anticoagulation-associated intracerebral hemorrhage and the safety of thrombolytic treatment in ischemic stroke occurring during treatment with anticoagulants. With the approval of the direct oral anticoagulants these problems have become of particular contemporary relevance. Of course, results from experimental translational studies on stroke cannot be directly translated into clinical routine. Nevertheless, these investigations help to understand the underlying processes and mechanisms and provide proof of concept data for new treatment strategies. This review summarizes the most relevant results in this field of research with a particular focus on practical clinical questions.
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Affiliation(s)
- C Foerch
- Klinik für Neurologie, Goethe-Universität, Schleusenweg 2-16, 60528, Frankfurt am Main, Deutschland.
| | - J H Schäfer
- Klinik für Neurologie, Goethe-Universität, Schleusenweg 2-16, 60528, Frankfurt am Main, Deutschland
| | - W Pfeilschifter
- Klinik für Neurologie, Goethe-Universität, Schleusenweg 2-16, 60528, Frankfurt am Main, Deutschland
| | - F Bohmann
- Klinik für Neurologie, Goethe-Universität, Schleusenweg 2-16, 60528, Frankfurt am Main, Deutschland
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von der Brelie C, Doukas A, Naumann R, Dempfle A, Larsen N, Synowitz M, Jansen O, Mehdorn M, Jadik S. Clinical and radiological course of intracerebral haemorrhage associated with the new non-vitamin K anticoagulants. Acta Neurochir (Wien) 2017; 159:101-109. [PMID: 27873051 DOI: 10.1007/s00701-016-3026-7] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2016] [Accepted: 11/09/2016] [Indexed: 11/30/2022]
Abstract
BACKGROUND Clinical outcome and mortality in intracerebral haemorrhage (ICH) associated with anticoagulant treatment is poor. Novel direct oral anticoagulant drugs (NOACs) are increasingly prescribed. Management of NOAC-associated ICH might be more challenging. The aim of this study was to compare the clinical and radiological course of ICH patients being treated with different forms of oral anticoagulant drugs. METHOD The study is a retrospective observational study. Haemorrhage in other intracranial compartments except the ventricular system were explicitly excluded. Four groups were categorised and compared with regard to their clinical and radiological course (NOACs, vitamin K antagonists [VKAs], platelet inhibitors and patients without anticoagulant/antiplatelet drugs). Clinical as well as radiological parameters were analysed. RESULTS Overall, 182 patients were included (2011 to early 2016). Twenty-five patients with NOAC-associated ICH were included (47 with VKAs, 50 with platelet inhibitors and 60 patients without anticoagulant/antiplatelet drugs). The frequency of NOAC-associated ICH increased over the years. Diabetes was found significantly more often in the NOAC patients (p = 0.05). The clinical and radiological courses in the three different patient groups with impaired coagulation were similar. Mortality was significantly higher in patient groups with impaired coagulation (p = 0.04) compared to those without anticoagulant/antiplatelet drugs. Multivariate analysis revealed the Glasgow Coma Scale (GCS) score as a strong predictor for worse outcome and mortality. CONCLUSIONS The frequency of NOAC-associated ICH increased in the last 5 years. Diabetes might be a risk factor for ICH when receiving NOACs. Clinical outcome in NOAC-associated ICH is poor and mortality is as high as in patients with other oral anticoagulant/antiplatelet drugs.
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Affiliation(s)
- Christian von der Brelie
- Department of Neurosurgery, University Hospital of Schleswig Holstein, Campus Kiel, Arnold Heller Straße 3, 24103, Kiel, Germany.
- Department of Neurosurgery, University Hospital of Göttingen, Robert Koch Strasse 40, 37075, Göttingen, Germany.
| | - Alexandros Doukas
- Department of Neurosurgery, University Hospital of Schleswig Holstein, Campus Kiel, Arnold Heller Straße 3, 24103, Kiel, Germany
| | - Rebecca Naumann
- Department of Neurosurgery, University Hospital of Schleswig Holstein, Campus Kiel, Arnold Heller Straße 3, 24103, Kiel, Germany
| | - Astrid Dempfle
- Institute of Medical Informatics and Statistics, University Hospital of Schleswig Holstein, Campus Kiel, Kiel, Germany
| | - Naomi Larsen
- Department of Radiology, University Hospital of Schleswig Holstein, Campus Kiel, Arnold Heller Straße 3, 24103, Kiel, Germany
| | - Michael Synowitz
- Department of Neurosurgery, University Hospital of Schleswig Holstein, Campus Kiel, Arnold Heller Straße 3, 24103, Kiel, Germany
| | - Olav Jansen
- Department of Radiology, University Hospital of Schleswig Holstein, Campus Kiel, Arnold Heller Straße 3, 24103, Kiel, Germany
| | - Maximilian Mehdorn
- Department of Neurosurgery, University Hospital of Schleswig Holstein, Campus Kiel, Arnold Heller Straße 3, 24103, Kiel, Germany
| | - Senol Jadik
- Department of Neurosurgery, University Hospital of Schleswig Holstein, Campus Kiel, Arnold Heller Straße 3, 24103, Kiel, Germany
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Petzold T, Thienel M, Konrad I, Schubert I, Regenauer R, Hoppe B, Lorenz M, Eckart A, Chandraratne S, Lennerz C, Kolb C, Braun D, Jamasbi J, Brandl R, Braun S, Siess W, Schulz C, Massberg S. Oral thrombin inhibitor aggravates platelet adhesion and aggregation during arterial thrombosis. Sci Transl Med 2016; 8:367ra168. [DOI: 10.1126/scitranslmed.aad6712] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2015] [Accepted: 08/31/2016] [Indexed: 12/13/2022]
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Mittal MK, LacKamp A. Intracerebral Hemorrhage: Perihemorrhagic Edema and Secondary Hematoma Expansion: From Bench Work to Ongoing Controversies. Front Neurol 2016; 7:210. [PMID: 27917153 PMCID: PMC5116572 DOI: 10.3389/fneur.2016.00210] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2016] [Accepted: 11/08/2016] [Indexed: 12/30/2022] Open
Abstract
Intracerebral hemorrhage (ICH) is a medical emergency, which often leads to severe disability and death. ICH-related poor outcomes are due to primary injury causing structural damage and mass effect and secondary injury in the perihemorrhagic region over several days to weeks. Secondary injury after ICH can be due to hematoma expansion (HE) or a consequence of repair pathway along the continuum of neuroinflammation, neuronal death, and perihemorrhagic edema (PHE). This review article is focused on PHE and HE and will cover the animal studies, related human studies, and clinical trials relating to these mechanisms of secondary brain injury in ICH patients.
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Affiliation(s)
- Manoj K Mittal
- Department of Neurology, University of Kansas Medical Center , Kansas City, KS , USA
| | - Aaron LacKamp
- Department of Anesthesiology, University of Kansas Medical Center , Kansas City, KS , USA
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Guan J, Hawryluk GWJ. Targeting Secondary Hematoma Expansion in Spontaneous Intracerebral Hemorrhage - State of the Art. Front Neurol 2016; 7:187. [PMID: 27826284 PMCID: PMC5078502 DOI: 10.3389/fneur.2016.00187] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2016] [Accepted: 10/13/2016] [Indexed: 12/20/2022] Open
Abstract
Spontaneous intracerebral hemorrhage (SICH), defined broadly as intracerebral hemorrhage not related to trauma, results in long-term disability or death in a large proportion of afflicted patients. Current management of this disease is predominantly supportive, including airway protection, optimization of hemodynamic parameters, and management of intracranial pressure. No active treatments that demonstrate beneficial effects on clinical outcome are currently available. Animal models of SICH have allowed for the elucidation of multiple pathways that may be attractive therapeutic targets. A minority of these, such as aggressive blood pressure management and recombinant activated factor VII administration, have led to large-scale clinical trials. There remains a critical need for further translational research in the realm of SICH.
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Affiliation(s)
- Jian Guan
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah , Salt Lake City, UT , USA
| | - Gregory W J Hawryluk
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah , Salt Lake City, UT , USA
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Schlunk F, Pfeilschifter W, Yigitkanli K, Lo EH, Foerch C. Treatment with FTY720 has no beneficial effects on short-term outcome in an experimental model of intracerebral hemorrhage. EXPERIMENTAL & TRANSLATIONAL STROKE MEDICINE 2016; 8:1. [PMID: 26893821 PMCID: PMC4758011 DOI: 10.1186/s13231-016-0016-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/24/2015] [Accepted: 02/02/2016] [Indexed: 12/17/2022]
Abstract
BACKGROUND No evidence-based therapy is available for patients with acute intracerebral hemorrhage (ICH). In view of the profound inflammatory reaction in the perilesional tissue, we investigated in a well-characterized experimental model whether the administration of the immunomodulator fingolimod (FTY720) is neuroprotective in acute ICH. METHODS ICH was induced by means of a stereotactic intrastriatal injection of collagenase type VII-S. FTY720 (1 mg/kg) was administered intraperitoneally 1 h after ICH induction. Hematoma volume was assessed spectrophotometrically at 24 h after ICH induction. The following endpoints were determined at 24 and 72 h, respectively: mortality rate and neurologic outcomes, edema formation, and MMP-9 activity. RESULTS Twenty-four hour after ICH induction, hematoma volume was not statistically different between groups. No difference was found in mortality and neurologic outcomes at 24 and 72 h between FTY720 treated mice and controls. Edema formation was present in both groups on the ipsilateral side with no statistical difference between groups at both time points. No difference was found in MMP-9 levels after 24 and 72 h between groups. CONCLUSIONS Our results suggest that FTY720 has no beneficial effects in the acute phase of experimental ICH.
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Affiliation(s)
- Frieder Schlunk
- Department of Neurology, Johann Wolfgang Goethe-University, Schleusenweg 2-16, 60528 Frankfurt, Germany ; Neuroprotection Research Laboratory, Massachusetts General Hospital, Harvard Medical School, Charlestown, MA USA
| | - Waltraud Pfeilschifter
- Department of Neurology, Johann Wolfgang Goethe-University, Schleusenweg 2-16, 60528 Frankfurt, Germany
| | - Kazim Yigitkanli
- Neuroprotection Research Laboratory, Massachusetts General Hospital, Harvard Medical School, Charlestown, MA USA
| | - Eng H Lo
- Neuroprotection Research Laboratory, Massachusetts General Hospital, Harvard Medical School, Charlestown, MA USA
| | - Christian Foerch
- Department of Neurology, Johann Wolfgang Goethe-University, Schleusenweg 2-16, 60528 Frankfurt, Germany ; Neuroprotection Research Laboratory, Massachusetts General Hospital, Harvard Medical School, Charlestown, MA USA
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Tykocki T, Guzek K. Anticoagulation Therapy in Traumatic Brain Injury. World Neurosurg 2016; 89:497-504. [PMID: 26850974 DOI: 10.1016/j.wneu.2016.01.063] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2015] [Revised: 01/16/2016] [Accepted: 01/19/2016] [Indexed: 10/22/2022]
Abstract
BACKGROUND Optimal anticoagulation therapy (AT) in patients with traumatic brain injury (TBI) is a challenging task and proper management is strongly correlated with clinical outcomes. Only limited data are available on AT after TBI and practical decision making is based on the opinion of experts. This review sought to critically assess different therapeutic options using AT and antiplatelet agents in the perioperative period after TBI. METHODS A comprehensive review of the literature was performed to summarize relevant data on AT in patients with TBI. RESULTS Patients with preinjury AT with TBI require emergent neurosurgical treatment and they are also at high risk of developing thromboembolic complications or hematoma expansion. New oral anticoagulants offer a lower incidence of intracranial hemorrhage compared with warfarin. The rate of intracranial hemorrhage during new oral anticoagulants or heparin therapy is significantly lower than that with vitamin K antagonists.
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Affiliation(s)
- Tomasz Tykocki
- Department of Neurosurgery, Institute of Psychiatry and Neurology, Warsaw, Poland.
| | - Krystyna Guzek
- Department of Cardiac Arrhythmias, Institute of Cardiology, Warsaw, Poland
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Wilson D, Charidimou A, Shakeshaft C, Ambler G, White M, Cohen H, Yousry T, Al-Shahi Salman R, Lip GYH, Brown MM, Jäger HR, Werring DJ. Volume and functional outcome of intracerebral hemorrhage according to oral anticoagulant type. Neurology 2015; 86:360-6. [PMID: 26718576 DOI: 10.1212/wnl.0000000000002310] [Citation(s) in RCA: 85] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2015] [Accepted: 09/03/2015] [Indexed: 12/18/2022] Open
Abstract
OBJECTIVE To compare intracerebral hemorrhage (ICH) volume and clinical outcome of non-vitamin K oral anticoagulants (NOAC)-associated ICH to warfarin-associated ICH. METHODS In this multicenter cross-sectional observational study of patients with anticoagulant-associated ICH, consecutive patients with NOAC-ICH were compared to those with warfarin-ICH selected from a population of 344 patients with anticoagulant-associated ICH. ICH volume was measured by an observer blinded to clinical details. Outcome measures were ICH volume and clinical outcome adjusted for confounding factors. RESULTS We compared 11 patients with NOAC-ICH to 52 patients with warfarin-ICH. The median ICH volume was 2.4 mL (interquartile range [IQR] 0.3-5.4 mL) for NOAC-ICH vs 8.9 mL (IQR 4.0-21.3 mL) for warfarin-ICH (p = 0.0028). In univariate linear regression, use of warfarin (difference in cube root volume 1.61; 95% confidence interval [CI] 0.69 to 2.53) and lobar ICH location (compared with nonlobar ICH; difference in cube root volume 1.52; 95% CI 2.20 to 0.85) were associated with larger ICH volumes. In multivariable linear regression adjusting for confounding factors (sex, hypertension, previous ischemic stroke, white matter disease burden, and premorbid modified Rankin Scale score [mRS]), warfarin use remained independently associated with larger ICH (cube root) volumes (coefficient 0.64; 95% CI 0.24 to 1.25; p = 0.042). Ordered logistic regression showed an increased odds of a worse clinical outcome (as measured by discharge mRS) in warfarin-ICH compared with NOAC-ICH: odds ratio 4.46 (95% CI 1.10 to 18.14; p = 0.037). CONCLUSIONS In this small prospective observational study, patients with NOAC-associated ICH had smaller ICH volumes and better clinical outcomes compared with warfarin-associated ICH.
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Affiliation(s)
- Duncan Wilson
- From the Stroke Research Group (D.W., A.C., M.M.B., D.J.W.) and the Department of Brain Repair and Rehabilitation (D.W., A.C., C.S., M.W., T.Y., H.R.J., D.J.W.), UCL Institute of Neurology; Department of Statistical Science (G.A.), UCL; Lysholm Department of Neuroradiology (M.W., T.Y., H.R.J.), National Hospital for Neurology and Neurosurgery (D.W., A.C., M.M.B., D.J.W.), London; University College London Hospitals NHS Foundation Trust (H.C.); Division of Clinical Neurosciences (R.A.-S.S.), Centre for Clinical Brain Sciences, School of Clinical Sciences, University of Edinburgh; and University of Birmingham Centre for Cardiovascular Sciences (G.Y.H.L.), City Hospital, UK
| | - Andreas Charidimou
- From the Stroke Research Group (D.W., A.C., M.M.B., D.J.W.) and the Department of Brain Repair and Rehabilitation (D.W., A.C., C.S., M.W., T.Y., H.R.J., D.J.W.), UCL Institute of Neurology; Department of Statistical Science (G.A.), UCL; Lysholm Department of Neuroradiology (M.W., T.Y., H.R.J.), National Hospital for Neurology and Neurosurgery (D.W., A.C., M.M.B., D.J.W.), London; University College London Hospitals NHS Foundation Trust (H.C.); Division of Clinical Neurosciences (R.A.-S.S.), Centre for Clinical Brain Sciences, School of Clinical Sciences, University of Edinburgh; and University of Birmingham Centre for Cardiovascular Sciences (G.Y.H.L.), City Hospital, UK
| | - Clare Shakeshaft
- From the Stroke Research Group (D.W., A.C., M.M.B., D.J.W.) and the Department of Brain Repair and Rehabilitation (D.W., A.C., C.S., M.W., T.Y., H.R.J., D.J.W.), UCL Institute of Neurology; Department of Statistical Science (G.A.), UCL; Lysholm Department of Neuroradiology (M.W., T.Y., H.R.J.), National Hospital for Neurology and Neurosurgery (D.W., A.C., M.M.B., D.J.W.), London; University College London Hospitals NHS Foundation Trust (H.C.); Division of Clinical Neurosciences (R.A.-S.S.), Centre for Clinical Brain Sciences, School of Clinical Sciences, University of Edinburgh; and University of Birmingham Centre for Cardiovascular Sciences (G.Y.H.L.), City Hospital, UK
| | - Gareth Ambler
- From the Stroke Research Group (D.W., A.C., M.M.B., D.J.W.) and the Department of Brain Repair and Rehabilitation (D.W., A.C., C.S., M.W., T.Y., H.R.J., D.J.W.), UCL Institute of Neurology; Department of Statistical Science (G.A.), UCL; Lysholm Department of Neuroradiology (M.W., T.Y., H.R.J.), National Hospital for Neurology and Neurosurgery (D.W., A.C., M.M.B., D.J.W.), London; University College London Hospitals NHS Foundation Trust (H.C.); Division of Clinical Neurosciences (R.A.-S.S.), Centre for Clinical Brain Sciences, School of Clinical Sciences, University of Edinburgh; and University of Birmingham Centre for Cardiovascular Sciences (G.Y.H.L.), City Hospital, UK
| | - Mark White
- From the Stroke Research Group (D.W., A.C., M.M.B., D.J.W.) and the Department of Brain Repair and Rehabilitation (D.W., A.C., C.S., M.W., T.Y., H.R.J., D.J.W.), UCL Institute of Neurology; Department of Statistical Science (G.A.), UCL; Lysholm Department of Neuroradiology (M.W., T.Y., H.R.J.), National Hospital for Neurology and Neurosurgery (D.W., A.C., M.M.B., D.J.W.), London; University College London Hospitals NHS Foundation Trust (H.C.); Division of Clinical Neurosciences (R.A.-S.S.), Centre for Clinical Brain Sciences, School of Clinical Sciences, University of Edinburgh; and University of Birmingham Centre for Cardiovascular Sciences (G.Y.H.L.), City Hospital, UK
| | - Hannah Cohen
- From the Stroke Research Group (D.W., A.C., M.M.B., D.J.W.) and the Department of Brain Repair and Rehabilitation (D.W., A.C., C.S., M.W., T.Y., H.R.J., D.J.W.), UCL Institute of Neurology; Department of Statistical Science (G.A.), UCL; Lysholm Department of Neuroradiology (M.W., T.Y., H.R.J.), National Hospital for Neurology and Neurosurgery (D.W., A.C., M.M.B., D.J.W.), London; University College London Hospitals NHS Foundation Trust (H.C.); Division of Clinical Neurosciences (R.A.-S.S.), Centre for Clinical Brain Sciences, School of Clinical Sciences, University of Edinburgh; and University of Birmingham Centre for Cardiovascular Sciences (G.Y.H.L.), City Hospital, UK
| | - Tarek Yousry
- From the Stroke Research Group (D.W., A.C., M.M.B., D.J.W.) and the Department of Brain Repair and Rehabilitation (D.W., A.C., C.S., M.W., T.Y., H.R.J., D.J.W.), UCL Institute of Neurology; Department of Statistical Science (G.A.), UCL; Lysholm Department of Neuroradiology (M.W., T.Y., H.R.J.), National Hospital for Neurology and Neurosurgery (D.W., A.C., M.M.B., D.J.W.), London; University College London Hospitals NHS Foundation Trust (H.C.); Division of Clinical Neurosciences (R.A.-S.S.), Centre for Clinical Brain Sciences, School of Clinical Sciences, University of Edinburgh; and University of Birmingham Centre for Cardiovascular Sciences (G.Y.H.L.), City Hospital, UK
| | - Rustam Al-Shahi Salman
- From the Stroke Research Group (D.W., A.C., M.M.B., D.J.W.) and the Department of Brain Repair and Rehabilitation (D.W., A.C., C.S., M.W., T.Y., H.R.J., D.J.W.), UCL Institute of Neurology; Department of Statistical Science (G.A.), UCL; Lysholm Department of Neuroradiology (M.W., T.Y., H.R.J.), National Hospital for Neurology and Neurosurgery (D.W., A.C., M.M.B., D.J.W.), London; University College London Hospitals NHS Foundation Trust (H.C.); Division of Clinical Neurosciences (R.A.-S.S.), Centre for Clinical Brain Sciences, School of Clinical Sciences, University of Edinburgh; and University of Birmingham Centre for Cardiovascular Sciences (G.Y.H.L.), City Hospital, UK
| | - Gregory Y H Lip
- From the Stroke Research Group (D.W., A.C., M.M.B., D.J.W.) and the Department of Brain Repair and Rehabilitation (D.W., A.C., C.S., M.W., T.Y., H.R.J., D.J.W.), UCL Institute of Neurology; Department of Statistical Science (G.A.), UCL; Lysholm Department of Neuroradiology (M.W., T.Y., H.R.J.), National Hospital for Neurology and Neurosurgery (D.W., A.C., M.M.B., D.J.W.), London; University College London Hospitals NHS Foundation Trust (H.C.); Division of Clinical Neurosciences (R.A.-S.S.), Centre for Clinical Brain Sciences, School of Clinical Sciences, University of Edinburgh; and University of Birmingham Centre for Cardiovascular Sciences (G.Y.H.L.), City Hospital, UK
| | - Martin M Brown
- From the Stroke Research Group (D.W., A.C., M.M.B., D.J.W.) and the Department of Brain Repair and Rehabilitation (D.W., A.C., C.S., M.W., T.Y., H.R.J., D.J.W.), UCL Institute of Neurology; Department of Statistical Science (G.A.), UCL; Lysholm Department of Neuroradiology (M.W., T.Y., H.R.J.), National Hospital for Neurology and Neurosurgery (D.W., A.C., M.M.B., D.J.W.), London; University College London Hospitals NHS Foundation Trust (H.C.); Division of Clinical Neurosciences (R.A.-S.S.), Centre for Clinical Brain Sciences, School of Clinical Sciences, University of Edinburgh; and University of Birmingham Centre for Cardiovascular Sciences (G.Y.H.L.), City Hospital, UK
| | - Hans Rolf Jäger
- From the Stroke Research Group (D.W., A.C., M.M.B., D.J.W.) and the Department of Brain Repair and Rehabilitation (D.W., A.C., C.S., M.W., T.Y., H.R.J., D.J.W.), UCL Institute of Neurology; Department of Statistical Science (G.A.), UCL; Lysholm Department of Neuroradiology (M.W., T.Y., H.R.J.), National Hospital for Neurology and Neurosurgery (D.W., A.C., M.M.B., D.J.W.), London; University College London Hospitals NHS Foundation Trust (H.C.); Division of Clinical Neurosciences (R.A.-S.S.), Centre for Clinical Brain Sciences, School of Clinical Sciences, University of Edinburgh; and University of Birmingham Centre for Cardiovascular Sciences (G.Y.H.L.), City Hospital, UK
| | - David J Werring
- From the Stroke Research Group (D.W., A.C., M.M.B., D.J.W.) and the Department of Brain Repair and Rehabilitation (D.W., A.C., C.S., M.W., T.Y., H.R.J., D.J.W.), UCL Institute of Neurology; Department of Statistical Science (G.A.), UCL; Lysholm Department of Neuroradiology (M.W., T.Y., H.R.J.), National Hospital for Neurology and Neurosurgery (D.W., A.C., M.M.B., D.J.W.), London; University College London Hospitals NHS Foundation Trust (H.C.); Division of Clinical Neurosciences (R.A.-S.S.), Centre for Clinical Brain Sciences, School of Clinical Sciences, University of Edinburgh; and University of Birmingham Centre for Cardiovascular Sciences (G.Y.H.L.), City Hospital, UK.
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Potpara TS, Lip GYH. Oral anticoagulant therapy in atrial fibrillation patients at high stroke and bleeding risk. Prog Cardiovasc Dis 2015; 58:177-94. [PMID: 26162958 DOI: 10.1016/j.pcad.2015.07.003] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Atrial fibrillation (AF) is associated with a 5-fold greater risk of ischemic stroke or systemic embolism compared with normal sinus rhythm. Cardioembolic AF-related strokes are often more severe, fatal or associated with greater permanent disability and higher recurrence rates than strokes of other aetiologies. These strokes may be effectively prevented with oral anticoagulant (OAC) therapy, using either vitamin K antagonists (VKAs) or non-vitamin K antagonist OACs (NOACs) such as the direct thrombin inhibitor dabigatran or direct factor Xa inhibitors rivaroxaban, apixaban or edoxaban. Most AF patients have a positive net clinical benefit from OAC, excluding those with AF and no conventional stroke risk factors. Balancing the risks of stroke and bleeding is necessary for optimal use of OAC in clinical practice, and modifiable bleeding risk factors must be addressed. Concerns remain over 'non-changeable' bleeding risk factors such as older age, significant renal or hepatic impairment, prior stroke(s) or prior bleeding event(s) and active malignancies. Such AF patients are often termed 'special' AF populations, due to their 'special' risk profile that includes increased risks of both thromboembolic and bleeding events, and due to fear of bleeding complications these AF patients are often denied OAC. Evidence shows, however, that the absolute benefits of OAC are the greatest in patients at the highest risk, and NOACs may offer even a greater net clinical benefit compared to warfarin particularly in these high risk patients. In this review article, we summarize available data on stroke prevention in AF patients at increased risk of both stroke and bleeding and discuss the use of NOACs for thromboprophylaxis in these 'special' AF populations.
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Affiliation(s)
- Tatjana S Potpara
- School of Medicine, Belgrade University, Belgrade, Serbia; Cardiology Clinic, Clinical Centre of Serbia, Belgrade, Serbia
| | - Gregory Y H Lip
- School of Medicine, Belgrade University, Belgrade, Serbia; University of Birmingham Centre for Cardiovascular Sciences, City Hospital, Birmingham B18 7QH, United Kingdom.
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The Pathophysiology of Intracerebral Hemorrhage Formation and Expansion. Transl Stroke Res 2015; 6:257-63. [DOI: 10.1007/s12975-015-0410-1] [Citation(s) in RCA: 98] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2015] [Accepted: 05/20/2015] [Indexed: 10/23/2022]
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Łukasik M, Zawilska K, Undas A. Intracranial bleedings in patients on long-term anticoagulant treatment: Benefits from oral thrombin and factor Xa inhibitors in clinical practice. Neurol Neurochir Pol 2015; 49:171-9. [PMID: 26048605 DOI: 10.1016/j.pjnns.2015.04.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2015] [Revised: 04/17/2015] [Accepted: 04/29/2015] [Indexed: 11/27/2022]
Abstract
Dabigatran, a direct thrombin inhibitor and activated factor X inhibitors, rivaroxaban and apixaban, used in the prevention of stroke or systemic embolism in patients with nonvalvular atrial fibrillation (AF), have several advantages over vitamin K antagonists (VKAs). The non-vitamin K oral anticoagulants (NOACs) have been shown to reduce the risk of intracranial bleedings by 50%. The current review summarizes the available data on the epidemiology, mechanisms and treatment of intracranial bleedings observed on oral anticoagulation with the focus on the specificity of NOACs in this context.
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Affiliation(s)
- Maria Łukasik
- Department of Neurology, Poznan University of Medical Sciences, Poznan, Poland.
| | | | - Anetta Undas
- Institute of Cardiology, Jagiellonian University School of Medicine and John Paul II Hospital, Krakow, Poland.
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Tanoue S, Inamasu J, Yamada M, Toyama H, Hirose Y. Does Dabigatran Increase the Risk of Delayed Hematoma Expansion in a Rat Model of Collagenase-induced Intracerebral Hemorrhage? J Stroke Cerebrovasc Dis 2015; 24:374-80. [DOI: 10.1016/j.jstrokecerebrovasdis.2014.09.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2014] [Revised: 09/01/2014] [Accepted: 09/03/2014] [Indexed: 01/15/2023] Open
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Vanassche T, Hirsh J, Eikelboom JW, Ginsberg JS. Organ-specific bleeding patterns of anticoagulant therapy: lessons from clinical trials. Thromb Haemost 2014; 112:918-23. [PMID: 25187203 DOI: 10.1160/th14-04-0346] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2014] [Accepted: 07/10/2014] [Indexed: 12/13/2022]
Abstract
Anticoagulants are effective at preventing and treating thrombosis, but can cause bleeding. For decades, vitamin K antagonists (VKAs) have been the only available oral anticoagulants. The development of non-VKA oral anticoagulants (NOACs), which inhibit either factor Xa or thrombin stoichiometrically, has provided alternatives to VKAs for several indications. The results of recent large-scale randomised controlled trials comparing NOACs with VKAs for the prevention of stroke in patients with non-valvular atrial fibrillation (AF) have produced some unexpected results. As a group, NOACs showed similar efficacy as warfarin, but a reduced risk of major bleeding. The reduction in bleeding with NOACs was greatest with intracranial hemorrhage. In contrast, the relative risk of gastro-intestinal bleeding was increased with some NOACs. In this review, we explore the potential mechanisms as well as the implications of these organ-specific bleeding patterns.
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Affiliation(s)
| | | | - John W Eikelboom
- John Eikelboom, 237 Barton Street East, Hamilton, ON, L9K 1H8, Canada, Tel.: +1 905 527 4322 ext 40323, Fax: +1 905 521 1551, E-mail:
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Veltkamp R, Horstmann S. Treatment of Intracerebral Hemorrhage Associated with New Oral Anticoagulant Use. Clin Lab Med 2014; 34:587-94. [DOI: 10.1016/j.cll.2014.06.007] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Derlon V, Corbonnois G, Martin M, Toussaint-Hacquard M, Audibert G. [Hemorrhagic stroke and new oral anticoagulants]. ANNALES FRANCAISES D'ANESTHESIE ET DE REANIMATION 2014; 33:540-547. [PMID: 25282445 DOI: 10.1016/j.annfar.2014.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
The recent release of new oral anticoagulants (NOAC) raises the question of the management of intracranial hemorrhage occurring during treatment with these molecules. Dabigatran, rivaroxaban and apixaban have different pharmacological characteristics that physicians need to know to adjust their prescription to each patient. Studies of efficacy and safety prior to the marketing of these molecules showed a decreased risk of intracranial hemorrhage compared with vitamin K antagonists. However, no reliable data are available regarding the prognosis of these hemorrhages occurring during NOAC treatment. In addition, there is no specific antidote and reversal protocol validated in humans. So, physicians are in a difficult situation when critical bleeding occurs. The timing of recovering normal hemostatic capacity is then a determinant factor of prognosis. Studies in animals or healthy volunteers showed a correction of the biological parameters using prothrombin complex concentrates activated or not, without reducing the volume of hematoma. On this basis, proposals have been issued by the french group of interest for perioperative hemostasis (GIHP) for the management of bleeding under NOAC treatment, which include management of intracranial hemorrhage.
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Affiliation(s)
- V Derlon
- Service d'anesthésie-réanimation, hôpital Central, CHU de Nancy, 29, avenue du Maréchal-de-Lattre-de-Tassigny, 54000 Nancy, France
| | - G Corbonnois
- Service d'anesthésie-réanimation, hôpital Central, CHU de Nancy, 29, avenue du Maréchal-de-Lattre-de-Tassigny, 54000 Nancy, France
| | - M Martin
- Service d'hématologie biologique, CHU de Brabois, 4, rue de Morvan, 54511 Vandœuvre-lès-Nancy cedex, France
| | - M Toussaint-Hacquard
- Service d'hématologie biologique, CHU de Brabois, 4, rue de Morvan, 54511 Vandœuvre-lès-Nancy cedex, France
| | - G Audibert
- Service d'anesthésie-réanimation, hôpital Central, CHU de Nancy, 29, avenue du Maréchal-de-Lattre-de-Tassigny, 54000 Nancy, France.
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Diener HC, Stanford S, Abdul-Rahim A, Christensen L, Hougaard KD, Bakhai A, Veltkamp R, Worthmann H. Anti-thrombotic therapy in patients with atrial fibrillation and intracranial hemorrhage. Expert Rev Neurother 2014; 14:1019-28. [DOI: 10.1586/14737175.2014.945435] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Alonso A, Bengtson LGS, MacLehose RF, Lutsey PL, Chen LY, Lakshminarayan K. Intracranial hemorrhage mortality in atrial fibrillation patients treated with dabigatran or warfarin. Stroke 2014; 45:2286-91. [PMID: 24994722 PMCID: PMC4116615 DOI: 10.1161/strokeaha.114.006016] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2014] [Accepted: 06/06/2014] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND PURPOSE In randomized trials, patients with atrial fibrillation (AF) receiving dabigatran, a direct oral anticoagulant, had lower risk of intracranial bleeding (ICB) than those on warfarin. However, concerns exist about potential worse outcomes in dabigatran users if bleeding occurs, given the lack of approved reversal agents. Thus, we examined in-hospital mortality in AF patients with ICB being treated with dabigatran versus warfarin in a real-world population in the United States. METHODS We analyzed healthcare utilization claims in the Truven Health Marketscan Research Databases. The study sample included patients with AF admitted to a hospital with a primary diagnosis of ICB. Information on medications, inpatient, and outpatient diagnoses was obtained from available claims. Propensity score-adjusted risk ratios and 95% confidence intervals of in-hospital mortality comparing current users of dabigatran versus warfarin were estimated using relative risk regression. RESULTS Among 2391 AF patients admitted with ICB (2290 on warfarin, 101 on dabigatran), 531 died during their admission. In-hospital mortality was similar in those treated with warfarin (22%) or dabigatran (20%). Compared with warfarin users, the propensity score-adjusted risk ratio (95% confidence interval) of mortality in dabigatran users was 0.93 (0.62-1.37). Associations were similar across different ICB subtypes (intracerebral hemorrhage, subarachnoid hemorrhage, and subdural hematoma). CONCLUSIONS In this sample of AF patients with ICB on oral anticoagulants, dabigatran was not associated with higher in-hospital mortality compared with warfarin. Hence, reluctance to use dabigatran because of a lack of approved reversal agents is not supported by our results.
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Affiliation(s)
- Alvaro Alonso
- From the Division of Epidemiology and Community Health, School of Public Health (A.A., L.G.S.B., R.F.M., P.L.L., K.L.), University of Minnesota, Minneapolis; and Cardiovascular Division, Department of Medicine (L.Y.C.) and Department of Neurology (K.L.), University of Minnesota Medical School, Minneapolis.
| | - Lindsay G S Bengtson
- From the Division of Epidemiology and Community Health, School of Public Health (A.A., L.G.S.B., R.F.M., P.L.L., K.L.), University of Minnesota, Minneapolis; and Cardiovascular Division, Department of Medicine (L.Y.C.) and Department of Neurology (K.L.), University of Minnesota Medical School, Minneapolis
| | - Richard F MacLehose
- From the Division of Epidemiology and Community Health, School of Public Health (A.A., L.G.S.B., R.F.M., P.L.L., K.L.), University of Minnesota, Minneapolis; and Cardiovascular Division, Department of Medicine (L.Y.C.) and Department of Neurology (K.L.), University of Minnesota Medical School, Minneapolis
| | - Pamela L Lutsey
- From the Division of Epidemiology and Community Health, School of Public Health (A.A., L.G.S.B., R.F.M., P.L.L., K.L.), University of Minnesota, Minneapolis; and Cardiovascular Division, Department of Medicine (L.Y.C.) and Department of Neurology (K.L.), University of Minnesota Medical School, Minneapolis
| | - Lin Y Chen
- From the Division of Epidemiology and Community Health, School of Public Health (A.A., L.G.S.B., R.F.M., P.L.L., K.L.), University of Minnesota, Minneapolis; and Cardiovascular Division, Department of Medicine (L.Y.C.) and Department of Neurology (K.L.), University of Minnesota Medical School, Minneapolis
| | - Kamakshi Lakshminarayan
- From the Division of Epidemiology and Community Health, School of Public Health (A.A., L.G.S.B., R.F.M., P.L.L., K.L.), University of Minnesota, Minneapolis; and Cardiovascular Division, Department of Medicine (L.Y.C.) and Department of Neurology (K.L.), University of Minnesota Medical School, Minneapolis
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Li G, Fan RM, Chen JL, Wang CM, Zeng YC, Han C, Jiao S, Xia XP, Chen W, Yao ST. Neuroprotective effects of argatroban and C5a receptor antagonist (PMX53) following intracerebral haemorrhage. Clin Exp Immunol 2014; 175:285-95. [PMID: 24117111 DOI: 10.1111/cei.12220] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/07/2013] [Indexed: 01/14/2023] Open
Abstract
Intracerebral haemorrhage (ICH) is a subtype of stroke that associated with neurological dysfunction and inflammation, which may be ameliorated by a neuroprotective strategy targeting the complement cascade. The protective effect of C5a-receptor antagonist (PMX53) solely and in combination with thrombin antagonist (argatroban) was investigated in the ICH mouse model, respectively. Adult male C57BL/6J wild-type (WT) mice and C3(-/-) mice were randomized to receive PMX53/argatroban 1, 3 and 5 days after ICH. A double injection technique was used to infuse 25 μl of autologous whole blood into the right striatum. Mice in the sham group received only needle insertion. Brain water content and mRNA of inflammatory factors were measured on the first, third and fifth days after ICH, respectively. Neurological dysfunction was assessed using a 28-point neurological scoring system in the three cohorts, namely, on days 1, 3 and 5 following ICH. Animals treated with PMX53/argatroban demonstrated significant improvements in neurological function and fewer neurological apoptosis detected by TUNEL [terminal deoxynucleotidyl transferase (TdT)-mediated dUTP nick end-labelling] and βIII-tubulin dual-staining compared with vehicle-treated animals. Compared with sham-treated mice, the brain water content in argatroban/PMX53-treated mice was decreased significantly in both the ipsilateral cortex and ipsilateral striatum. Administration of PMX53/argatroban provided a synergistic neuroprotective effect via reducing inflammatory factors and brain oedema, leading to improvements in neurofunctional outcome. The results of this study indicated that simultaneous blockade of the thrombin and C5a receptors represent a promising neuroprotective strategy in haemorrhagic stroke.
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Affiliation(s)
- G Li
- Department of Cerebrovascular, the First Affliated Hospital of Zunyi Medical College, Zunyi, Guizhou, China
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Schaefer JH, Leung W, Wu L, Van Cott EM, Lok J, Whalen M, van Leyen K, Lauer A, van Ryn J, Lo EH, Foerch C. Translational insights into traumatic brain injury occurring during dabigatran or warfarin anticoagulation. J Cereb Blood Flow Metab 2014; 34:870-5. [PMID: 24549187 PMCID: PMC4013768 DOI: 10.1038/jcbfm.2014.31] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2013] [Revised: 01/13/2014] [Accepted: 01/21/2014] [Indexed: 11/09/2022]
Abstract
To date, only limited data are available on the effects of pretreatment with novel oral anticoagulants in the event of traumatic brain injury (TBI). We determined intracerebral hemorrhage volume and functional outcome in a standardized TBI model in mice treated with warfarin or dabigatran. Additionally, we investigated whether excess concentrations of dabigatran could increase bleeding and whether this was preventable by using prothrombin complex concentrate (PCC). C57 mice were treated orally with warfarin or dabigatran; sham-treated mice served as controls. Effective anticoagulation was verified by measurement of international normalized ratio and diluted thrombin time, and TBI was induced by controlled cortical impact (CCI). Twenty-four hours after CCI, intracerebral hemorrhage volume was larger in warfarin-pretreated mice than in controls (10.1 ± 4.9 vs 4.1 ± 1.7 μL; analysis of variance post hoc P=0.001), but no difference was found between controls and dabigatran-pretreated mice (5.3 ± 1.5 μL). PCC applied 30 minutes after CCI did not reliably reduce intracerebral hemorrhage induced by excess dabigatran concentration compared with saline (10.4 ± 11.2 vs 8.7 ± 7.1 μL). Our data suggest pathophysiological differences in TBI occurring during warfarin and dabigatran anticoagulation. The reduced hemorrhage formation under dabigatran therapy could present a safety advantage compared with warfarin. An excess dabigatran concentration, however, can increase hemorrhage.
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Affiliation(s)
- Jan Hendrik Schaefer
- 1] Department of Neurology, Goethe University, Frankfurt am Main, Germany [2] Neuroprotection Research Laboratory, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Wendy Leung
- Neuroprotection Research Laboratory, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Limin Wu
- 1] Neuroprotection Research Laboratory, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA [2] Department of Neurology, The First Bethune Hospital of Jilin University, Changchun, China
| | - Elizabeth M Van Cott
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Josephine Lok
- 1] Neuroprotection Research Laboratory, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA [2] Department of Pediatrics, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Michael Whalen
- 1] Department of Pediatrics, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA [2] Neuroscience Center, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Klaus van Leyen
- Neuroprotection Research Laboratory, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Arne Lauer
- Department of Neurology, Goethe University, Frankfurt am Main, Germany
| | - Joanne van Ryn
- CardioMetabolic Disease Research, Boehringer Ingelheim GmbH & Co. KG, Biberach, Germany
| | - Eng H Lo
- Neuroprotection Research Laboratory, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Christian Foerch
- Department of Neurology, Goethe University, Frankfurt am Main, Germany
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Komori M, Yasaka M, Kokuba K, Matsuoka H, Fujimoto S, Yoshida M, Kameda K, Shono T, Nagata S, Ago T, Kitazono T, Okada Y. Intracranial hemorrhage during dabigatran treatment. Circ J 2014; 78:1335-41. [PMID: 24662438 DOI: 10.1253/circj.cj-13-1534] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND The incidence of intracranial bleeding during dabigatran treatment is lower than that during warfarin treatment. The characteristics of intracranial hemorrhage during dabigatran therapy, however, remain unclear. METHODS AND RESULTS The clinical data and treatment summaries of 9 intracranial bleeds that developed during dabigatran treatment in 8 patients with non-valvular atrial fibrillation were retrospectively reviewed. Five patients had small-moderate subdural hematomas, 2 had intracerebral hemorrhage and 1 had traumatic subarachnoid and parenchymal hemorrhage associated with cerebral contusion. Activated partial thromboplastin time upon admission ranged from 31.6 to 72.4s. After admission, systolic blood pressure in the 2 patients with intracerebral hemorrhage was maintained below 140 mmHg, and the subdural hematomas in 4 patients were surgically treated. None of the hematomas became enlarged and outcome was good in most cases. CONCLUSIONS Hematomas that arise due to acute intracranial bleeding during dabigatran treatment seem to remain small to moderate, hard to expand, and manageable.
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Affiliation(s)
- Motohiro Komori
- Department of Cerebrovascular Medicine and Neurology, Clinical Research Institute, National Hospital Organization Kyushu Medical Center
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Blood-spinal cord barrier disruption contributes to early motor-neuron degeneration in ALS-model mice. Proc Natl Acad Sci U S A 2014; 111:E1035-42. [PMID: 24591593 DOI: 10.1073/pnas.1401595111] [Citation(s) in RCA: 178] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Humans with ALS and transgenic rodents expressing ALS-associated superoxide dismutase (SOD1) mutations develop spontaneous blood-spinal cord barrier (BSCB) breakdown, causing microvascular spinal-cord lesions. The role of BSCB breakdown in ALS disease pathogenesis in humans and mice remains, however, unclear, although chronic blood-brain barrier opening has been shown to facilitate accumulation of toxic blood-derived products in the central nervous system, resulting in secondary neurodegenerative changes. By repairing the BSCB and/or removing the BSCB-derived injurious stimuli, we now identify that accumulation of blood-derived neurotoxic hemoglobin and iron in the spinal cord leads to early motor-neuron degeneration in SOD1(G93A) mice at least in part through iron-dependent oxidant stress. Using spontaneous or warfarin-accelerated microvascular lesions, motor-neuron dysfunction and injury were found to be proportional to the degree of BSCB disruption at early disease stages in SOD1(G93A) mice. Early treatment with an activated protein C analog restored BSCB integrity that developed from spontaneous or warfarin-accelerated microvascular lesions in SOD1(G93A) mice and eliminated neurotoxic hemoglobin and iron deposits. Restoration of BSCB integrity delayed onset of motor-neuron impairment and degeneration. Early chelation of blood-derived iron and antioxidant treatment mitigated early motor-neuronal injury. Our data suggest that BSCB breakdown contributes to early motor-neuron degeneration in ALS mice and that restoring BSCB integrity during an early disease phase retards the disease process.
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Miyamoto K, Aiba T, Nakajima I, Yamada Y, Okamura H, Noda T, Satomi K, Ishihara M, Anzai T, Yasuda S, Ogawa H, Kamakura S, Shimizu W. Efficacy and safety of novel anticoagulant dabigatran in clinical practice for Japanese patients with non-valvular atrial fibrillation. J Arrhythm 2014. [DOI: 10.1016/j.joa.2013.04.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Comparison of the effect of edoxaban, a direct factor Xa inhibitor, with a direct thrombin inhibitor, melagatran, and heparin on intracerebral hemorrhage induced by collagenase in rats. Thromb Res 2013; 133:622-8. [PMID: 23932349 DOI: 10.1016/j.thromres.2013.07.015] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2013] [Revised: 06/25/2013] [Accepted: 07/10/2013] [Indexed: 01/28/2023]
Abstract
INTRODUCTION Intracerebral hemorrhage (ICH) is a major clinical concern with anticoagulation therapy. The effect of a new oral direct FXa inhibitor, edoxaban, was determined in a rat model of ICH and compared with a direct thrombin inhibitor, melagatran, and heparin. METHODS To induce ICH, 0.1 U collagenase type VII was injected into the striatum of male Wistar rats under anesthesia with thiopental or halothane. Immediately after ICH induction, edoxaban, melagatran, or heparin were infused intravenously. Five hours after ICH induction, the brain was removed and ICH size was measured. To estimate the margin of safety, antithrombotic effects were evaluated in a rat venous thrombosis model. RESULTS Edoxaban at 6mg/kg/h significantly increased ICH volume (1.8-fold) and prolonged prothrombin time (PT) 2.8-fold compared to the vehicle group. No deaths were observed with edoxaban. Melagatran at 1mg/kg/h increased ICH volume at 1mg/kg/h (2.8-fold) with 6.1-fold PT prolongation. At 3mg/kg/h, all rats died due to severe ICH (3.9-fold). Heparin at both 100 and 500U/kg/h significantly increased ICH. At 500U/kg/h, 5 out of 8 rats died. The doses required for 50% inhibition of thrombosis of edoxaban, melagatran, and heparin were 0.045mg/kg/h, 0.14mg/kg/h, and 55U/kg/h, respectively. The safety margins between antithrombotic and ICH exacerbation effects of these anticoagulants were 133, 7.1, and 1.8, respectively. CONCLUSION The safety margin of edoxaban was wider than that of melagatran or heparin. These results suggest that edoxaban may be preferable from the perspective of ICH exacerbation risk.
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Won SY, Schlunk F, Dinkel J, Karatas H, Leung W, Hayakawa K, Lauer A, Steinmetz H, Lo EH, Foerch C, Gupta R. Imaging of contrast medium extravasation in anticoagulation-associated intracerebral hemorrhage with dual-energy computed tomography. Stroke 2013; 44:2883-90. [PMID: 23920016 DOI: 10.1161/strokeaha.113.001224] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Contrast medium extravasation (CE) in intracerebral hemorrhage (ICH) is a marker of ongoing bleeding and a predictor of hematoma expansion. The aims of the study were to establish an ICH model in which CE can be quantified, characterized in ICH during warfarin and dabigatran anticoagulation, and to evaluate effects of prothrombin complex concentrates on CE in warfarin-associated ICH. METHODS CD1-mice were pretreated orally with warfarin, dabigatran, or vehicle. Prothrombin complex concentrates were administered in a subgroup of warfarin-treated mice. ICH was induced by stereotactic injection of collagenase VIIs into the right striatum. Contrast agent (350 μL Isovue 370 mg/mL) was injected intravenously after ICH induction (2-3.5 hours). Thirty minutes later, mice were euthanized, and CE was measured by quantifying the iodine content in the hematoma using dual-energy computed tomography. RESULTS The optimal time point for contrast injection was found to be 3 hours after ICH induction, allowing detection of both an increase and a decrease of CE using dual-energy computed tomography. CE was higher in the warfarin group compared with the controls (P=0.002). There was no significant difference in CE between dabigatran-treated mice and controls. CE was higher in the sham-treated warfarin group than in the prothrombin complex concentrates-treated warfarin group (P<0.001). CONCLUSIONS Dual-energy computed tomography allows quantifying CE, as a marker of ongoing bleeding, in a model of anticoagulation-associated ICH. Dabigatran induces less CE in ICH than warfarin and consequently reduces risks of hematoma expansion. This constitutes a potential safety advantage of dabigatran over warfarin. Nevertheless, in case of warfarin anticoagulation, prothrombin complex concentrates reduce this side effect.
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Affiliation(s)
- Sae-Yeon Won
- From the Department of Neurology, Goethe-University, Frankfurt am Main, Germany (S.-Y.W., F.S., A.L., H.S., C.F.); Neuroprotection Research Laboratory, Massachusetts General Hospital, Charlestown (S.-Y.W., F.S., H.K., W.L., K.H., E.L.); and Department of Radiology, Massachusetts General Hospital, Boston (J.D., R.G.)
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