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Sashida R, Suehiro E, Tanaka T, Shiomi N, Yatsushige H, Hirota S, Hasegawa S, Karibe H, Miyata A, Kawakita K, Haji K, Aihara H, Yokobori S, Inaji M, Maeda T, Onuki T, Oshio K, Komoribayashi N, Suzuki M, Shiomi T, Matsuno A. Effects of dual antiplatelet therapy (DAPT) compared to single antiplatelet therapy (SAPT) in patients with traumatic brain injury. Clin Neurol Neurosurg 2024; 244:108418. [PMID: 38959785 DOI: 10.1016/j.clineuro.2024.108418] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2024] [Revised: 06/27/2024] [Accepted: 06/28/2024] [Indexed: 07/05/2024]
Abstract
Japan is one of the world's most aging societies and the number of elderly patients taking antithrombotic drugs is increasing. In recent years, dual antiplatelet therapy (DAPT), in which two antiplatelet drugs are administered, has become common in anticipation of its high therapeutic efficacy. However, there are concerns about increased bleeding complications in use of DAPT. Therefore, the goal of this study was to investigate the effects of DAPT in patients with traumatic brain injury (TBI). A prospective, multicenter, observational study was conducted from December 2019 to May 2021 to examine the effects of antithrombotic drugs and reversal drugs in 721 elderly patients with TBI. In the current study, the effect of DAPT on TBI was examined in a secondary analysis. Among the registered patients, 132 patients taking antiplatelet drugs only were divided into those treated with single antiplatelet therapy (SAPT) (n=106) and those treated with DAPT (n=26) prior to TBI. Glasgow Coma Scale (GCS) on admission, pupillary findings, course during hospitalization, and outcome were compared in the two groups. A similar analysis was performed in patients with a mild GCS of 13-15 (n=95) and a moderate to severe GCS of 3-12 (n=37) on admission. The DAPT group had significantly more males (67.0 % vs. 96.2 %), a higher severity of illness on admission, and a higher frequency of brain herniation findings on head CT (21.7 % vs. 46.2 %), resulting in significantly higher mortality (12.3 % vs. 30.8 %). The only significant factor for mortality was severity on admission. The rate of DAPT was significantly higher in patients with a moderate to severe GCS on admission, and DAPT was the only significant factor related to severity on admission. These findings suggest that the severity of injury on admission influences the outcome six months after injury, and that patients with more severe TBI on admission are more likely to have been treated with DAPT compared to SAPT.
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Affiliation(s)
- Ryohei Sashida
- Department of Neurosurgery, International University of Health and Welfare, School of Medicine, Narita, Japan.
| | - Eiichi Suehiro
- Department of Neurosurgery, International University of Health and Welfare, School of Medicine, Narita, Japan.
| | - Tatsuya Tanaka
- Department of Neurosurgery, International University of Health and Welfare, School of Medicine, Narita, Japan.
| | - Naoto Shiomi
- Emergency Medical Care Center, Saiseikai Shiga Hospital, Ritto, Japan.
| | - Hiroshi Yatsushige
- Department of Neurosurgery, NHO Disaster Medical Center, Tachikawa, Japan.
| | - Shin Hirota
- Department of Neurosurgery, Tsuchiura Kyodo General Hospital, Tsuchiura, Japan.
| | - Shu Hasegawa
- Department of Neurosurgery, Kumamoto Red Cross Hospital, Kumamoto, Japan.
| | - Hiroshi Karibe
- Department of Neurosurgery, Sendai City Hospital, Sendai, Japan.
| | - Akihiro Miyata
- Department of Neurosurgery, Chiba Emergency Medical Center, Chiba, Japan.
| | - Kenya Kawakita
- Emergency Medical Center, Kagawa University Hospital, Kita-gun, Japan.
| | - Kohei Haji
- Department of Neurosurgery, Yamaguchi University School of Medicine, Ube, Japan.
| | - Hideo Aihara
- Department of Neurosurgery, Hyogo prefectual Kakogawa Medical Center, Kakogawa, Japan.
| | - Shoji Yokobori
- Department of Emergency and Critical Care Medicine, Graduate School of Medicine, Nippon Medical School, Bunkyo-ku, Japan.
| | - Motoki Inaji
- Department of Neurosurgery, Tokyo Medical and Dental University, Bunkyo-ku, Japan.
| | - Takeshi Maeda
- Department of Neurological Surgery, Nihon University School of Medicine, Itabashi, ku, Japan.
| | - Takahiro Onuki
- Department of Emergency Medicine, Teikyo University School of Medicine, Itabashi-ku, Japan.
| | - Kotaro Oshio
- Department of Neurosurgery, St. Marianna University School of Medicine, Kawasaki, Japan.
| | - Nobukazu Komoribayashi
- Iwate Prefectural Advanced Critical Care and Emergency Center, Iwate Medical University, Yahaba, Japan.
| | - Michiyasu Suzuki
- Department of Neurosurgery, Yamaguchi University School of Medicine, Ube, Japan.
| | - Takayuki Shiomi
- Department of Pathology, School of Medicine, International University of Health and Welfare, Narita, Japan.
| | - Akira Matsuno
- Department of Neurosurgery, International University of Health and Welfare, School of Medicine, Narita, Japan.
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Yamazaki N, Koga M, Doijiri R, Inoue M, Miwa K, Yoshimura S, Fukuda-Doi M, Aoki J, Asakura K, Sasaki M, Kitazono T, Kimura K, Minematsu K, Yamamoto H, Ihara M, Toyoda K. Magnetic Resonance Imaging-Guided Intravenous Thrombolysis in Cardioembolic Stroke Patients With Unknown Time of Onset - Subanalysis of the THAWS Randomized Control Trial. Circ J 2024; 88:382-387. [PMID: 38220173 DOI: 10.1253/circj.cj-23-0662] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2024]
Abstract
BACKGROUND We investigated the clinical effect of intravenous thrombolysis using a magnetic resonance imaging (MRI)-guided approach in cardioembolic stroke (CE) patients with unknown time of onset.Methods and Results: This subanalysis of the THAWS trial assessed the efficacy and safety of alteplase 0.6 mg/kg in CE patients with unknown time of onset and showing diffusion-weighted imaging-fluid-attenuated inversion recovery mismatch. Patients were classified as CE and non-CE using the SSS-TOAST classification system during the acute period. The efficacy outcome was a modified Rankin Scale score of 0-1 at 90 days. In all, 126 patients from the THAWS trial were included in this study, of whom 45 (35.7%) were diagnosed with CE. In the CE group, a favorable outcome was numerically more frequent in the alteplase than control group (52% vs. 35%; adjusted odds ratio [aOR] 2.25; 95% confidence interval [CI] 0.50-9.99). However, in the non-CE group, favorable outcomes were comparable between the alteplase and control groups (44% vs. 55%, respectively; aOR 0.39; 95% CI 0.12-1.21). Treatment-by-cohort interaction for a favorable outcome was modestly significant between the CE and non-CE groups (P=0.069). In the CE group, no patients experienced symptomatic intracranial hemorrhage (ICH) or parenchymal hematoma Type II following thrombolysis. CONCLUSIONS When an MRI-guided approach is used, CE patients with unknown time of onset appear to be suitable candidates for thrombolysis.
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Affiliation(s)
- Naoya Yamazaki
- Department of Neurology, Iwate Prefectural Central Hospital
| | - Masatoshi Koga
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center
| | | | - Manabu Inoue
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center
| | - Kaori Miwa
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center
| | - Sohei Yoshimura
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center
| | - Mayumi Fukuda-Doi
- Department of Data Science, National Cerebral and Cardiovascular Center
| | - Junya Aoki
- Department of Neurology, Graduate School of Medicine, Nippon Medical School
| | - Koko Asakura
- Department of Data Science, National Cerebral and Cardiovascular Center
| | - Makoto Sasaki
- Institute for Biomedical Sciences, Iwate Medical University
| | - Takanari Kitazono
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University
| | - Kazumi Kimura
- Department of Neurology, Graduate School of Medicine, Nippon Medical School
| | | | - Haruko Yamamoto
- Center for Advancing Clinical and Translational Sciences, National Cerebral and Cardiovascular Center
| | - Masafumi Ihara
- Department of Neurology, National Cerebral and Cardiovascular Center
| | - Kazunori Toyoda
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center
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Zhang X, Jing J, Wang A, Xie X, Johnston SC, Li H, Bath PM, Xu Q, Lin J, Wang Y, Zhao X, Li Z, Jiang Y, Liu L, Chen W, Gong X, Li J, Han X, Meng X, Wang Y. Efficacy and safety of dual antiplatelet therapy in the elderly for stroke prevention: a subgroup analysis of the CHANCE-2 trial. Stroke Vasc Neurol 2024:svn-2023-002450. [PMID: 38286485 DOI: 10.1136/svn-2023-002450] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Accepted: 12/16/2023] [Indexed: 01/31/2024] Open
Abstract
OBJECTIVES Evidence of the optimal antiplatelet therapy for elderly patients who had a stroke is limited, especially those elder than 80 years. This study aimed to explore the efficacy and safety of dual antiplatelet therapy (DAPT) in old-old patients compared with younger patients in the ticagrelor or Clopidogrel with aspirin in High-risk patients with Acute Non-disabling Cerebrovascular Events-II (CHANCE-2) trial. METHODS CHANCE-2 was a randomised, double-blind, placebo-controlled trial in China involving patients with high-risk transient ischaemic attack or minor stroke with CYP2C19 loss-of-function alleles. In our substudy, all enrolled patients were stratified by age: old-old (≥80 years), young-old (65-80 years) and younger (<65 years). The primary outcomes were stroke recurrence and moderate to severe bleeding within 90 days, respectively. RESULTS Of all the 6412 patients, 406 (6.3%) were old-old, 2755 (43.0%) were young-old and 3251 (50.7%) were younger. Old-old patients were associated with higher composite vascular events (HR 1.41, 95% CI 1.00 to 1.98, p=0.048), disabling stroke (OR 2.43, 95% CI 1.52 to 3.88, p=0.0002), severe or moderate bleeding (HR 8.40, 95% CI 1.95 to 36.21, p=0.004) and mortality (HR 7.56, 95% CI 2.23 to 25.70, p=0.001) within 90 days. Ticagrelor-aspirin group was associated with lower risks of stroke recurrence within 90 days in younger patients (HR 0.68, 95% CI 0.51 to 0.91, p=0.008), which was no differences in old-old patients. CONCLUSION Elderly patients aged over 80 in CHANCE-2 trial had higher risks of composite vascular events, disabling stroke, severe or moderate bleeding and mortality within 90 days. Genotype-guided DAPT might not be as effective in old-old patients as in younger ones. TRIAL REGISTRATION NUMBER NCT04078737.
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Affiliation(s)
- Xinmiao Zhang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Jing Jing
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Anxin Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Xuewei Xie
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | | | - Hao Li
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Philip M Bath
- Stroke Trials Unit, Mental Health & Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Qin Xu
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Jinxi Lin
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Yilong Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Xingquan Zhao
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Zixiao Li
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Yong Jiang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Liping Liu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Weifeng Chen
- Department of Neurology, Xingyang People's Hospital, Henan, China
| | - Xuhai Gong
- Daqing Oilfield General Hospital, Daqing, Heilongjiang, China
| | - Jianhua Li
- The First Hospital of Fangshan District, Beijing, China
| | | | - Xia Meng
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Yongjun Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
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Kalaria RN, Akinyemi RO, Paddick SM, Ihara M. Current perspectives on prevention of vascular cognitive impairment and promotion of vascular brain health. Expert Rev Neurother 2024; 24:25-44. [PMID: 37916306 PMCID: PMC10872925 DOI: 10.1080/14737175.2023.2273393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Accepted: 10/17/2023] [Indexed: 11/03/2023]
Abstract
INTRODUCTION The true global burden of vascular cognitive impairment (VCI) is unknown. Reducing risk factors for stroke and cardiovascular disease would inevitably curtail VCI. AREAS COVERED The authors review current diagnosis, epidemiology, and risk factors for VCI. VCI increases in older age and by inheritance of known genetic traits. They emphasize modifiable risk factors identified by the 2020 Lancet Dementia Commission. The most profound risks for VCI also include lower education, cardiometabolic factors, and compromised cognitive reserve. Finally, they discuss pharmacological and non-pharmacological interventions. EXPERT OPINION By virtue of the high frequencies of stroke and cardiovascular disease the global prevalence of VCI is expectedly higher than prevalent neurodegenerative disorders causing dementia. Since ~ 90% of the global burden of stroke can be attributed to modifiable risk factors, a formidable opportunity arises to reduce the burden of not only stroke but VCI outcomes including progression from mild to the major in form of vascular dementia. Strict control of vascular risk factors and secondary prevention of cerebrovascular disease via pharmacological interventions will impact on burden of VCI. Non-pharmacological measures by adopting healthy diets and encouraging physical and cognitive activities and urging multidomain approaches are important for prevention of VCI and preservation of vascular brain health.
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Affiliation(s)
- Raj N Kalaria
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Rufus O Akinyemi
- Neuroscience and Ageing Research Unit, Institute for Advanced Medical Research and Training, College of Medicine, University of Ibadan, Ibadan, Nigeria
| | - Stella-Maria Paddick
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Masafumi Ihara
- Department of Neurology, National Cerebral and Cardiovascular Centre, Osaka, Japan
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Gao Y, Chen W, Pan Y, Jing J, Wang C, Johnston SC, Amarenco P, Bath PM, Jiang L, Yang Y, Wang T, Han S, Meng X, Lin J, Zhao X, Liu L, Zhao J, Li Y, Zang Y, Zhang S, Yang H, Yang J, Wang Y, Li D, Wang Y, Liu D, Kang G, Wang Y, Wang Y. Dual Antiplatelet Treatment up to 72 Hours after Ischemic Stroke. N Engl J Med 2023; 389:2413-2424. [PMID: 38157499 DOI: 10.1056/nejmoa2309137] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2024]
Abstract
BACKGROUND Dual antiplatelet treatment has been shown to lower the risk of recurrent stroke as compared with aspirin alone when treatment is initiated early (≤24 hours) after an acute mild stroke. The effect of clopidogrel plus aspirin as compared with aspirin alone administered within 72 hours after the onset of acute cerebral ischemia from atherosclerosis has not been well studied. METHODS In 222 hospitals in China, we conducted a double-blind, randomized, placebo-controlled, two-by-two factorial trial involving patients with mild ischemic stroke or high-risk transient ischemic attack (TIA) of presumed atherosclerotic cause who had not undergone thrombolysis or thrombectomy. Patients were randomly assigned, in a 1:1 ratio, within 72 hours after symptom onset to receive clopidogrel (300 mg on day 1 and 75 mg daily on days 2 to 90) plus aspirin (100 to 300 mg on day 1 and 100 mg daily on days 2 to 21) or matching clopidogrel placebo plus aspirin (100 to 300 mg on day 1 and 100 mg daily on days 2 to 90). There was no interaction between this component of the factorial trial design and a second part that compared immediate with delayed statin treatment (not reported here). The primary efficacy outcome was new stroke, and the primary safety outcome was moderate-to-severe bleeding - both assessed within 90 days. RESULTS A total of 6100 patients were enrolled, with 3050 assigned to each trial group. TIA was the qualifying event for enrollment in 13.1% of the patients. A total of 12.8% of the patients were assigned to a treatment group no more than 24 hours after stroke onset, and 87.2% were assigned after 24 hours and no more than 72 hours after stroke onset. A new stroke occurred in 222 patients (7.3%) in the clopidogrel-aspirin group and in 279 (9.2%) in the aspirin group (hazard ratio, 0.79; 95% confidence interval [CI], 0.66 to 0.94; P = 0.008). Moderate-to-severe bleeding occurred in 27 patients (0.9%) in the clopidogrel-aspirin group and in 13 (0.4%) in the aspirin group (hazard ratio, 2.08; 95% CI, 1.07 to 4.04; P = 0.03). CONCLUSIONS Among patients with mild ischemic stroke or high-risk TIA of presumed atherosclerotic cause, combined clopidogrel-aspirin therapy initiated within 72 hours after stroke onset led to a lower risk of new stroke at 90 days than aspirin therapy alone but was associated with a low but higher risk of moderate-to-severe bleeding. (Funded by the National Natural Science Foundation of China and others; INSPIRES ClinicalTrials.gov number, NCT03635749.).
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Affiliation(s)
- Ying Gao
- From the Department of Neurology, Beijing Tiantan Hospital (Y.G., W.C., Y.P., J.J., C.W., Y.Y., T.W., S.H., X.M., X.Z., L.L., Yongjun Wang, Yilong Wang), the Advanced Innovation Center for Human Brain Protection (Yongjun Wang, Yilong Wang), Beijing Laboratory of Oral Health (Yilong Wang), and Beijing Municipal Key Laboratory of Clinical Epidemiology (Yilong Wang), Capital Medical University, the China National Clinical Research Center for Neurological Diseases (Y.P., J.J., C.W., L.J., X.M., J.L., X.Z., L.L., Yongjun Wang, Yilong Wang), the National Center for Neurological Disorders (Yongjun Wang, Yilong Wang), the Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences (Yongjun Wang), and the Chinese Institute for Brain Research (Yilong Wang), Beijing, the Department of Neurology, Weihai Wendeng District People's Hospital, Weihai (J.Z.), the Department of Neurology, Sui Chinese Medical Hospital, Shangqiu (Y.L.), the Department of Neurology, Qinghe People's Hospital, Xingtai (Y.Z.), the Department of Neurology, Biyang People's Hospital, Zhumadian (S.Z.), the Department of Neurology, Jiyuan Chinese Medical Hospital, Jiyuan (H.Y.), the Department of Neurology, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an (J.Y.), the Department of Neurology, Affiliated Shuyang Hospital of Xuzhou Medical University, Suqian (Yuanwei Wang), the Department of Neurology, Mengzhou People's Hospital (D. Li), and the Department of Neurology, Xiuwu People's Hospital (G.K.), Jiaozuo, and the Department of Neurology, Hejian People's Hospital, Cangzhou (Yanxia Wang, D. Liu) - all in China; the Department of Neurology, University of California, San Francisco, San Francisco (S.C.J.); the Department of Neurology and Stroke Center, Assistance Publique-Hôpitaux de Paris, Bichat Hospital, INSERM Laboratory for Vascular Translational Science-Unité 1148, University of Paris, Paris (P.A.); the Population Health Research Institute, McMaster University, Hamilton, ON, Canada (P.A.); and the Stroke Trials Unit, Mental Health and Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom (P.M.B.)
| | - Weiqi Chen
- From the Department of Neurology, Beijing Tiantan Hospital (Y.G., W.C., Y.P., J.J., C.W., Y.Y., T.W., S.H., X.M., X.Z., L.L., Yongjun Wang, Yilong Wang), the Advanced Innovation Center for Human Brain Protection (Yongjun Wang, Yilong Wang), Beijing Laboratory of Oral Health (Yilong Wang), and Beijing Municipal Key Laboratory of Clinical Epidemiology (Yilong Wang), Capital Medical University, the China National Clinical Research Center for Neurological Diseases (Y.P., J.J., C.W., L.J., X.M., J.L., X.Z., L.L., Yongjun Wang, Yilong Wang), the National Center for Neurological Disorders (Yongjun Wang, Yilong Wang), the Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences (Yongjun Wang), and the Chinese Institute for Brain Research (Yilong Wang), Beijing, the Department of Neurology, Weihai Wendeng District People's Hospital, Weihai (J.Z.), the Department of Neurology, Sui Chinese Medical Hospital, Shangqiu (Y.L.), the Department of Neurology, Qinghe People's Hospital, Xingtai (Y.Z.), the Department of Neurology, Biyang People's Hospital, Zhumadian (S.Z.), the Department of Neurology, Jiyuan Chinese Medical Hospital, Jiyuan (H.Y.), the Department of Neurology, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an (J.Y.), the Department of Neurology, Affiliated Shuyang Hospital of Xuzhou Medical University, Suqian (Yuanwei Wang), the Department of Neurology, Mengzhou People's Hospital (D. Li), and the Department of Neurology, Xiuwu People's Hospital (G.K.), Jiaozuo, and the Department of Neurology, Hejian People's Hospital, Cangzhou (Yanxia Wang, D. Liu) - all in China; the Department of Neurology, University of California, San Francisco, San Francisco (S.C.J.); the Department of Neurology and Stroke Center, Assistance Publique-Hôpitaux de Paris, Bichat Hospital, INSERM Laboratory for Vascular Translational Science-Unité 1148, University of Paris, Paris (P.A.); the Population Health Research Institute, McMaster University, Hamilton, ON, Canada (P.A.); and the Stroke Trials Unit, Mental Health and Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom (P.M.B.)
| | - Yuesong Pan
- From the Department of Neurology, Beijing Tiantan Hospital (Y.G., W.C., Y.P., J.J., C.W., Y.Y., T.W., S.H., X.M., X.Z., L.L., Yongjun Wang, Yilong Wang), the Advanced Innovation Center for Human Brain Protection (Yongjun Wang, Yilong Wang), Beijing Laboratory of Oral Health (Yilong Wang), and Beijing Municipal Key Laboratory of Clinical Epidemiology (Yilong Wang), Capital Medical University, the China National Clinical Research Center for Neurological Diseases (Y.P., J.J., C.W., L.J., X.M., J.L., X.Z., L.L., Yongjun Wang, Yilong Wang), the National Center for Neurological Disorders (Yongjun Wang, Yilong Wang), the Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences (Yongjun Wang), and the Chinese Institute for Brain Research (Yilong Wang), Beijing, the Department of Neurology, Weihai Wendeng District People's Hospital, Weihai (J.Z.), the Department of Neurology, Sui Chinese Medical Hospital, Shangqiu (Y.L.), the Department of Neurology, Qinghe People's Hospital, Xingtai (Y.Z.), the Department of Neurology, Biyang People's Hospital, Zhumadian (S.Z.), the Department of Neurology, Jiyuan Chinese Medical Hospital, Jiyuan (H.Y.), the Department of Neurology, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an (J.Y.), the Department of Neurology, Affiliated Shuyang Hospital of Xuzhou Medical University, Suqian (Yuanwei Wang), the Department of Neurology, Mengzhou People's Hospital (D. Li), and the Department of Neurology, Xiuwu People's Hospital (G.K.), Jiaozuo, and the Department of Neurology, Hejian People's Hospital, Cangzhou (Yanxia Wang, D. Liu) - all in China; the Department of Neurology, University of California, San Francisco, San Francisco (S.C.J.); the Department of Neurology and Stroke Center, Assistance Publique-Hôpitaux de Paris, Bichat Hospital, INSERM Laboratory for Vascular Translational Science-Unité 1148, University of Paris, Paris (P.A.); the Population Health Research Institute, McMaster University, Hamilton, ON, Canada (P.A.); and the Stroke Trials Unit, Mental Health and Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom (P.M.B.)
| | - Jing Jing
- From the Department of Neurology, Beijing Tiantan Hospital (Y.G., W.C., Y.P., J.J., C.W., Y.Y., T.W., S.H., X.M., X.Z., L.L., Yongjun Wang, Yilong Wang), the Advanced Innovation Center for Human Brain Protection (Yongjun Wang, Yilong Wang), Beijing Laboratory of Oral Health (Yilong Wang), and Beijing Municipal Key Laboratory of Clinical Epidemiology (Yilong Wang), Capital Medical University, the China National Clinical Research Center for Neurological Diseases (Y.P., J.J., C.W., L.J., X.M., J.L., X.Z., L.L., Yongjun Wang, Yilong Wang), the National Center for Neurological Disorders (Yongjun Wang, Yilong Wang), the Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences (Yongjun Wang), and the Chinese Institute for Brain Research (Yilong Wang), Beijing, the Department of Neurology, Weihai Wendeng District People's Hospital, Weihai (J.Z.), the Department of Neurology, Sui Chinese Medical Hospital, Shangqiu (Y.L.), the Department of Neurology, Qinghe People's Hospital, Xingtai (Y.Z.), the Department of Neurology, Biyang People's Hospital, Zhumadian (S.Z.), the Department of Neurology, Jiyuan Chinese Medical Hospital, Jiyuan (H.Y.), the Department of Neurology, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an (J.Y.), the Department of Neurology, Affiliated Shuyang Hospital of Xuzhou Medical University, Suqian (Yuanwei Wang), the Department of Neurology, Mengzhou People's Hospital (D. Li), and the Department of Neurology, Xiuwu People's Hospital (G.K.), Jiaozuo, and the Department of Neurology, Hejian People's Hospital, Cangzhou (Yanxia Wang, D. Liu) - all in China; the Department of Neurology, University of California, San Francisco, San Francisco (S.C.J.); the Department of Neurology and Stroke Center, Assistance Publique-Hôpitaux de Paris, Bichat Hospital, INSERM Laboratory for Vascular Translational Science-Unité 1148, University of Paris, Paris (P.A.); the Population Health Research Institute, McMaster University, Hamilton, ON, Canada (P.A.); and the Stroke Trials Unit, Mental Health and Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom (P.M.B.)
| | - Chunjuan Wang
- From the Department of Neurology, Beijing Tiantan Hospital (Y.G., W.C., Y.P., J.J., C.W., Y.Y., T.W., S.H., X.M., X.Z., L.L., Yongjun Wang, Yilong Wang), the Advanced Innovation Center for Human Brain Protection (Yongjun Wang, Yilong Wang), Beijing Laboratory of Oral Health (Yilong Wang), and Beijing Municipal Key Laboratory of Clinical Epidemiology (Yilong Wang), Capital Medical University, the China National Clinical Research Center for Neurological Diseases (Y.P., J.J., C.W., L.J., X.M., J.L., X.Z., L.L., Yongjun Wang, Yilong Wang), the National Center for Neurological Disorders (Yongjun Wang, Yilong Wang), the Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences (Yongjun Wang), and the Chinese Institute for Brain Research (Yilong Wang), Beijing, the Department of Neurology, Weihai Wendeng District People's Hospital, Weihai (J.Z.), the Department of Neurology, Sui Chinese Medical Hospital, Shangqiu (Y.L.), the Department of Neurology, Qinghe People's Hospital, Xingtai (Y.Z.), the Department of Neurology, Biyang People's Hospital, Zhumadian (S.Z.), the Department of Neurology, Jiyuan Chinese Medical Hospital, Jiyuan (H.Y.), the Department of Neurology, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an (J.Y.), the Department of Neurology, Affiliated Shuyang Hospital of Xuzhou Medical University, Suqian (Yuanwei Wang), the Department of Neurology, Mengzhou People's Hospital (D. Li), and the Department of Neurology, Xiuwu People's Hospital (G.K.), Jiaozuo, and the Department of Neurology, Hejian People's Hospital, Cangzhou (Yanxia Wang, D. Liu) - all in China; the Department of Neurology, University of California, San Francisco, San Francisco (S.C.J.); the Department of Neurology and Stroke Center, Assistance Publique-Hôpitaux de Paris, Bichat Hospital, INSERM Laboratory for Vascular Translational Science-Unité 1148, University of Paris, Paris (P.A.); the Population Health Research Institute, McMaster University, Hamilton, ON, Canada (P.A.); and the Stroke Trials Unit, Mental Health and Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom (P.M.B.)
| | - S Claiborne Johnston
- From the Department of Neurology, Beijing Tiantan Hospital (Y.G., W.C., Y.P., J.J., C.W., Y.Y., T.W., S.H., X.M., X.Z., L.L., Yongjun Wang, Yilong Wang), the Advanced Innovation Center for Human Brain Protection (Yongjun Wang, Yilong Wang), Beijing Laboratory of Oral Health (Yilong Wang), and Beijing Municipal Key Laboratory of Clinical Epidemiology (Yilong Wang), Capital Medical University, the China National Clinical Research Center for Neurological Diseases (Y.P., J.J., C.W., L.J., X.M., J.L., X.Z., L.L., Yongjun Wang, Yilong Wang), the National Center for Neurological Disorders (Yongjun Wang, Yilong Wang), the Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences (Yongjun Wang), and the Chinese Institute for Brain Research (Yilong Wang), Beijing, the Department of Neurology, Weihai Wendeng District People's Hospital, Weihai (J.Z.), the Department of Neurology, Sui Chinese Medical Hospital, Shangqiu (Y.L.), the Department of Neurology, Qinghe People's Hospital, Xingtai (Y.Z.), the Department of Neurology, Biyang People's Hospital, Zhumadian (S.Z.), the Department of Neurology, Jiyuan Chinese Medical Hospital, Jiyuan (H.Y.), the Department of Neurology, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an (J.Y.), the Department of Neurology, Affiliated Shuyang Hospital of Xuzhou Medical University, Suqian (Yuanwei Wang), the Department of Neurology, Mengzhou People's Hospital (D. Li), and the Department of Neurology, Xiuwu People's Hospital (G.K.), Jiaozuo, and the Department of Neurology, Hejian People's Hospital, Cangzhou (Yanxia Wang, D. Liu) - all in China; the Department of Neurology, University of California, San Francisco, San Francisco (S.C.J.); the Department of Neurology and Stroke Center, Assistance Publique-Hôpitaux de Paris, Bichat Hospital, INSERM Laboratory for Vascular Translational Science-Unité 1148, University of Paris, Paris (P.A.); the Population Health Research Institute, McMaster University, Hamilton, ON, Canada (P.A.); and the Stroke Trials Unit, Mental Health and Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom (P.M.B.)
| | - Pierre Amarenco
- From the Department of Neurology, Beijing Tiantan Hospital (Y.G., W.C., Y.P., J.J., C.W., Y.Y., T.W., S.H., X.M., X.Z., L.L., Yongjun Wang, Yilong Wang), the Advanced Innovation Center for Human Brain Protection (Yongjun Wang, Yilong Wang), Beijing Laboratory of Oral Health (Yilong Wang), and Beijing Municipal Key Laboratory of Clinical Epidemiology (Yilong Wang), Capital Medical University, the China National Clinical Research Center for Neurological Diseases (Y.P., J.J., C.W., L.J., X.M., J.L., X.Z., L.L., Yongjun Wang, Yilong Wang), the National Center for Neurological Disorders (Yongjun Wang, Yilong Wang), the Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences (Yongjun Wang), and the Chinese Institute for Brain Research (Yilong Wang), Beijing, the Department of Neurology, Weihai Wendeng District People's Hospital, Weihai (J.Z.), the Department of Neurology, Sui Chinese Medical Hospital, Shangqiu (Y.L.), the Department of Neurology, Qinghe People's Hospital, Xingtai (Y.Z.), the Department of Neurology, Biyang People's Hospital, Zhumadian (S.Z.), the Department of Neurology, Jiyuan Chinese Medical Hospital, Jiyuan (H.Y.), the Department of Neurology, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an (J.Y.), the Department of Neurology, Affiliated Shuyang Hospital of Xuzhou Medical University, Suqian (Yuanwei Wang), the Department of Neurology, Mengzhou People's Hospital (D. Li), and the Department of Neurology, Xiuwu People's Hospital (G.K.), Jiaozuo, and the Department of Neurology, Hejian People's Hospital, Cangzhou (Yanxia Wang, D. Liu) - all in China; the Department of Neurology, University of California, San Francisco, San Francisco (S.C.J.); the Department of Neurology and Stroke Center, Assistance Publique-Hôpitaux de Paris, Bichat Hospital, INSERM Laboratory for Vascular Translational Science-Unité 1148, University of Paris, Paris (P.A.); the Population Health Research Institute, McMaster University, Hamilton, ON, Canada (P.A.); and the Stroke Trials Unit, Mental Health and Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom (P.M.B.)
| | - Philip M Bath
- From the Department of Neurology, Beijing Tiantan Hospital (Y.G., W.C., Y.P., J.J., C.W., Y.Y., T.W., S.H., X.M., X.Z., L.L., Yongjun Wang, Yilong Wang), the Advanced Innovation Center for Human Brain Protection (Yongjun Wang, Yilong Wang), Beijing Laboratory of Oral Health (Yilong Wang), and Beijing Municipal Key Laboratory of Clinical Epidemiology (Yilong Wang), Capital Medical University, the China National Clinical Research Center for Neurological Diseases (Y.P., J.J., C.W., L.J., X.M., J.L., X.Z., L.L., Yongjun Wang, Yilong Wang), the National Center for Neurological Disorders (Yongjun Wang, Yilong Wang), the Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences (Yongjun Wang), and the Chinese Institute for Brain Research (Yilong Wang), Beijing, the Department of Neurology, Weihai Wendeng District People's Hospital, Weihai (J.Z.), the Department of Neurology, Sui Chinese Medical Hospital, Shangqiu (Y.L.), the Department of Neurology, Qinghe People's Hospital, Xingtai (Y.Z.), the Department of Neurology, Biyang People's Hospital, Zhumadian (S.Z.), the Department of Neurology, Jiyuan Chinese Medical Hospital, Jiyuan (H.Y.), the Department of Neurology, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an (J.Y.), the Department of Neurology, Affiliated Shuyang Hospital of Xuzhou Medical University, Suqian (Yuanwei Wang), the Department of Neurology, Mengzhou People's Hospital (D. Li), and the Department of Neurology, Xiuwu People's Hospital (G.K.), Jiaozuo, and the Department of Neurology, Hejian People's Hospital, Cangzhou (Yanxia Wang, D. Liu) - all in China; the Department of Neurology, University of California, San Francisco, San Francisco (S.C.J.); the Department of Neurology and Stroke Center, Assistance Publique-Hôpitaux de Paris, Bichat Hospital, INSERM Laboratory for Vascular Translational Science-Unité 1148, University of Paris, Paris (P.A.); the Population Health Research Institute, McMaster University, Hamilton, ON, Canada (P.A.); and the Stroke Trials Unit, Mental Health and Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom (P.M.B.)
| | - Lingling Jiang
- From the Department of Neurology, Beijing Tiantan Hospital (Y.G., W.C., Y.P., J.J., C.W., Y.Y., T.W., S.H., X.M., X.Z., L.L., Yongjun Wang, Yilong Wang), the Advanced Innovation Center for Human Brain Protection (Yongjun Wang, Yilong Wang), Beijing Laboratory of Oral Health (Yilong Wang), and Beijing Municipal Key Laboratory of Clinical Epidemiology (Yilong Wang), Capital Medical University, the China National Clinical Research Center for Neurological Diseases (Y.P., J.J., C.W., L.J., X.M., J.L., X.Z., L.L., Yongjun Wang, Yilong Wang), the National Center for Neurological Disorders (Yongjun Wang, Yilong Wang), the Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences (Yongjun Wang), and the Chinese Institute for Brain Research (Yilong Wang), Beijing, the Department of Neurology, Weihai Wendeng District People's Hospital, Weihai (J.Z.), the Department of Neurology, Sui Chinese Medical Hospital, Shangqiu (Y.L.), the Department of Neurology, Qinghe People's Hospital, Xingtai (Y.Z.), the Department of Neurology, Biyang People's Hospital, Zhumadian (S.Z.), the Department of Neurology, Jiyuan Chinese Medical Hospital, Jiyuan (H.Y.), the Department of Neurology, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an (J.Y.), the Department of Neurology, Affiliated Shuyang Hospital of Xuzhou Medical University, Suqian (Yuanwei Wang), the Department of Neurology, Mengzhou People's Hospital (D. Li), and the Department of Neurology, Xiuwu People's Hospital (G.K.), Jiaozuo, and the Department of Neurology, Hejian People's Hospital, Cangzhou (Yanxia Wang, D. Liu) - all in China; the Department of Neurology, University of California, San Francisco, San Francisco (S.C.J.); the Department of Neurology and Stroke Center, Assistance Publique-Hôpitaux de Paris, Bichat Hospital, INSERM Laboratory for Vascular Translational Science-Unité 1148, University of Paris, Paris (P.A.); the Population Health Research Institute, McMaster University, Hamilton, ON, Canada (P.A.); and the Stroke Trials Unit, Mental Health and Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom (P.M.B.)
| | - Yingying Yang
- From the Department of Neurology, Beijing Tiantan Hospital (Y.G., W.C., Y.P., J.J., C.W., Y.Y., T.W., S.H., X.M., X.Z., L.L., Yongjun Wang, Yilong Wang), the Advanced Innovation Center for Human Brain Protection (Yongjun Wang, Yilong Wang), Beijing Laboratory of Oral Health (Yilong Wang), and Beijing Municipal Key Laboratory of Clinical Epidemiology (Yilong Wang), Capital Medical University, the China National Clinical Research Center for Neurological Diseases (Y.P., J.J., C.W., L.J., X.M., J.L., X.Z., L.L., Yongjun Wang, Yilong Wang), the National Center for Neurological Disorders (Yongjun Wang, Yilong Wang), the Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences (Yongjun Wang), and the Chinese Institute for Brain Research (Yilong Wang), Beijing, the Department of Neurology, Weihai Wendeng District People's Hospital, Weihai (J.Z.), the Department of Neurology, Sui Chinese Medical Hospital, Shangqiu (Y.L.), the Department of Neurology, Qinghe People's Hospital, Xingtai (Y.Z.), the Department of Neurology, Biyang People's Hospital, Zhumadian (S.Z.), the Department of Neurology, Jiyuan Chinese Medical Hospital, Jiyuan (H.Y.), the Department of Neurology, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an (J.Y.), the Department of Neurology, Affiliated Shuyang Hospital of Xuzhou Medical University, Suqian (Yuanwei Wang), the Department of Neurology, Mengzhou People's Hospital (D. Li), and the Department of Neurology, Xiuwu People's Hospital (G.K.), Jiaozuo, and the Department of Neurology, Hejian People's Hospital, Cangzhou (Yanxia Wang, D. Liu) - all in China; the Department of Neurology, University of California, San Francisco, San Francisco (S.C.J.); the Department of Neurology and Stroke Center, Assistance Publique-Hôpitaux de Paris, Bichat Hospital, INSERM Laboratory for Vascular Translational Science-Unité 1148, University of Paris, Paris (P.A.); the Population Health Research Institute, McMaster University, Hamilton, ON, Canada (P.A.); and the Stroke Trials Unit, Mental Health and Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom (P.M.B.)
| | - Tingting Wang
- From the Department of Neurology, Beijing Tiantan Hospital (Y.G., W.C., Y.P., J.J., C.W., Y.Y., T.W., S.H., X.M., X.Z., L.L., Yongjun Wang, Yilong Wang), the Advanced Innovation Center for Human Brain Protection (Yongjun Wang, Yilong Wang), Beijing Laboratory of Oral Health (Yilong Wang), and Beijing Municipal Key Laboratory of Clinical Epidemiology (Yilong Wang), Capital Medical University, the China National Clinical Research Center for Neurological Diseases (Y.P., J.J., C.W., L.J., X.M., J.L., X.Z., L.L., Yongjun Wang, Yilong Wang), the National Center for Neurological Disorders (Yongjun Wang, Yilong Wang), the Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences (Yongjun Wang), and the Chinese Institute for Brain Research (Yilong Wang), Beijing, the Department of Neurology, Weihai Wendeng District People's Hospital, Weihai (J.Z.), the Department of Neurology, Sui Chinese Medical Hospital, Shangqiu (Y.L.), the Department of Neurology, Qinghe People's Hospital, Xingtai (Y.Z.), the Department of Neurology, Biyang People's Hospital, Zhumadian (S.Z.), the Department of Neurology, Jiyuan Chinese Medical Hospital, Jiyuan (H.Y.), the Department of Neurology, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an (J.Y.), the Department of Neurology, Affiliated Shuyang Hospital of Xuzhou Medical University, Suqian (Yuanwei Wang), the Department of Neurology, Mengzhou People's Hospital (D. Li), and the Department of Neurology, Xiuwu People's Hospital (G.K.), Jiaozuo, and the Department of Neurology, Hejian People's Hospital, Cangzhou (Yanxia Wang, D. Liu) - all in China; the Department of Neurology, University of California, San Francisco, San Francisco (S.C.J.); the Department of Neurology and Stroke Center, Assistance Publique-Hôpitaux de Paris, Bichat Hospital, INSERM Laboratory for Vascular Translational Science-Unité 1148, University of Paris, Paris (P.A.); the Population Health Research Institute, McMaster University, Hamilton, ON, Canada (P.A.); and the Stroke Trials Unit, Mental Health and Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom (P.M.B.)
| | - Shangrong Han
- From the Department of Neurology, Beijing Tiantan Hospital (Y.G., W.C., Y.P., J.J., C.W., Y.Y., T.W., S.H., X.M., X.Z., L.L., Yongjun Wang, Yilong Wang), the Advanced Innovation Center for Human Brain Protection (Yongjun Wang, Yilong Wang), Beijing Laboratory of Oral Health (Yilong Wang), and Beijing Municipal Key Laboratory of Clinical Epidemiology (Yilong Wang), Capital Medical University, the China National Clinical Research Center for Neurological Diseases (Y.P., J.J., C.W., L.J., X.M., J.L., X.Z., L.L., Yongjun Wang, Yilong Wang), the National Center for Neurological Disorders (Yongjun Wang, Yilong Wang), the Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences (Yongjun Wang), and the Chinese Institute for Brain Research (Yilong Wang), Beijing, the Department of Neurology, Weihai Wendeng District People's Hospital, Weihai (J.Z.), the Department of Neurology, Sui Chinese Medical Hospital, Shangqiu (Y.L.), the Department of Neurology, Qinghe People's Hospital, Xingtai (Y.Z.), the Department of Neurology, Biyang People's Hospital, Zhumadian (S.Z.), the Department of Neurology, Jiyuan Chinese Medical Hospital, Jiyuan (H.Y.), the Department of Neurology, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an (J.Y.), the Department of Neurology, Affiliated Shuyang Hospital of Xuzhou Medical University, Suqian (Yuanwei Wang), the Department of Neurology, Mengzhou People's Hospital (D. Li), and the Department of Neurology, Xiuwu People's Hospital (G.K.), Jiaozuo, and the Department of Neurology, Hejian People's Hospital, Cangzhou (Yanxia Wang, D. Liu) - all in China; the Department of Neurology, University of California, San Francisco, San Francisco (S.C.J.); the Department of Neurology and Stroke Center, Assistance Publique-Hôpitaux de Paris, Bichat Hospital, INSERM Laboratory for Vascular Translational Science-Unité 1148, University of Paris, Paris (P.A.); the Population Health Research Institute, McMaster University, Hamilton, ON, Canada (P.A.); and the Stroke Trials Unit, Mental Health and Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom (P.M.B.)
| | - Xia Meng
- From the Department of Neurology, Beijing Tiantan Hospital (Y.G., W.C., Y.P., J.J., C.W., Y.Y., T.W., S.H., X.M., X.Z., L.L., Yongjun Wang, Yilong Wang), the Advanced Innovation Center for Human Brain Protection (Yongjun Wang, Yilong Wang), Beijing Laboratory of Oral Health (Yilong Wang), and Beijing Municipal Key Laboratory of Clinical Epidemiology (Yilong Wang), Capital Medical University, the China National Clinical Research Center for Neurological Diseases (Y.P., J.J., C.W., L.J., X.M., J.L., X.Z., L.L., Yongjun Wang, Yilong Wang), the National Center for Neurological Disorders (Yongjun Wang, Yilong Wang), the Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences (Yongjun Wang), and the Chinese Institute for Brain Research (Yilong Wang), Beijing, the Department of Neurology, Weihai Wendeng District People's Hospital, Weihai (J.Z.), the Department of Neurology, Sui Chinese Medical Hospital, Shangqiu (Y.L.), the Department of Neurology, Qinghe People's Hospital, Xingtai (Y.Z.), the Department of Neurology, Biyang People's Hospital, Zhumadian (S.Z.), the Department of Neurology, Jiyuan Chinese Medical Hospital, Jiyuan (H.Y.), the Department of Neurology, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an (J.Y.), the Department of Neurology, Affiliated Shuyang Hospital of Xuzhou Medical University, Suqian (Yuanwei Wang), the Department of Neurology, Mengzhou People's Hospital (D. Li), and the Department of Neurology, Xiuwu People's Hospital (G.K.), Jiaozuo, and the Department of Neurology, Hejian People's Hospital, Cangzhou (Yanxia Wang, D. Liu) - all in China; the Department of Neurology, University of California, San Francisco, San Francisco (S.C.J.); the Department of Neurology and Stroke Center, Assistance Publique-Hôpitaux de Paris, Bichat Hospital, INSERM Laboratory for Vascular Translational Science-Unité 1148, University of Paris, Paris (P.A.); the Population Health Research Institute, McMaster University, Hamilton, ON, Canada (P.A.); and the Stroke Trials Unit, Mental Health and Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom (P.M.B.)
| | - Jinxi Lin
- From the Department of Neurology, Beijing Tiantan Hospital (Y.G., W.C., Y.P., J.J., C.W., Y.Y., T.W., S.H., X.M., X.Z., L.L., Yongjun Wang, Yilong Wang), the Advanced Innovation Center for Human Brain Protection (Yongjun Wang, Yilong Wang), Beijing Laboratory of Oral Health (Yilong Wang), and Beijing Municipal Key Laboratory of Clinical Epidemiology (Yilong Wang), Capital Medical University, the China National Clinical Research Center for Neurological Diseases (Y.P., J.J., C.W., L.J., X.M., J.L., X.Z., L.L., Yongjun Wang, Yilong Wang), the National Center for Neurological Disorders (Yongjun Wang, Yilong Wang), the Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences (Yongjun Wang), and the Chinese Institute for Brain Research (Yilong Wang), Beijing, the Department of Neurology, Weihai Wendeng District People's Hospital, Weihai (J.Z.), the Department of Neurology, Sui Chinese Medical Hospital, Shangqiu (Y.L.), the Department of Neurology, Qinghe People's Hospital, Xingtai (Y.Z.), the Department of Neurology, Biyang People's Hospital, Zhumadian (S.Z.), the Department of Neurology, Jiyuan Chinese Medical Hospital, Jiyuan (H.Y.), the Department of Neurology, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an (J.Y.), the Department of Neurology, Affiliated Shuyang Hospital of Xuzhou Medical University, Suqian (Yuanwei Wang), the Department of Neurology, Mengzhou People's Hospital (D. Li), and the Department of Neurology, Xiuwu People's Hospital (G.K.), Jiaozuo, and the Department of Neurology, Hejian People's Hospital, Cangzhou (Yanxia Wang, D. Liu) - all in China; the Department of Neurology, University of California, San Francisco, San Francisco (S.C.J.); the Department of Neurology and Stroke Center, Assistance Publique-Hôpitaux de Paris, Bichat Hospital, INSERM Laboratory for Vascular Translational Science-Unité 1148, University of Paris, Paris (P.A.); the Population Health Research Institute, McMaster University, Hamilton, ON, Canada (P.A.); and the Stroke Trials Unit, Mental Health and Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom (P.M.B.)
| | - Xingquan Zhao
- From the Department of Neurology, Beijing Tiantan Hospital (Y.G., W.C., Y.P., J.J., C.W., Y.Y., T.W., S.H., X.M., X.Z., L.L., Yongjun Wang, Yilong Wang), the Advanced Innovation Center for Human Brain Protection (Yongjun Wang, Yilong Wang), Beijing Laboratory of Oral Health (Yilong Wang), and Beijing Municipal Key Laboratory of Clinical Epidemiology (Yilong Wang), Capital Medical University, the China National Clinical Research Center for Neurological Diseases (Y.P., J.J., C.W., L.J., X.M., J.L., X.Z., L.L., Yongjun Wang, Yilong Wang), the National Center for Neurological Disorders (Yongjun Wang, Yilong Wang), the Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences (Yongjun Wang), and the Chinese Institute for Brain Research (Yilong Wang), Beijing, the Department of Neurology, Weihai Wendeng District People's Hospital, Weihai (J.Z.), the Department of Neurology, Sui Chinese Medical Hospital, Shangqiu (Y.L.), the Department of Neurology, Qinghe People's Hospital, Xingtai (Y.Z.), the Department of Neurology, Biyang People's Hospital, Zhumadian (S.Z.), the Department of Neurology, Jiyuan Chinese Medical Hospital, Jiyuan (H.Y.), the Department of Neurology, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an (J.Y.), the Department of Neurology, Affiliated Shuyang Hospital of Xuzhou Medical University, Suqian (Yuanwei Wang), the Department of Neurology, Mengzhou People's Hospital (D. Li), and the Department of Neurology, Xiuwu People's Hospital (G.K.), Jiaozuo, and the Department of Neurology, Hejian People's Hospital, Cangzhou (Yanxia Wang, D. Liu) - all in China; the Department of Neurology, University of California, San Francisco, San Francisco (S.C.J.); the Department of Neurology and Stroke Center, Assistance Publique-Hôpitaux de Paris, Bichat Hospital, INSERM Laboratory for Vascular Translational Science-Unité 1148, University of Paris, Paris (P.A.); the Population Health Research Institute, McMaster University, Hamilton, ON, Canada (P.A.); and the Stroke Trials Unit, Mental Health and Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom (P.M.B.)
| | - Liping Liu
- From the Department of Neurology, Beijing Tiantan Hospital (Y.G., W.C., Y.P., J.J., C.W., Y.Y., T.W., S.H., X.M., X.Z., L.L., Yongjun Wang, Yilong Wang), the Advanced Innovation Center for Human Brain Protection (Yongjun Wang, Yilong Wang), Beijing Laboratory of Oral Health (Yilong Wang), and Beijing Municipal Key Laboratory of Clinical Epidemiology (Yilong Wang), Capital Medical University, the China National Clinical Research Center for Neurological Diseases (Y.P., J.J., C.W., L.J., X.M., J.L., X.Z., L.L., Yongjun Wang, Yilong Wang), the National Center for Neurological Disorders (Yongjun Wang, Yilong Wang), the Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences (Yongjun Wang), and the Chinese Institute for Brain Research (Yilong Wang), Beijing, the Department of Neurology, Weihai Wendeng District People's Hospital, Weihai (J.Z.), the Department of Neurology, Sui Chinese Medical Hospital, Shangqiu (Y.L.), the Department of Neurology, Qinghe People's Hospital, Xingtai (Y.Z.), the Department of Neurology, Biyang People's Hospital, Zhumadian (S.Z.), the Department of Neurology, Jiyuan Chinese Medical Hospital, Jiyuan (H.Y.), the Department of Neurology, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an (J.Y.), the Department of Neurology, Affiliated Shuyang Hospital of Xuzhou Medical University, Suqian (Yuanwei Wang), the Department of Neurology, Mengzhou People's Hospital (D. Li), and the Department of Neurology, Xiuwu People's Hospital (G.K.), Jiaozuo, and the Department of Neurology, Hejian People's Hospital, Cangzhou (Yanxia Wang, D. Liu) - all in China; the Department of Neurology, University of California, San Francisco, San Francisco (S.C.J.); the Department of Neurology and Stroke Center, Assistance Publique-Hôpitaux de Paris, Bichat Hospital, INSERM Laboratory for Vascular Translational Science-Unité 1148, University of Paris, Paris (P.A.); the Population Health Research Institute, McMaster University, Hamilton, ON, Canada (P.A.); and the Stroke Trials Unit, Mental Health and Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom (P.M.B.)
| | - Jinguo Zhao
- From the Department of Neurology, Beijing Tiantan Hospital (Y.G., W.C., Y.P., J.J., C.W., Y.Y., T.W., S.H., X.M., X.Z., L.L., Yongjun Wang, Yilong Wang), the Advanced Innovation Center for Human Brain Protection (Yongjun Wang, Yilong Wang), Beijing Laboratory of Oral Health (Yilong Wang), and Beijing Municipal Key Laboratory of Clinical Epidemiology (Yilong Wang), Capital Medical University, the China National Clinical Research Center for Neurological Diseases (Y.P., J.J., C.W., L.J., X.M., J.L., X.Z., L.L., Yongjun Wang, Yilong Wang), the National Center for Neurological Disorders (Yongjun Wang, Yilong Wang), the Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences (Yongjun Wang), and the Chinese Institute for Brain Research (Yilong Wang), Beijing, the Department of Neurology, Weihai Wendeng District People's Hospital, Weihai (J.Z.), the Department of Neurology, Sui Chinese Medical Hospital, Shangqiu (Y.L.), the Department of Neurology, Qinghe People's Hospital, Xingtai (Y.Z.), the Department of Neurology, Biyang People's Hospital, Zhumadian (S.Z.), the Department of Neurology, Jiyuan Chinese Medical Hospital, Jiyuan (H.Y.), the Department of Neurology, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an (J.Y.), the Department of Neurology, Affiliated Shuyang Hospital of Xuzhou Medical University, Suqian (Yuanwei Wang), the Department of Neurology, Mengzhou People's Hospital (D. Li), and the Department of Neurology, Xiuwu People's Hospital (G.K.), Jiaozuo, and the Department of Neurology, Hejian People's Hospital, Cangzhou (Yanxia Wang, D. Liu) - all in China; the Department of Neurology, University of California, San Francisco, San Francisco (S.C.J.); the Department of Neurology and Stroke Center, Assistance Publique-Hôpitaux de Paris, Bichat Hospital, INSERM Laboratory for Vascular Translational Science-Unité 1148, University of Paris, Paris (P.A.); the Population Health Research Institute, McMaster University, Hamilton, ON, Canada (P.A.); and the Stroke Trials Unit, Mental Health and Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom (P.M.B.)
| | - Ying Li
- From the Department of Neurology, Beijing Tiantan Hospital (Y.G., W.C., Y.P., J.J., C.W., Y.Y., T.W., S.H., X.M., X.Z., L.L., Yongjun Wang, Yilong Wang), the Advanced Innovation Center for Human Brain Protection (Yongjun Wang, Yilong Wang), Beijing Laboratory of Oral Health (Yilong Wang), and Beijing Municipal Key Laboratory of Clinical Epidemiology (Yilong Wang), Capital Medical University, the China National Clinical Research Center for Neurological Diseases (Y.P., J.J., C.W., L.J., X.M., J.L., X.Z., L.L., Yongjun Wang, Yilong Wang), the National Center for Neurological Disorders (Yongjun Wang, Yilong Wang), the Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences (Yongjun Wang), and the Chinese Institute for Brain Research (Yilong Wang), Beijing, the Department of Neurology, Weihai Wendeng District People's Hospital, Weihai (J.Z.), the Department of Neurology, Sui Chinese Medical Hospital, Shangqiu (Y.L.), the Department of Neurology, Qinghe People's Hospital, Xingtai (Y.Z.), the Department of Neurology, Biyang People's Hospital, Zhumadian (S.Z.), the Department of Neurology, Jiyuan Chinese Medical Hospital, Jiyuan (H.Y.), the Department of Neurology, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an (J.Y.), the Department of Neurology, Affiliated Shuyang Hospital of Xuzhou Medical University, Suqian (Yuanwei Wang), the Department of Neurology, Mengzhou People's Hospital (D. Li), and the Department of Neurology, Xiuwu People's Hospital (G.K.), Jiaozuo, and the Department of Neurology, Hejian People's Hospital, Cangzhou (Yanxia Wang, D. Liu) - all in China; the Department of Neurology, University of California, San Francisco, San Francisco (S.C.J.); the Department of Neurology and Stroke Center, Assistance Publique-Hôpitaux de Paris, Bichat Hospital, INSERM Laboratory for Vascular Translational Science-Unité 1148, University of Paris, Paris (P.A.); the Population Health Research Institute, McMaster University, Hamilton, ON, Canada (P.A.); and the Stroke Trials Unit, Mental Health and Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom (P.M.B.)
| | - Yingzhuo Zang
- From the Department of Neurology, Beijing Tiantan Hospital (Y.G., W.C., Y.P., J.J., C.W., Y.Y., T.W., S.H., X.M., X.Z., L.L., Yongjun Wang, Yilong Wang), the Advanced Innovation Center for Human Brain Protection (Yongjun Wang, Yilong Wang), Beijing Laboratory of Oral Health (Yilong Wang), and Beijing Municipal Key Laboratory of Clinical Epidemiology (Yilong Wang), Capital Medical University, the China National Clinical Research Center for Neurological Diseases (Y.P., J.J., C.W., L.J., X.M., J.L., X.Z., L.L., Yongjun Wang, Yilong Wang), the National Center for Neurological Disorders (Yongjun Wang, Yilong Wang), the Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences (Yongjun Wang), and the Chinese Institute for Brain Research (Yilong Wang), Beijing, the Department of Neurology, Weihai Wendeng District People's Hospital, Weihai (J.Z.), the Department of Neurology, Sui Chinese Medical Hospital, Shangqiu (Y.L.), the Department of Neurology, Qinghe People's Hospital, Xingtai (Y.Z.), the Department of Neurology, Biyang People's Hospital, Zhumadian (S.Z.), the Department of Neurology, Jiyuan Chinese Medical Hospital, Jiyuan (H.Y.), the Department of Neurology, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an (J.Y.), the Department of Neurology, Affiliated Shuyang Hospital of Xuzhou Medical University, Suqian (Yuanwei Wang), the Department of Neurology, Mengzhou People's Hospital (D. Li), and the Department of Neurology, Xiuwu People's Hospital (G.K.), Jiaozuo, and the Department of Neurology, Hejian People's Hospital, Cangzhou (Yanxia Wang, D. Liu) - all in China; the Department of Neurology, University of California, San Francisco, San Francisco (S.C.J.); the Department of Neurology and Stroke Center, Assistance Publique-Hôpitaux de Paris, Bichat Hospital, INSERM Laboratory for Vascular Translational Science-Unité 1148, University of Paris, Paris (P.A.); the Population Health Research Institute, McMaster University, Hamilton, ON, Canada (P.A.); and the Stroke Trials Unit, Mental Health and Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom (P.M.B.)
| | - Shuo Zhang
- From the Department of Neurology, Beijing Tiantan Hospital (Y.G., W.C., Y.P., J.J., C.W., Y.Y., T.W., S.H., X.M., X.Z., L.L., Yongjun Wang, Yilong Wang), the Advanced Innovation Center for Human Brain Protection (Yongjun Wang, Yilong Wang), Beijing Laboratory of Oral Health (Yilong Wang), and Beijing Municipal Key Laboratory of Clinical Epidemiology (Yilong Wang), Capital Medical University, the China National Clinical Research Center for Neurological Diseases (Y.P., J.J., C.W., L.J., X.M., J.L., X.Z., L.L., Yongjun Wang, Yilong Wang), the National Center for Neurological Disorders (Yongjun Wang, Yilong Wang), the Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences (Yongjun Wang), and the Chinese Institute for Brain Research (Yilong Wang), Beijing, the Department of Neurology, Weihai Wendeng District People's Hospital, Weihai (J.Z.), the Department of Neurology, Sui Chinese Medical Hospital, Shangqiu (Y.L.), the Department of Neurology, Qinghe People's Hospital, Xingtai (Y.Z.), the Department of Neurology, Biyang People's Hospital, Zhumadian (S.Z.), the Department of Neurology, Jiyuan Chinese Medical Hospital, Jiyuan (H.Y.), the Department of Neurology, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an (J.Y.), the Department of Neurology, Affiliated Shuyang Hospital of Xuzhou Medical University, Suqian (Yuanwei Wang), the Department of Neurology, Mengzhou People's Hospital (D. Li), and the Department of Neurology, Xiuwu People's Hospital (G.K.), Jiaozuo, and the Department of Neurology, Hejian People's Hospital, Cangzhou (Yanxia Wang, D. Liu) - all in China; the Department of Neurology, University of California, San Francisco, San Francisco (S.C.J.); the Department of Neurology and Stroke Center, Assistance Publique-Hôpitaux de Paris, Bichat Hospital, INSERM Laboratory for Vascular Translational Science-Unité 1148, University of Paris, Paris (P.A.); the Population Health Research Institute, McMaster University, Hamilton, ON, Canada (P.A.); and the Stroke Trials Unit, Mental Health and Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom (P.M.B.)
| | - Hongqin Yang
- From the Department of Neurology, Beijing Tiantan Hospital (Y.G., W.C., Y.P., J.J., C.W., Y.Y., T.W., S.H., X.M., X.Z., L.L., Yongjun Wang, Yilong Wang), the Advanced Innovation Center for Human Brain Protection (Yongjun Wang, Yilong Wang), Beijing Laboratory of Oral Health (Yilong Wang), and Beijing Municipal Key Laboratory of Clinical Epidemiology (Yilong Wang), Capital Medical University, the China National Clinical Research Center for Neurological Diseases (Y.P., J.J., C.W., L.J., X.M., J.L., X.Z., L.L., Yongjun Wang, Yilong Wang), the National Center for Neurological Disorders (Yongjun Wang, Yilong Wang), the Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences (Yongjun Wang), and the Chinese Institute for Brain Research (Yilong Wang), Beijing, the Department of Neurology, Weihai Wendeng District People's Hospital, Weihai (J.Z.), the Department of Neurology, Sui Chinese Medical Hospital, Shangqiu (Y.L.), the Department of Neurology, Qinghe People's Hospital, Xingtai (Y.Z.), the Department of Neurology, Biyang People's Hospital, Zhumadian (S.Z.), the Department of Neurology, Jiyuan Chinese Medical Hospital, Jiyuan (H.Y.), the Department of Neurology, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an (J.Y.), the Department of Neurology, Affiliated Shuyang Hospital of Xuzhou Medical University, Suqian (Yuanwei Wang), the Department of Neurology, Mengzhou People's Hospital (D. Li), and the Department of Neurology, Xiuwu People's Hospital (G.K.), Jiaozuo, and the Department of Neurology, Hejian People's Hospital, Cangzhou (Yanxia Wang, D. Liu) - all in China; the Department of Neurology, University of California, San Francisco, San Francisco (S.C.J.); the Department of Neurology and Stroke Center, Assistance Publique-Hôpitaux de Paris, Bichat Hospital, INSERM Laboratory for Vascular Translational Science-Unité 1148, University of Paris, Paris (P.A.); the Population Health Research Institute, McMaster University, Hamilton, ON, Canada (P.A.); and the Stroke Trials Unit, Mental Health and Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom (P.M.B.)
| | - Jianbo Yang
- From the Department of Neurology, Beijing Tiantan Hospital (Y.G., W.C., Y.P., J.J., C.W., Y.Y., T.W., S.H., X.M., X.Z., L.L., Yongjun Wang, Yilong Wang), the Advanced Innovation Center for Human Brain Protection (Yongjun Wang, Yilong Wang), Beijing Laboratory of Oral Health (Yilong Wang), and Beijing Municipal Key Laboratory of Clinical Epidemiology (Yilong Wang), Capital Medical University, the China National Clinical Research Center for Neurological Diseases (Y.P., J.J., C.W., L.J., X.M., J.L., X.Z., L.L., Yongjun Wang, Yilong Wang), the National Center for Neurological Disorders (Yongjun Wang, Yilong Wang), the Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences (Yongjun Wang), and the Chinese Institute for Brain Research (Yilong Wang), Beijing, the Department of Neurology, Weihai Wendeng District People's Hospital, Weihai (J.Z.), the Department of Neurology, Sui Chinese Medical Hospital, Shangqiu (Y.L.), the Department of Neurology, Qinghe People's Hospital, Xingtai (Y.Z.), the Department of Neurology, Biyang People's Hospital, Zhumadian (S.Z.), the Department of Neurology, Jiyuan Chinese Medical Hospital, Jiyuan (H.Y.), the Department of Neurology, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an (J.Y.), the Department of Neurology, Affiliated Shuyang Hospital of Xuzhou Medical University, Suqian (Yuanwei Wang), the Department of Neurology, Mengzhou People's Hospital (D. Li), and the Department of Neurology, Xiuwu People's Hospital (G.K.), Jiaozuo, and the Department of Neurology, Hejian People's Hospital, Cangzhou (Yanxia Wang, D. Liu) - all in China; the Department of Neurology, University of California, San Francisco, San Francisco (S.C.J.); the Department of Neurology and Stroke Center, Assistance Publique-Hôpitaux de Paris, Bichat Hospital, INSERM Laboratory for Vascular Translational Science-Unité 1148, University of Paris, Paris (P.A.); the Population Health Research Institute, McMaster University, Hamilton, ON, Canada (P.A.); and the Stroke Trials Unit, Mental Health and Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom (P.M.B.)
| | - Yuanwei Wang
- From the Department of Neurology, Beijing Tiantan Hospital (Y.G., W.C., Y.P., J.J., C.W., Y.Y., T.W., S.H., X.M., X.Z., L.L., Yongjun Wang, Yilong Wang), the Advanced Innovation Center for Human Brain Protection (Yongjun Wang, Yilong Wang), Beijing Laboratory of Oral Health (Yilong Wang), and Beijing Municipal Key Laboratory of Clinical Epidemiology (Yilong Wang), Capital Medical University, the China National Clinical Research Center for Neurological Diseases (Y.P., J.J., C.W., L.J., X.M., J.L., X.Z., L.L., Yongjun Wang, Yilong Wang), the National Center for Neurological Disorders (Yongjun Wang, Yilong Wang), the Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences (Yongjun Wang), and the Chinese Institute for Brain Research (Yilong Wang), Beijing, the Department of Neurology, Weihai Wendeng District People's Hospital, Weihai (J.Z.), the Department of Neurology, Sui Chinese Medical Hospital, Shangqiu (Y.L.), the Department of Neurology, Qinghe People's Hospital, Xingtai (Y.Z.), the Department of Neurology, Biyang People's Hospital, Zhumadian (S.Z.), the Department of Neurology, Jiyuan Chinese Medical Hospital, Jiyuan (H.Y.), the Department of Neurology, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an (J.Y.), the Department of Neurology, Affiliated Shuyang Hospital of Xuzhou Medical University, Suqian (Yuanwei Wang), the Department of Neurology, Mengzhou People's Hospital (D. Li), and the Department of Neurology, Xiuwu People's Hospital (G.K.), Jiaozuo, and the Department of Neurology, Hejian People's Hospital, Cangzhou (Yanxia Wang, D. Liu) - all in China; the Department of Neurology, University of California, San Francisco, San Francisco (S.C.J.); the Department of Neurology and Stroke Center, Assistance Publique-Hôpitaux de Paris, Bichat Hospital, INSERM Laboratory for Vascular Translational Science-Unité 1148, University of Paris, Paris (P.A.); the Population Health Research Institute, McMaster University, Hamilton, ON, Canada (P.A.); and the Stroke Trials Unit, Mental Health and Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom (P.M.B.)
| | - Dali Li
- From the Department of Neurology, Beijing Tiantan Hospital (Y.G., W.C., Y.P., J.J., C.W., Y.Y., T.W., S.H., X.M., X.Z., L.L., Yongjun Wang, Yilong Wang), the Advanced Innovation Center for Human Brain Protection (Yongjun Wang, Yilong Wang), Beijing Laboratory of Oral Health (Yilong Wang), and Beijing Municipal Key Laboratory of Clinical Epidemiology (Yilong Wang), Capital Medical University, the China National Clinical Research Center for Neurological Diseases (Y.P., J.J., C.W., L.J., X.M., J.L., X.Z., L.L., Yongjun Wang, Yilong Wang), the National Center for Neurological Disorders (Yongjun Wang, Yilong Wang), the Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences (Yongjun Wang), and the Chinese Institute for Brain Research (Yilong Wang), Beijing, the Department of Neurology, Weihai Wendeng District People's Hospital, Weihai (J.Z.), the Department of Neurology, Sui Chinese Medical Hospital, Shangqiu (Y.L.), the Department of Neurology, Qinghe People's Hospital, Xingtai (Y.Z.), the Department of Neurology, Biyang People's Hospital, Zhumadian (S.Z.), the Department of Neurology, Jiyuan Chinese Medical Hospital, Jiyuan (H.Y.), the Department of Neurology, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an (J.Y.), the Department of Neurology, Affiliated Shuyang Hospital of Xuzhou Medical University, Suqian (Yuanwei Wang), the Department of Neurology, Mengzhou People's Hospital (D. Li), and the Department of Neurology, Xiuwu People's Hospital (G.K.), Jiaozuo, and the Department of Neurology, Hejian People's Hospital, Cangzhou (Yanxia Wang, D. Liu) - all in China; the Department of Neurology, University of California, San Francisco, San Francisco (S.C.J.); the Department of Neurology and Stroke Center, Assistance Publique-Hôpitaux de Paris, Bichat Hospital, INSERM Laboratory for Vascular Translational Science-Unité 1148, University of Paris, Paris (P.A.); the Population Health Research Institute, McMaster University, Hamilton, ON, Canada (P.A.); and the Stroke Trials Unit, Mental Health and Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom (P.M.B.)
| | - Yanxia Wang
- From the Department of Neurology, Beijing Tiantan Hospital (Y.G., W.C., Y.P., J.J., C.W., Y.Y., T.W., S.H., X.M., X.Z., L.L., Yongjun Wang, Yilong Wang), the Advanced Innovation Center for Human Brain Protection (Yongjun Wang, Yilong Wang), Beijing Laboratory of Oral Health (Yilong Wang), and Beijing Municipal Key Laboratory of Clinical Epidemiology (Yilong Wang), Capital Medical University, the China National Clinical Research Center for Neurological Diseases (Y.P., J.J., C.W., L.J., X.M., J.L., X.Z., L.L., Yongjun Wang, Yilong Wang), the National Center for Neurological Disorders (Yongjun Wang, Yilong Wang), the Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences (Yongjun Wang), and the Chinese Institute for Brain Research (Yilong Wang), Beijing, the Department of Neurology, Weihai Wendeng District People's Hospital, Weihai (J.Z.), the Department of Neurology, Sui Chinese Medical Hospital, Shangqiu (Y.L.), the Department of Neurology, Qinghe People's Hospital, Xingtai (Y.Z.), the Department of Neurology, Biyang People's Hospital, Zhumadian (S.Z.), the Department of Neurology, Jiyuan Chinese Medical Hospital, Jiyuan (H.Y.), the Department of Neurology, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an (J.Y.), the Department of Neurology, Affiliated Shuyang Hospital of Xuzhou Medical University, Suqian (Yuanwei Wang), the Department of Neurology, Mengzhou People's Hospital (D. Li), and the Department of Neurology, Xiuwu People's Hospital (G.K.), Jiaozuo, and the Department of Neurology, Hejian People's Hospital, Cangzhou (Yanxia Wang, D. Liu) - all in China; the Department of Neurology, University of California, San Francisco, San Francisco (S.C.J.); the Department of Neurology and Stroke Center, Assistance Publique-Hôpitaux de Paris, Bichat Hospital, INSERM Laboratory for Vascular Translational Science-Unité 1148, University of Paris, Paris (P.A.); the Population Health Research Institute, McMaster University, Hamilton, ON, Canada (P.A.); and the Stroke Trials Unit, Mental Health and Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom (P.M.B.)
| | - Dongqi Liu
- From the Department of Neurology, Beijing Tiantan Hospital (Y.G., W.C., Y.P., J.J., C.W., Y.Y., T.W., S.H., X.M., X.Z., L.L., Yongjun Wang, Yilong Wang), the Advanced Innovation Center for Human Brain Protection (Yongjun Wang, Yilong Wang), Beijing Laboratory of Oral Health (Yilong Wang), and Beijing Municipal Key Laboratory of Clinical Epidemiology (Yilong Wang), Capital Medical University, the China National Clinical Research Center for Neurological Diseases (Y.P., J.J., C.W., L.J., X.M., J.L., X.Z., L.L., Yongjun Wang, Yilong Wang), the National Center for Neurological Disorders (Yongjun Wang, Yilong Wang), the Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences (Yongjun Wang), and the Chinese Institute for Brain Research (Yilong Wang), Beijing, the Department of Neurology, Weihai Wendeng District People's Hospital, Weihai (J.Z.), the Department of Neurology, Sui Chinese Medical Hospital, Shangqiu (Y.L.), the Department of Neurology, Qinghe People's Hospital, Xingtai (Y.Z.), the Department of Neurology, Biyang People's Hospital, Zhumadian (S.Z.), the Department of Neurology, Jiyuan Chinese Medical Hospital, Jiyuan (H.Y.), the Department of Neurology, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an (J.Y.), the Department of Neurology, Affiliated Shuyang Hospital of Xuzhou Medical University, Suqian (Yuanwei Wang), the Department of Neurology, Mengzhou People's Hospital (D. Li), and the Department of Neurology, Xiuwu People's Hospital (G.K.), Jiaozuo, and the Department of Neurology, Hejian People's Hospital, Cangzhou (Yanxia Wang, D. Liu) - all in China; the Department of Neurology, University of California, San Francisco, San Francisco (S.C.J.); the Department of Neurology and Stroke Center, Assistance Publique-Hôpitaux de Paris, Bichat Hospital, INSERM Laboratory for Vascular Translational Science-Unité 1148, University of Paris, Paris (P.A.); the Population Health Research Institute, McMaster University, Hamilton, ON, Canada (P.A.); and the Stroke Trials Unit, Mental Health and Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom (P.M.B.)
| | - Guangming Kang
- From the Department of Neurology, Beijing Tiantan Hospital (Y.G., W.C., Y.P., J.J., C.W., Y.Y., T.W., S.H., X.M., X.Z., L.L., Yongjun Wang, Yilong Wang), the Advanced Innovation Center for Human Brain Protection (Yongjun Wang, Yilong Wang), Beijing Laboratory of Oral Health (Yilong Wang), and Beijing Municipal Key Laboratory of Clinical Epidemiology (Yilong Wang), Capital Medical University, the China National Clinical Research Center for Neurological Diseases (Y.P., J.J., C.W., L.J., X.M., J.L., X.Z., L.L., Yongjun Wang, Yilong Wang), the National Center for Neurological Disorders (Yongjun Wang, Yilong Wang), the Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences (Yongjun Wang), and the Chinese Institute for Brain Research (Yilong Wang), Beijing, the Department of Neurology, Weihai Wendeng District People's Hospital, Weihai (J.Z.), the Department of Neurology, Sui Chinese Medical Hospital, Shangqiu (Y.L.), the Department of Neurology, Qinghe People's Hospital, Xingtai (Y.Z.), the Department of Neurology, Biyang People's Hospital, Zhumadian (S.Z.), the Department of Neurology, Jiyuan Chinese Medical Hospital, Jiyuan (H.Y.), the Department of Neurology, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an (J.Y.), the Department of Neurology, Affiliated Shuyang Hospital of Xuzhou Medical University, Suqian (Yuanwei Wang), the Department of Neurology, Mengzhou People's Hospital (D. Li), and the Department of Neurology, Xiuwu People's Hospital (G.K.), Jiaozuo, and the Department of Neurology, Hejian People's Hospital, Cangzhou (Yanxia Wang, D. Liu) - all in China; the Department of Neurology, University of California, San Francisco, San Francisco (S.C.J.); the Department of Neurology and Stroke Center, Assistance Publique-Hôpitaux de Paris, Bichat Hospital, INSERM Laboratory for Vascular Translational Science-Unité 1148, University of Paris, Paris (P.A.); the Population Health Research Institute, McMaster University, Hamilton, ON, Canada (P.A.); and the Stroke Trials Unit, Mental Health and Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom (P.M.B.)
| | - Yongjun Wang
- From the Department of Neurology, Beijing Tiantan Hospital (Y.G., W.C., Y.P., J.J., C.W., Y.Y., T.W., S.H., X.M., X.Z., L.L., Yongjun Wang, Yilong Wang), the Advanced Innovation Center for Human Brain Protection (Yongjun Wang, Yilong Wang), Beijing Laboratory of Oral Health (Yilong Wang), and Beijing Municipal Key Laboratory of Clinical Epidemiology (Yilong Wang), Capital Medical University, the China National Clinical Research Center for Neurological Diseases (Y.P., J.J., C.W., L.J., X.M., J.L., X.Z., L.L., Yongjun Wang, Yilong Wang), the National Center for Neurological Disorders (Yongjun Wang, Yilong Wang), the Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences (Yongjun Wang), and the Chinese Institute for Brain Research (Yilong Wang), Beijing, the Department of Neurology, Weihai Wendeng District People's Hospital, Weihai (J.Z.), the Department of Neurology, Sui Chinese Medical Hospital, Shangqiu (Y.L.), the Department of Neurology, Qinghe People's Hospital, Xingtai (Y.Z.), the Department of Neurology, Biyang People's Hospital, Zhumadian (S.Z.), the Department of Neurology, Jiyuan Chinese Medical Hospital, Jiyuan (H.Y.), the Department of Neurology, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an (J.Y.), the Department of Neurology, Affiliated Shuyang Hospital of Xuzhou Medical University, Suqian (Yuanwei Wang), the Department of Neurology, Mengzhou People's Hospital (D. Li), and the Department of Neurology, Xiuwu People's Hospital (G.K.), Jiaozuo, and the Department of Neurology, Hejian People's Hospital, Cangzhou (Yanxia Wang, D. Liu) - all in China; the Department of Neurology, University of California, San Francisco, San Francisco (S.C.J.); the Department of Neurology and Stroke Center, Assistance Publique-Hôpitaux de Paris, Bichat Hospital, INSERM Laboratory for Vascular Translational Science-Unité 1148, University of Paris, Paris (P.A.); the Population Health Research Institute, McMaster University, Hamilton, ON, Canada (P.A.); and the Stroke Trials Unit, Mental Health and Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom (P.M.B.)
| | - Yilong Wang
- From the Department of Neurology, Beijing Tiantan Hospital (Y.G., W.C., Y.P., J.J., C.W., Y.Y., T.W., S.H., X.M., X.Z., L.L., Yongjun Wang, Yilong Wang), the Advanced Innovation Center for Human Brain Protection (Yongjun Wang, Yilong Wang), Beijing Laboratory of Oral Health (Yilong Wang), and Beijing Municipal Key Laboratory of Clinical Epidemiology (Yilong Wang), Capital Medical University, the China National Clinical Research Center for Neurological Diseases (Y.P., J.J., C.W., L.J., X.M., J.L., X.Z., L.L., Yongjun Wang, Yilong Wang), the National Center for Neurological Disorders (Yongjun Wang, Yilong Wang), the Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences (Yongjun Wang), and the Chinese Institute for Brain Research (Yilong Wang), Beijing, the Department of Neurology, Weihai Wendeng District People's Hospital, Weihai (J.Z.), the Department of Neurology, Sui Chinese Medical Hospital, Shangqiu (Y.L.), the Department of Neurology, Qinghe People's Hospital, Xingtai (Y.Z.), the Department of Neurology, Biyang People's Hospital, Zhumadian (S.Z.), the Department of Neurology, Jiyuan Chinese Medical Hospital, Jiyuan (H.Y.), the Department of Neurology, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an (J.Y.), the Department of Neurology, Affiliated Shuyang Hospital of Xuzhou Medical University, Suqian (Yuanwei Wang), the Department of Neurology, Mengzhou People's Hospital (D. Li), and the Department of Neurology, Xiuwu People's Hospital (G.K.), Jiaozuo, and the Department of Neurology, Hejian People's Hospital, Cangzhou (Yanxia Wang, D. Liu) - all in China; the Department of Neurology, University of California, San Francisco, San Francisco (S.C.J.); the Department of Neurology and Stroke Center, Assistance Publique-Hôpitaux de Paris, Bichat Hospital, INSERM Laboratory for Vascular Translational Science-Unité 1148, University of Paris, Paris (P.A.); the Population Health Research Institute, McMaster University, Hamilton, ON, Canada (P.A.); and the Stroke Trials Unit, Mental Health and Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom (P.M.B.)
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6
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Woodhouse LJ, Appleton JP, Christensen H, Dineen RA, England TJ, James M, Krishnan K, Montgomery AA, Ranta A, Robinson TG, Sprigg N, Bath PM. Bleeding with intensive versus guideline antiplatelet therapy in acute cerebral ischaemia. Sci Rep 2023; 13:11717. [PMID: 37474599 PMCID: PMC10359249 DOI: 10.1038/s41598-023-38474-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Accepted: 07/09/2023] [Indexed: 07/22/2023] Open
Abstract
Intensive antiplatelet therapy did not reduce recurrent stroke/transient ischaemic attack (TIA) events as compared with guideline treatment in the Triple Antiplatelets for Reducing Dependency after Ischaemic Stroke (TARDIS) trial, but did increase the frequency and severity of bleeding. In this pre-specified analysis, we investigated predictors of bleeding and the association of bleeding with outcome. TARDIS was an international prospective randomised open-label blinded-endpoint trial in participants with ischaemic stroke or TIA within 48 h of onset. Participants were randomised to 30 days of intensive antiplatelet therapy (aspirin, clopidogrel, dipyridamole) or guideline-based therapy (either clopidogrel alone or combined aspirin and dipyridamole). Bleeding was defined using the International Society on Thrombosis and Haemostasis five-level ordered categorical scale: fatal, major, moderate, minor, none. Of 3,096 participants, bleeding severity was: fatal 0.4%, major 1.5%, moderate 1.2%, minor 11.4%, none 85.5%. Major/fatal bleeding was increased with intensive as compared with guideline therapy: 39 vs. 17 participants, adjusted hazard ratio 2.21, 95% CI 1.24-3.93, p = 0.007. Bleeding events diverged between treatment groups in the 8-35 day period but not in the 0-7 or 36-90 day epochs. In multivariate analysis more, and more severe, bleeding events were seen with increasing age, female sex, pre-morbid dependency, increased time to randomisation, prior major bleed, prior antiplatelet therapy and in those randomised to triple vs guideline antiplatelet therapy. More severe bleeding was associated with worse clinical outcomes across multiple physical, emotional and quality of life domains.Trial registration ISRCTN47823388 .
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Affiliation(s)
- Lisa J Woodhouse
- Stroke Trials Unit, Mental Health and Clinical Neuroscience, School of Medicine, South Block D Floor, Queen's Medical Centre, University of Nottingham, Nottingham, NG7 2UH, UK
| | - Jason P Appleton
- Stroke Trials Unit, Mental Health and Clinical Neuroscience, School of Medicine, South Block D Floor, Queen's Medical Centre, University of Nottingham, Nottingham, NG7 2UH, UK
- Stroke, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, NG7 2UH, UK
| | - Hanne Christensen
- Bispebjerg and Frederiksberg Hospital, Department of Neurology, University of Copenhagen, Copenhagen, Denmark
| | - Rob A Dineen
- Radiological Sciences, Mental Health and Clinical Neuroscience, School of Medicine, Queens Medical Centre, University of Nottingham, Nottingham, NG7 2UH, UK
| | - Timothy J England
- Stroke Trials Unit, Mental Health and Clinical Neuroscience, School of Medicine, South Block D Floor, Queen's Medical Centre, University of Nottingham, Nottingham, NG7 2UH, UK
- Derby Stroke Centre, University Hospitals of Derby and Burton, Derby, DE22 3NE, UK
| | - Marilyn James
- Nottingham Clinical Trials Unit, Applied Health Research Building, School of Medicine, University of Nottingham, University Park, Nottingham, NG7 2RD, UK
| | - Kailash Krishnan
- Stroke Trials Unit, Mental Health and Clinical Neuroscience, School of Medicine, South Block D Floor, Queen's Medical Centre, University of Nottingham, Nottingham, NG7 2UH, UK
- Stroke, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, NG7 2UH, UK
| | - Alan A Montgomery
- Nottingham Clinical Trials Unit, Applied Health Research Building, School of Medicine, University of Nottingham, University Park, Nottingham, NG7 2RD, UK
| | - Anna Ranta
- Department of Medicine, University of Otago, Wellington, New Zealand
- Department of Neurology, Wellington Hospital, Wellington, New Zealand
| | - Thompson G Robinson
- Department of Cardiovascular Sciences and NIHR Leicester Biomedical Research Centre, University of Leicester, Leicester, UK
| | - Nikola Sprigg
- Stroke Trials Unit, Mental Health and Clinical Neuroscience, School of Medicine, South Block D Floor, Queen's Medical Centre, University of Nottingham, Nottingham, NG7 2UH, UK
- Stroke, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, NG7 2UH, UK
| | - Philip M Bath
- Stroke Trials Unit, Mental Health and Clinical Neuroscience, School of Medicine, South Block D Floor, Queen's Medical Centre, University of Nottingham, Nottingham, NG7 2UH, UK.
- Stroke, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, NG7 2UH, UK.
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7
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Shi T, Chen S, Long Y, Gu Z. Safety and efficacy of stenting for symptomatic intracranial artery stenosis: a systematic reveiw and meta-analysis. Front Pharmacol 2023; 14:1122842. [PMID: 37361212 PMCID: PMC10285394 DOI: 10.3389/fphar.2023.1122842] [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: 12/13/2022] [Accepted: 05/30/2023] [Indexed: 06/28/2023] Open
Abstract
Background: Stroke is currently the second-leading cause of death just behind ischaemic heart disease. Drug therapy is currently the standard of care for patients with symptomatic intracranial artery stenosis (sICAS). Stenting is an important treatment for the prevention and treatment of ischemic stroke. It has been suggested that vertebral artery stenting might reduce this risk, but operation-related complications limit the application of stenting in the treatment of ischemic stroke. The differences in the safety and efficacy of stenting combined with drugs and drugs alone in the treatment of sICAS are unclear. The aim of this study was to assess the impact of both treatment modalities on the prognosis of patients with sICAS through a systematic review and meta-analysis. Methods: The Chinese databases (CNKI, Wanfang, VIP, CBM, DUXIU) and English databases (Pubmed, Embase, Ovid_medline, Cochrane library, Web of science)were searched to identify all studies describing sICAS. The "Risk of Bias Assessment" tool and the "Jadad Scale" provided by the Cochrane Collaboration were used to evaluate the risk of bias and quality of the collected literature. The risk ratio (RR) and its 95% confidence interval (CI) were determined using Stata statistical software version 14.0. Results: A total of 11 studies were included, comprising a total of 1,915 patients. The combined results of the study showed no significant difference between the incidence of transient cerebral ischemia (TIA)and stroke in patients with sICAS treated with drugs in combination with stents versus drugs alone. The incidence of death or stroke, cerebral haemorrhage, disabling stroke or death was significantly higher in patients receiving stent-combined drug therapy versus drug therapy alone for sICAS. Conclusion: Studies suggest that stenting combined with medication for patients with sICAS may increase the incidence of death or stroke, cerebral haemorrhage, stroke or death, but has no significant effect on the incidence of TIA and stroke. The studies report inadequate and conflicting data and therefore the safety and efficacy of stenting for sICAS should be interpreted with caution. Systematic Review Registration: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42022377090, identifier CRD42022377090.
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Affiliation(s)
- Ting Shi
- The Department of Blood Transfusion, Yongchuan Hospital, Chongqing Medical University, Chongqing, China
| | - ShiJian Chen
- The Department of Clinical Laboratory Medicine, Yongchuan Hospital, Chongqing Medical University, Chongqing, China
| | - YongPei Long
- The Department of Clinical Laboratory Medicine, Yongchuan Hospital, Chongqing Medical University, Chongqing, China
| | - ZhongDeng Gu
- The Department of Rehabilitation, Yongchuan Hospital, Chongqing Medical University, Chongqing, China
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8
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Xie Z, Guo X, Han L, Wang X, Yan Q, Shu C, Fan Z, Zhao M. Differences in primary and secondary stroke prevention strategies for Chinese men and women. Prev Med Rep 2023; 33:102219. [PMID: 37223569 PMCID: PMC10201908 DOI: 10.1016/j.pmedr.2023.102219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2022] [Revised: 03/17/2023] [Accepted: 04/23/2023] [Indexed: 05/25/2023] Open
Abstract
This study aimed to explore whether stroke prevention strategies differ for men and women. Data used were from China Kadoorie Biobank. According to the China-PAR Project model, a predicted 10-year stroke risk of ≥7% is defined as a high stroke risk. The effects of risk factor control and medication use as primary and secondary stroke prevention strategies were assessed, respectively. Logistic regression models were used to assess the sex-specific differences in the primary and secondary stroke prevention practices. Of the 512,715 participants (59.0% women), 218,972 (57.4% women) had a high risk of stroke and 8884 (44.7% women) had an established stroke. Of high-risk participants, women were considerably less likely than men to receive antiplatelets (odds ratio [OR], 0.80; [95% confidence interval, CI, 0.72-0.89]), antihypertensives (0.46[0.44-0.48]), and antidiabetics (0.65[0.60-0.70]). Meanwhile, stroke women were significantly less likely to receive antiplatelets (0.75[0.65-0.85]) but more likely to receive antidiabetics (1.56 [1.34-1.82]) than their male counterparts. Besides, differences were found in risk factor control between women and men. Sex-specific differences in stroke prevention strategies are prevalent in China. Effective prevention requires the implementation of better overall nationwide strategies and special emphasis on women.
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Affiliation(s)
- Zenghua Xie
- Department of Neurology, Beilun District People’s Hospital, Ningbo, Zhejiang, China
| | - Xu Guo
- Department of Rehabilitation Medicine, Hwa Mei Hospital, University of the Chinese Academy of Sciences, Ningbo, Zhejiang, China
| | - Liyuan Han
- Hwa Mei Hospital, Key Laboratory of Diagnosis and Treatment of Digestive System Tumors of Zhejiang Province, University of Chinese Academy of Sciences, Ningbo, Zhejiang, China
- Department of Global Health, Ningbo Institute of Life and Health Industry, University of Chinese Academy of Sciences, Ningbo, Zhejiang, China
| | - Xin Wang
- Department of Neurology, Beilun District People’s Hospital, Ningbo, Zhejiang, China
| | - Qianqian Yan
- Hwa Mei Hospital, Key Laboratory of Diagnosis and Treatment of Digestive System Tumors of Zhejiang Province, University of Chinese Academy of Sciences, Ningbo, Zhejiang, China
- Department of Global Health, Ningbo Institute of Life and Health Industry, University of Chinese Academy of Sciences, Ningbo, Zhejiang, China
| | - Chang Shu
- Tianjin Cerebral Vascular and Neural Degenerative Disease Key Laboratory, Tianjin Neurosurgery Institute, Tianjin Huanhu Hospital, Tianjin, China
| | - Zhenyi Fan
- Department of Neurology, Hwa Mei Hospital, University of Chinese Academy of Science, Ningbo, Zhejiang, China
| | - Miaomiao Zhao
- Department of Health Management, School of Public Health, Nantong University, Nantong, Jiangsu, China
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9
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Gao Y, Pan Y, Han S, Chen W, Jing J, Wang C, Yang Y, Wang T, Meng X, Zhao X, Liu L, Li H, Johnston SC, Amarenco P, Bath PM, Wang Y, Wang Y. Rationale and design of a randomised double-blind 2×2 factorial trial comparing the effect of a 3-month intensive statin and antiplatelet therapy for patients with acute mild ischaemic stroke or high-risk TIA with intracranial or extracranial atherosclerosis (INSPIRES). Stroke Vasc Neurol 2023; 8:249-258. [PMID: 36707080 PMCID: PMC10359782 DOI: 10.1136/svn-2022-002084] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Accepted: 01/08/2023] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND It remains unclear if intensive antiplatelet and statin treatments begun within 24-72 hours of cerebral ischaemic events from intracranial or extracranial atherosclerosis is effective or safe. METHODS The Intensive Statin and Antiplatelet Therapy for High-risk Intracranial or Extracranial Atherosclerosis (INSPIRES) trial is a randomised, double-blind, placebo-controlled, multicentre and 2×2 factorial trial. 6100 individuals between the ages of 35 and 80 who have experienced a mild ischaemic stroke or high-risk transient ischaemic attack (TIA) within the previous 72 hours that is attributed to ≥50% atherosclerotic stenosis of a major intracranial or extracranial artery or multiple infarctions of atherosclerotic origin will be enrolled in the trial. Eligible subjects will be randomised 1:1:1:1 to one of four groups: (1) intensive antiplatelet therapy (combined clopidogrel and aspirin for days 1-21, then aspirin placebo and clopidogrel for days 22-90) plus immediate intensive statin therapy(atorvastatin at a dose of 80 mg daily for the first 21 days, then 40 mg daily for days 22-90); (2) intensive antiplatelet therapy plus delayed intensive statin therapy (atorvastatin placebo for days 1-3, followed by 40 mg per day of atorvastatin for days 4-90); (3) standard antiplatelet therapy (combination of clopidogrel placebo with aspirin for 90 days) plus immediate intensive statin therapy and (4) standard antiplatelet therapy plus delayed intensive statin therapy. The primary efficacy endpoint is any new stroke (ischaemic or haemorrhagic) within 90 days after randomisation. The primary safety endpoint is moderate to severe bleeding at 90 days. CONCLUSION The INSPIRES trial will assess the efficacy and safety of intensive antiplatelet therapy and immediate intensive statin therapy begun within 72 hours of onset in decreasing the recurrent stroke at 90 days in patients with acute mild ischaemic stroke or high-risk TIA of intracranial or extracranial atherosclerosis origin. TRIAL REGISTRATION NUMBER NCT03635749.
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Affiliation(s)
- Ying Gao
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yuesong Pan
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Shangrong Han
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Weiqi Chen
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Jing Jing
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Chunjuan Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yingying Yang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Tingting Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xia Meng
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xingquan Zhao
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Liping Liu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Hao Li
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - S Claiborne Johnston
- Dean's Office, Dell Medical School, University of Texas at Austin, Austin, Texas, USA
| | - Pierre Amarenco
- Department of Neurology and Stroke Center, Assistance Publique-Hôpitaux de Paris (APHP), Bichat Hospital, INSERM LVTS-U1148, University of Paris, Paris, France
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Philip M Bath
- Stroke Trials Unit, Mental Health & Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Yongjun Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Advanced Innovation Center for Human Brain Protection, Capital Medical University, Beijing, China
- National Center for Neurological Diseases, Beijing, China
- Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences, Beijing, China
| | - Yilong Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Advanced Innovation Center for Human Brain Protection, Capital Medical University, Beijing, China
- National Center for Neurological Diseases, Beijing, China
- Chinese Institute for Brain Research, Beijing, China
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10
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Rusin G, Kubica J, Malinowski KP, Słowik A, Undas A. Factors affecting self-reported bleeding acceptance in acute ischemic stroke survivors on various types of antithrombotic therapy. J Stroke Cerebrovasc Dis 2023; 32:106894. [PMID: 36402092 DOI: 10.1016/j.jstrokecerebrovasdis.2022.106894] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Revised: 11/07/2022] [Accepted: 11/11/2022] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVES Prior ischemic cerebrovascular event and younger age have been shown to increase bleeding acceptance among anticoagulated outpatients with atrial fibrillation (AF). We sought to determine factors affecting bleeding acceptance in acute ischemic stroke (AIS) survivors on various types of antithrombotic therapy. MATERIALS AND METHODS We enrolled 173 consecutive patients hospitalized for AIS (aged 68.2±11.7 years, 54.9% male), including 54 (31.2%) with AF, who had favorable functional outcome. On discharge, the Bleeding ratio, defined as the declared maximum number of major bleedings that a patient is willing to accept to prevent one major stroke, was evaluated. We assessed the predicted bleeding risk in non-cardioembolic and cardioembolic stroke survivors using S2TOP-BLEED and HAS-BLED scores, respectively. RESULTS Patients with the low Bleeding ratio, defined as 5 (median) or less accepted bleeds (n=92; 53.2%), were older and more likely to receive thrombolysis and/or thrombectomy, with no impact of previous stroke. Prior major bleed (odds ratio [OR] 4.67; 95% confidence interval [CI] 0.92-23.72), AF with use of oral anticoagulants (OR 2.35, 95% CI 1.12-4.93), reperfusion treatment (OR 1.95, 95% CI 1.02-3.76), and hospitalization ≤10 days (OR 4.56; 95% CI 1.50-13.87) were associated with the low Bleeding Ratio. Prior use of anticoagulants or aspirin as well as HAS-BLED and S2TOP-BLEED scores did not affect the bleeding acceptance. CONCLUSIONS Lower bleeding acceptance declared on discharge by AIS survivors is determined by prior bleeding, anticoagulation in AF, reperfusion treatment, and duration of hospitalization, which might affect medication adherence. The results might help optimize post-discharge management and educational efforts in patients on antithrombotic therapy.
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Affiliation(s)
- Gabriela Rusin
- Department of Neurology, University Hospital, Krakow, Poland
| | - Jadwiga Kubica
- Department of Neurology, University Hospital, Krakow, Poland; Institute of Physiotherapy, Faculty of Health Science, Jagiellonian University Medical College, Krakow, Poland
| | - Krzysztof Piotr Malinowski
- Department of Bioinformatics and Telemedicine, Faculty of Medicine, Jagiellonian University Medical College, Kraków, Poland; Center for Digital Medicine and Robotics, Jagiellonian University Medical College, Kraków, Poland
| | - Agnieszka Słowik
- Department of Neurology, University Hospital, Krakow, Poland; Department of Neurology, Jagiellonian University Medical College, Kraków, Poland
| | - Anetta Undas
- Department of Thromboembolic Disorders, Institute of Cardiology, Jagiellonian University Medical College, Kraków, Poland; Center for Research and Innovative Technology John Paul II Hospital, Kraków, Poland.
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11
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Cilostazol-based dual anti-platelet agents for Asian patients: An updated network meta-analysis. J Neurol Sci 2022; 442:120457. [PMID: 36272270 DOI: 10.1016/j.jns.2022.120457] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Revised: 10/04/2022] [Accepted: 10/06/2022] [Indexed: 11/24/2022]
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12
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Long term survival after a first transient ischaemic attack in England: A retrospective matched cohort study. J Stroke Cerebrovasc Dis 2022; 31:106663. [PMID: 35907306 DOI: 10.1016/j.jstrokecerebrovasdis.2022.106663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Revised: 07/03/2022] [Accepted: 07/17/2022] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVE Transient ischaemic attacks (TIA) serve as warning signs for future stroke, and the impact of TIA on long term survival is uncertain. We assessed the long-term hazards of all-cause mortality following a first episode of a transient ischaemic attack (TIA). DESIGN Retrospective matched cohort study. METHODS Cohort study using electronic primary health care records from The Health Improvement Network (THIN) database in the United Kingdom. Cases born in or before 1960, resident in England, with a first diagnosis of TIA between January 1986 and January 2017 were matched to three controls on age, sex and general practice. The primary outcome was all-cause mortality. The hazards of all-cause mortality were estimated using a time-varying Double-Cox Weibull survival model with a random frailty effect of general practice, while adjusting for different socio-demographic factors, medical therapies, and comorbidities. RESULTS 20,633 cases and 58,634 controls were included. During the study period, 24,176 participants died comprising of 7,745 (37.5%) cases and 16,431(28.0%) controls. In terms of hazards of mortality, cases aged 39 to 60 years at the first TIA event had the highest hazard ratio (HR) of mortality compared to their 39-60 years matched controls (HR = 3.04 (2.91 - 3.18)). The HR for cases aged 61-70 years, 71-76 years and 77+ years were 1.98 (1.55 - 2.30), 1.79 (1.20 - 2.07) and 1.52 (1.15 - 1.97) compared to their same-aged matched controls. Cases aged 39-60 at TIA onset who were prescribed aspirin were associated with reduced HR of 0.93 (0.84 - 1.01), 0.90 (0.82 - 0.98) and 0.88 (0.80 - 0.96) at 5, 10 and 15 years respectively, compared to the same aged cases who were not prescribed any antiplatelet. Statistically significant reductions in hazard ratios were observed with aspirin at 10 and 15 years in all age groups. Hazard ratio point estimates for other antiplatelets (dipyridamole or clopidogrel) and dual antiplatelet therapy were very similar to aspirin at 5, 10 and 15 years but with wider confidence intervals that included 1. There was no survival benefit associated with antiplatelet prescription in controls. CONCLUSIONS The overall risk of death was considerably elevated in all age groups after a first-ever TIA event. Aspirin prescription was associated with a reduced risk. These findings support the use of aspirin in secondary prevention for people with a TIA. The results do not support the use of antiplatelet medication in people without TIA.
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13
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Abbott AL. Extra-Cranial Carotid Artery Stenosis: An Objective Analysis of the Available Evidence. Front Neurol 2022; 13:739999. [PMID: 35800089 PMCID: PMC9253595 DOI: 10.3389/fneur.2022.739999] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Accepted: 01/24/2022] [Indexed: 12/26/2022] Open
Abstract
Background and Purpose Carotid stenosis is arterial disease narrowing of the origin of the internal carotid artery (main brain artery). Knowing how to best manage this is imperative because it is common in older people and an important cause of stroke. Inappropriately high expectations have grown regarding the value of carotid artery procedures, such as surgery (endarterectomy) and stenting, for lowering the stroke risk associated with carotid stenosis. Meanwhile, the improving and predominant value of medical intervention (lifestyle coaching and medication) continues to be underappreciated. Methods and Results This article aims to be an objective presentation and discussion of the scientific literature critical for decision making when the primary goal is to optimize patient outcome. This compilation follows from many years of author scrutiny to separate fact from fiction. Common sense conclusions are drawn from factual statements backed by original citations. Detailed research methodology is given in cited papers. This article has been written in plain language given the importance of the general public understanding this topic. Issues covered include key terminology and the economic impact of carotid stenosis. There is a summary of the evidence-base regarding the efficacy and safety of procedural and medical (non-invasive) interventions for both asymptomatic and symptomatic patients. Conclusions are drawn with respect to current best management and research priorities. Several "furphies" (misconceptions) are exposed that are commonly used to make carotid stenting and endarterectomy outcomes appear similar. Ongoing randomized trials are mentioned and why they are unlikely to identify a routine practice indication for carotid artery procedures. There is a discussion of relevant worldwide guidelines regarding carotid artery procedures, including how they should be improved. There is an outline of systematic changes that are resulting in better application of the evidence-base. Conclusion The cornerstone of stroke prevention is medical intervention given it is non-invasive and protects against all arterial disease complications in all at risk. The "big" question is, does a carotid artery procedure add patient benefit in the modern era and, if so, for whom?
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Affiliation(s)
- Anne L. Abbott
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, VIC, Australia
- Neurology Private Practice, Knox Private Hospital, Wantirna, VIC, Australia
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Liu T, Wang Y, Niu X, Li Y, Zhang K, Fan H, Ren J, Li J, Ma L, Li X, Wu X. Evaluation of the association between admission systolic blood pressure and the choice of initial antiplatelet therapy for minor ischemic stroke in real-world. J Clin Hypertens (Greenwich) 2022; 24:465-474. [PMID: 35297147 PMCID: PMC8989760 DOI: 10.1111/jch.14466] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2021] [Revised: 02/12/2022] [Accepted: 02/27/2022] [Indexed: 11/30/2022]
Abstract
To evaluate whether admission systolic blood pressure (SBP) is associated with the choice of initial antiplatelet therapy for minor stroke. Eligible patients retrospectively gathered from 2010 to 2018. Finally, 1312 of 1494 patients were divided into three groups: aspirin monotherapy (AM, n = 538, 41.0%), dual antiplatelet therapy with aspirin and load-clopidogrel (clopidogrel loading dose of 300 mg on the first day, DAPT-ALC, n = 474, 35.6%), and dual antiplatelet therapy with aspirin and unload-clopidogrel (clopidogrel 75 mg daily with no loading dose, DAPT-AUC, n = 300, 22.9%). The mean ± SD age of final patients was 62.0 ± 12.7 years old; 903 (70.9%) participants were male. Patients in the DAPT-ALC group were more likely to be younger, to arrive earlier, and to have a lower proportion of intracerebral hemorrhage than those in the AM group. DAPT-AUC group patients were more like to have a history of acute myocardial infarction and less likely to have a history of ICH than the AM group (4.7% vs. 1.7% and .3% vs. 2.6%, p < .05). Overall, there was a likely "S-shaped" association between the selection of the DAPT-ALC or DAPT-AUC scheme and admission systolic blood pressure (P for nonlinearity = .012). Compared with the SBP < 140 mmHg group, the SBP ≥ 180 mmHg group was more likely to be given DAPT-AUC (OR = 2.92 [1.62-5.26], p < .001) than DAPT-ALC. Our findings support that admission SBP is associated with the choice of initial antiplatelet, especially when the SBP was greater than or equal to 180 mmHg.
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Affiliation(s)
- Tingting Liu
- Shanxi Medical University, Taiyuan City, China.,Department of Neurology, First Hospital of Shanxi Medical University, Taiyuan City, Shanxi Province, China
| | - Yongle Wang
- Shanxi Medical University, Taiyuan City, China
| | - Xiaoyuan Niu
- Department of Neurology, First Hospital of Shanxi Medical University, Taiyuan City, Shanxi Province, China
| | - Yanan Li
- Shanxi Medical University, Taiyuan City, China
| | - Kaili Zhang
- Department of Neurology, The Bethune Hospital of Shanxi Province, Taiyuan, Shanxi Province, China
| | - Haimei Fan
- Department of Neurology, Taiyuan Iron and Steel Group, Taiyuan, Shanxi Province, China
| | - Jing Ren
- Shanxi Medical University, Taiyuan City, China
| | - Juan Li
- Shanxi Medical University, Taiyuan City, China
| | - Liansheng Ma
- Department of Neurology, First Hospital of Shanxi Medical University, Taiyuan City, Shanxi Province, China
| | - Xinyi Li
- Department of Neurology, The Bethune Hospital of Shanxi Province, Taiyuan, Shanxi Province, China
| | - Xuemei Wu
- Department of Neurology, Taiyuan Iron and Steel Group, Taiyuan, Shanxi Province, China
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16
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Paraskevas KI, Mikhailidis DP, Antignani PL, Baradaran H, Bokkers RP, Cambria RP, Dardik A, Davies AH, Eckstein HH, Faggioli G, Fernandes E Fernandes J, Fraedrich G, Geroulakos G, Gloviczki P, Golledge J, Gupta A, Jezovnik MK, Kakkos SK, Katsiki N, Knoflach M, Kooi ME, Lanza G, Liapis CD, Loftus IM, Mansilha A, Millon A, Nicolaides AN, Pini R, Poredos P, Ricco JB, Riles TS, Ringleb PA, Rundek T, Saba L, Schlachetzki F, Silvestrini M, Spinelli F, Stilo F, Sultan S, Suri JS, Zeebregts CJ, Chaturvedi S. Optimal management of asymptomatic carotid stenosis in 2021: the jury is still out. An International, multispecialty, expert review and position statement. INT ANGIOL 2021; 41:158-169. [PMID: 34913633 DOI: 10.23736/s0392-9590.21.04825-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVES The recommendations of international guidelines for the management of asymptomatic carotid stenosis (ACS) often vary considerably and extend from a conservative approach with risk factor modification and best medical treatment (BMT) alone, to a more aggressive approach with a carotid intervention plus BMT. The aim of the current multispecialty position statement is to reconcile the conflicting views on the topic. MATERIALS AND METHODS A literature review was performed with a focus on data from recent studies. RESULTS Several clinical and imaging high-risk features have been identified that are associated with an increased long-term ipsilateral ischemic stroke risk in patients with ACS. Such high-risk clinical/imaging features include intraplaque hemorrhage, impaired cerebrovascular reserve, carotid plaque echolucency/ulceration/ neovascularization, a lipid-rich necrotic core, a thin or ruptured fibrous cap, silent brain infarction, a contralateral transient ischemic attack/stroke episode, male patients <75 years and microembolic signals on transcranial Doppler. There is growing evidence that 80-99% ACS indicate a higher stroke risk than 50-79% stenoses. CONCLUSIONS Although aggressive risk factor control and BMT should be implemented in all ACS patients, several high-risk features that may increase the risk of a future cerebrovascular event are now documented. Consequently, some guidelines recommend a prophylactic carotid intervention in high-risk patients to prevent future cerebrovascular events. Until the results of the much-anticipated randomized controlled trials emerge, the jury is still out regarding the optimal management of ACS patients.
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Affiliation(s)
| | - Dimitri P Mikhailidis
- Department of Clinical Biochemistry, Royal Free Hospital Campus, University College London Medical School, University College London (UCL), London, UK
| | | | - Hediyeh Baradaran
- Department of Radiology, University of Utah, Salt Lake City, UT, USA
| | - Reinoud P Bokkers
- Department of Radiology, Medical Imaging Center, University Medical Center Groningen, Groningen, The Netherlands
| | - Richard P Cambria
- Division of Vascular and Endovascular Surgery, St. Elizabeth's Medical Center, Brighton, MA, USA
| | - Alan Dardik
- Division of Vascular and Endovascular Surgery, Yale University School of Medicine, New Haven, CT, USA
| | - Alun H Davies
- Section of Vascular Surgery, Imperial College & Imperial Healthcare NHS Trust, London, UK
| | - Hans-Henning Eckstein
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Gianluca Faggioli
- Vascular Surgery, Policlinico S. Orsola Malpighi, University of Bologna Alma Mater Studiorum, Bologna, Italy
| | | | - Gustav Fraedrich
- Department of Vascular Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - George Geroulakos
- Department of Vascular Surgery, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Peter Gloviczki
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN, USA
| | - Jonathan Golledge
- Queensland Research Centre for Peripheral Vascular Disease, James Cook University and Townsville University Hospital, Townsville, Australia
| | - Ajay Gupta
- Department of Radiology, Weill Cornell Medicine, New York, NY, USA
| | - Mateja K Jezovnik
- Department of Advanced Cardiopulmonary Therapies and Transplantation, The University of Texas Health Science Centre at Houston, Houston, Texas, USA
| | - Stavros K Kakkos
- Department of Vascular Surgery, University of Patras Medical School, Patras, Greece
| | - Niki Katsiki
- First Department of Internal Medicine, AHEPA University Hospital, Thessaloniki, Greece
| | - Michael Knoflach
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - M Eline Kooi
- CARIM School for Cardiovascular Diseases, Maastricht University, Maastricht, The Netherlands.,Department of Radiology and Nuclear Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Gaetano Lanza
- Vascular Surgery Department, IRCSS MultiMedica Hospital, Castellanza, Varese, Italy
| | | | - Ian M Loftus
- St. George's Vascular Institute, St. George's University London, London, UK
| | - Armando Mansilha
- Faculty of Medicine of the University of Porto, Porto, Portugal.,Department of Angiology and Vascular Surgery, Hospital de S. Joao, Porto, Portugal
| | - Antoine Millon
- Department of Vascular and Endovascular Surgery, Louis Pradel Hospital, Hospices Civils de Lyon, Lyon, France
| | - Andrew N Nicolaides
- Department of Surgery, University of Nicosia Medical School, Nicosia, Cyprus
| | - Rodolfo Pini
- Vascular Surgery, Policlinico S. Orsola Malpighi, University of Bologna Alma Mater Studiorum, Bologna, Italy
| | - Pavel Poredos
- Department of Vascular Disease, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Jean-Baptiste Ricco
- Department of Clinical Research, University of Poitiers, CHU de Poitiers, Poitiers, France
| | - Thomas S Riles
- Department of Surgery, Division of Vascular Surgery, New York University Langone Medical Centre, New York, NY, USA
| | | | - Tatjana Rundek
- Department of Neurology, Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Luca Saba
- Department of Radiology, Azienda Ospedaliera Universitaria di Cagliari, Cagliari, Italy
| | | | - Mauro Silvestrini
- Neurological Clinic, Department of Experimental and Clinical Medicine, Marche Polytechnic University, Ancona, Italy
| | - Francesco Spinelli
- Vascular Surgery Division, Campus Bio-Medico University of Rome, Rome, Italy
| | - Francesco Stilo
- Vascular Surgery Division, Campus Bio-Medico University of Rome, Rome, Italy
| | - Sherif Sultan
- Western Vascular Institute, Department of Vascular and Endovascular Surgery, University Hospital Galway, National University of Ireland, Galway, Ireland
| | - Jasjit S Suri
- Stroke Diagnosis and Monitoring Division, AtheroPointTM, Roseville, CA, USA
| | - Clark J Zeebregts
- Division of Vascular Surgery, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Seemant Chaturvedi
- Department of Neurology & Stroke Program, University of Maryland School of Medicine, Baltimore, MD, USA
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17
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Paraskevas KI, Mikhailidis DP, Antignani PL, Baradaran H, Bokkers RPH, Cambria RP, Dardik A, Davies AH, Eckstein HH, Faggioli G, E Fernandes JF, Fraedrich G, Geroulakos G, Gloviczki P, Golledge J, Gupta A, Jezovnik MK, Kakkos SK, Katsiki N, Knoflach M, Kooi ME, Lanza G, Liapis CD, Loftus IM, Mansilha A, Millon A, Nicolaides AN, Pini R, Poredos P, Ricco JB, Riles TS, Ringleb PA, Rundek T, Saba L, Schlachetzki F, Silvestrini M, Spinelli F, Stilo F, Sultan S, Suri JS, Zeebregts CJ, Chaturvedi S. Optimal Management of Asymptomatic Carotid Stenosis in 2021: The Jury is Still Out. An International, Multispecialty, Expert Review and Position Statement. J Stroke Cerebrovasc Dis 2021; 31:106182. [PMID: 34735900 DOI: 10.1016/j.jstrokecerebrovasdis.2021.106182] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 10/14/2021] [Accepted: 10/17/2021] [Indexed: 01/19/2023] Open
Abstract
OBJECTIVES The recommendations of international guidelines for the management of asymptomatic carotid stenosis (ACS) often vary considerably and extend from a conservative approach with risk factor modification and best medical treatment (BMT) alone, to a more aggressive approach with a carotid intervention plus BMT. The aim of the current multispecialty position statement is to reconcile the conflicting views on the topic. MATERIALS AND METHODS A literature review was performed with a focus on data from recent studies. RESULTS Several clinical and imaging high-risk features have been identified that are associated with an increased long-term ipsilateral ischemic stroke risk in patients with ACS. Such high-risk clinical/imaging features include intraplaque hemorrhage, impaired cerebrovascular reserve, carotid plaque echolucency/ulceration/ neovascularization, a lipid-rich necrotic core, a thin or ruptured fibrous cap, silent brain infarction, a contralateral transient ischemic attack/stroke episode, male patients < 75 years and microembolic signals on transcranial Doppler. There is growing evidence that 80-99% ACS indicate a higher stroke risk than 50-79% stenoses. CONCLUSIONS Although aggressive risk factor control and BMT should be implemented in all ACS patients, several high-risk features that may increase the risk of a future cerebrovascular event are now documented. Consequently, some guidelines recommend a prophylactic carotid intervention in high-risk patients to prevent future cerebrovascular events. Until the results of the much-anticipated randomized controlled trials emerge, the jury is still out regarding the optimal management of ACS patients.
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Affiliation(s)
- Kosmas I Paraskevas
- Department of Vascular Surgery, Central Clinic of Athens, 24, Alexander Papagou street, N. Iraklio, Athens 14122, Greece.
| | - Dimitri P Mikhailidis
- Department of Clinical Biochemistry, Royal Free Hospital Campus, University College London Medical School, University College London (UCL), London, UK
| | | | - Hediyeh Baradaran
- Department of Radiology, University of Utah, Salt Lake City, UT, United States
| | - Reinoud P H Bokkers
- Department of Radiology, Medical Imaging Center, University Medical Center Groningen, Groningen, the Netherland
| | - Richard P Cambria
- Division of Vascular and Endovascular Surgery, St. Elizabeth's Medical Center, Brighton, MA, United States
| | - Alan Dardik
- Division of Vascular and Endovascular Surgery, Yale University School of Medicine, New Haven, CT, United States
| | - Alun H Davies
- Section of Vascular Surgery, Imperial College and Imperial Healthcare NHS Trust, London, UK
| | - Hans-Henning Eckstein
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Gianluca Faggioli
- Vascular Surgery, University of Bologna "Alma Mater Studiorum", Policlinico S. Orsola Malpighi, Bologna, Italy
| | | | - Gustav Fraedrich
- Department of Vascular Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - George Geroulakos
- Department of Vascular Surgery, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Peter Gloviczki
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN, United States
| | - Jonathan Golledge
- Queensland Research Center for Peripheral Vascular Disease, James Cook University, Townsville University Hospital, Townsville, Queensland, Australia
| | - Ajay Gupta
- Department of Radiology, Weill Cornell Medicine, New York, United States
| | - Mateja K Jezovnik
- Department of Advanced Cardiopulmonary Therapies and Transplantation, The University of Texas Health Science Center, Houston, TX, United States
| | - Stavros K Kakkos
- Department of Vascular Surgery, University of Patras Medical School, Patras, Greece
| | - Niki Katsiki
- First Department of Internal Medicine, AHEPA University Hospital, Thessaloniki, Greece
| | - Michael Knoflach
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - M Eline Kooi
- CARIM School for Cardiovascular Diseases, Maastricht University, Maastricht, the Netherland; Department of Radiology and Nuclear Medicine, Maastricht University Medical Center, Maastricht, the Netherland
| | - Gaetano Lanza
- Vascular Surgery Department, IRCSS MultiMedica Hospital, Castellanza, Italy
| | | | - Ian M Loftus
- St. George's Vascular Institute, St. George's University of London, London, UK
| | - Armando Mansilha
- Faculty of Medicine of the University of Porto, Porto, Portugal; Department of Angiology and Vascular Surgery, Hospital de S. Joao, Porto, Portugal
| | - Antoine Millon
- Department of Vascular and Endovascular Surgery, Louis Pradel Hospital, Hospices Civils de Lyon, France
| | - Andrew N Nicolaides
- Department of Surgery, University of Nicosia Medical School, Nicosia, Cyprus
| | - Rodolfo Pini
- Vascular Surgery, University of Bologna "Alma Mater Studiorum", Policlinico S. Orsola Malpighi, Bologna, Italy
| | - Pavel Poredos
- Department of Vascular Disease, University Medical Center, Ljubljana, Slovenia
| | - Jean-Baptiste Ricco
- Department of Clinical Research, University of Poitiers, CHU de Poitiers, Poitiers, France
| | - Thomas S Riles
- Department of Surgery, Division of Vascular Surgery, New York University, Langone Medical Center, New York, United States
| | | | - Tatjana Rundek
- Department of Neurology, Miller School of Medicine, University of Miami, Miami, FL, United States
| | - Luca Saba
- Department of Radiology, Azienda Ospedaliera Universitaria Di Cagliari, Cagliari, Italy
| | | | - Mauro Silvestrini
- Neurological Clinic, Department of Experimental and Clinical Medicine, Marche Polytechnic University, Ancona, Italy
| | - Francesco Spinelli
- Vascular Surgery Division, Campus Bio-Medico University of Rome, Rome, Italy
| | - Francesco Stilo
- Vascular Surgery Division, Campus Bio-Medico University of Rome, Rome, Italy
| | - Sherif Sultan
- Department of Vascular and Endovascular Surgery, Western Vascular Institute, University Hospital Galway, National University of Ireland, Galway, Ireland
| | - Jasjit S Suri
- Stroke Diagnosis and Monitoring Division, AtheroPointTM, Roseville, United States
| | - Clark J Zeebregts
- Division of Vascular Surgery, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, the Netherland
| | - Seemant Chaturvedi
- Department of Neurology and Stroke Program, University of Maryland School of Medicine, Baltimore, MD, United States
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AbuRahma AF, Avgerinos ED, Chang RW, Darling RC, Duncan AA, Forbes TL, Malas MB, Perler BA, Powell RJ, Rockman CB, Zhou W. The Society for Vascular Surgery implementation document for management of extracranial cerebrovascular disease. J Vasc Surg 2021; 75:26S-98S. [PMID: 34153349 DOI: 10.1016/j.jvs.2021.04.074] [Citation(s) in RCA: 60] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 04/28/2021] [Indexed: 12/24/2022]
Affiliation(s)
- Ali F AbuRahma
- Department of Surgery, West Virginia University-Charleston Division, Charleston, WV.
| | - Efthymios D Avgerinos
- Division of Vascular Surgery, University of Pittsburgh School of Medicine, UPMC Hearrt & Vascular Institute, Pittsburgh, Pa
| | - Robert W Chang
- Vascular Surgery, Permanente Medical Group, San Francisco, Calif
| | | | - Audra A Duncan
- Division of Vascular & Endovascular Surgery, University of Western Ontario, London, Ontario, Canada
| | - Thomas L Forbes
- Division of Vascular & Endovascular Surgery, University of Western Ontario, London, Ontario, Canada
| | - Mahmoud B Malas
- Vascular & Endovascular Surgery, University of California San Diego, La Jolla, Calif
| | - Bruce Alan Perler
- Division of Vascular Surgery & Endovascular Therapy, Johns Hopkins, Baltimore, Md
| | | | - Caron B Rockman
- Division of Vascular Surgery, New York University Langone, New York, NY
| | - Wei Zhou
- Division of Vascular Surgery, University of Arizona, Tucson, Ariz
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Canadian Stroke Best Practice Recommendations: Secondary Prevention of Stroke Update 2020. Can J Neurol Sci 2021; 49:315-337. [PMID: 34140063 DOI: 10.1017/cjn.2021.127] [Citation(s) in RCA: 52] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
The 2020 update of the Canadian Stroke Best Practice Recommendations (CSBPR) for the Secondary Prevention of Stroke includes current evidence-based recommendations and expert opinions intended for use by clinicians across a broad range of settings. They provide guidance for the prevention of ischemic stroke recurrence through the identification and management of modifiable vascular risk factors. Recommendations address triage, diagnostic testing, lifestyle behaviors, vaping, hypertension, hyperlipidemia, diabetes, atrial fibrillation, other cardiac conditions, antiplatelet and anticoagulant therapies, and carotid and vertebral artery disease. This update of the previous 2017 guideline contains several new or revised recommendations. Recommendations regarding triage and initial assessment of acute transient ischemic attack (TIA) and minor stroke have been simplified, and selected aspects of the etiological stroke workup are revised. Updated treatment recommendations based on new evidence have been made for dual antiplatelet therapy for TIA and minor stroke; anticoagulant therapy for atrial fibrillation; embolic strokes of undetermined source; low-density lipoprotein lowering; hypertriglyceridemia; diabetes treatment; and patent foramen ovale management. A new section has been added to provide practical guidance regarding temporary interruption of antithrombotic therapy for surgical procedures. Cancer-associated ischemic stroke is addressed. A section on virtual care delivery of secondary stroke prevention services in included to highlight a shifting paradigm of care delivery made more urgent by the global pandemic. In addition, where appropriate, sex differences as they pertain to treatments have been addressed. The CSBPR include supporting materials such as implementation resources to facilitate the adoption of evidence into practice and performance measures to enable monitoring of uptake and effectiveness of recommendations.
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Trifan G, Gorelick PB, Testai FD. Efficacy and Safety of Using Dual Versus Monotherapy Antiplatelet Agents in Secondary Stroke Prevention: Systematic Review and Meta-Analysis of Randomized Controlled Clinical Trials. Circulation 2021; 143:2441-2453. [PMID: 33926204 DOI: 10.1161/circulationaha.121.053782] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Dual antiplatelet treatment (DAPT) with aspirin plus clopidogrel for a limited time is recommended after minor noncardioembolic stroke. METHODS We performed a meta-analysis of all major studies that compared the efficacy and safety of DAPT versus monotherapy for the secondary prevention of recurrent stroke or transient ischemic attack. The primary outcomes were stroke and the composite of stroke, transient ischemic attack, acute coronary syndrome, and death from any cause. The safety outcome was major hemorrhage. Relative risk (RR) and 95% CIs were calculated. Heterogeneity was assessed by I2 and Cochrane Q statistics. RESULTS The analysis included 27 358 patients, the quality of evidence was moderate to low, and the heterogeneity for all the comparisons was low (I2≤25%). Compared with monotherapy, DAPT reduced the risk of recurrent stroke (RR, 0.71 [95% CI, 0.63-0.81]) and composite outcome (RR, 0.76 [95% CI, 0.69-0.83]) but increased the risk of major bleeding (RR, 2.17 [95% CI, 1.45-3.25]). In the subgroup analysis, ≤30 days of DAPT increased the risk of hemorrhage relative to monotherapy (RR, 1.94 [95% CI, 1.08-3.52]). In the sensitivity analysis, the risk for hemorrhage with ≤30 days of DAPT after excluding the combination of aspirin plus ticagrelor was comparable to monotherapy (RR, 1.42 [95% CI, 0.77-2.60]). However, the risk for stroke recurrence and composite outcomes in the subgroup and sensitivity analyses remain decreased compared with monotherapy. CONCLUSIONS DAPT decreases the risk of recurrent stroke and composite events compared with monotherapy. DAPT increases the risk of major hemorrhage, except if the treatment is limited to 30 days and does not include the combination of aspirin plus ticagrelor.
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Affiliation(s)
- Gabriela Trifan
- Department of Neurology and Rehabilitation, University of Illinois at Chicago, College of Medicine
| | - Philip B Gorelick
- Department of Neurology and Rehabilitation, University of Illinois at Chicago, College of Medicine
| | - Fernando D Testai
- Department of Neurology and Rehabilitation, University of Illinois at Chicago, College of Medicine
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21
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Leung TW, Wang L, Zou X, Soo Y, Pu Y, Ip HL, Chan A, Au LWC, Fan F, Ma SH, Ip B, Ma K, Lau AYL, Leung H, Hui KF, Li R, Li SH, Fu M, Fong WC, Liu J, Mok V, Wong KSL, Miao Z, Ma N, Yu SCH, Leng X. Plaque morphology in acute symptomatic intracranial atherosclerotic disease. J Neurol Neurosurg Psychiatry 2020; 92:jnnp-2020-325027. [PMID: 33239439 PMCID: PMC7958085 DOI: 10.1136/jnnp-2020-325027] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Revised: 10/19/2020] [Accepted: 11/06/2020] [Indexed: 01/31/2023]
Abstract
BACKGROUND Intracranial atherosclerotic disease (ICAD) is globally a major ischaemic stroke subtype with high recurrence. Understanding the morphology of symptomatic ICAD plaques, largely unknown by far, may help identify vulnerable lesions prone to relapse. METHODS We prospectively recruited patients with acute ischaemic stroke or transient ischaemic attack attributed to high-grade ICAD (60%-99% stenosis). Plaque morphological parameters were assessed in three-dimensional rotational angiography, including surface contour, luminal stenosis, plaque length/thickness, upstream shoulder angulation, axial/longitudinal plaque distribution and presence of adjoining branch atheromatous disease (BAD). We compared morphological features of smooth, irregular and ulcerative plaques and correlated them with cerebral ischaemic lesion load downstream in MRI. RESULTS Among 180 recruited patients (median age=60 years; 63.3% male; median stenosis=75%), plaque contour was smooth (51 (28.3%)), irregular (101 (56.1%)) or ulcerative (28 (15.6%)). Surface ulcers were mostly at proximal (46.4%) and middle one-third (35.7%) of the lesions. Most (84.4%) plaques were eccentric, and half had their maximum thickness over the distal end. Ulcerative lesions were thicker (medians 1.6 vs 1.3 mm; p=0.003), had steeper upstream shoulder angulation (56.2° vs 31.0°; p<0.001) and more adjoining BAD (83.3% vs 57.0%; p=0.033) than non-ulcerative plaques. Ulcerative plaques were significantly associated with coexisting acute and chronic infarcts downstream (35.7% vs 12.5%; adjusted OR 4.29, 95% CI 1.65 to 11.14, p=0.003). Sensitivity analyses in patients with anterior-circulation ICAD lesions showed similar results in the associations between the plaque types and infarct load. CONCLUSIONS Ulcerative intracranial atherosclerotic plaques were associated with vulnerable morphological features and had a higher cumulative infarct load downstream.
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Affiliation(s)
- Thomas W Leung
- Department of Medicine & Therapeutics, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Li Wang
- Department of Medicine & Therapeutics, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Xinying Zou
- Department of Neurology, Beijing Tiantan Hospital, Beijing, China
| | - Yannie Soo
- Department of Medicine & Therapeutics, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Yuehua Pu
- Department of Neurology, Beijing Tiantan Hospital, Beijing, China
| | - Hing Lung Ip
- Department of Medicine & Therapeutics, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Anne Chan
- Department of Medicine & Therapeutics, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Lisa Wing Chi Au
- Department of Medicine & Therapeutics, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Florence Fan
- Department of Medicine & Therapeutics, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Sze Ho Ma
- Department of Medicine & Therapeutics, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Bonaventure Ip
- Department of Medicine & Therapeutics, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Karen Ma
- Department of Medicine & Therapeutics, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Alexander Yuk-Lun Lau
- Department of Medicine & Therapeutics, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Howan Leung
- Department of Medicine & Therapeutics, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Kwok Fai Hui
- Department of Medicine and Geriatrics, The United Christian Hospital, Hong Kong SAR, China
| | - Richard Li
- Department of Medicine, Pamela Youde Nethersole Eastern Hospital, Hong Kong SAR, China
| | - Siu Hung Li
- Department of Medicine, North District Hospital, Hong Kong SAR, China
| | - Michael Fu
- Department of Medicine and Geriatric, Tuen Mun Hospital, Hong Kong SAR, China
| | - Wing Chi Fong
- Department of Medicine, The Queen Elizabeth Hospital, Hong Kong SAR, China
| | - Jia Liu
- Shenzhen Institutes of Advanced Technology Chinese Academy of Sciences, Shenzhen, Guangdong, China
| | - Vincent Mok
- Department of Medicine & Therapeutics, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Ka Sing Lawrence Wong
- Department of Medicine & Therapeutics, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Zhongrong Miao
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Beijing, China
| | - Ning Ma
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Beijing, China
| | - Simon C H Yu
- Department of Imaging and Interventional Radiology, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Xinyi Leng
- Department of Medicine & Therapeutics, The Chinese University of Hong Kong, Hong Kong SAR, China
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22
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Dual antiplatelet therapy reduced stroke risk in transient ischemic attack with positive diffusion weighted imaging. Sci Rep 2020; 10:19132. [PMID: 33154471 PMCID: PMC7644691 DOI: 10.1038/s41598-020-75666-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Accepted: 10/07/2020] [Indexed: 11/23/2022] Open
Abstract
Dual antiplatelet therapy (DAPT) reduced stroke risk in high-risk transient ischemic attack (TIA) patients assessed by ABCD2 score. Patients with positive diffusion-weighted imaging (DWI) were identified as imaging-based high-risk. The present study aims to investigate whether DAPT could reduce stroke risk in TIA with DWI positive. The study enrolled TIA patients within 72 h of onset from the prospective TIA database of the First Affiliated Hospital of Zhengzhou University. The predictive outcome was ischemic stroke at 90-day. The relationship between DAPT and stroke was analyzed in a cox proportional hazards model. The Kaplan–Meier curves of TIA patients with DAPT and monotherapy were plotted. Total of 661 TIA patients were enrolled, 279 of whom were DWI positive and 281 used DAPT. The 90-day stroke risk was higher in patients used monotherapy than those used DAPT in TIA with positive DWI (23.7% vs. 13.4%, p = 0.029). DAPT was associated with reduced stroke risk in TIA patients with positive DWI (hazard ratio [HR] = 0.54; 95% confidence interval [CI], 0.30–0.97; p = 0.037). However, the benefit didn’t exist in TIA patients with negative DWI (HR = 0.43; 95% CI, 0.14–1.33; p = 0.142). Early use of DAPT reduced stroke risk in TIA patients with positive DWI.
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23
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Microangiopathie cérébrale: du diagnostic à la prise en charge small vessel disease of the brain: Diagnosis and management. Rev Med Interne 2020; 41:469-474. [PMID: 32718708 DOI: 10.1016/j.revmed.2020.04.018] [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] [Received: 11/17/2019] [Revised: 02/18/2020] [Accepted: 04/21/2020] [Indexed: 11/24/2022]
Abstract
Small vessel disease of the brain is commonly identified among ageing people. It causes almost 25% of strokes and is associated with cognitive impairment and dementia as well as gait difficulties. Its diagnosis is usually made on MRI in the presence of deep white matter and basal ganglia hyperintensities as well as deep lacunar infarcts (lacunes), microbleeds and enlarged perivascular spaces. MRI is also of importance to identify the main differential diagnoses including inflammatory disorders, cerebral amyloid angiopathy and other genetic causes of microangiopathy. Small vessel disease is associated with the main vascular risk factors including notably age and hypertension but whether controlling these vascular risk factors is beneficial is still not clear. Here, we provide a comprehensive review underlining the main diagnostic features of cerebral microangiopathy and summarise the main therapeutic approaches (notably blood pressure normalisation and physical activity) used to control its development and prevent strokes as well as the development of cognitive involvement and gait impairment.
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24
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Albay CEQ, Leyson FGD, Cheng FC. Dual versus mono antiplatelet therapy for acute non- cardio embolic ischemic stroke or transient ischemic attack, an efficacy and safety analysis - updated meta-analysis. BMC Neurol 2020; 20:224. [PMID: 32493229 PMCID: PMC7268473 DOI: 10.1186/s12883-020-01808-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Accepted: 05/26/2020] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND New evidence on the efficacy and safety of dual antiplatelet therapy for secondary stroke prevention have been realized in the recent years. An updated meta analysis was done to determine the effect of the various dual antiplatelets vs aspirin alone on recurrence rate of ischemic stroke, cardiovascular morbidity and mortality, and its safety profile as reported through major bleeding. METHODS PubMed, Cochrane and Science Direct data bases were utilized, RCTs evaluating dual antiplatelet vs mono antiplatelet therapy for acute ischemic stroke or transient ischemic attack within < 72 h from ictus were searched up to July 2019. Risk ratio at 95% confidence intervals were calculated to evaluate stroke recurrence, cardiac events and mortality, and major bleeding. RESULTS Sixteen randomized controlled trials with a population of 28, 032 patients were pooled into a meta-analysis. Dual antiplatelet therapy was significantly superior over mono antiplatelet therapy in the reduction of stroke (RR 0.75, 95% CI:0.68-0.83, p value< 0.00001) and composite events namely cardiovascular morbidity and mortality (0.73 95% CI: 0.65-0.82, p value < 0.00001), while bleeding events were noted to be not significant (1.22 95% CI: 0.87-1.70, p value = 0.25). CONCLUSION In acute non-cardioembolic ischemic strokes or those who have suffered a transient ischemic attack, dual antiplatelet therapy was associated with efficacy in stroke recurrence and composite cardiac events, with a non-significant risk of major bleeding.
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Affiliation(s)
| | | | - Federick C. Cheng
- Cardinal Santos Medical Center, 10 Wilson St. Greenhills West, 1502 San Juan City, NCR Philippines
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25
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Evaluating Effectiveness and Safety in Chronic Kidney Disease with Atrial Flutter Using an Anticoagulation Strategy. ACTA ACUST UNITED AC 2020; 56:medicina56060266. [PMID: 32481685 PMCID: PMC7353883 DOI: 10.3390/medicina56060266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2020] [Revised: 05/25/2020] [Accepted: 05/26/2020] [Indexed: 12/02/2022]
Abstract
Background and objectives: Recent randomized trials of oral antithrombotic drugs with atrial flutter (AFL) excluded patients with renal impairment because of their increased risk of bleeding. To date, no relevant studies have assessed the effectiveness and safety of different antithrombotic drugs in chronic kidney disease (CKD) patients with AFL. This cohort study evaluated the effectiveness and safety of different antithrombotic drugs in CKD patients with AFL. This study also investigated the risk of cardiovascular events from antithrombotic drugs through different risk profiles of stroke stratified by the CHA2DS2-VASc score. Materials and Methods: This cohort study was performed in patients with AFL and CKD who were extracted from the National Health Insurance (NHI) Database in Taiwan. Oral antithrombotic therapy (oral anticoagulants (OAC) or antiplatelets (APT)) was administered to patients who had been diagnosed with AFL after being diagnosed with CKD between 2011 and 2015. Primary outcomes, including ischemic stroke, systemic embolism, and composite of stroke, and secondary outcomes, including major adverse cardiac events (MACEs), major bleeding, all-cause mortality, and cardiovascular-related death, were examined. Results: A total of 2468 patients were included in this study. The results showed no statistically significant differences in the risk of primary outcomes. For the secondary outcomes, there were also no statistically significant differences in the risk of MACEs and major bleeding. However, the pooled results indicated that the hazard ratio (HR) for all-cause mortality with OAC was 0.24 (95% confidence interval (CI) = 0.10–0.55) compared with combination therapy, and the HR for APT compared with OAC was 2.86 (95% CI = 1.48–5.53). Conclusions: In the studied population, OAC or APT alone were proved equally effective for stroke prophylaxis. Furthermore, OAC might reduce the all-cause mortality rate compared with APT and should be considered as the first choice of oral antithrombotic drugs in patients with AFL and CKD.
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26
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Koga M, Yamamoto H, Inoue M, Asakura K, Aoki J, Hamasaki T, Kanzawa T, Kondo R, Ohtaki M, Itabashi R, Kamiyama K, Iwama T, Nakase T, Yakushiji Y, Igarashi S, Nagakane Y, Takizawa S, Okada Y, Doijiri R, Tsujino A, Ito Y, Ohnishi H, Inoue T, Takagi Y, Hasegawa Y, Shiokawa Y, Sakai N, Osaki M, Uesaka Y, Yoshimura S, Urabe T, Ueda T, Ihara M, Kitazono T, Sasaki M, Oita A, Yoshimura S, Fukuda-Doi M, Miwa K, Kimura K, Minematsu K, Toyoda K. Thrombolysis With Alteplase at 0.6 mg/kg for Stroke With Unknown Time of Onset: A Randomized Controlled Trial. Stroke 2020; 51:1530-1538. [PMID: 32248771 PMCID: PMC7185058 DOI: 10.1161/strokeaha.119.028127] [Citation(s) in RCA: 49] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Supplemental Digital Content is available in the text. We assessed whether lower-dose alteplase at 0.6 mg/kg is efficacious and safe for acute fluid-attenuated inversion recovery-negative stroke with unknown time of onset.
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Affiliation(s)
- Masatoshi Koga
- From the Department of Cerebrovascular Medicine (M.K., M. Inoue, S. Yoshimura, M.F.-D., K. Miwa, K. Minematsu, K. Toyoda)
| | - Haruko Yamamoto
- Center for Advancing Clinical and Translational Sciences (H.Y.), National Cerebral and Cardiovascular Center, Suita
| | - Manabu Inoue
- From the Department of Cerebrovascular Medicine (M.K., M. Inoue, S. Yoshimura, M.F.-D., K. Miwa, K. Minematsu, K. Toyoda)
| | - Koko Asakura
- Department of Data Science (K.A., T.H., M.F-D.), National Cerebral and Cardiovascular Center, Suita
| | - Junya Aoki
- Department of Neurology, Graduate School of Medicine, Nippon Medical School, Tokyo (J.A., K. Kimura)
| | - Toshimitsu Hamasaki
- Department of Data Science (K.A., T.H., M.F-D.), National Cerebral and Cardiovascular Center, Suita
| | - Takao Kanzawa
- Department of Stroke Medicine, Institute of Brain and Blood Vessels, Mihara Memorial Hospital, Isesaki (T. Kanzawa)
| | - Rei Kondo
- Department of Neurosurgery, Yamagata City Hospital Saiseikan (R. Kondo)
| | - Masafumi Ohtaki
- Department of Neurosurgery, Obihiro Kosei Hospital (M. Ohtaki)
| | - Ryo Itabashi
- Department of Stroke Neurology, Kohnan Hospital, Sendai (R.I.)
| | - Kenji Kamiyama
- Department of Neurosurgery, Nakamura Memorial Hospital, Sapporo (K. Kamiyama)
| | - Toru Iwama
- Department of Neurosurgery, Gifu University School of Medicine (T. Iwama)
| | - Taizen Nakase
- Department of Stroke Science, Research Institute for Brain and Blood Vessels, Akita (T.N.).,Department of Neurosurgery, Akita University (T.N.)
| | - Yusuke Yakushiji
- Division of Neurology, Department of Internal Medicine, Saga University Faculty of Medicine (Y.Y.)
| | | | | | - Shunya Takizawa
- Division of Neurology, Department of Internal Medicine, Tokai University School of Medicine, Isehara (S.T.)
| | - Yasushi Okada
- Department of Cerebrovascular Medicine and Neurology, Cerebrovascular Center, National Hospital Organization Kyushu Medical Center, Fukuoka (Y.O.)
| | - Ryosuke Doijiri
- Department of Neurology, Iwate Prefectural Central Hospital, Morioka (R.D.)
| | - Akira Tsujino
- Department of Neurology and Strokology, Nagasaki University Graduate School of Biomedical Sciences (A.T.)
| | - Yasuhiro Ito
- Department of Neurology, Toyota Memorial Hospital (Y.I.)
| | - Hideyuki Ohnishi
- Department of Neurosurgery, Ohnishi Neurological Center, Akashi (H.O.)
| | - Takeshi Inoue
- Department of Stroke Medicine, Kawasaki Medical School General Medical Center, Okayama (T. Inoue)
| | | | - Yasuhiro Hasegawa
- Department of Neurology, St. Marianna University School of Medicine, Kawasaki (Y.H.)
| | - Yoshiaki Shiokawa
- Department of Neurosurgery, Kyorin University School of Medicine, Mitaka (Y.S.)
| | - Nobuyuki Sakai
- Department of Neurosurgery, Kobe City Medical Center General Hospital (N.S.)
| | - Masato Osaki
- Department of Cerebrovascular Medicine, Stroke Center, Steel Memorial Yawata Hospital, Kitakyushu (M.O.)
| | | | - Shinichi Yoshimura
- Department of Neurosurgery, Hyogo College of Medicine, Nishinomiya (S. Yoshimura)
| | - Takao Urabe
- Department of Neurology, Juntendo University Urayasu Hospital (T. Urabe)
| | - Toshihiro Ueda
- Department of Strokology, Stroke Center, St. Marianna University Toyoko Hospital, Kawasaki (T. Ueda)
| | - Masafumi Ihara
- Department of Neurology (M. Ihara), National Cerebral and Cardiovascular Center, Suita
| | - Takanari Kitazono
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka (T. Kitazono)
| | - Makoto Sasaki
- Institute for Biomedical Sciences, Iwate Medical University, Yahaba (M.S.)
| | - Akira Oita
- Department of Pharmacy (A.O.), National Cerebral and Cardiovascular Center, Suita
| | - Sohei Yoshimura
- From the Department of Cerebrovascular Medicine (M.K., M. Inoue, S. Yoshimura, M.F.-D., K. Miwa, K. Minematsu, K. Toyoda)
| | - Mayumi Fukuda-Doi
- From the Department of Cerebrovascular Medicine (M.K., M. Inoue, S. Yoshimura, M.F.-D., K. Miwa, K. Minematsu, K. Toyoda).,Department of Data Science (K.A., T.H., M.F-D.), National Cerebral and Cardiovascular Center, Suita
| | - Kaori Miwa
- From the Department of Cerebrovascular Medicine (M.K., M. Inoue, S. Yoshimura, M.F.-D., K. Miwa, K. Minematsu, K. Toyoda)
| | - Kazumi Kimura
- Department of Neurology, Graduate School of Medicine, Nippon Medical School, Tokyo (J.A., K. Kimura)
| | - Kazuo Minematsu
- From the Department of Cerebrovascular Medicine (M.K., M. Inoue, S. Yoshimura, M.F.-D., K. Miwa, K. Minematsu, K. Toyoda).,Headquarters of the Iseikai Medical Corporation, Osaka, Japan (K. Minematsu)
| | - Kazunori Toyoda
- From the Department of Cerebrovascular Medicine (M.K., M. Inoue, S. Yoshimura, M.F.-D., K. Miwa, K. Minematsu, K. Toyoda)
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27
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Pugliese F, Arasaratnam P, Moellenberg M, Dani S. Short- vs. long-term dual antiplatelet therapy in secondary prevention for ischaemic stroke: a network metanalysis. EUROPEAN HEART JOURNAL. QUALITY OF CARE & CLINICAL OUTCOMES 2019; 5:298-309. [PMID: 31050716 DOI: 10.1093/ehjqcco/qcz024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Revised: 04/08/2019] [Accepted: 04/24/2019] [Indexed: 11/12/2022]
Abstract
AIMS This review aimed to compare the efficacy and safety of short-term (≤3 months) and long-term (≥1 year) dual-antiplatelet therapy (DAPT) in secondary prevention for ischaemic stroke. METHODS AND RESULTS We searched MEDLINE, EMBASE (Ovid), PubMed, Cochrane Library, ClinicalTrials.gov, and Google Advanced Search for randomized controlled trials. The population consisted of patients with recent ischaemic stroke or transient ischaemic attack. The intervention was DAPT with a combination of aspirin, clopidogrel, and dipyridamole compared to either aspirin or clopidogrel in monotherapy. The primary outcome was the rate of all recurrent stroke (ischaemic and haemorrhagic). Secondary outcomes were ischaemic stroke, all bleeding, severe bleeding, all-cause death, cardiovascular death, and myocardial infarction. Data were pooled by network metanalysis and pairwise metanalyses. Sixteen studies with 55 261 participants were included. Compared to aspirin, DAPT with aspirin clopidogrel decreased the risk of recurrent stroke [short-term odds ratio (OR) 0.67, 95% confidence interval (CI) 0.58-0.77; long-term OR 0.84, 95% CI 0.70-1.01] at the expense of increased risk of bleeding (short-term OR 1.76, 95% CI 1.26-2.46; long-term OR 2.25, 95% CI 1.97-2.57). Dual antiplatelet therapy with aspirin clopidogrel and clopidogrel in monotherapy had similar long-term risk of recurrent stroke (OR 0.98, 95% CI 0.83-1.14), but DAPT was associated with increased risk of bleeding (OR 2.77, 95% CI 2.21-3.46). Network metanalysis showed that short-term aspirin clopidogrel DAPT had the best risk-benefit profile, followed by long-term aspirin clopidogrel DAPT and clopidogrel alone. Aspirin dipyridamole DAPT was less effective. CONCLUSION Short-term DAPT had better risk-benefit profile than long-term DAPT.
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Affiliation(s)
- Francesca Pugliese
- Centre for Advanced Cardiovascular Imaging, William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, Charterhouse Square, London, UK.,NIHR Barts Biomedical Research Centre, Barts Health NHS Trust, West Smithfield, London, UK.,Department of Health Policy, London School of Economics and Political Science, London, UK
| | - Punitha Arasaratnam
- Department of Health Policy, London School of Economics and Political Science, London, UK.,Division of Cardiology, Department of Medicine, Ng Teng Fong General Hospital, 1 Jurong East Street 21, Singapore, Singapore
| | - Marcus Moellenberg
- Department of Health Policy, London School of Economics and Political Science, London, UK.,Department of Cardiology and Pulmonology, Fachkrankenhaus Kloster Grafschaft Schmallenberg, Annostraße 1, Schmallenberg, Germany
| | - Sourbha Dani
- Department of Health Policy, London School of Economics and Political Science, London, UK.,Northern Light Cardiology, Eastern Maine Medical Center, 1 Northeast Drive, Bangor, ME, USA
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28
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Patti G, Sticchi A, Bisignani A, Pelliccia F, Pasceri V, Speciale G, Penco M. Meta-Regression to Identify Patients Deriving the Greatest Benefit from Dual Antiplatelet Therapy after Stroke or Transient Ischemic Attack Without Thrombolytic or Thrombectomy Treatment. Am J Cardiol 2019; 124:627-635. [PMID: 31248591 DOI: 10.1016/j.amjcard.2019.05.013] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2019] [Revised: 05/01/2019] [Accepted: 05/13/2019] [Indexed: 12/24/2022]
Abstract
The patient's profile drawing the greatest benefit from dual antiplatelet therapy (DAPT) after a noncardioembolic, ischemic cerebrovascular event is not well characterized. Aim of this metaregression analysis was to compare DAPT versus single antiplatelet therapy (SAPT) in patients with stroke or transient ischemic attack (TIA). We searched randomized trials evaluating clinical outcome with aspirin plus a P2Y12 inhibitor versus SAPT in patients with noncardioembolic stroke or TIA. Primary end point was the incidence of recurrent stroke; safety outcome measure was major bleeding. Eleven trials were included in the analysis, enrolling 24,175 patients treated with DAPT (aspirin plus clopidogrel, n = 12,074) or SAPT (n = 12,101) after a stroke or TIA event. In the DAPT group the rates of recurrent stroke were lower (7.1% vs 8.8% with SAPT; odds ratios [OR] 0.74, 95% confidence interval 0.62 to 0.88; p = 0.0007) and the incidence of major bleeding was twofold higher (OR 2.01, 1.35 to 3.01; p = 0.0006). Metaregression indicated a positive correlation between prevention of recurrent stroke by DAPT and baseline stroke severity (p = 0.019), baseline risk profile (p = 0.0001), or prevalence of carotid atherosclerosis (p = 0.040). DAPT was more effective when initiated ≤7 days (OR 0.67, 0.58 to 0.77; p < 0.00001) and used for ≤3 months (OR 0.66, 0.58 to 0.76; p < 0.00001) after the event. In conclusion, in patients with stroke or TIA, the highest benefit of DAPT was observed in patients with higher baseline risk profile, greater stroke severity, or concomitant carotid disease, and when DAPT was initiated early and given for ≤3 months.
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Affiliation(s)
- Giuseppe Patti
- University of L'Aquila, L'Aquila, Italy; Campus Bio-Medico Hospital, Rome, Italy.
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29
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Das AS, Regenhardt RW, Feske SK, Gurol ME. Treatment Approaches to Lacunar Stroke. J Stroke Cerebrovasc Dis 2019; 28:2055-2078. [PMID: 31151838 PMCID: PMC7456600 DOI: 10.1016/j.jstrokecerebrovasdis.2019.05.004] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Revised: 04/15/2019] [Accepted: 05/02/2019] [Indexed: 12/12/2022] Open
Abstract
Lacunar strokes are appropriately named for their ability to cavitate and form ponds or "little lakes" (Latin: lacune -ae meaning pond or pit is a diminutive form of lacus meaning lake). They account for a substantial proportion of both symptomatic and asymptomatic ischemic strokes. In recent years, there have been several advances in the management of large vessel occlusions. New therapies such as non-vitamin K antagonist oral anticoagulants and left atrial appendage closure have recently been developed to improve stroke prevention in atrial fibrillation; however, the treatment of small vessel disease-related strokes lags frustratingly behind. Since Fisher characterized the lacunar syndromes and associated infarcts in the late 1960s, there have been no therapies specifically targeting lacunar stroke. Unfortunately, many therapeutic agents used for the treatment of ischemic stroke in general offer only a modest benefit in reducing recurrent stroke while adding to the risk of intracerebral hemorrhage and systemic bleeding. Escalation of antithrombotic treatments beyond standard single antiplatelet agents has not been effective in long-term lacunar stroke prevention efforts, unequivocally increasing intracerebral hemorrhage risk without providing a significant benefit. In this review, we critically review the available treatments for lacunar stroke based on evidence from clinical trials. For several of the major drugs, we summarize the adverse effects in the context of this unique patient population. We also discuss the role of neuroprotective therapies and neural repair strategies as they may relate to recovery from lacunar stroke.
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Affiliation(s)
- Alvin S Das
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Robert W Regenhardt
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Steven K Feske
- Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Mahmut Edip Gurol
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.
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30
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Greving JP, Diener HC, Reitsma JB, Bath PM, Csiba L, Hacke W, Kappelle LJ, Koudstaal PJ, Leys D, Mas JL, Sacco RL, Algra A. Antiplatelet Therapy After Noncardioembolic Stroke. Stroke 2019; 50:1812-1818. [PMID: 31177983 PMCID: PMC6594726 DOI: 10.1161/strokeaha.118.024497] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Background and Purpose- We assessed the efficacy and safety of antiplatelet agents after noncardioembolic stroke or transient ischemic attack and examined how these vary according to patients' demographic and clinical characteristics. Methods- We did a network meta-analysis (NMA) of data from 6 randomized trials of the effects of commonly prescribed antiplatelet agents in the long-term (≥3 months) secondary prevention of noncardioembolic stroke or transient ischemic attack. Individual patient data from 43 112 patients were pooled and reanalyzed. Main outcomes were serious vascular events (nonfatal stroke, nonfatal myocardial infarction, or vascular death), major bleeding, and net clinical benefit (serious vascular event or major bleeding). Subgroup analyses were done according to age, sex, ethnicity, hypertension, qualifying diagnosis, type of vessel involved (large versus small vessel disease), and time from qualifying event to randomization. Results- Aspirin/dipyridamole combination (RRNMA-adj, 0.83; 95% CI, 0.74-0.94) significantly reduced the risk of vascular events compared with aspirin, as did clopidogrel (RRNMA-adj, 0.88; 95% CI, 0.78-0.98), and aspirin/clopidogrel combination (RRNMA-adj, 0.83; 95% CI, 0.71-0.96). Clopidogrel caused significantly less major bleeding and intracranial hemorrhage than aspirin, aspirin/dipyridamole combination, and aspirin/clopidogrel combination. Aspirin/clopidogrel combination caused significantly more major bleeding than aspirin, aspirin/dipyridamole combination, and clopidogrel. Net clinical benefit was similar for clopidogrel and aspirin/dipyridamole combination (RRNMA-adj, 0.99; 95% CI, 0.93-1.05). Subgroup analyses showed no heterogeneity of treatment effectiveness across prespecified subgroups. The excess risk of major bleeding associated with aspirin/clopidogrel combination compared with clopidogrel alone was higher in patients aged <65 years than it was in patients ≥65 years (RRNMA-adj, 3.9 versus 1.7). Conclusions- Results favor clopidogrel and aspirin/dipyridamole combination for long-term secondary prevention after noncardioembolic stroke or transient ischemic attack, regardless of patient characteristics. Aspirin/clopidogrel combination was associated with a significantly higher risk of major bleeding compared with other antiplatelet regimens.
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Affiliation(s)
- Jacoba P Greving
- From the Julius Center for Health Sciences and Primary Care (J.P.G., J.B.R., A.A.)
| | | | - Johannes B Reitsma
- From the Julius Center for Health Sciences and Primary Care (J.P.G., J.B.R., A.A.)
| | - Philip M Bath
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, United Kingdom (P.M.B.)
| | - László Csiba
- Department of Neurology, University of Debrecen Medical and Health Science Center, Hungary (L.C.)
| | - Werner Hacke
- Department of Neurology, University of Heidelberg, Germany (W.H.)
| | - L Jaap Kappelle
- Department of Neurology and Neurosurgery (L.J.K., A.A.), UMC Utrecht, Utrecht University, the Netherlands
| | - Peter J Koudstaal
- Department of Neurology, Erasmus MC, Rotterdam, the Netherlands (P.J.K.)
| | - Didier Leys
- Department of Neurology, Roger Salengro Hospital, Lille, France (D.L.)
| | - Jean-Louis Mas
- Department of Neurology, Hôpital Sainte-Anne, Université Paris Descartes, France (J.-L.M.)
| | - Ralph L Sacco
- Department of Neurology, Miller School of Medicine, University of Miami, Coral Gables, FL (R.L.S.)
| | - Ale Algra
- From the Julius Center for Health Sciences and Primary Care (J.P.G., J.B.R., A.A.).,Department of Neurology and Neurosurgery (L.J.K., A.A.), UMC Utrecht, Utrecht University, the Netherlands
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31
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Xie X, Wang X, Laskowitz DT, Zhao X, Miao Z, Liu L, Li H, Meng X, Wang Y, Wang Y. Effect of dual versus mono antiplatelet therapy on recurrent stroke modulated by activated partial thromboplastin time. Eur J Neurol 2019; 26:1168-e78. [PMID: 30972875 DOI: 10.1111/ene.13961] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2018] [Accepted: 04/03/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND PURPOSE The efficacy of dual antiplatelet treatment may be modified by many factors. The aim was to assess whether the effect of clopidogrel plus aspirin versus aspirin alone on recurrent stroke would be affected by admission activated partial thromboplastin time (aPTT). METHODS Data were derived from the Clopidogrel in High-Risk Patients with Acute Nondisabling Cerebrovascular Events (CHANCE) trial. A total of 5074 patients were categorized into three groups based on the aPTT distribution according to the 15th and 85th percentile. The primary outcome was any stroke within 90 days. The interaction of aPTT with antiplatelet therapy on stroke risk was assessed with a Cox proportional hazards model with adjustment for covariates. RESULTS In the high aPTT group (defined as ≥35.9 s), stroke occurred in 6.7% of patients in the clopidogrel-aspirin arm and 11.9% in the aspirin arm [adjusted hazard ratio (HR) 0.50; 95% confidence interval (CI) 0.29-0.85]. In the medium aPTT group (24.6-35.8 s), stroke occurred in 7.7% of patients in the clopidogrel-aspirin arm and 11.8% in the aspirin arm (adjusted HR 0.62; 95% CI 0.50-0.75). Furthermore, in the low aPTT group (≤24.5 s), stroke occurred in 11.2% of patients in the clopidogrel-aspirin arm and 9.9% in the aspirin arm (adjusted HR 1.07; 95% CI 0.65-1.62). The interaction P value of antiplatelet therapy with aPTT level at the cut-point of approximately 25 s or below was significant (P < 0.05). CONCLUSIONS Dual antiplatelet therapy was superior to single antiplatelet therapy in the high or medium aPTT group but not in the low aPTT group.
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Affiliation(s)
- X Xie
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - X Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - D T Laskowitz
- Department of Neurology, Duke University Medical Center, Durham, NC, USA
| | - X Zhao
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Z Miao
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China.,Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - L Liu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - H Li
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - X Meng
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Y Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Y Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
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32
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Huang YC, Tsai YH, Lee JD, Yang JT, Pan YT. A Novel Neuroimaging Model to Predict Early Neurological Deterioration After Acute Ischemic Stroke. Curr Neurovasc Res 2019; 15:129-137. [PMID: 29766805 PMCID: PMC6350204 DOI: 10.2174/1567202615666180516120022] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Revised: 04/12/2018] [Accepted: 04/14/2018] [Indexed: 12/02/2022]
Abstract
Objective: In acute ischemic stroke, early neurological deterioration (END) may occur in up to one-third of patients. However, there is still no satisfying or comprehensive predictive model for all the stroke subtypes. We propose a practical model to predict END using magnetic resonance imaging (MRI). Method: Patients with anterior circulation infarct were recruited and they underwent an MRI within 24 hours of stroke onset. END was defined as an elevation of ≥2 points on the National Institute of Health Stroke Scale (NIHSS) within 72 hours of stroke onset. We examined the relationships of END to individual END models, including: A, infarct swelling; B, small subcortical infarct; C, mis-match; and D, recurrence. Results: There were 163 patients recruited and 43 (26.4%) of them had END. The END models A, B and C significantly predicted END respectively after adjusting for confounding factors (p=0.022, p=0.007 and p<0.001 respectively). In END model D, we examined all imaging predictors of Recur-rence Risk Estimator (RRE) individually and only the “multiple acute infarcts” pattern was signifi-cantly associated with END (p=0.032). When applying END models A, B, C and D, they success-fully predicted END (p<0.001; odds ratio: 17.5[95% confidence interval: 5.1–60.8]), with 93.0% sensitivity, 60.0% specificity, 45.5% positive predictive value and 96.0% negative predictive value. Conclusion: The results demonstrate that the proposed model could predict END in all stroke sub-types of anterior circulation infarction. It provides a practical model for clinical physicians to select high-risk patients for more aggressive treatment to prevent END.
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Affiliation(s)
- Yen-Chu Huang
- Department of Neurology, Chang Gung Memorial Hospital at Chiayi, Chang-Gung University, College of Medicine, Putz, Taiwan
| | - Yuan-Hsiung Tsai
- Department of Diagnostic Radiology, Chang Gung Memorial Hospital at Chiayi, Chang-Gung University, College of Medicine, Putz, Taiwan
| | - Jiann-Der Lee
- Department of Neurology, Chang Gung Memorial Hospital at Chiayi, Chang-Gung University, College of Medicine, Putz, Taiwan
| | - Jen-Tsung Yang
- Department of Neurosurgery, Chang Gung Memorial Hospital at Chiayi, Chang-Gung University, College of Medicine, Putz, Taiwan
| | - Yi-Ting Pan
- Department of Neurology, Chang Gung Memorial Hospital at Chiayi, Chang-Gung University, College of Medicine, Putz, Taiwan
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33
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Bath PM, Woodhouse LJ, Appleton JP, Beridze M, Christensen H, Dineen RA, Flaherty K, Duley L, England TJ, Havard D, Heptinstall S, James M, Kasonde C, Krishnan K, Markus HS, Montgomery AA, Pocock S, Randall M, Ranta A, Robinson TG, Scutt P, Venables GS, Sprigg N. Triple versus guideline antiplatelet therapy to prevent recurrence after acute ischaemic stroke or transient ischaemic attack: the TARDIS RCT. Health Technol Assess 2019; 22:1-76. [PMID: 30179153 DOI: 10.3310/hta22480] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Two antiplatelet agents are better than one for preventing recurrent stroke after acute ischaemic stroke or transient ischaemic attack (TIA). Therefore, intensive treatment with three agents might be better still, providing it does not cause undue bleeding. OBJECTIVE To compare the safety and efficacy of intensive therapy with guideline antiplatelet therapy for acute ischaemic stroke and TIA. DESIGN International prospective randomised open-label blinded end-point parallel-group superiority clinical trial. SETTING Acute hospitals at 106 sites in four countries. PARTICIPANTS Patients > 50 years of age with acute non-cardioembolic ischaemic stroke or TIA within 48 hours of ictus (stroke). INTERVENTIONS Participants were allocated at random by computer to 1 month of intensive (combined aspirin, clopidogrel and dipyridamole) or guideline (combined aspirin and dipyridamole, or clopidogrel alone) antiplatelet agents, and followed for 90 days. MAIN OUTCOME MEASURES The primary outcome was the incidence and severity of any recurrent stroke (ischaemic, haemorrhagic; assessed using the modified Rankin Scale) or TIA within 90 days by blinded telephone follow-up. Analysis using ordinal logistic regression was by intention to treat. Other outcomes included bleeding and its severity, death, myocardial infarction (MI), disability, mood, cognition and quality of life. RESULTS The trial was stopped early on the recommendation of the Data Monitoring Committee after recruitment of 3096 participants (intensive, n = 1556; guideline, n = 1540) from 106 hospitals in four countries between April 2009 and March 2016. The incidence and severity of recurrent stroke or TIA did not differ between intensive and guideline therapy in 3070 (99.2%) participants with data [93 vs. 105 stroke/TIA events; adjusted common odds ratio 0.90, 95% confidence interval (CI) 0.67 to 1.20; p = 0.47]. Major (encompassing fatal) bleeding was increased with intensive as compared with guideline therapy [39 vs. 17 participants; adjusted hazard ratio (aHR) 2.23, 95% CI 1.25 to 3.96; p = 0.006]. There were no differences between the treatment groups in all-cause mortality, or the composite of death, stroke, MI and major bleeding (aHR 1.02, 95% CI 0.77 to 1.35; p = 0.88). LIMITATIONS Patients and investigators were not blinded to treatment. The comparator group comprised two guideline strategies because of changes in national guidelines during the trial. The trial was stopped early, thereby reducing its statistical power. CONCLUSIONS The use of three antiplatelet agents is associated with increased bleeding without any significant reduction in recurrence of stroke or TIA. FUTURE WORK The safety and efficacy of dual antiplatelet therapy (combined aspirin and clopidogrel) versus aspirin remains to be defined. Further research is required on identifying individual patient response to antiplatelets, and the relationship between response and the subsequent risks of vascular recurrent events and bleeding complications. TRIAL REGISTRATION Current Controlled Trials ISRCTN47823388. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 22, No. 48. See the NIHR Journal Library website for further project information. The Triple Antiplatelets for Reducing Dependency after Ischaemic Stroke (TARDIS) vanguard phase was funded by the British Heart Foundation (grant PG/08/083/25779, from 1 April 2009 to 30 September 2012) and indirect funding was provided by the Stroke Association through its funding of the Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK. There was no commercial support for the trial and antiplatelet drugs were sourced locally at each site. The trial was sponsored by the University of Nottingham.
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Affiliation(s)
- Philip M Bath
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK.,Stroke, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Lisa J Woodhouse
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Jason P Appleton
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK.,Stroke, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Maia Beridze
- Department of Neurology, Hospital of War Veterans, Tbilisi, Georgia
| | - Hanne Christensen
- Department of Neurology, Bispebjerg and Frederiksberg Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Robert A Dineen
- Radiological Sciences, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Katie Flaherty
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Lelia Duley
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - Timothy J England
- Vascular Medicine, Division of Medical Sciences and Graduate Entry Medicine, University of Nottingham, Nottingham, UK
| | - Diane Havard
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Stan Heptinstall
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Marilyn James
- Health Economics, Division of Rehabilitation and Ageing, University of Nottingham, Nottingham, UK
| | | | - Kailash Krishnan
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK.,Stroke, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Hugh S Markus
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Alan A Montgomery
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - Stuart Pocock
- Medical Statistics Unit, London School of Hygiene & Tropical Medicine, London, UK
| | - Marc Randall
- Department of Neurology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Annamarei Ranta
- Department of Neurology, Wellington Hospital and University of Otago, Wellington, New Zealand
| | - Thompson G Robinson
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Polly Scutt
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Graham S Venables
- Department of Neurology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Nikola Sprigg
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK.,Stroke, Nottingham University Hospitals NHS Trust, Nottingham, UK
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34
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Ma Y, Liu Y, Xu J, Wang Y, Du F, Wang Y. The influence of mean arterial pressure on the efficacy and safety of dual antiplatelet therapy in minor stroke or transient ischemic attack patients. J Clin Hypertens (Greenwich) 2019; 21:598-604. [PMID: 30957391 DOI: 10.1111/jch.13527] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2018] [Revised: 01/23/2019] [Accepted: 02/03/2019] [Indexed: 11/27/2022]
Abstract
Mean arterial pressure (MAP) is the strongest predictor of stroke. The combination of clopidogrel and aspirin within 24 hours after onset has been suggested by the Clopidogrel in High-Risk Patients with Acute Nondisabling Cerebrovascular Events (CHANCE) study to be superior to aspirin alone. However, it is not clear whether poststroke blood pressure has an influence on the efficacy and safety of dual antiplatelet treatment. We have performed a post hoc analysis from the CHANCE trial. Patients were stratified into three groups based on MAP levels. Among patients with MAP <102 mm Hg, there was no significant difference in stroke recurrence between the clopidogrel-aspirin group and the aspirin group (7.7% vs 7.5%; hazard ratio [HR], 1.03; 95% confidence interval [CI], 0.73-1.45). However, compared to aspirin treatment, the clopidogrel-aspirin dual treatment was more effective at reducing the risk of stroke in patients with MAP ≥113 mm Hg (6.9% vs 12.3%, HR, 0.55; 95% CI, 0.39-0.78) or 102-113 mm Hg (9.5% vs 14.9%, HR, 0.62; 95% CI, 0.48-0.81). There was a significant interaction between MAP and antiplatelet therapy as it relates to stroke recurrence (P for interaction = 0.037), and a similar result was found for combined vascular events (P for interaction = 0.027). In conclusion, dual antiplatelet therapy may be more effective at reducing combined vascular events in patients with higher MAP after minor stroke or transient ischemic attack.
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Affiliation(s)
- Yan Ma
- Department of Cardiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Ying Liu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Jie Xu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Yilong Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Fenghe Du
- Department of Cardiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yongjun Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
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35
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Hao Q, Tampi M, O'Donnell M, Foroutan F, Siemieniuk RA, Guyatt G. Clopidogrel plus aspirin versus aspirin alone for acute minor ischaemic stroke or high risk transient ischaemic attack: systematic review and meta-analysis. BMJ 2018; 363:k5108. [PMID: 30563866 PMCID: PMC6298178 DOI: 10.1136/bmj.k5108] [Citation(s) in RCA: 85] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVE To assess the effectiveness and safety of dual agent antiplatelet therapy combining clopidogrel and aspirin to prevent recurrent thrombotic and bleeding events compared with aspirin alone in patients with acute minor ischaemic stroke or transient ischaemic attack (TIA). DESIGN Systematic review and meta-analysis of randomised, placebo controlled trials. DATA SOURCES Medline, Embase, Cochrane Central Register of Controlled Trials, Cochrane Library, ClinicalTrials.gov, WHO website, PsycINFO, and grey literature up to 4 July 2018. ELIGIBILITY CRITERIA FOR SELECTING STUDIES AND METHODS Two reviewers independently screened potentially eligible studies according to predefined selection criteria and assessed the risk of bias using a modified version of the Cochrane risk of bias tool. A third team member reviewed all final decisions, and the team resolved disagreements through discussion. When reports omitted data that were considered important, clarification and additional information was sought from the authors. The analysis was conducted in RevMan 5.3 and MAGICapp based on GRADE methodology. RESULTS Three eligible trials involving 10 447 participants were identified. Compared with aspirin alone, dual antiplatelet therapy with clopidogrel and aspirin that was started within 24 hours of symptom onset reduced the risk of non-fatal recurrent stroke (relative risk 0.70, 95% confidence interval 0.61 to 0.80, I2=0%, absolute risk reduction 1.9%, high quality evidence), without apparent impact on all cause mortality (1.27, 0.73 to 2.23, I2=0%, moderate quality evidence) but with a likely increase in moderate or severe extracranial bleeding (1.71, 0.92 to 3.20, I2=32%, absolute risk increase 0.2%, moderate quality evidence). Most stroke events, and the separation in incidence curves between dual and single therapy arms, occurred within 10 days of randomisation; any benefit after 21 days is extremely unlikely. CONCLUSIONS Dual antiplatelet therapy with clopidogrel and aspirin given within 24 hours after high risk TIA or minor ischaemic stroke reduces subsequent stroke by about 20 in 1000 population, with a possible increase in moderate to severe bleeding of 2 per 1000 population. Discontinuation of dual antiplatelet therapy within 21 days, and possibly as early as 10 days, of initiation is likely to maximise benefit and minimise harms.
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Affiliation(s)
- Qiukui Hao
- The Center of Gerontology and Geriatrics (National Clinical Research Center for Geriatrics), West China Hospital, Sichuan University, Chengdu, China
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada
| | - Malavika Tampi
- American Dental Association, Center for Evidence-based Dentistry, Chicago, IL, USA
| | - Martin O'Donnell
- Health Research Board Clinical Research Facility, Department of Medicine, NUI Galway, Galway, Ireland
| | - Farid Foroutan
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada
| | - Reed Ac Siemieniuk
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada
| | - Gordon Guyatt
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada
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36
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Venturelli PM, Appleton JP, Anderson CS, Bath PM. Acute Treatment of Stroke (Except Thrombectomy). Curr Neurol Neurosci Rep 2018; 18:77. [PMID: 30229395 DOI: 10.1007/s11910-018-0883-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
PURPOSE OF REVIEW The management of patients with acute stroke has been revolutionized in recent years with the advent of new effective treatments. In this rapidly evolving field, we provide an update on the management of acute stroke excluding thrombectomy, looking to recent, ongoing, and future trials. RECENT FINDINGS Large definitive trials have provided insight into acute stroke care including broadening the therapeutic window for thrombolysis, alternatives to standard dose alteplase, the use of dual antiplatelet therapy early after minor ischemic stroke, and treating elevated blood pressure in intracerebral hemorrhage. Further ongoing and future trials are eagerly awaited in this ever-expanding area. Although definitive trials have led to improvements in acute stroke care, there remains a need for further research to improve our understanding of pathophysiological mechanisms underlying different stroke types with the potential for treatments to be tailored to the individual.
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Affiliation(s)
- Paula Muñoz Venturelli
- Clinical Research Center, Instituto de Ciencias e Innovación en Medicina, Facultad de Medicina, Clínica Alemana Universidad del Desarrollo, Santiago, Chile.,Department of Neurology and Psychiatry, Clínica Alemana de Santiago, Santiago, Chile.,The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Jason P Appleton
- Stroke Trials Unit, Division of Clinical Neurosciences, University of Nottingham, Nottingham, UK.,Stroke, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Craig S Anderson
- Clinical Research Center, Instituto de Ciencias e Innovación en Medicina, Facultad de Medicina, Clínica Alemana Universidad del Desarrollo, Santiago, Chile. .,The George Institute for Global Health, University of New South Wales, Sydney, Australia. .,The George Institute China at Peking University Health Science Center, Beijing, China.
| | - Philip M Bath
- Stroke Trials Unit, Division of Clinical Neurosciences, University of Nottingham, Nottingham, UK.,Stroke, Nottingham University Hospitals NHS Trust, Nottingham, UK
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37
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Ding L, Peng B. Efficacy and safety of dual antiplatelet therapy in the elderly for stroke prevention: a systematic review and meta‐analysis. Eur J Neurol 2018; 25:1276-1284. [PMID: 29855121 DOI: 10.1111/ene.13695] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Accepted: 05/23/2018] [Indexed: 11/30/2022]
Affiliation(s)
- L. Ding
- Department of Neurology Peking Union Medical College Hospital Chinese Academy of Medical Sciences Peking Union Medical College Beijing China
| | - B. Peng
- Department of Neurology Peking Union Medical College Hospital Chinese Academy of Medical Sciences Peking Union Medical College Beijing China
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38
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De Filippo O, Raposeiras Roubin S, Lipinski MJ, Abu Assi E, D’Ascenzo F. Another brick in the wall: The impact of ticagrelor use on the incidence of stroke in a large registry. Eur J Prev Cardiol 2018; 25:1216-1218. [DOI: 10.1177/2047487318785457] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
Affiliation(s)
- Ovidio De Filippo
- Department of Medical Sciences, Division of Cardiology, AOU Città della Salute e della Scienza, University of Turin, Italy
| | | | | | - Emad Abu Assi
- Department of Cardiology, University Hospital Álvaro Cunqueiro, Vigo, Spain
| | - Fabrizio D’Ascenzo
- Department of Medical Sciences, Division of Cardiology, AOU Città della Salute e della Scienza, University of Turin, Italy
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39
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Yang Y, Zhou M, Zhong X, Wang Y, Zhao X, Liu L, Wang Y. Dual versus mono antiplatelet therapy for acute non-cardioembolic ischaemic stroke or transient ischaemic attack: a systematic review and meta-analysis. Stroke Vasc Neurol 2018; 3:107-116. [PMID: 30022798 PMCID: PMC6047341 DOI: 10.1136/svn-2018-000168] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Accepted: 05/31/2018] [Indexed: 12/18/2022] Open
Abstract
Objective Recent years have seen new evidence on the efficacy and safety of dual antiplatelet therapy for secondary stroke prevention. We updated a meta-analysis of randomised controlled trials evaluating dual antiplatelet versus monotherapy for patients with acute non-cardioembolic ischaemic stroke (IS) or transient ischaemic attack (TIA). Methods We searched PubMed and identified randomised controlled trials evaluating dual antiplatelet versus monotherapy for acute non-cardioembolic IS or TIA within 3 days of ictus up to May 2018. Risk ratio (RR) with 95% CI were calculated using random effects models. Clinical endpoints included stroke recurrence, composite vascular events and major bleeding. Results 18 randomised controlled trials including 15 515 patients were pooled in the meta-analysis. When compared with monotherapy among patients with acute IS or TIA, dual antiplatelet therapy reduced the risk of stroke recurrence (RR 0.69; 95% CI 0.61 to 0.78; p<0.001) and composite vascular events (RR 0.72; 95% CI 0.64 to 0.80; p<0.001). Dual therapy was associated with a significant increase in the risk of major bleeding (RR 1.77; 95% CI 1.09 to 2.87; p=0.02) when all trial data were combined. However, when all previous trials before the completion of the POINT trial were analysed, dual antiplatelet versus monotherapy was not associated with a significant increase in the risk of major bleeding (RR 1.46; 95% CI 0.77 to 2.75; p=0.25). Conclusions Among patients with acute non-cardioembolic IS or TIA within 3 days of ictus, dual antiplatelet therapy was associated with a reduction in stroke recurrence, and composite vascular events, when compared with monotherapy. However, a significant increase in the risk of major bleeding was observed.
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Affiliation(s)
- Yingying Yang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Mengyuan Zhou
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China
| | - Xi Zhong
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China
| | - Yongjun Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China
| | - Xingquan Zhao
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China
| | - Liping Liu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China
| | - Yilong Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China
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Abstract
PURPOSE OF REVIEW Vertebrobasilar stenosis accounts for 20% of posterior circulation strokes and is associated with high risk of early stroke recurrence. We review data from randomized controlled trials examining whether stenting may reduce this risk, including the recently published Vertebral Artery Ischaemia Stenting Trial (VIST). RECENT FINDINGS VIST and VAST (Vertebral Artery Stenting Trial), having recruited both intracranial and extracranial vertebral stenosis and showed a low rate of perioperative stroke for extracranial (0 and 2%, respectively), but a higher rate for intracranial stenosis (15 and 22%, respectively). In VIST, the primary endpoint of stroke occurred in five patients in the stent group vs. 12 in the medical group (hazard ratio 0.40; 95% confidence interval 0.14-1.13, P = 0.08), although when days from last symptoms were adjusted for, the hazard ratio was 0.34 (95% confidence interval 0.12-0.98; P = 0.046). SAMMPRIS (Stenting and Aggressive Medical Management for the Prevention of Recurrent Stroke in Intracranial Stenosis) recruited only intracranial vertebral stenosis and showed a better outcome with intensive medical therapy than stenting. SUMMARY Stenting of extracranial stenosis can be performed with a low operative risk. VIST suggests it may reduce longer term stroke risk, but this needs confirming in larger trials. For intracranial stenosis, due to a higher operative risk, current evidence favours medical treatment. SAMMPRIS have emphasized the need for intensive medical therapy whether or not stenting is performed.
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Antiplatelet therapy after stroke: should it differ in the acute and chronic phase after stroke. Curr Opin Neurol 2018; 31:14-22. [PMID: 29084062 DOI: 10.1097/wco.0000000000000509] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Reviewing existing evidence regarding well tolerated and effective antiplatelet treatment in patients with acute or chronic, noncardioembolic ischemic stroke and transient ischemic attack (TIA). RECENT FINDINGS For patients with high-risk stroke or TIA, for instance, minor stroke or high-risk TIA, or stroke of atherosclerotic origin with evidence suggesting risk of artery-to-artery embolism or with high-grade, symptomatic arterial stenosis, early initiated, short-term dual antiplatelet (e.g. aspirin and clopidogrel) is effective in reducing the risk of recurrent stroke and other vascular events which does not increase the risk of severe or fatal bleeding, as compared with mono antiplatelet therapy. However, long-term application of aggressive antiplatelet therapies after a noncardioembolic stroke or TIA increases the bleeding risks. Triple antiplatelet therapy is not appropriate for noncardioembolic stroke or TIA, in view of the high bleeding risk. In addition, emerging antiplatelets such as ticagrelor and cilostazol may work better in certain subgroups of stroke patients, which warrants further investigation. SUMMARY Antiplatelet therapies should differ in the acute and chronic phases among patients with high-risk stroke or TIA when more aggressive antiplatelet treatment is reasonable in the acute phase, but no solid evidence supports different antiplatelet strategies in acute and chronic phases in patients with low-risk noncardioembolic stroke.
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Jones DW, Brott TG, Schermerhorn ML. Trials and Frontiers in Carotid Endarterectomy and Stenting. Stroke 2018; 49:1776-1783. [PMID: 29866753 DOI: 10.1161/strokeaha.117.019496] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2017] [Revised: 04/19/2018] [Accepted: 04/30/2018] [Indexed: 11/16/2022]
Affiliation(s)
- Douglas W Jones
- From the Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine, MA (D.W.J.)
| | - Thomas G Brott
- Department of Neurology, Mayo Clinic, Jacksonville, FL (T.G.B.)
| | - Marc L Schermerhorn
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (M.L.S.).
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Ma Y, Liu Y, Xu J, Wang Y, Wang Y, Du F. Effect of dual antiplatelet on recurrent stroke in minor stroke or TIA depends on bodyweight. Ther Clin Risk Manag 2018; 14:861-870. [PMID: 29773949 PMCID: PMC5947844 DOI: 10.2147/tcrm.s156694] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Objective To assess whether bodyweight influences the efficacy and safety of dual antiplatelet therapy (DAT) in male patients with minor stroke or transient ischemic attack patients. Materials and methods All 3,420 male participants coming from the Clopidogrel in High-Risk Patients with Acute Non-disabling Cerebrovascular Events trial were divided into 3 groups based on bodyweight (<65 kg, 65–75 kg, and ≥75 kg). The stroke outcomes included stroke recurrence, combined vascular events, and bleeding events during 90 days of follow-up. The interaction of the treatment effects of DAT among patients with different bodyweight was assessed by Cox proportional hazards models. Results DAT is superior to mono antiplatelet therapy (MAT) for reducing stroke recurrence among patients with weight <65 kg (5.0% vs 11.7%; hazard ratio [HR], 0.41; 95% CI: 0.22–0.76) and 65–75 kg (6.7% vs 10.8%, HR, 0.62; 95% CI: 0.43–0.89). However, no significant difference was found in stroke recurrence between DAT and MAT in patients with weight ≥75 kg (9.4% vs 11.6%; HR, 0.80; 95% CI: 0.58–1.10). A significant interaction was observed between weight and antiplatelet therapy on stroke recurrence (p<0.05). Similar result was found for combined vascular events. More bleeding events were found in DAT group among patients with <65 kg (3.7% vs 2.2%), but with no significant difference. Conclusion DAT does not show benefit in patients with higher weight, compared with MAT. Bleeding events found in the DAT group were not more than the MAT group among patients with lower weight. Clinical trial registration URL: http://www.ClinicalTrials.gov. Unique identifier: NCT00979589.
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Affiliation(s)
- Yan Ma
- Department of Cardiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Ying Liu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Jie Xu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Yilong Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Yongjun Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Fenghe Du
- Department of Cardiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
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44
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Bath PM, Woodhouse LJ, Appleton JP, Beridze M, Christensen H, Dineen RA, Duley L, England TJ, Flaherty K, Havard D, Heptinstall S, James M, Krishnan K, Markus HS, Montgomery AA, Pocock SJ, Randall M, Ranta A, Robinson TG, Scutt P, Venables GS, Sprigg N. Antiplatelet therapy with aspirin, clopidogrel, and dipyridamole versus clopidogrel alone or aspirin and dipyridamole in patients with acute cerebral ischaemia (TARDIS): a randomised, open-label, phase 3 superiority trial. Lancet 2018; 391:850-859. [PMID: 29274727 PMCID: PMC5854459 DOI: 10.1016/s0140-6736(17)32849-0] [Citation(s) in RCA: 107] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2017] [Revised: 09/23/2017] [Accepted: 11/02/2017] [Indexed: 01/10/2023]
Abstract
BACKGROUND Intensive antiplatelet therapy with three agents might be more effective than guideline treatment for preventing recurrent events in patients with acute cerebral ischaemia. We aimed to compare the safety and efficacy of intensive antiplatelet therapy (combined aspirin, clopidogrel, and dipyridamole) with that of guideline-based antiplatelet therapy. METHODS We did an international, prospective, randomised, open-label, blinded-endpoint trial in adult participants with ischaemic stroke or transient ischaemic attack (TIA) within 48 h of onset. Participants were assigned in a 1:1 ratio using computer randomisation to receive loading doses and then 30 days of intensive antiplatelet therapy (combined aspirin 75 mg, clopidogrel 75 mg, and dipyridamole 200 mg twice daily) or guideline-based therapy (comprising either clopidogrel alone or combined aspirin and dipyridamole). Randomisation was stratified by country and index event, and minimised with prognostic baseline factors, medication use, time to randomisation, stroke-related factors, and thrombolysis. The ordinal primary outcome was the combined incidence and severity of any recurrent stroke (ischaemic or haemorrhagic; assessed using the modified Rankin Scale) or TIA within 90 days, as assessed by central telephone follow-up with masking to treatment assignment, and analysed by intention to treat. This trial is registered with the ISRCTN registry, number ISRCTN47823388. FINDINGS 3096 participants (1556 in the intensive antiplatelet therapy group, 1540 in the guideline antiplatelet therapy group) were recruited from 106 hospitals in four countries between April 7, 2009, and March 18, 2016. The trial was stopped early on the recommendation of the data monitoring committee. The incidence and severity of recurrent stroke or TIA did not differ between intensive and guideline therapy (93 [6%] participants vs 105 [7%]; adjusted common odds ratio [cOR] 0·90, 95% CI 0·67-1·20, p=0·47). By contrast, intensive antiplatelet therapy was associated with more, and more severe, bleeding (adjusted cOR 2·54, 95% CI 2·05-3·16, p<0·0001). INTERPRETATION Among patients with recent cerebral ischaemia, intensive antiplatelet therapy did not reduce the incidence and severity of recurrent stroke or TIA, but did significantly increase the risk of major bleeding. Triple antiplatelet therapy should not be used in routine clinical practice. FUNDING National Institutes of Health Research Health Technology Assessment Programme, British Heart Foundation.
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Affiliation(s)
- Philip M Bath
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK; Stroke, Nottingham University Hospitals NHS Trust, City Hospital Campus, Nottingham, UK.
| | - Lisa J Woodhouse
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Jason P Appleton
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK; Stroke, Nottingham University Hospitals NHS Trust, City Hospital Campus, Nottingham, UK
| | | | - Hanne Christensen
- Bispebjerg and Frederiksberg Hospital, University of Copenhagen, Department of Neurology, Copenhagen, Denmark
| | - Robert A Dineen
- Radiological Sciences, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Lelia Duley
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - Timothy J England
- Vascular Medicine, Division of Medical Sciences & GEM, University of Nottingham, Nottingham, UK
| | - Katie Flaherty
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Diane Havard
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Stan Heptinstall
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Marilyn James
- Health Economics, Division of Rehabilitation and Ageing, University of Nottingham, Nottingham, UK
| | - Kailash Krishnan
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK; Stroke, Nottingham University Hospitals NHS Trust, City Hospital Campus, Nottingham, UK
| | - Hugh S Markus
- Stroke Research Group, Department of Clinical Neurosciences, University of Cambridge, Cambridge Biomedical Campus, Cambridge, UK
| | - Alan A Montgomery
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - Stuart J Pocock
- Department of Medical Statistics, London School of Hygiene & Tropical Medicine, London, UK
| | - Marc Randall
- Department of Neurology, Leeds General Infirmary, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Annemarei Ranta
- Department of Neurology, Wellington Hospital and University of Otago, Wellington, New Zealand
| | - Thompson G Robinson
- Department of Cardiovascular Sciences and NIHR Leicester Cardiovascular Research Centre, University of Leicester, Leicester, UK
| | - Polly Scutt
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Graham S Venables
- Department of Neurology, Sheffield Teaching Hospitals NHS Foundation Trust, Royal Hallamshire Hospital, Sheffield, UK
| | - Nikola Sprigg
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK; Stroke, Nottingham University Hospitals NHS Trust, City Hospital Campus, Nottingham, UK
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45
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Naylor AR, Ricco JB, de Borst GJ, Debus S, de Haro J, Halliday A, Hamilton G, Kakisis J, Kakkos S, Lepidi S, Markus HS, McCabe DJ, Roy J, Sillesen H, van den Berg JC, Vermassen F, Kolh P, Chakfe N, Hinchliffe RJ, Koncar I, Lindholt JS, Vega de Ceniga M, Verzini F, Archie J, Bellmunt S, Chaudhuri A, Koelemay M, Lindahl AK, Padberg F, Venermo M. Editor's Choice - Management of Atherosclerotic Carotid and Vertebral Artery Disease: 2017 Clinical Practice Guidelines of the European Society for Vascular Surgery (ESVS). Eur J Vasc Endovasc Surg 2018; 55:3-81. [PMID: 28851594 DOI: 10.1016/j.ejvs.2017.06.021] [Citation(s) in RCA: 797] [Impact Index Per Article: 132.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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46
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Wein T, Lindsay MP, Côté R, Foley N, Berlingieri J, Bhogal S, Bourgoin A, Buck BH, Cox J, Davidson D, Dowlatshahi D, Douketis J, Falconer J, Field T, Gioia L, Gubitz G, Habert J, Jaspers S, Lum C, McNamara Morse D, Pageau P, Rafay M, Rodgerson A, Semchuk B, Sharma M, Shoamanesh A, Tamayo A, Smitko E, Gladstone DJ. Canadian stroke best practice recommendations: Secondary prevention of stroke, sixth edition practice guidelines, update 2017. Int J Stroke 2017; 13:420-443. [DOI: 10.1177/1747493017743062] [Citation(s) in RCA: 143] [Impact Index Per Article: 20.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
The 2017 update of The Canadian Stroke Best Practice Recommendations for the Secondary Prevention of Stroke is a collection of current evidence-based recommendations intended for use by clinicians across a wide range of settings. The goal is to provide guidance for the prevention of ischemic stroke recurrence through the identification and management of modifiable vascular risk factors. Recommendations include those related to diagnostic testing, diet and lifestyle, smoking, hypertension, hyperlipidemia, diabetes, antiplatelet and anticoagulant therapies, carotid artery disease, atrial fibrillation, and other cardiac conditions. Notable changes in this sixth edition include the development of core elements for delivering secondary stroke prevention services, the addition of a section on cervical artery dissection, new recommendations regarding the management of patent foramen ovale, and the removal of the recommendations on management of sleep apnea. The Canadian Stroke Best Practice Recommendations include a range of supporting materials such as implementation resources to facilitate the adoption of evidence to practice, and related performance measures to enable monitoring of uptake and effectiveness of the recommendations. The guidelines further emphasize the need for a systems approach to stroke care, involving an interprofessional team, with access to specialists regardless of patient location, and the need to overcome geographic barriers to ensure equity in access within a universal health care system.
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Affiliation(s)
- Theodore Wein
- McGill University, Canada
- Montreal General Hospital, Canada
| | | | - Robert Côté
- McGill University, Canada
- Montreal General Hospital, Canada
| | - Norine Foley
- Western University, Canada
- workHORSE Consulting, London
| | | | | | | | - Brian H Buck
- Division of Neurology, Department of Medicine, University of Alberta, Canada
| | - Jafna Cox
- Department of Medicine, Dalhousie University, Canada
| | | | | | - Jim Douketis
- Divisions of General Internal Medicine, Hematology and Thromboembolism, McMaster University Department of Medicine, Canada
- Thrombosis Canada, Canada
| | | | - Thalia Field
- Faculty of Medicine, University of British Columbia, Canada
| | - Laura Gioia
- Department of Neurosciences, CHUM-Centre Hospitalier de l’Université de Montréal, Hôpital Notre Dame, Canada
| | - Gord Gubitz
- Department of Medicine, Dalhousie University, Canada
- Queen Elizabeth II Stroke Program, Nova Scotia, Canada
| | - Jeffrey Habert
- Department of Family and Community Medicine, University of Toronto, Canada
| | | | - Cheemun Lum
- Stroke Program, Ottawa Civic Hospital, Canada
| | | | - Paul Pageau
- Department of Emergency Medicine, The University of Ottawa, Canada
| | - Mubeen Rafay
- Winnipeg Children’s Hospital, Canada
- University of Manitoba, Canada
| | | | | | - Mukul Sharma
- Population Health Research Institute, McMaster University, Canada
| | | | | | | | - David J Gladstone
- Sunnybrook Health Sciences Centre, Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, Canada
- University of Toronto Department of Medicine, Toronto, Canada
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47
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Shi ZY, Deng JX, Fu S, Wang L, Wang Q, Liu B, Li YQ, Deng JB. Protective effect of autophagy in neural ischemia and hypoxia: Negative regulation of the Wnt/β-catenin pathway. Int J Mol Med 2017; 40:1699-1708. [PMID: 29039446 PMCID: PMC5716434 DOI: 10.3892/ijmm.2017.3158] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2017] [Accepted: 09/26/2017] [Indexed: 01/08/2023] Open
Abstract
Autophagy is a highly conserved process of self-digestion to promote cell survival in response to nutrient starvation and other metabolic stresses. However, whether ischemic-hypoxic (IH) injury-induced autophagy acts as a neuroprotective mechanism or leads to neuroinjury is a subject of debate. It is known that autophagy is regulated by signaling pathways, including the mammalian target of rapamycin pathway. However, in neural IH injury, whether other signaling pathways are involved in the regulation of autophagy remains to be fully elucidated. In the present study, using the autophagy agonist (rampycin), autophagy antagonist [3-methyl adenine (3-MA)] and lysosome antagonist (MHY1485), autophagy was intervened with at oxygen-glucose deprivation (OGD) 6 h, in order to elucidate the regulatory mechanisms of autophagy. Using immunocytochemistry and western blot analysis, the expression levels of stress-related proteins, such as hypoxia-inducible factor-1α (HIF-1α) (a key regulator in hypoxia) and cyclooxygenase 2 (COX2; inflammatory indicator), were analyzed. In addition, the upstream proteins (Wnt1 and Wnt3a), downstream proteins (Dvl2, β-catenin) and target proteins (C-myc and cyclin D) in the Wnt/β-catenin signaling pathway were examined by immunocytochemistry and western blot analysis. The present study revealed that autophagy was activated with the upregulation of autophagic flux in IH injury; it was demonstrated that autophagy had a protective role in IH injury. The Wnt/β-catenin pathway was involved in IH injury regulation, and the upstream proteins in the Wnt/β-catenin signaling pathway were upregulated, whereas downstream proteins were downregulated by the activity of autophagy accordingly.
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Affiliation(s)
- Zhen-Yu Shi
- Institute of Neurobiology, Nursing College, Henan University, Kaifeng, Henan 475004, P.R. China
| | - Jie-Xin Deng
- Institute of Neurobiology, Nursing College, Henan University, Kaifeng, Henan 475004, P.R. China
| | - Su Fu
- Institute of Neurobiology, Nursing College, Henan University, Kaifeng, Henan 475004, P.R. China
| | - Lai Wang
- Institute of Neurobiology, College of Life Science, Henan University, Kaifeng, Henan 475004, P.R. China
| | - Qiang Wang
- Institute of Neurobiology, Nursing College, Henan University, Kaifeng, Henan 475004, P.R. China
| | - Bin Liu
- Institute of Neurobiology, Nursing College, Henan University, Kaifeng, Henan 475004, P.R. China
| | - Yong-Qiang Li
- Institute of Neurobiology, Nursing College, Henan University, Kaifeng, Henan 475004, P.R. China
| | - Jin-Bo Deng
- Institute of Neurobiology, Nursing College, Henan University, Kaifeng, Henan 475004, P.R. China
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Naylor AR, Vega de Ceniga M. Something Old, Something New, Something Borrowed, and Something Blue. Eur J Vasc Endovasc Surg 2017; 54:413-414. [PMID: 28888385 DOI: 10.1016/j.ejvs.2017.08.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2017] [Accepted: 08/01/2017] [Indexed: 11/17/2022]
Affiliation(s)
- A R Naylor
- Department of Vascular Surgery at Leicester Royal Infirmary, Leicester, UK.
| | - M Vega de Ceniga
- Department of Vascular Surgery Hospital de Galdakao-Usansolo, Galdakao, Bizkaia, Spain
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49
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Fiolaki A, Katsanos AH, Kyritsis AP, Papadaki S, Kosmidou M, Moschonas IC, Tselepis AD, Giannopoulos S. High on treatment platelet reactivity to aspirin and clopidogrel in ischemic stroke: A systematic review and meta-analysis. J Neurol Sci 2017; 376:112-116. [DOI: 10.1016/j.jns.2017.03.010] [Citation(s) in RCA: 67] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2016] [Revised: 01/31/2017] [Accepted: 03/08/2017] [Indexed: 11/16/2022]
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50
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Christophe BR, Mehta SH, Garton ALA, Sisti J, Connolly ES. Current and future perspectives on the treatment of cerebral ischemia. Expert Opin Pharmacother 2017; 18:573-580. [PMID: 28393614 DOI: 10.1080/14656566.2017.1309022] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
INTRODUCTION After heart disease and combined forms of cancer, stroke is the leading cause of death in the United States. Currently, tissue-plasminogen activator (tPA) thrombolysis is the only thrombolytic therapy that has been shown to improve patient outcome. Presently, the only antithrombotic drug treatment that has proven effective at improving acute ischemic stroke patient outcome is aspirin administration. Despite these studies, no clinical trials have yet demonstrated a reliably effective pharmacological treatment. Areas covered: We conducted a search of recent drug studies for ischemic stroke on clinicaltrials.gov in addition to a literature search for acute ischemic stroke therapy using PubMed. This review details our findings of recent advancements in the pharmacological treatment of acute ischemic stroke. Expert commentary: We concluded that recent attempts to establish new pharmacological treatment protocols for acute ischemic stroke have had limited success, but many Phase III and Phase IV clinical trials demonstrate promise. Moreover, several studies have demonstrated the efficacy of dual-antiplatelet therapies at reducing risk of secondary stroke. Studies for novel therapeutic targets for neuroprotection have been largely unsuccessful. Some trials had positive results; however, there is much room for improvement and other studies show promise in their preliminary stages.
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Affiliation(s)
- Brandon R Christophe
- a Department of Neurological Surgery , Columbia University Medical Center , New York , NY , USA
| | - Shyle H Mehta
- a Department of Neurological Surgery , Columbia University Medical Center , New York , NY , USA
| | - Andrew L A Garton
- a Department of Neurological Surgery , Columbia University Medical Center , New York , NY , USA
| | - Jonathan Sisti
- a Department of Neurological Surgery , Columbia University Medical Center , New York , NY , USA
| | - E Sander Connolly
- a Department of Neurological Surgery , Columbia University Medical Center , New York , NY , USA
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