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Nasreldein A, Shoamnesh A, Foli N, Makboul M, Salah S, Faßbender K, Walter S. Prevalence and Risk Factors of Cerebral Microbleeds among Egyptian Patients with Acute Ischemic Stroke. Neuroepidemiology 2024:1-9. [PMID: 39019020 DOI: 10.1159/000540296] [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: 11/25/2023] [Accepted: 07/01/2024] [Indexed: 07/19/2024] Open
Abstract
BACKGROUND Cerebral microbleeds (CMBs) are markers of underlying hemorrhage-prone cerebral small vessel disease detected on MRI. They are associated with a heightened risk of stroke and cognitive decline. The prevalence of CMBs among Egyptian patients with ischemic stroke is not well studied. Our aim was to detect the prevalence of CMBs and associated risk factors among Egyptian patients with ischemic stroke. METHODS A prospective, cross-sectional, single-center study of consecutive patients with ischemic stroke. Patients were recruited between January 2021 and January 2022 at the Assiut University Hospital in the south of Egypt. Patients with known bleeding diathesis were excluded. All participants underwent full neurological assessment, urgent laboratory investigations, and MRI with T2* sequence. RESULTS The study included 404 patients, 191 (47.3%) of them were females. The mean age of the study population was 61 ± 1 years, and the mean NIHSS on admission was 12 ± 5. The prevalence of CMB was 26.5%, of whom 6.5% were young adults (age ≤45 years). CMBs were detected in 34.6% of patients with stroke caused by large artery atherosclerosis, 28.0% with small vessel disease stroke subtype, 25.2% with stroke of undetermined cause, and in 12.1% with cardioembolic stroke. History of AF, hypertension, dyslipidemia, Fazekas score >2, dual antiplatelet use, combined antiplatelet with anticoagulant treatment, and thrombolytic therapy remained independently associated with CMBs following multivariable regression analyses. CONCLUSION The high number of identified CMBs needs to inform subsequent therapeutic management of these patients. We are unable to determine whether the association between CMBs and antithrombotic use is a causal relationship or rather confounded by indication for these treatments in our observational study. To understand more about the underlying cause of this finding, more studies are needed.
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Affiliation(s)
- Ahmed Nasreldein
- Department of Neurology, Assiut University Hospitals, Assiut University, Assiut, Egypt
| | - Ashkan Shoamnesh
- Division of Neurology, Department of Medicine, McMaster University/Population Health Research Institute, Hamilton, Ontario, Canada
| | - Nageh Foli
- Department of Neurology, Assiut University Hospitals, Assiut University, Assiut, Egypt
| | - Marwa Makboul
- Department of Radiology, Assiut University Hospitals, Assiut University, Assiut, Egypt
| | - Sabreen Salah
- Department of Neurology, Assiut University Hospitals, Assiut University, Assiut, Egypt
| | - Klaus Faßbender
- Department of Neurology, Saarland University Hospital, Homburg, Germany
| | - Silke Walter
- Department of Neurology, Saarland University Hospital, Homburg, Germany
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Guo T, Ma T, Bai X, Wang J, Wang Y. Intracranial hemorrhage risk in patients with cerebral microbleeds after mechanical thrombectomy for acute ischemic stroke: a systematic review and meta-analysis. Neurol Sci 2024; 45:3021-3029. [PMID: 38351360 DOI: 10.1007/s10072-024-07393-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Accepted: 02/05/2024] [Indexed: 06/15/2024]
Abstract
Background and purpose intracranial hemorrhage risk in patients with cerebral microbleeds (CMBs) after mechanical thrombectomy for acute ischemic stroke (AIS) was investigated. We searched PubMed and Embase from inception to 29 August 2023 for relevant studies, calculated pooled odds ratio (ORs) of intracerebral hemorrhage (ICH) subtypes in AIS patients with CMB presence, 1-4 or ≥ 5 CMBs versus CMB absence, and with different CMB locations after mechanical thrombectomy. ICH subtypes included any ICH, symptomatic and asymptomatic ICH, hemorrhage outside infarct (including subarachnoid hemorrhage), hemorrhagic infarction, and parenchymal hemorrhage after mechanical thrombectomy. Five eligible studies enrolling 2051 patients were included. No significant association was shown between CMB locations (lobar, deep, infratentorial or mixed) and ICH risk. CMB presence or 1-4 CMBs did not significantly increase the risk of any ICH, symptomatic or asymptomatic ICH, ICH outside infarct, subarachnoid hemorrhage, hemorrhagic infarction, or parenchymal hemorrhage. CMBs ≥ 5 increased the risk of any ICH (OR 2.58, 95% CI 1.16-5.72), parenchymal hemorrhage (OR 3.38, 95% CI 1.43-7.97) and parenchymal hemorrhage-2 (OR 5.33, 2.05-13.86), without increasing hemorrhagic infarction or parenchymal haemorrhage-1 risk. After adjusted for possible confounding factors, increases in CMB burden were associated with hemorrhagic complications but not with symptomatic ICH. In AIS patients who received mechanical thrombectomy, no association was shown between CMB location and ICH risk. ICH risk was not significantly increased by CMB presence or 1-4 CMBs. ICH risk in patients with ≥ 5 CMBs requires further study.
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Affiliation(s)
- Tingting Guo
- Department of Neurology, People's Hospital of Liaoning Province, Shenhe District, 33 Wenyi Road, Shenyang, 110016, People's Republic of China
| | - Teng Ma
- Dalian Medical University, Dalian, People's Republic of China
| | - Xuan Bai
- Department of Neurology, People's Hospital of Liaoning Province, Shenhe District, 33 Wenyi Road, Shenyang, 110016, People's Republic of China
| | - Jian Wang
- Department of Neurology, People's Hospital of Liaoning Province, Shenhe District, 33 Wenyi Road, Shenyang, 110016, People's Republic of China
| | - Yujie Wang
- Department of Neurology, People's Hospital of Liaoning Province, Shenhe District, 33 Wenyi Road, Shenyang, 110016, People's Republic of China.
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3
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Li G, Wang C, Wang S, Wang L, Hao Y, Xiong Y, Zhao X. Clinical significance of the Microbleed Anatomical Rating Scale score in ischemic stroke patients treated with intravenous thrombolysis. Postgrad Med J 2024; 100:421-426. [PMID: 38366658 DOI: 10.1093/postmj/qgae018] [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: 11/20/2023] [Revised: 01/05/2024] [Accepted: 01/14/2024] [Indexed: 02/18/2024]
Abstract
BACKGROUND Conflicting results were shown on the relationship between cerebral microbleeds (CMBs) burden and functional outcomes in patients treated with intravenous tissues plasminogen activator (IV tPA). We aimed to investigate the relationship between CMBs burden and functional outcomes using the Microbleed Anatomical Rating Scale (MARS) and determine its optimal cutoff value. METHODS A retrospective study was conducted to include patients treated with IV tPA in our stroke center, and the MARS was used to assess the CMBs burden. Other clinical data including demographic factors, stroke severity, vascular risk factors, and clinical outcomes were also documented. Another mediation analysis was performed to investigate whether early neurological improvement could mediate the association between MARS and functional outcomes. RESULTS A total of 408 patients were included. A cutoff value of 1.5 could predict functional outcomes in patients treated with IV tPA. Based on that cutoff value, MARS showed an independent relationship with functional outcomes [adjusted OR (Odds Ratio) 0.841, 95% confidence interval (CI) 0.720-0.982, P = .029]. A shift analysis showed that higher MARS score (MARS ≥1.5) was related with poor functional outcome according to mRS score distribution (OR = 0.519, 95% CI 0.336-0.803, P = .003). Total effect (indirect + direct effect) was calculated and showed in figure. Early neurological improvement mediated 24% of the effect of MARS score on functional outcomes. CONCLUSION Our study showed that MARS could be a potential method to assess the functional outcome based on CMBs in patients treated with IV tPA, and MARS score ≥ 1.5 might be an optimal threshold for poor functional outcome.
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Affiliation(s)
- Guangshuo Li
- Department of Neurology, Capital Medical University, Beijing Tiantan Hospital, Beijing 100070, China
| | - Chuanying Wang
- Department of Neurology, Capital Medical University, Beijing Tiantan Hospital, Beijing 100070, China
| | - Shang Wang
- Department of Neurology, Capital Medical University, Beijing Tiantan Hospital, Beijing 100070, China
- China National Clinical Research Center for Neurological Diseases, Beijing 100070, China
| | - Liyuan Wang
- Department of Neurology, Capital Medical University, Beijing Tiantan Hospital, Beijing 100070, China
| | - Yahui Hao
- China National Clinical Research Center for Neurological Diseases, Beijing 100070, China
| | - Yunyun Xiong
- Department of Neurology, Capital Medical University, Beijing Tiantan Hospital, Beijing 100070, China
- China National Clinical Research Center for Neurological Diseases, Beijing 100070, China
- Chinese Institute for Brain Research, Beijing Tiantan Hospital, Beijing 100070, China
| | - Xingquan Zhao
- Department of Neurology, Capital Medical University, Beijing Tiantan Hospital, Beijing 100070, China
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4
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Tipirneni S, Stanwell P, Weissert R, Bhaskar SMM. Prevalence and Impact of Cerebral Microbleeds on Clinical and Safety Outcomes in Acute Ischaemic Stroke Patients Receiving Reperfusion Therapy: A Systematic Review and Meta-Analysis. Biomedicines 2023; 11:2865. [PMID: 37893237 PMCID: PMC10604359 DOI: 10.3390/biomedicines11102865] [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: 09/27/2023] [Revised: 10/15/2023] [Accepted: 10/16/2023] [Indexed: 10/29/2023] Open
Abstract
BACKGROUND Cerebral microbleeds (CMBs), a notable neuroimaging finding often associated with cerebral microangiopathy, demonstrate a heightened prevalence in patients diagnosed with acute ischemic stroke (AIS), which is in turn linked to less favourable clinical prognoses. Nevertheless, the exact prevalence of CMBs and their influence on post-reperfusion therapy outcomes remain inadequately elucidated. MATERIALS AND METHODS Through systematic searches of PubMed, Embase and Cochrane databases, studies were identified adhering to specific inclusion criteria: (a) AIS patients, (b) age ≥ 18 years, (c) CMBs at baseline, (d) availability of comparative data between CMB-positive and CMB-negative groups, along with relevant post-reperfusion therapy outcomes. The data extracted were analysed using forest plots of odds ratios, and random-effects modelling was applied to investigate the association between CMBs and symptomatic intracerebral haemorrhage (sICH), haemorrhagic transformation (HT), 90-day functional outcomes, and 90-day mortality post-reperfusion therapy. RESULTS In a total cohort of 9776 AIS patients who underwent reperfusion therapy, 1709 had CMBs, with a pooled prevalence of 19% (ES 0.19; 95% CI: 0.16, 0.23, p < 0.001). CMBs significantly increased the odds of sICH (OR 2.57; 95% CI: 1.72; 3.83; p < 0.0001), HT (OR 1.53; 95% CI: 1.25; 1.88; p < 0.0001), as well as poor functional outcomes at 90 days (OR 1.59; 95% CI: 1.34; 1.89; p < 0.0001) and 90-day mortality (OR 1.65; 95% CI: 1.27; 2.16; p < 0.0001), relative to those without CMBs, in AIS patients undergoing reperfusion therapy (encompassing intravenous thrombolysis [IVT], endovascular thrombectomy [EVT], either IVT or EVT, and bridging therapy). Variations in the level of association can be observed among different subgroups of reperfusion therapy. CONCLUSIONS This meta-analysis underscores a significant association between CMBs and adverse postprocedural safety outcomes encompassing sICH, HT, poor functional outcome, and increased mortality in AIS patients undergoing reperfusion therapy. The notable prevalence of CMBs in both the overall AIS population and those undergoing reperfusion therapy emphasizes their importance in post-stroke prognostication.
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Affiliation(s)
- Shraddha Tipirneni
- Global Health Neurology Lab, Sydney, NSW 2150, Australia
- UNSW Medicine and Health, South Western Sydney Clinical Campuses, University of New South Wales (UNSW), Sydney, NSW 2170, Australia
- Neurovascular Imaging Laboratory, Ingham Institute for Applied Medical Research, Clinical Sciences Stream, Sydney, NSW 2170, Australia
| | - Peter Stanwell
- School of Health Sciences, University of Newcastle, Newcastle, NSW 2308, Australia
| | - Robert Weissert
- Department of Neurology, Regensburg University Hospital, University of Regensburg, 93053 Regensburg, Germany
| | - Sonu M. M. Bhaskar
- Global Health Neurology Lab, Sydney, NSW 2150, Australia
- Neurovascular Imaging Laboratory, Ingham Institute for Applied Medical Research, Clinical Sciences Stream, Sydney, NSW 2170, Australia
- NSW Brain Clot Bank, NSW Health Pathology, Sydney, NSW 2170, Australia
- Department of Neurology & Neurophysiology, Liverpool Hospital & South Western Sydney Local Health District (SWSLHD), Liverpool, NSW 2170, Australia
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5
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Elfil M, Ghaith HS, Bayoumi A, Elmashad A, Aladawi M, Al-Ani M, Najdawi Z, Mammadli G, Russo B, Toth G, Nour M, Asif K, Nguyen TN, Gandhi CD, Kaur G, Hussain MS, Czap AL, El-Ghanem M, Mansour OY, Khandelwal P, Mayer S, Al-Mufti F. Impact of pre-treatment cerebral microbleeds on the outcomes of endovascular thrombectomy: A systematic review and meta-analysis. J Stroke Cerebrovasc Dis 2023; 32:107324. [PMID: 37660553 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Revised: 08/18/2023] [Accepted: 08/21/2023] [Indexed: 09/05/2023] Open
Abstract
OBJECTIVE/AIM To investigate the effect of cerebral microbleeds (CMBs) on the functional and safety outcomes of endovascular thrombectomy (EVT) in patients with acute ischemic stroke (AIS) due to large vessel occlusion (LVO). METHODS This study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines for systematic review and meta-analysis. We included observational studies that recruited AIS-LVO patients, used susceptibility-sensitive magnetic resonance imaging (MRI) to detect CMBs, and examined the association between them and predefined outcome events. The extracted data included study and population characteristics, risk of bias domains, and outcome measures. The outcomes of interest included functional independence, revascularization success, procedural and hemorrhagic adverse events. We conducted a meta-analysis using the Mantel-Haenszel method and calculated the risk ratios. RESULTS Four studies with a total of 1,514 patients were included. A significant reduction in the likelihood of achieving a favorable functional outcome was observed in patients with CMBs (Risk ratio (RR) 0.69, 95% confidence interval (CI): 0.52 to 0.91, P=0.01). No significant differences were observed between the CMBs and no CMBs groups in terms of successful revascularization, mortality, intracranial hemorrhage (ICH), subarachnoid hemorrhage (SAH), and parenchymal hematoma. CONCLUSIONS The presence of CMBs significantly reduced the likelihood of achieving functional independence post-EVT in AIS-LVO patients. However, CMBs did not impact the rates of successful revascularization, mortality, or the occurrence of various hemorrhagic events. Future research should explore the mechanisms of this association and strategies to mitigate its impact.
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Affiliation(s)
- Mohamed Elfil
- Department of Neurological Sciences, University of Nebraska Medical Center, Omaha, NE, USA
| | | | - Ahmed Bayoumi
- Department of Neurology, McGovern Medical School, UTHealth, Houston, TX, USA
| | - Ahmed Elmashad
- Department of Neurology, Yale University, New Haven, CT, USA
| | - Mohammad Aladawi
- Department of Neurological Sciences, University of Nebraska Medical Center, Omaha, NE, USA
| | - Mina Al-Ani
- Department of Radiology, SUNY Downstate Health Sciences University, Brooklyn, NY, USA
| | - Zaid Najdawi
- Department of Neurological Sciences, University of Nebraska Medical Center, Omaha, NE, USA
| | - Gular Mammadli
- Department of Neurology, Westchester Medical Center, Valhalla, NY, USA
| | - Brittany Russo
- Department of Neurology, Westchester Medical Center, Valhalla, NY, USA
| | - Gabor Toth
- Cerebrovascular Center, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - May Nour
- Department of Neurology, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Kaiz Asif
- Ascension Health and University of Illinois-Chicago, Chicago, IL, USA
| | - Thanh N Nguyen
- Department of Neurology, Boston University Chobanian and Avedisian School of Medicine, Boston, MA, USA
| | - Chirag D Gandhi
- Department of Neurosurgery, Westchester Medical Center, Valhalla, NY, USA
| | - Gurmeen Kaur
- Department of Neurosurgery, Westchester Medical Center, Valhalla, NY, USA
| | - M Shazam Hussain
- Cerebrovascular Center, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Alexandra L Czap
- Department of Neurology, McGovern Medical School, UTHealth, Houston, TX, USA
| | - Mohammad El-Ghanem
- Neuroendovascular Surgery, HCA Houston Northwest/University of Houston College of Medicine, Houston, TX, USA
| | - Ossama Yassin Mansour
- Department of Neurology, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Priyank Khandelwal
- Department of Neurosurgery, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Stephan Mayer
- Department of Neurology, Westchester Medical Center, Valhalla, NY, USA
| | - Fawaz Al-Mufti
- Department of Neurosurgery, Westchester Medical Center, Valhalla, NY, USA.
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6
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Leonte A, Laurent-Chabalier S, Wacongne A, Parvu T, Hackius M, Thouvenot E, Renard D. Brain hemorrhage on 24h-CT and functional outcome in stroke patients with cerebral amyloid angiopathy features on pre-thrombolysis MRI treated with intravenous thrombolysis: A case series. J Stroke Cerebrovasc Dis 2023; 32:106907. [PMID: 36442282 DOI: 10.1016/j.jstrokecerebrovasdis.2022.106907] [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: 10/06/2022] [Revised: 11/15/2022] [Accepted: 11/20/2022] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND AND OBJECTIVES In stroke patients treated with intravenous thrombolysis (IVT), presence and high number of strictly lobar cerebral microbleeds (compatible with cerebral amyloid angiopathy, CAA) seems to be associated with increased risk of hemorrhagic transformation, symptomatic hemorrhagic transformation, remote hemorrhage, and poor functional outcome. Some of these CAA patients with cerebral microbleeds also have chronic lobar intracerebral hemorrhage. Few data are available on IVT-treated CAA patients showing cortical superficial siderosis. There are no reports studying factors associated with brain hemorrhagic complication or functional outcome in IVT-treated CAA patients. We present a case series study of IVT-treated stroke patients with CAA features on pre-IVT MRI in whom we have evaluated brain hemorrhagic complications on 24 h-CT and functional outcome after IVT. MATERIAL AND METHODS In our stroke center, IVT decision in patients with CAA MRI features is at the physician's discretion. We retrospectively screened our stroke database between January 2015 and July 2022 for pre-IVT imaging of 959 consecutive IVT-treated stroke patients without ongoing anticoagulation therapy for probable CAA MRI features defined by modified Boston criteria. After exclusion of 119 patients with missing MRI (n = 47), MRI showing motion artefacts (n = 49) or with alternative chronic brain hemorrhage cause on MRI (n = 23), 15 IVT-treated patients with probable CAA on pre-IVT MRI were identified. In these 15 patients, clinical, biological and MRI characteristics were compared between patients with vs. without post-IVT hemorrhage and between patients with poor (MRS 3-6) vs. good (MRS 0-2) functional outcome at discharge. RESULTS Two patients showed brain hemorrhage on 24 h-CT and both died after 40 and 31 days respectively. The remaining patients had no brain hemorrhage and showed very good outcome except one. Atrial fibrillation (p = 0.029) and Fazekas scale (p = 0.029) were associated with brain hemorrhage whereas atrial fibrillation (p = 0.0022), NIHSS (p = 0.027), blood glucose level (p = 0.024), CRP (p = 0.022) and DWI ASPECT (p = 0.016) were associated with poor outcome. DISCUSSION Consequences of IVT in CAA patients can be dramatic. Larger studies are needed to compare IVT risks and outcome between CAA and non-CAA patients, also including CAA patients with chronic intracerebral hemorrhage or cortical superficial siderosis. In addition, future studies should try to identify clinical, biological and radiological features at high risk for brain hemorrhage and poor outcome in order to assess the risk-benefit ratio for IVT in CAA. CLINICAL TRIAL REGISTRATION-URL http://www. CLINICALTRIALS gov. Unique identifier: NCT05565144.
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Affiliation(s)
- Adelina Leonte
- Department of Neurology, CHU Nîmes, University Montpellier, CHU Nîmes, Hôpital Carémeau, 4, Rue du Pr Debré, Nîmes 30900, France
| | - Sabine Laurent-Chabalier
- Department of Biostatistics, Clinical Epidemiology, Public Health and Innovation in Methodology, CHU Nîmes, University Montpellier, Nîmes, France
| | - Anne Wacongne
- Department of Neurology, CHU Nîmes, University Montpellier, CHU Nîmes, Hôpital Carémeau, 4, Rue du Pr Debré, Nîmes 30900, France
| | - Teodora Parvu
- Department of Neurology, CHU Nîmes, University Montpellier, CHU Nîmes, Hôpital Carémeau, 4, Rue du Pr Debré, Nîmes 30900, France
| | - Marc Hackius
- Department of Neurology, CHU Nîmes, University Montpellier, CHU Nîmes, Hôpital Carémeau, 4, Rue du Pr Debré, Nîmes 30900, France
| | - Eric Thouvenot
- Department of Neurology, CHU Nîmes, University Montpellier, CHU Nîmes, Hôpital Carémeau, 4, Rue du Pr Debré, Nîmes 30900, France; Institut de Génomique Fonctionnelle, CNRS UMR5203, INSERM 1191, University Montpellier, Montpellier, France
| | - Dimitri Renard
- Department of Neurology, CHU Nîmes, University Montpellier, CHU Nîmes, Hôpital Carémeau, 4, Rue du Pr Debré, Nîmes 30900, France.
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7
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Exploring the Impact of Cerebral Microbleeds on Stroke Management. Neurol Int 2023; 15:188-224. [PMID: 36810469 PMCID: PMC9944881 DOI: 10.3390/neurolint15010014] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Revised: 01/17/2023] [Accepted: 01/26/2023] [Indexed: 02/04/2023] Open
Abstract
Stroke constitutes a major cause of functional disability and mortality, with increasing prevalence. Thus, the timely and accurate prognosis of stroke outcomes based on clinical or radiological markers is vital for both physicians and stroke survivors. Among radiological markers, cerebral microbleeds (CMBs) constitute markers of blood leakage from pathologically fragile small vessels. In the present review, we evaluated whether CMBs affect ischemic and hemorrhagic stroke outcomes and explored the fundamental question of whether CMBs may shift the risk-benefit balance away from reperfusion therapy or antithrombotic use in acute ischemic stroke patients. A literature review of two databases (MEDLINE and Scopus) was conducted to identify all the relevant studies published between 1 January 2012 and 9 November 2022. Only full-text articles published in the English language were included. Forty-one articles were traced and included in the present review. Our findings highlight the utility of CMB assessments, not only in the prognostication of hemorrhagic complications of reperfusion therapy, but also in forecasting hemorrhagic and ischemic stroke patients' functional outcomes, thus indicating that a biomarker-based approach may aid in the provision of counseling for patients and families, improve the selection of more appropriate medical therapies, and contribute to a more accurate choice of patients for reperfusion therapy.
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8
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Zheng L, Leng X, Nie X, Yan H, Tian X, Pan Y, Yang Z, Wen M, Pu Y, Gu W, Miao Z, Leung TW, Liu L. Small vessel disease burden may not portend unfavorable outcome after thrombectomy for acute large vessel occlusion. Eur Radiol 2022; 32:7824-7832. [PMID: 35475935 DOI: 10.1007/s00330-022-08795-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Revised: 03/18/2022] [Accepted: 04/01/2022] [Indexed: 01/03/2023]
Abstract
OBJECTIVES We aimed to investigate the correlation between an overall cerebral small vessel disease (CSVD) burden and outcomes after endovascular treatment (EVT) for patients with acute ischemic stroke (AIS) due to large vessel occlusion (LVO). METHODS In a multicenter registry study, we enrolled patients with EVT for anterior-circulation LVO-stroke. In 3.0-T MR imaging, we assessed 4 CSVD imaging markers, lacunes, white matter hyperintensities, cerebral microbleeds, and enlarged perivascular spaces, each assigned a score of 0 or 1 and summed up to an overall CSVD burden score of 0-4. We dichotomized the overall CSVD severity as none to mild (score 0-2) and moderate to severe (3-4). Primary outcome was 90-day functional dependence or death (modified Rankin Scale (mRS) 3-6). Secondary outcomes included increase in NIH Stroke Scale ≥ 4 within 24 h (early neurological deterioration (END)) and within 7 days, symptomatic intracranial hemorrhage, 90-day mRS 2-6, and 90-day mortality. RESULTS Among 311 patients (63.0% male; mean age 65.1 ± 12.7 years), 260 (83.6%) had none-to-mild and 51 (16.4%) had moderate-to-severe overall CSVD burden. Moderate-to-severe CSVD burden was not significantly associated with the primary outcome (47.1% versus 45.4%; p > 0.05 in univariate and multivariate logistic regression), or the secondary outcomes except for a higher risk of END (11.8% versus 3.1%; p < 0.05 in multivariate analyses). Sensitivity analyses with 0-1 versus 2-4 of the CSVD burden score, and the score as an ordinal variable, showed similar results. CONCLUSIONS An overall moderate-to-severe CSVD burden was not associated with 90-day functional dependence or death, after EVT for anterior-circulation LVO. TRIAL REGISTRATION ChiCTR1900022154 KEY POINTS: • Moderate-to-severe cerebral small vessel disease burden on MRI should not be an exclusion indicator in determining the eligibility of an acute ischemic stroke patient for endovascular treatment.
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Affiliation(s)
- Lina Zheng
- Department of Medicine & Therapeutics, 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
| | - Ximing Nie
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, 119 West Road, South 4th Ring, Fengtai District, Beijing, 100070, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Hongyi Yan
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, 119 West Road, South 4th Ring, Fengtai District, Beijing, 100070, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Xuan Tian
- Department of Medicine & Therapeutics, The Chinese University of Hong Kong, Hong Kong, SAR, China
| | - Yuesong Pan
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, 119 West Road, South 4th Ring, Fengtai District, Beijing, 100070, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Zhonghua Yang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, 119 West Road, South 4th Ring, Fengtai District, Beijing, 100070, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Miao Wen
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, 119 West Road, South 4th Ring, Fengtai District, Beijing, 100070, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Yuehua Pu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, 119 West Road, South 4th Ring, Fengtai District, Beijing, 100070, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Weibin Gu
- Department of Radiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Zhongrong Miao
- Department of Interventional Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Thomas W Leung
- Department of Medicine & Therapeutics, The Chinese University of Hong Kong, Hong Kong, SAR, China
| | - Liping Liu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, 119 West Road, South 4th Ring, Fengtai District, Beijing, 100070, China. .,China National Clinical Research Center for Neurological Diseases, Beijing, China.
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9
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Lee SJ, Hwang YH, Hong JM, Choi JW, Park JH, Park B, Kang DH, Kim YW, Kim YS, Hong JH, Yoo J, Kim CH, Sohn SI, Lee JS. Influence of cerebral microbleeds on mechanical thrombectomy outcomes. Sci Rep 2022; 12:3637. [PMID: 35256626 PMCID: PMC8901625 DOI: 10.1038/s41598-022-07432-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Accepted: 02/17/2022] [Indexed: 11/24/2022] Open
Abstract
In ischemic stroke patients undergoing endovascular treatment (EVT), we aimed to test the hypothesis that cerebral microbleeds (CMBs) are associated with clinical outcomes, while estimating the mediating effects of hemorrhagic transformation (HT), small-vessel disease burden (white matter hyperintensities, WMH), and procedural success. From a multicenter EVT registry, patients who underwent pretreatment MR imaging were analyzed. They were trichotomized according to presence of CMBs (none vs. 1–4 vs. ≥ 5). The association between CMB burden and 3-month mRS was evaluated using multivariable ordinal logistic regression, and mediation analyses were conducted to estimate percent mediation. Of 577 patients, CMBs were present in 91 (15.8%); 67 (11.6%) had 1–4 CMBs, and 24 (4.2%) had ≥ 5. Increases in CMBs were associated with hemorrhagic complications (β = 0.27 [0.06–0.047], p = 0.010) in multivariable analysis. The CMB effect on outcome was partially mediated by post-procedural HT degree (percent mediation, 14% [0–42]), WMH (23% [7–57]) and lower rates of successful reperfusion (6% [0–25]). In conclusion, the influence of CMBs on clinical outcomes is mediated by small-vessel disease burden, post-procedural HT, and lower reperfusion rates, listed in order of percent mediation size.
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Aker L, Abandeh L, Abdelhady M, Aboughalia H, Vattoth S. Susceptibility-weighted Imaging in Neuroradiology: Practical Imaging Principles, Pearls and Pitfalls. Curr Probl Diagn Radiol 2021; 51:568-578. [PMID: 34210556 DOI: 10.1067/j.cpradiol.2021.05.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Accepted: 05/10/2021] [Indexed: 01/13/2023]
Abstract
Susceptibility-weighted imaging (SWI) was one of the recent and helpful advancement in magnetic resonance imaging. Its utilization -provided valuable information for the radiologists in multiple fields, including neuroradiology. SWI was able to demonstrate cerebral paramagnetic and diamagnetic substances. Therefore, the applications of this imaging technique were diverse in research and clinical neuroradiology. This article reviewed the basic technical steps, various clinical applications of SWI, and potential limitations. The practicing radiologist needs to be oriented about using SWI and phase images in the right- and left-handed MRI systems to demonstrate different brain pathologies, including neurovascular diseases, traumatic brain injuries, brain tumors, infectious and inflammatory, and neurodegenerative diseases.
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Affiliation(s)
- Loai Aker
- Department of Clinical Imaging, Hamad Medical Corporation,Doha,Qatar.
| | - Laith Abandeh
- Department of Radiology, University of Washington, Seattle,WA
| | | | - Hassan Aboughalia
- Radiology Department, Seattle Children's Hospital, University of Washington Medical Center,Seattle,WA
| | - Surjith Vattoth
- Neuroradiology Section, University of Arkansas for Medical Sciences (UAMS),Little Rock,AR
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Chen J, Duris K, Yang X. Effect of cerebral microbleeds on hemorrhagic transformation and functional prognosis after intravenous thrombolysis of cerebral infarction. BRAIN HEMORRHAGES 2021. [DOI: 10.1016/j.hest.2021.05.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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Xu T, Wang Y, Yuan J, Chen Y, Luo H. Small Vessel Disease Burden and Outcomes of Mechanical Thrombectomy in Ischemic Stroke: A Systematic Review and Meta-Analysis. Front Neurol 2021; 12:602037. [PMID: 33897580 PMCID: PMC8058474 DOI: 10.3389/fneur.2021.602037] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Accepted: 03/01/2021] [Indexed: 01/11/2023] Open
Abstract
Background: Cerebral small vessel disease (SVD) is prevalent in the population, especially among elderly individuals. Substantial uncertainties remain about the clinical relevance of SVD with outcomes of mechanical thrombectomy (MT) in acute ischemic stroke (AIS). Objectives: This systematic review and meta-analysis was performed to evaluate the association between SVD and clinical outcomes in patients with AIS undergoing MT. Methods: We systematically searched the Medline, Embase, and Cochrane databases for relevant clinical studies. The exposure of SVD mainly included leukoaraiosis, cerebral microbleeds (CMBs), and lacunes. The pooled OR was used to calculate the association between each subtype of SVD and outcomes of MT. The primary outcome was poor functional outcome, which was defined as a modified Rankin Scale score (mRS) ≥3 at 90 days after MT. The secondary outcomes included mortality at 90 days, in-hospital mortality, intracranial hemorrhage (ICH) and symptomatic intracranial hemorrhage (sICH), successful recanalization and futile recanalization (FR), early neurological improvement, and early neurological deterioration (END) after MT. Results: Overall, 20 studies with 5,189 patients with AIS undergoing MT were included. High leukoaraiosis burden (HLB) at baseline was associated with increased risks of poor functional outcome at 90 days (OR 2.70, 95% CI 2.01–3.63; p < 0.001; 10 studies; n = 2,004), in-hospital mortality (OR 4.06, 95% CI 1.48–11.13; p = 0.006; 2 studies; n = 314), FR (OR 5.00, 95% CI 2.86–8.73; p < 0.001; 3 studies; n = 493), and END (OR 2.65, 95% CI 1.09–6.45; 1 study; n = 273) after MT. HLB (VSS 3–4 or FS ≥ 2) at baseline was not associated with mortality at 90 days, ICH, or sICH after MT. CMBs at baseline were found to be associated with increased risks of poor functional outcome at 90 days (OR 1.84, 95% CI 1.17–2.90; p = 0.008; 2 studies; n = 1,924) after MT. We found no association between the presence of lacunes and poor functional outcome at 90 days after MT. Conclusions: In patients with AIS undergoing MT, HLB and CMBs were associated with increased risks of unfavorable outcomes after MT.
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Affiliation(s)
- Tao Xu
- Department of Neurology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - You Wang
- Department of Neurology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Jinxian Yuan
- Department of Neurology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Yangmei Chen
- Department of Neurology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Haiyan Luo
- Department of Neurology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
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Wilson D, Ambler G, Lee KJ, Lim JS, Shiozawa M, Koga M, Li L, Lovelock C, Chabriat H, Hennerici M, Wong YK, Mak HKF, Prats-Sánchez L, Martínez-Domeño A, Inamura S, Yoshifuji K, Arsava EM, Horstmann S, Purrucker J, Lam BYK, Wong A, Kim YD, Song TJ, Schrooten M, Lemmens R, Eppinger S, Gattringer T, Uysal E, Tanriverdi Z, Bornstein NM, Assayag EB, Hallevi H, Tanaka J, Hara H, Coutts SB, Hert L, Polymeris A, Seiffge DJ, Lyrer P, Algra A, Kappelle J, Al-Shahi Salman R, Jäger HR, Lip GYH, Mattle HP, Panos LD, Mas JL, Legrand L, Karayiannis C, Phan T, Gunkel S, Christ N, Abrigo J, Leung T, Chu W, Chappell F, Makin S, Hayden D, Williams DJ, Kooi ME, van Dam-Nolen DHK, Barbato C, Browning S, Wiegertjes K, Tuladhar AM, Maaijwee N, Guevarra C, Yatawara C, Mendyk AM, Delmaire C, Köhler S, van Oostenbrugge R, Zhou Y, Xu C, Hilal S, Gyanwali B, Chen C, Lou M, Staals J, Bordet R, Kandiah N, de Leeuw FE, Simister R, van der Lugt A, Kelly PJ, Wardlaw JM, Soo Y, Fluri F, Srikanth V, Calvet D, Jung S, Kwa VIH, Engelter ST, Peters N, Smith EE, Yakushiji Y, Orken DN, Fazekas F, Thijs V, Heo JH, Mok V, Veltkamp R, Ay H, Imaizumi T, Gomez-Anson B, Lau KK, Jouvent E, Rothwell PM, Toyoda K, Bae HJ, Marti-Fabregas J, Werring DJ. Cerebral microbleeds and stroke risk after ischaemic stroke or transient ischaemic attack: a pooled analysis of individual patient data from cohort studies. Lancet Neurol 2019; 18:653-665. [PMID: 31130428 PMCID: PMC6562236 DOI: 10.1016/s1474-4422(19)30197-8] [Citation(s) in RCA: 129] [Impact Index Per Article: 25.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Revised: 04/26/2019] [Accepted: 05/01/2019] [Indexed: 12/28/2022]
Abstract
BACKGROUND Cerebral microbleeds are a neuroimaging biomarker of stroke risk. A crucial clinical question is whether cerebral microbleeds indicate patients with recent ischaemic stroke or transient ischaemic attack in whom the rate of future intracranial haemorrhage is likely to exceed that of recurrent ischaemic stroke when treated with antithrombotic drugs. We therefore aimed to establish whether a large burden of cerebral microbleeds or particular anatomical patterns of cerebral microbleeds can identify ischaemic stroke or transient ischaemic attack patients at higher absolute risk of intracranial haemorrhage than ischaemic stroke. METHODS We did a pooled analysis of individual patient data from cohort studies in adults with recent ischaemic stroke or transient ischaemic attack. Cohorts were eligible for inclusion if they prospectively recruited adult participants with ischaemic stroke or transient ischaemic attack; included at least 50 participants; collected data on stroke events over at least 3 months follow-up; used an appropriate MRI sequence that is sensitive to magnetic susceptibility; and documented the number and anatomical distribution of cerebral microbleeds reliably using consensus criteria and validated scales. Our prespecified primary outcomes were a composite of any symptomatic intracranial haemorrhage or ischaemic stroke, symptomatic intracranial haemorrhage, and symptomatic ischaemic stroke. We registered this study with the PROSPERO international prospective register of systematic reviews, number CRD42016036602. FINDINGS Between Jan 1, 1996, and Dec 1, 2018, we identified 344 studies. After exclusions for ineligibility or declined requests for inclusion, 20 322 patients from 38 cohorts (over 35 225 patient-years of follow-up; median 1·34 years [IQR 0·19-2·44]) were included in our analyses. The adjusted hazard ratio [aHR] comparing patients with cerebral microbleeds to those without was 1·35 (95% CI 1·20-1·50) for the composite outcome of intracranial haemorrhage and ischaemic stroke; 2·45 (1·82-3·29) for intracranial haemorrhage and 1·23 (1·08-1·40) for ischaemic stroke. The aHR increased with increasing cerebral microbleed burden for intracranial haemorrhage but this effect was less marked for ischaemic stroke (for five or more cerebral microbleeds, aHR 4·55 [95% CI 3·08-6·72] for intracranial haemorrhage vs 1·47 [1·19-1·80] for ischaemic stroke; for ten or more cerebral microbleeds, aHR 5·52 [3·36-9·05] vs 1·43 [1·07-1·91]; and for ≥20 cerebral microbleeds, aHR 8·61 [4·69-15·81] vs 1·86 [1·23-1·82]). However, irrespective of cerebral microbleed anatomical distribution or burden, the rate of ischaemic stroke exceeded that of intracranial haemorrhage (for ten or more cerebral microbleeds, 64 ischaemic strokes [95% CI 48-84] per 1000 patient-years vs 27 intracranial haemorrhages [17-41] per 1000 patient-years; and for ≥20 cerebral microbleeds, 73 ischaemic strokes [46-108] per 1000 patient-years vs 39 intracranial haemorrhages [21-67] per 1000 patient-years). INTERPRETATION In patients with recent ischaemic stroke or transient ischaemic attack, cerebral microbleeds are associated with a greater relative hazard (aHR) for subsequent intracranial haemorrhage than for ischaemic stroke, but the absolute risk of ischaemic stroke is higher than that of intracranial haemorrhage, regardless of cerebral microbleed presence, antomical distribution, or burden. FUNDING British Heart Foundation and UK Stroke Association.
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Affiliation(s)
- Duncan Wilson
- Stroke Research Centre, Department of Brain Repair and Rehabilitation, UCL Queen Square Institute of Neurology, London, UK; National Hospital for Neurology and Neurosurgery, London UK; New Zealand Brain Research Institute, Christchurch, New Zealand
| | - Gareth Ambler
- Department of Statistical Science, University College London, London, UK
| | - Keon-Joo Lee
- Department of Neurology, Seoul National University Bundang Hospital, Seoul National University School of Medicine, Seongnam, South Korea
| | - Jae-Sung Lim
- Department of Neurology, Hallym University Sacred Heart Hospital, Anyang, South Korea
| | - Masayuki Shiozawa
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Masatoshi Koga
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Linxin Li
- Centre for Prevention of Stroke and Dementia, University of Oxford, Oxford, UK
| | - Caroline Lovelock
- Centre for Prevention of Stroke and Dementia, University of Oxford, Oxford, UK
| | - Hugues Chabriat
- Assistance Publique Hôpitaux de Paris, Lariboisière Hospital, Department of Neurology, Paris, France; Département Hospitalo-Universtaire NeuroVasc, University Paris Diderot, and INSERM U1141, Paris, France
| | - Michael Hennerici
- Department of Neurology, Universitätsmedizin Mannheim, University of Heidelberg, Mannheim, Germany
| | - Yuen Kwun Wong
- Division of Neurology, Department of Medicine, The University of Hong Kong, Hong Kong
| | - Henry Ka Fung Mak
- Department of Diagnostic Radiology, The University of Hong Kong, Hong Kong
| | - Luis Prats-Sánchez
- Department of Neurology, Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute, Barcelona, Spain
| | - Alejandro Martínez-Domeño
- Department of Neurology, Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute, Barcelona, Spain
| | - Shigeru Inamura
- Department of Neurosurgery, Kushiro City General Hospital, Kushiro, Japan
| | - Kazuhisa Yoshifuji
- Department of Neurosurgery, Kushiro City General Hospital, Kushiro, Japan
| | - Ethem Murat Arsava
- Departments of Neurology and Radiology, Massachusetts General Hospital, Harvard Medical School, Boston MA, USA
| | - Solveig Horstmann
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Jan Purrucker
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Bonnie Yin Ka Lam
- Therese Pei Fong Chow Research Centre for Prevention of Dementia, Gerald Choa Neuroscience Centre, Lui Che Woo Institute of Innovative Medicine, Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong
| | - Adrian Wong
- Therese Pei Fong Chow Research Centre for Prevention of Dementia, Gerald Choa Neuroscience Centre, Lui Che Woo Institute of Innovative Medicine, Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong
| | - Young Dae Kim
- Department of Neurology, Yonsei University College of Medicine, Seoul, South Korea
| | - Tae-Jin Song
- Department of Neurology, Ewha Womans University College of Medicine, Seoul, South Korea
| | | | - Robin Lemmens
- Experimental Neurology and Leuven Institute for Neuroscience and Disease, Katholieke Universiteit Leuven, University of Leuven, Laboratory of Neurobiology, Leuven, Belgium
| | | | | | - Ender Uysal
- Department of Neurology, Demiroglu Bilim University, Istanbul, Turkey
| | - Zeynep Tanriverdi
- Department of Neurology, Demiroglu Bilim University, Istanbul, Turkey
| | - Natan M Bornstein
- Department of Neurology, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel; Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Einor Ben Assayag
- Department of Neurology, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel; Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Hen Hallevi
- Department of Neurology, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel; Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Jun Tanaka
- Division of Neurology, Department of Internal Medicine, Saga University Faculty of Medicine, Nabeshima, Saga, Japan
| | - Hideo Hara
- Division of Neurology, Department of Internal Medicine, Saga University Faculty of Medicine, Nabeshima, Saga, Japan
| | - Shelagh B Coutts
- Calgary Stroke Program, Department of Clinical Neurosciences, Radiology and Community Health Sciences, Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
| | - Lisa Hert
- Department of Neurology and Stroke Centre, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Alexandros Polymeris
- Department of Neurology and Stroke Centre, University Hospital Basel and University of Basel, Basel, Switzerland
| | - David J Seiffge
- Stroke Research Centre, Department of Brain Repair and Rehabilitation, UCL Queen Square Institute of Neurology, London, UK; National Hospital for Neurology and Neurosurgery, London UK; Department of Neurology and Stroke Centre, University Hospital Basel and University of Basel, Basel, Switzerland; Department of Diagnostic and Interventional Neuroradiology and Department of Neurology Inselspital, University Hospital Bern, University of Bern, Bern, Switzerland
| | - Philippe Lyrer
- Department of Neurology and Stroke Centre, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Ale Algra
- Julius Centre for Health Sciences and Primary Care, University Medical Center Utrecht and Utrecht University, Utrecht, Netherlands; Department of Neurology and Neurosurgery, Utrecht Stroke Centre, University Medical Center Utrecht and Utrecht University, Utrecht, Netherlands
| | - Jaap Kappelle
- Department of Neurology and Neurosurgery, Utrecht Stroke Centre, University Medical Center Utrecht and Utrecht University, Utrecht, Netherlands
| | - Rustam Al-Shahi Salman
- Centre for Clinical Brain Sciences, School of Clinical Sciences, University of Edinburgh, Edinburgh, UK
| | - Hans R Jäger
- Lysholm Department of Neuroradiology and the Neuroradiological Academic Unit, Department of Brain Repair and Rehabilitation, UCL Institute of Neurology and the National Hospital for Neurology and Neurosurgery, London, UK
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart and Chest Hospital, Liverpool, UK; Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Heinrich P Mattle
- Department of Diagnostic and Interventional Neuroradiology and Department of Neurology Inselspital, University Hospital Bern, University of Bern, Bern, Switzerland
| | - Leonidas D Panos
- Department of Diagnostic and Interventional Neuroradiology and Department of Neurology Inselspital, University Hospital Bern, University of Bern, Bern, Switzerland
| | - Jean-Louis Mas
- Department of Neurology, Sainte-Anne Hospital, Paris Descartes University, INSERM U1266, Paris, France
| | - Laurence Legrand
- Department of Neuroradiology, Sainte-Anne Hospital, Paris Descartes University, INSERM U1266, Paris, France
| | | | - Thanh Phan
- Stroke and Ageing Research Group, School of Clinical Sciences at Monash Health, Monash University, Melbourne, VIC, Australia
| | - Sarah Gunkel
- Department of Neurology, University Hospital of Würzburg, Josef-Schneider Strasse 11, Würzburg, Germany
| | - Nicolas Christ
- Department of Neurology, University Hospital of Würzburg, Josef-Schneider Strasse 11, Würzburg, Germany
| | - Jill Abrigo
- Department of Imaging and Interventional Radiology, Prince of Wales Hospital, The Chinese University of Hong Kong, Ma Liu Shui, Hong Kong
| | - Thomas Leung
- Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Ma Liu Shui, Hong Kong
| | - Winnie Chu
- Department of Imaging and Interventional Radiology, Prince of Wales Hospital, The Chinese University of Hong Kong, Ma Liu Shui, Hong Kong
| | - Francesca Chappell
- Edinburgh Imaging, School of Clinical Sciences, University of Edinburgh, Edinburgh, UK; UK Dementia Institute at the University of Edinburgh, School of Clinical Sciences, University of Edinburgh, Edinburgh, UK
| | - Stephen Makin
- Institute of Cardiovascular and Medical Science, University of Glasgow, Glasgow, UK
| | - Derek Hayden
- The Neurovascular Research Unit and Health Research Board, Stroke Clinical Trials Network Ireland, University College Dublin, Dublin, Ireland
| | - David J Williams
- Department of Geriatric and Stroke Medicine, Royal College of Surgeons in Ireland, Dublin, Ireland; Beaumont Hospital Dublin, Ireland
| | - M Eline Kooi
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Centre, Maastricht, Netherlands
| | - Dianne H K van Dam-Nolen
- Department of Radiology and Nuclear Medicine, Erasmus Medical Centre, University Medical Centre, Rotterdam, Netherlands
| | - Carmen Barbato
- Stroke Research Centre, Department of Brain Repair and Rehabilitation, UCL Queen Square Institute of Neurology, London, UK; National Hospital for Neurology and Neurosurgery, London UK; Comprehensive Stroke Service, University College London Hospitals NHS Trust, London, UK
| | - Simone Browning
- Stroke Research Centre, Department of Brain Repair and Rehabilitation, UCL Queen Square Institute of Neurology, London, UK; National Hospital for Neurology and Neurosurgery, London UK; Comprehensive Stroke Service, University College London Hospitals NHS Trust, London, UK
| | - Kim Wiegertjes
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Donders Centre for Medical Neuroscience, Radboud University Medical Center, Nijmegen, Netherlands
| | - Anil M Tuladhar
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Donders Centre for Medical Neuroscience, Radboud University Medical Center, Nijmegen, Netherlands
| | - Noortje Maaijwee
- Lucerne State Hospital; Switzerland Center for Neurology and Neurorehabilitation, Luzern, Switzerland
| | - Christine Guevarra
- Department of Neurology, National Neuroscience Institute, Singapore, Singapore
| | - Chathuri Yatawara
- Department of Neurology, National Neuroscience Institute, Singapore, Singapore
| | - Anne-Marie Mendyk
- University of Lille, Inserm, CHU de Lille, Degenerative and vascular cognitive disorders U1171, Lille, France
| | - Christine Delmaire
- University of Lille, Inserm, CHU de Lille, Degenerative and vascular cognitive disorders U1171, Lille, France
| | - Sebastian Köhler
- Department of Psychiatry and Neuropsychology, School for Mental Health and Neuroscience, Maastricht University, Maastricht, Netherlands
| | - Robert van Oostenbrugge
- Department of Neurology, CARIM School for Cardiovascular Diseases, Maastricht University Medical Centre, Maastricht, Netherlands
| | - Ying Zhou
- Department of Neurology, The 2nd Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China
| | - Chao Xu
- Department of Neurology, The 2nd Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China
| | - Saima Hilal
- Memory Aging and Cognition Centre, National University Health System, Singapore, Singapore
| | - Bibek Gyanwali
- Memory Aging and Cognition Centre, National University Health System, Singapore, Singapore
| | - Christopher Chen
- Memory Aging and Cognition Centre, National University Health System, Singapore, Singapore
| | - Min Lou
- Department of Neurology, The 2nd Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China
| | - Julie Staals
- Department of Neurology, CARIM School for Cardiovascular Diseases, Maastricht University Medical Centre, Maastricht, Netherlands
| | - Régis Bordet
- University of Lille, Inserm, CHU de Lille, Degenerative and vascular cognitive disorders U1171, Lille, France
| | - Nagaendran Kandiah
- Department of Neurology, National Neuroscience Institute, Singapore, Singapore
| | - Frank-Erik de Leeuw
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Donders Centre for Medical Neuroscience, Radboud University Medical Center, Nijmegen, Netherlands
| | - Robert Simister
- Stroke Research Centre, Department of Brain Repair and Rehabilitation, UCL Queen Square Institute of Neurology, London, UK; National Hospital for Neurology and Neurosurgery, London UK; Comprehensive Stroke Service, University College London Hospitals NHS Trust, London, UK
| | - Aad van der Lugt
- Department of Radiology and Nuclear Medicine, Erasmus Medical Centre, University Medical Centre, Rotterdam, Netherlands
| | - Peter J Kelly
- The Neurovascular Research Unit and Health Research Board, Stroke Clinical Trials Network Ireland, University College Dublin, Dublin, Ireland
| | - Joanna M Wardlaw
- Edinburgh Imaging, School of Clinical Sciences, University of Edinburgh, Edinburgh, UK; UK Dementia Institute at the University of Edinburgh, School of Clinical Sciences, University of Edinburgh, Edinburgh, UK
| | - Yannie Soo
- Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Ma Liu Shui, Hong Kong
| | - Felix Fluri
- Department of Neurology, University Hospital of Würzburg, Josef-Schneider Strasse 11, Würzburg, Germany
| | - Velandai Srikanth
- Peninsula Clinical School, Peninsula Health, Monash University, Melbourne, VIC, Australia
| | - David Calvet
- Department of Neurology, Sainte-Anne Hospital, Paris Descartes University, INSERM U1266, Paris, France
| | - Simon Jung
- Department of Diagnostic and Interventional Neuroradiology and Department of Neurology Inselspital, University Hospital Bern, University of Bern, Bern, Switzerland
| | - Vincent I H Kwa
- Department of Neurology, Onze Lieve Vrouwe Gasthuis, Amsterdam, Netherlands
| | - Stefan T Engelter
- Department of Neurology and Stroke Centre, University Hospital Basel and University of Basel, Basel, Switzerland; Neurology and Neurorehabilitation, University Department of Geriatric Medicine Felix Platter, University of Basel, Basel, Switzerland
| | - Nils Peters
- Department of Neurology and Stroke Centre, University Hospital Basel and University of Basel, Basel, Switzerland; Neurology and Neurorehabilitation, University Department of Geriatric Medicine Felix Platter, University of Basel, Basel, Switzerland
| | - Eric E Smith
- Calgary Stroke Program, Department of Clinical Neurosciences, Radiology and Community Health Sciences, Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
| | - Yusuke Yakushiji
- Division of Neurology, Department of Internal Medicine, Saga University Faculty of Medicine, Nabeshima, Saga, Japan
| | | | - Franz Fazekas
- Department of Neurology, Medical University of Graz, Graz, Austria
| | - Vincent Thijs
- Stroke Division, Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, VIC, Australia; Department of Neurology, Austin Health, Melbourne, VIC, Australia; Department of Neurosciences, University Hospitals Leuven, Belgium
| | - Ji Hoe Heo
- Department of Neurology, Yonsei University College of Medicine, Seoul, South Korea
| | - Vincent Mok
- Therese Pei Fong Chow Research Centre for Prevention of Dementia, Gerald Choa Neuroscience Centre, Lui Che Woo Institute of Innovative Medicine, Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong
| | - Roland Veltkamp
- Department of Stroke Medicine, Imperial College London, London, UK; Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Hakan Ay
- Departments of Neurology and Radiology, Massachusetts General Hospital, Harvard Medical School, Boston MA, USA
| | - Toshio Imaizumi
- Department of Neurosurgery, Kushiro City General Hospital, Kushiro, Japan
| | - Beatriz Gomez-Anson
- Unit of Neuroradiology, Hospital Santa Creu i Sant Pau, Universitat Autonoma, Barcelona, Spain
| | - Kui Kai Lau
- Division of Neurology, Department of Medicine, The University of Hong Kong, Hong Kong
| | - Eric Jouvent
- Assistance Publique Hôpitaux de Paris, Lariboisière Hospital, Department of Neurology, Paris, France; Département Hospitalo-Universtaire NeuroVasc, University Paris Diderot, and INSERM U1141, Paris, France
| | - Peter M Rothwell
- Centre for Prevention of Stroke and Dementia, University of Oxford, Oxford, UK
| | - Kazunori Toyoda
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Hee-Joon Bae
- Department of Neurology, Seoul National University Bundang Hospital, Seoul National University School of Medicine, Seongnam, South Korea
| | - Joan Marti-Fabregas
- Department of Neurology, Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute, Barcelona, Spain
| | - David J Werring
- Stroke Research Centre, Department of Brain Repair and Rehabilitation, UCL Queen Square Institute of Neurology, London, UK.
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Rai SP, Sanyal P, Pai S, Achappa B, Madi D, Mr P. Synergistic role of susceptibility-weighted imaging with diffusion-weighted imaging and magnetic resonance angiography in the evaluation of acute arterial stroke. J Int Med Res 2019; 47:2166-2176. [PMID: 30971155 PMCID: PMC6567791 DOI: 10.1177/0300060519840909] [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] [Indexed: 12/02/2022] Open
Abstract
Objective This study was performed to investigate whether diffusion-weighted imaging (DWI) and susceptibility-weighted imaging (SWI) are more effective than conventional imaging modalities for evaluation of stroke and selection of candidates for thrombolytic therapy. Methods Eighty patients who presented within 12 hours of onset of symptoms of brain ischemia underwent 1.5T magnetic resonance imaging. DWI and SWI were compared with conventional sequences (T1, T2, and fluid-attenuated inversion recovery [FLAIR]) and time-of-flight magnetic resonance angiography (TOF-MRA) to assess factors that affect stroke management and prognosis. Results The volume of brain tissue showing hyperintensity was significantly greater than that showing diffusion restriction in patients with a >6-hour symptom onset. The hypointensity sign (susceptibility sign) on SWI showed a sensitivity of 66.7%, specificity of 87.5%, positive predictive value of 88.9, and negative predictive value of 63.6 compared with TOF-MRA. Micro-hemorrhagic foci were significantly associated with 27-mL infarcts on DWI (sensitivity, 71.4%; specificity, 85.0%). Patients with DWI–SWI mismatch showed better responses to thrombolytics. FLAIR–DWI mismatch helped to assess the time of stroke onset. Conclusion DWI and SWI should be part of the routine imaging protocol in patients with acute stroke and serve as a decision-making tool for selection of patients for thrombolytic therapy.
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Affiliation(s)
- Santosh Pv Rai
- 1 Department of Radiodiagnosis, Kasturba Medical College Mangalore, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Pulastya Sanyal
- 1 Department of Radiodiagnosis, Kasturba Medical College Mangalore, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Shivananda Pai
- 2 Department of Neurology, Kasturba Medical College Mangalore, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Basavaprabhu Achappa
- 3 Department of Internal Medicine, Kasturba Medical College Mangalore, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Deepak Madi
- 3 Department of Internal Medicine, Kasturba Medical College Mangalore, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Pavan Mr
- 3 Department of Internal Medicine, Kasturba Medical College Mangalore, Manipal Academy of Higher Education, Manipal, Karnataka, India
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Pre-treatment cerebral microbleeds and intracranial hemorrhage in patients with ischemic stroke receiving endovascular therapy: a systematic review and meta-analysis. J Neurol 2019; 267:1227-1232. [PMID: 30689017 DOI: 10.1007/s00415-019-09210-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2018] [Revised: 01/16/2019] [Accepted: 01/19/2019] [Indexed: 10/27/2022]
Abstract
BACKGROUND AND PURPOSE Predicting the risk of intracranial hemorrhage (ICH) is an important aspect for improving the efficacy and safety of endovascular therapy (EVT). We intended to perform a systematic review and meta-analysis to show whether pre-treatment cerebral microbleeds (CMBs) were associated with an increased incidence of ICH in patients with ischemic stroke receiving EVT. METHODS We searched PubMed, EMBASE, Web of Science and Cochrane Library from their dates of inception to December 18, 2018, and also manually searched reference lists of relevant articles. Cumulative prevalence of CMBs and ICH was calculated. Relative risk and 95% confidence interval (CI) were calculated for the incidence of ICH in patients with CMBs versus those without after EVT. RESULTS Four studies involving 598 patients were included. The pooled prevalence of CMBs was 18% (95% CI 15-21%) and the pooled prevalence of ≥ 5 CMBs was 1% (95% CI 0-2%). The pooled incidence of ICH was 29% (95% CI 8-49%) in all patients, 25% (95% CI 5-45%) in those with CMBs and 29% (95% CI 8-50%) in those without CMBs. The pooled relative risk of ICH was 0.90 (95% CI 0.65-1.25, P = 0.528; I2 = 0%, P = 0.949) in patients with CMBs versus those without CMBs. CONCLUSIONS There is no evidence that pre-treatment CMBs were associated with an increased incidence of ICH in patients with ischemic stroke receiving EVT.
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Murai R, Kaji S, Kitai T, Kim K, Ota M, Koyama T, Furukawa Y. The Clinical Significance of Cerebral Microbleeds in Infective Endocarditis Patients. Semin Thorac Cardiovasc Surg 2019; 31:51-58. [DOI: 10.1053/j.semtcvs.2018.09.020] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Accepted: 09/21/2018] [Indexed: 11/11/2022]
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Choi KH, Kim JH, Kang KW, Kim JT, Choi SM, Lee SH, Park MS, Kim BC, Kim MK, Cho KH. Impact of Microbleeds on Outcome Following Recanalization in Patients With Acute Ischemic Stroke. Stroke 2019; 50:127-134. [PMID: 30580721 DOI: 10.1161/strokeaha.118.023084] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Background and Purpose- We analyzed the association between cerebral microbleeds (CMBs) and clinical outcome in acute ischemic stroke patients and especially in a subgroup of patients with successful recanalization. Methods- A total of 1532 acute ischemic stroke patients treated with intravenous thrombolysis or mechanical thrombectomy were enrolled in this prospective cohort study. The primary outcome was measured using the modified Rankin Scale at 3 months, according to the CMB status based on magnetic resonance imaging at admission. Favorable outcome was defined as functional independence with modified Rankin Scale scores of 0 to 2. Secondary outcomes included the occurrence of symptomatic intracranial hemorrhage. Results- There was no statistically significant association between the presence of CMB and favorable outcome at 3 months when considering all patients (44.3% versus 37.6%; P=0.121). In patients with recanalization, the number of patients with favorable outcomes was significantly higher in the CMB-negative than in the CMB-positive group (57.0% versus 36.0%; P<0.001). In the final multivariate analysis, the presence of CMB, and in particular high CMB burden (≥5), and lobar location, were significantly associated with less favorable 3-month outcomes (odds ratio=0.57; 95% CI, 0.33-0.97; P=0.038) and symptomatic intracranial hemorrhage (odds ratio=3.21; 95% CI, 1.37-7.49; P=0.007) in patients with recanalization. In the analysis of subgroups, a statistically significant interaction was found between CMB presence and recanalization in predicting functional outcomes at 3 months. Conclusions- These results indicate that the presence of CMBs, and especially high burden and lobar location, are independent predictors of poor 3-month clinical outcomes and may increase symptomatic intracranial hemorrhage risk in acute ischemic stroke patients with recanalization. Our findings suggest that CMBs lead to more unfavorable effects in patients with recanalization after large vessel occlusion than in those without recanalization.
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Affiliation(s)
- Kang-Ho Choi
- From the Department of Neurology (K.-H. Choi, K.-W.K.), Chonnam National University Hwasun Hospital, Republic of Korea
- Department of Neurology (K.-H. Choi, K.-W.K., J.-T.K., S.-M.C., S.-H.L., M.-S.P., B.-C.K., M.-K.K., K.-H. Cho,), Chonnam National University Hospital, Gwangju, Republic of Korea
| | - Ja-Hae Kim
- Molecular Imaging Center (J.-H.K.), Chonnam National University Hwasun Hospital, Republic of Korea
- Department of Nuclear Medicine (J.-H.K.), Chonnam National University Hospital, Gwangju, Republic of Korea
| | - Kyung-Wook Kang
- From the Department of Neurology (K.-H. Choi, K.-W.K.), Chonnam National University Hwasun Hospital, Republic of Korea
- Department of Neurology (K.-H. Choi, K.-W.K., J.-T.K., S.-M.C., S.-H.L., M.-S.P., B.-C.K., M.-K.K., K.-H. Cho,), Chonnam National University Hospital, Gwangju, Republic of Korea
| | - Joon-Tae Kim
- Department of Neurology (K.-H. Choi, K.-W.K., J.-T.K., S.-M.C., S.-H.L., M.-S.P., B.-C.K., M.-K.K., K.-H. Cho,), Chonnam National University Hospital, Gwangju, Republic of Korea
| | - Seong-Min Choi
- Department of Neurology (K.-H. Choi, K.-W.K., J.-T.K., S.-M.C., S.-H.L., M.-S.P., B.-C.K., M.-K.K., K.-H. Cho,), Chonnam National University Hospital, Gwangju, Republic of Korea
| | - Seung-Han Lee
- Department of Neurology (K.-H. Choi, K.-W.K., J.-T.K., S.-M.C., S.-H.L., M.-S.P., B.-C.K., M.-K.K., K.-H. Cho,), Chonnam National University Hospital, Gwangju, Republic of Korea
| | - Man-Seok Park
- Department of Neurology (K.-H. Choi, K.-W.K., J.-T.K., S.-M.C., S.-H.L., M.-S.P., B.-C.K., M.-K.K., K.-H. Cho,), Chonnam National University Hospital, Gwangju, Republic of Korea
| | - Byeong-Chae Kim
- Department of Neurology (K.-H. Choi, K.-W.K., J.-T.K., S.-M.C., S.-H.L., M.-S.P., B.-C.K., M.-K.K., K.-H. Cho,), Chonnam National University Hospital, Gwangju, Republic of Korea
| | - Myeong-Kyu Kim
- Department of Neurology (K.-H. Choi, K.-W.K., J.-T.K., S.-M.C., S.-H.L., M.-S.P., B.-C.K., M.-K.K., K.-H. Cho,), Chonnam National University Hospital, Gwangju, Republic of Korea
| | - Ki-Hyun Cho
- Department of Neurology (K.-H. Choi, K.-W.K., J.-T.K., S.-M.C., S.-H.L., M.-S.P., B.-C.K., M.-K.K., K.-H. Cho,), Chonnam National University Hospital, Gwangju, Republic of Korea
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Yan J, Qiu J, Wu X, Ge Y, Wang J, Wang Y. Pretreatment cerebral microbleeds and symptomatic intracerebral hemorrhage post-thrombolysis: a systematic review and meta-analysis. J Neurol 2018; 267:301-307. [PMID: 30542950 DOI: 10.1007/s00415-018-9156-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2018] [Revised: 12/07/2018] [Accepted: 12/10/2018] [Indexed: 12/31/2022]
Abstract
BACKGROUND AND PURPOSE Cerebral microbleeds (CMBs) are a possible predictor of symptomatic intracranial hemorrhage (sICH) and poor function outcome (PFO). We aimed to investigate the presence of CMBs on increased incidence of sICH and PFO in acute ischemic stroke patients receiving intravenous thrombolysis (IVT) treatment. METHODS We searched PubMed, EMBASE, and Cochrane Library from 1 January 1997 to 13 May 2018, for relevant studies and calculated the pooled relative risk (RR) for the incidence of sICH and PFO in patients with CMBs versus those without after IVT. RESULTS We included 2407 participants from nine studies. The cumulative sICH incidence was higher in patients with CMBs (6%, 95% CI 4-8%) than that in patients without CMBs (4%, 95% CI 2-6%) with pooled RR 1.51 (95% CI, 1.04-2.21; P = 0.031). Four studies including 1550 patients reported data on 3- to 6-month PFO. The cumulative PFO incidence was higher in patients with CMBs (53%, 95% CI 47-59%) than that in patients without CMBs (41%, 95% CI 36-46%) with pooled RR 1.25 (95% CI 1.11-1.41; P = 0.000). CONCLUSIONS The pretreatment CMBs were associated with increased incidence of sICH and PFO in acute ischemic stroke patients receiving IVT. However, it was not convincing enough to set the presence of CMBs as contraindication to IVT.
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Affiliation(s)
- Jiangzhi Yan
- Department of Neurology, Cerebrovascular Disease Center, People's Hospital, China Medical University, 33 Wenyi Road, Shenhe District, Shenyang, 110016, People's Republic of China
| | - Jianting Qiu
- Department of Neurology, Cerebrovascular Disease Center, People's Hospital, China Medical University, 33 Wenyi Road, Shenhe District, Shenyang, 110016, People's Republic of China
| | - Xiumei Wu
- Department of Neurology, Cerebrovascular Disease Center, People's Hospital, China Medical University, 33 Wenyi Road, Shenhe District, Shenyang, 110016, People's Republic of China
| | - Yonggui Ge
- Department of Neurology, Cerebrovascular Disease Center, People's Hospital, China Medical University, 33 Wenyi Road, Shenhe District, Shenyang, 110016, People's Republic of China
| | - Jian Wang
- Department of Neurology, Cerebrovascular Disease Center, People's Hospital, China Medical University, 33 Wenyi Road, Shenhe District, Shenyang, 110016, People's Republic of China
| | - Yujie Wang
- Department of Neurology, Cerebrovascular Disease Center, People's Hospital, China Medical University, 33 Wenyi Road, Shenhe District, Shenyang, 110016, People's Republic of China.
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Fladt J, Kronlage C, De Marchis GM. Cerebral White Matter Hyperintensities and Microbleeds in Acute Ischemic Stroke: Impact on Recanalization Therapies. A Review of the Literature. Neurosci Lett 2018; 687:55-64. [PMID: 30194982 DOI: 10.1016/j.neulet.2018.09.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2018] [Revised: 08/31/2018] [Accepted: 09/03/2018] [Indexed: 12/30/2022]
Abstract
Cerebral white matter hyperintensities (WMH) and cerebral microbleeds (CMBs) are frequently seen on brain imaging acquired for acute ischemic stroke. Given the raising use of recanalization therapies - both intravenous and endovascular - the interest on the impact of WMH and CMBs on the risk of intracerebral hemorrhage and on functional outcome is growing. In this review, we will discuss the relevance of WMH and CMBs among patients with an acute ischemic stroke, focusing on the implications for recanalization therapies.
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Affiliation(s)
- J Fladt
- Department of Neurology, University Hospital Basel, Switzerland
| | - C Kronlage
- Department of Neurology, University Hospital Basel, Switzerland
| | - G M De Marchis
- Department of Neurology, University Hospital Basel, Switzerland.
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20
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Li L, Liu MS, Li GQ, Zheng Y, Guo TL, Kang X, Yuan MT. Susceptibility-weighted Imaging in Thrombolytic Therapy of Acute Ischemic Stroke. Chin Med J (Engl) 2018; 130:2489-2497. [PMID: 29052571 PMCID: PMC5684633 DOI: 10.4103/0366-6999.216401] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
Objective: To provide a comprehensive and latest overview of susceptibility-weighted imaging (SWI) in the application of thrombolysis in acute ischemic stroke, and to update the decision-making effect and clinical value of SWI on identifying stroke patients suitable for thrombolytic therapy and possible benefits and risks followed. Data Sources: Literatures referred to this review were collected from PubMed, Medline, and EMBASE published till May 2017, using the search terms including susceptibility-weighted imaging, gradient-echo, T2*, thrombolysis, recombinant tissue plasminogen activator (rt-PA), thrombolytic therapy, and stroke. Study Selection: Papers in English or with available English abstracts were considered, with no limitation of study design. References were also identified from the bibliographies of identified articles and the authors’ files. Results: SWI is of guiding significance for thrombolytic therapy in stroke patients, it can predict the location and length of thrombus and ischemic penumbra. It is worthy of noting that susceptibility vessel sign (SVS) on SWI can be used to predict recanalization after thrombolytic therapy and whether it is better to implement endovascular thrombolectomy in combination or alone. SWI is sensitive in detecting cerebral microbleed (CMB), and CMB might not be a contraindication for thrombolytic therapy, yet CMBs in multiple foci could possibly be related to intracranial hemorrhage (ICH) after thrombolysis. SVS and CMB on SWI sequence are of instructive value in performing antiplatelet therapy after thrombolytic therapy. Cerebral venous change on SWI is related to lower recanalization rate and poor outcome after thrombolysis. Conclusions: It seems that SWI can be applied to guide individualized thrombolytic therapies and assist clinicians in making better decisions by weighing benefits and risks. However, there still exist controversies about the relationship between signs on SWI and thrombolytic therapy.
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Affiliation(s)
- Lin Li
- Department of Neurology, The First Affiliated Hospital, Chongqing Medical University, Chongqing 400016, China
| | - Ming-Su Liu
- Department of Neurology, The First Affiliated Hospital, Chongqing Medical University, Chongqing 400016, China
| | - Guang-Qin Li
- Department of Neurology, The First Affiliated Hospital, Chongqing Medical University, Chongqing 400016, China
| | - Yang Zheng
- Department of Neurology, The First Affiliated Hospital, Chongqing Medical University, Chongqing 400016, China
| | - Tong-Li Guo
- Department of Neurology, The First Affiliated Hospital, Chongqing Medical University, Chongqing 400016, China
| | - Xin Kang
- Department of Neurology, The First Affiliated Hospital, Chongqing Medical University, Chongqing 400016, China
| | - Mao-Ting Yuan
- Department of Neurology, The First Affiliated Hospital, Chongqing Medical University, Chongqing 400016, China
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Zand R, Tsivgoulis G, Sadighi A, Singh M, McCormack M, Shahjouei S, Goyal N, Noorbakhsh-Sabet N, Alexandrov AW, Alexandrov AV. Safety of Intravenous Thrombolysis in Chronic Intracranial Hemorrhage: A Five-Year Multicenter Study. J Stroke Cerebrovasc Dis 2018; 27:620-624. [DOI: 10.1016/j.jstrokecerebrovasdis.2017.09.037] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2017] [Accepted: 09/24/2017] [Indexed: 12/16/2022] Open
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Nagaraja N, Tasneem N, Shaban A, Dandapat S, Ahmed U, Policeni B, Olalde H, Shim H, Samaniego EA, Pieper C, Ortega-Gutierrez S, Leira EC, Adams HP. Cerebral Microbleeds are an Independent Predictor of Hemorrhagic Transformation Following Intravenous Alteplase Administration in Acute Ischemic Stroke. J Stroke Cerebrovasc Dis 2018; 27:1403-1411. [PMID: 29398533 DOI: 10.1016/j.jstrokecerebrovasdis.2017.12.044] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2017] [Revised: 11/10/2017] [Accepted: 12/22/2017] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND AND PURPOSE Intravenous alteplase (rt-PA) increases the risk of hemorrhagic transformation of acute ischemic stroke. The objective of our study was to evaluate clinical, laboratory, and imaging predictors on forecasting the risk of hemorrhagic transformation following treatment with rt-PA. We also evaluated the factors associated with cerebral microbleeds that increase the risk of hemorrhagic transformation. METHODS Consecutive patients with acute ischemic stroke admitted between January 1, 2009 and December 31, 2013 were included in the study if they received IV rt-PA, had magnetic resonance imaging (MRI) of the brain on admission, and computed tomography or MRI of the brain at 24 (18-36) hours later to evaluate for the presence of hemorrhagic transformation. The clinical data, lipid levels, platelet count, MRI, and computed tomography images were retrospectively reviewed. RESULTS The study included 366 patients, with mean age 67 ± 15 years; 46% were women and 88% were white. The median National Institutes of Health Stroke Scale (NIHSS) score was 6 (interquartile range 3-15). Hemorrhagic transformation was observed in 87 (23.8%) patients and cerebral microbleeds were noted in 95 (25.9%). Patients with hemorrhagic transformation tended to be older, nonwhite, have atrial fibrillation, higher baseline NIHSS score, lower cholesterol and triglyceride levels, and cerebral microbleeds and nonlacunar infarcts. Patients with cerebral microbleeds were more likely to be older, have hypertension, hyperlipidemia, previous history of stroke, and prior use of antithrombotics. On multivariate analysis race, NIHSS score, nonlacunar infarct, and presence of cerebral microbleeds were independently associated with hemorrhagic transformation following treatment with rt-PA. CONCLUSIONS Presence of cerebral microbleeds is an independent predictor of hemorrhagic transformation of acute ischemic stroke following treatment with rt-PA.
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Affiliation(s)
- Nandakumar Nagaraja
- Department of Neurology, University of Florida College of Medicine, Gainesville, Florida; Department of Neurology, Carver College of Medicine, University of Iowa, Iowa.
| | - Nudrat Tasneem
- Department of Neurology, Carver College of Medicine, University of Iowa, Iowa
| | - Amir Shaban
- Department of Neurology, Carver College of Medicine, University of Iowa, Iowa
| | - Sudeepta Dandapat
- Department of Neurology, Carver College of Medicine, University of Iowa, Iowa
| | - Uzair Ahmed
- Department of Neurology, Carver College of Medicine, University of Iowa, Iowa
| | - Bruno Policeni
- Department of Radiology, Carver College of Medicine, University of Iowa, Iowa
| | - Heena Olalde
- Department of Neurology, Carver College of Medicine, University of Iowa, Iowa
| | - Hyungsub Shim
- Department of Neurology, Carver College of Medicine, University of Iowa, Iowa
| | - Edgar A Samaniego
- Department of Neurology, Carver College of Medicine, University of Iowa, Iowa
| | - Connie Pieper
- Department of Neurology, Carver College of Medicine, University of Iowa, Iowa
| | | | - Enrique C Leira
- Department of Neurology, Carver College of Medicine, University of Iowa, Iowa
| | - Harold P Adams
- Department of Neurology, Carver College of Medicine, University of Iowa, Iowa
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Liang Y, Deng M, Chen Y, Mok V, Wang D, Ungvari GS, Chu CW, Berge E, Tang W. Enlarged perivascular spaces are associated with health-related quality of life in patients with acute ischemic stroke. CNS Neurosci Ther 2017; 23:973-979. [PMID: 29052954 PMCID: PMC6492717 DOI: 10.1111/cns.12766] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2017] [Revised: 09/19/2017] [Accepted: 09/19/2017] [Indexed: 01/30/2023] Open
Abstract
AIMS This study explored the association between enlarged perivascular spaces (EPVS) and the health-related quality of life (HRQoL) in patients with acute ischemic stroke. METHODS This was an observational study of consecutively screened patients with acute ischemic stroke from March 2010 to March 2015. EPVS were rated in the basal ganglia and the centrum semiovale with a validated scale. The HRQoL was assessed 3 months after the stroke onset using the Stroke-Specific Quality of Life (SSQoL). Linear regression models were used to study the association between EPVS and HRQoL. RESULTS The study included 648 patients (mean age 65.8 years; 40.0% women) with mild to moderately severe stroke (median NIHSS score 2), of whom 640 (98.8%) exhibited signs of small vessel disease. The median EPVS scores in the basal ganglia and the centrum semiovale were 1 each. In linear regression analysis, EPVS in the basal ganglia were associated with a lower total SSQoL score (P = 0.02) and lower mobility (P = 0.01), mood (P = 0.03), and self-care (P < 0.01). EPVS in the centrum semiovale were associated only with a lower SSQoL work/productivity subscore (P = 0.002). CONCLUSIONS EPVS are associated with lower HRQoL in patients with mild to moderate acute ischemic stroke. Early identification and intervention of EPVS may improve HRQoL in stroke survivors.
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Affiliation(s)
- Yan Liang
- Department of Psychiatrythe Chinese University of Hong KongHong KongChina
| | - Min Deng
- Department of Imaging and Interventional Radiologythe Chinese University of Hong KongHong KongChina
| | - Yang‐Kun Chen
- Department of NeurologyDongguan People's HospitalDongguanGuangdongChina
| | - Vincent Mok
- Department of Medicine and Therapeuticsthe Chinese University of Hong KongHong KongChina
| | - De‐Feng Wang
- Department of Imaging and Interventional Radiologythe Chinese University of Hong KongHong KongChina
| | - Gabor S. Ungvari
- Australia / Graylands HospitalUniversity of Notre DamePerthWAAustralia
| | - Chiu‐Wing Winnie Chu
- Department of Imaging and Interventional Radiologythe Chinese University of Hong KongHong KongChina
| | - Eivind Berge
- Departments of Internal Medicine and CardiologyOslo University HospitalOsloNorway
| | - Wai‐Kwong Tang
- Department of Psychiatrythe Chinese University of Hong KongHong KongChina
- Shenzhen Research Institutethe Chinese University of Hong KongShenzhenGuangdongChina
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Meisterernst J, Klinger-Gratz PP, Leidolt L, Lang MF, Schroth G, Mordasini P, Heldner MR, Mono ML, Kurmann R, Buehlmann M, Fischer U, Arnold M, Gralla J, Mattle HP, El-Koussy M, Jung S. Focal T2 and FLAIR hyperintensities within the infarcted area: A suitable marker for patient selection for treatment? PLoS One 2017; 12:e0185158. [PMID: 28957339 PMCID: PMC5619762 DOI: 10.1371/journal.pone.0185158] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2017] [Accepted: 09/07/2017] [Indexed: 12/03/2022] Open
Abstract
Background and purpose Some authors use FLAIR imaging to select patients for stroke treatment. However, the effect of hyperintensity on FLAIR images on outcome and bleeding has been addressed in only few studies with conflicting results. Methods 466 patients with anterior circulation strokes were included in this study. They all were examined with MRI before intravenous or endovascular treatment. Baseline data and 3 months outcome were recorded prospectively. Focal T2 and FLAIR hyperintensities within the ischemic lesion were evaluated by two raters, and the PROACT II classification was applied to assess bleeding complications on follow up imaging. Logistic regression analysis was used to determine predictors of bleeding complications and outcome and to analyze the influence of T2 or FLAIR hyperintensity on outcome. Results Focal hyperintensities were found in 142 of 307 (46.3%) patients with T2 weighted imaging and in 89 of 159 (56%) patients with FLAIR imaging. Hyperintensity in the basal ganglia, especially in the lentiform nucleus, on T2 weighted imaging was the only independent predictor of any bleeding after reperfusion treatment (33.8% in patients with vs. 18.2% in those without; p = 0.003) and there was a non-significant trend for more bleedings in patients with FLAIR hyperintensity within the basal ganglia (p = 0.069). However, there was no association of hyperintensity on T2 weighted or FLAIR images and symptomatic bleeding or worse outcome. Conclusion Our results question the assumption that T2 or FLAIR hyperintensities within the ischemic lesion should be used to exclude patients from reperfusion therapy, especially not from endovascular treatment.
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Affiliation(s)
- Julia Meisterernst
- Department of Neurology, Inselspital, University Hospital Bern and University of Bern, Bern, Switzerland
| | - Pascal P. Klinger-Gratz
- Department of Diagnostic and Interventional Neuroradiology, Inselspital, University Hospital Bern and University of Bern, Bern, Switzerland
- Department of Radiology, University Hospital of Basel, University of Basel, Basel, Switzerland
| | - Lars Leidolt
- Department of Diagnostic and Interventional Neuroradiology, Inselspital, University Hospital Bern and University of Bern, Bern, Switzerland
| | - Matthias F. Lang
- Department of Diagnostic and Interventional Neuroradiology, Inselspital, University Hospital Bern and University of Bern, Bern, Switzerland
- Department of Diagnostic, Interventional and Pediatric Radiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Gerhard Schroth
- Department of Diagnostic and Interventional Neuroradiology, Inselspital, University Hospital Bern and University of Bern, Bern, Switzerland
| | - Pasquale Mordasini
- Department of Diagnostic and Interventional Neuroradiology, Inselspital, University Hospital Bern and University of Bern, Bern, Switzerland
| | - Mirjam R. Heldner
- Department of Neurology, Inselspital, University Hospital Bern and University of Bern, Bern, Switzerland
| | - Marie-Luise Mono
- Department of Neurology, Inselspital, University Hospital Bern and University of Bern, Bern, Switzerland
| | - Rebekka Kurmann
- Department of Neurology, Inselspital, University Hospital Bern and University of Bern, Bern, Switzerland
| | - Monika Buehlmann
- Department of Neurology, Inselspital, University Hospital Bern and University of Bern, Bern, Switzerland
| | - Urs Fischer
- Department of Neurology, Inselspital, University Hospital Bern and University of Bern, Bern, Switzerland
| | - Marcel Arnold
- Department of Neurology, Inselspital, University Hospital Bern and University of Bern, Bern, Switzerland
| | - Jan Gralla
- Department of Diagnostic and Interventional Neuroradiology, Inselspital, University Hospital Bern and University of Bern, Bern, Switzerland
| | - Heinrich P. Mattle
- Department of Neurology, Inselspital, University Hospital Bern and University of Bern, Bern, Switzerland
| | - Marwan El-Koussy
- Department of Diagnostic and Interventional Neuroradiology, Inselspital, University Hospital Bern and University of Bern, Bern, Switzerland
| | - Simon Jung
- Department of Neurology, Inselspital, University Hospital Bern and University of Bern, Bern, Switzerland
- * E-mail:
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25
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Charidimou A, Turc G, Oppenheim C, Yan S, Scheitz JF, Erdur H, Klinger-Gratz PP, El-Koussy M, Takahashi W, Moriya Y, Wilson D, Kidwell CS, Saver JL, Sallem A, Moulin S, Edjlali-Goujon M, Thijs V, Fox Z, Shoamanesh A, Albers GW, Mattle HP, Benavente OR, Jäger HR, Ambler G, Aoki J, Baron JC, Kimura K, Kakuda W, Takizawa S, Jung S, Nolte CH, Lou M, Cordonnier C, Werring DJ. Microbleeds, Cerebral Hemorrhage, and Functional Outcome After Stroke Thrombolysis. Stroke 2017; 48:2084-2090. [DOI: 10.1161/strokeaha.116.012992] [Citation(s) in RCA: 74] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Background and Purpose—
We assessed whether the presence, number, and distribution of cerebral microbleeds (CMBs) on pre-intravenous thrombolysis MRI scans of acute ischemic stroke patients are associated with an increased risk of intracerebral hemorrhage (ICH) or poor functional outcome.
Methods—
We performed an individual patient data meta-analysis, including prospective and retrospective studies of acute ischemic stroke treated with intravenous tissue-type plasminogen activator. Using multilevel mixed-effects logistic regression, we investigated associations of pre-treatment CMB presence, burden (1, 2–4, ≥5, and >10), and presumed pathogenesis (cerebral amyloid angiopathy defined as strictly lobar CMBs and noncerebral amyloid angiopathy) with symptomatic ICH, parenchymal hematoma (within [parenchymal hemorrhage, PH] and remote from the ischemic area [remote parenchymal hemorrhage, PHr]), and poor 3- to 6-month functional outcome (modified Rankin score >2).
Results—
In 1973 patients from 8 centers, the crude prevalence of CMBs was 526 of 1973 (26.7%). A total of 77 of 1973 (3.9%) patients experienced symptomatic ICH, 210 of 1806 (11.6%) experienced PH, and 56 of 1720 (3.3%) experienced PHr. In adjusted analyses, patients with CMBs (compared with those without CMBs) had increased risk of PH (odds ratio: 1.50; 95% confidence interval: 1.09–2.07;
P
=0.013) and PHr (odds ratio: 3.04; 95% confidence interval: 1.73–5.35;
P
<0.001) but not symptomatic ICH. Both cerebral amyloid angiopathy and noncerebral amyloid angiopathy patterns of CMBs were associated with PH and PHr. Increasing CMB burden category was associated with the risk of symptomatic ICH (
P
=0.014), PH (
P
=0.013), and PHr (
P
<0.00001). Five or more and >10 CMBs independently predicted poor 3- to 6-month outcome (odds ratio: 1.85; 95% confidence interval: 1.10–3.12;
P
=0.020; and odds ratio: 3.99; 95% confidence interval: 1.55–10.22;
P
=0.004, respectively).
Conclusions—
Increasing CMB burden is associated with increased risk of ICH (including PHr) and poor 3- to 6-month functional outcome after intravenous thrombolysis for acute ischemic stroke.
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Affiliation(s)
- Andreas Charidimou
- From the Stroke Research Centre, UCL Institute of Neurology, London, United Kingdom (A.C., D.W., D.J.W.); Hemorrhagic Stroke Research Group, Massachusetts General Hospital, Boston (A.C.); Departments of Neurology and Radiology, Hôpital Sainte-Anne, Université Paris Descartes, France (G.T., C.O., M.E.-G., J.-C.B.); Department of Neurology, the 2nd Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China (S.Y., M.L.); Department of Neurology and Center for Stroke Research,
| | - Guillaume Turc
- From the Stroke Research Centre, UCL Institute of Neurology, London, United Kingdom (A.C., D.W., D.J.W.); Hemorrhagic Stroke Research Group, Massachusetts General Hospital, Boston (A.C.); Departments of Neurology and Radiology, Hôpital Sainte-Anne, Université Paris Descartes, France (G.T., C.O., M.E.-G., J.-C.B.); Department of Neurology, the 2nd Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China (S.Y., M.L.); Department of Neurology and Center for Stroke Research,
| | - Catherine Oppenheim
- From the Stroke Research Centre, UCL Institute of Neurology, London, United Kingdom (A.C., D.W., D.J.W.); Hemorrhagic Stroke Research Group, Massachusetts General Hospital, Boston (A.C.); Departments of Neurology and Radiology, Hôpital Sainte-Anne, Université Paris Descartes, France (G.T., C.O., M.E.-G., J.-C.B.); Department of Neurology, the 2nd Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China (S.Y., M.L.); Department of Neurology and Center for Stroke Research,
| | - Shenqiang Yan
- From the Stroke Research Centre, UCL Institute of Neurology, London, United Kingdom (A.C., D.W., D.J.W.); Hemorrhagic Stroke Research Group, Massachusetts General Hospital, Boston (A.C.); Departments of Neurology and Radiology, Hôpital Sainte-Anne, Université Paris Descartes, France (G.T., C.O., M.E.-G., J.-C.B.); Department of Neurology, the 2nd Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China (S.Y., M.L.); Department of Neurology and Center for Stroke Research,
| | - Jan F. Scheitz
- From the Stroke Research Centre, UCL Institute of Neurology, London, United Kingdom (A.C., D.W., D.J.W.); Hemorrhagic Stroke Research Group, Massachusetts General Hospital, Boston (A.C.); Departments of Neurology and Radiology, Hôpital Sainte-Anne, Université Paris Descartes, France (G.T., C.O., M.E.-G., J.-C.B.); Department of Neurology, the 2nd Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China (S.Y., M.L.); Department of Neurology and Center for Stroke Research,
| | - Hebun Erdur
- From the Stroke Research Centre, UCL Institute of Neurology, London, United Kingdom (A.C., D.W., D.J.W.); Hemorrhagic Stroke Research Group, Massachusetts General Hospital, Boston (A.C.); Departments of Neurology and Radiology, Hôpital Sainte-Anne, Université Paris Descartes, France (G.T., C.O., M.E.-G., J.-C.B.); Department of Neurology, the 2nd Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China (S.Y., M.L.); Department of Neurology and Center for Stroke Research,
| | - Pascal P. Klinger-Gratz
- From the Stroke Research Centre, UCL Institute of Neurology, London, United Kingdom (A.C., D.W., D.J.W.); Hemorrhagic Stroke Research Group, Massachusetts General Hospital, Boston (A.C.); Departments of Neurology and Radiology, Hôpital Sainte-Anne, Université Paris Descartes, France (G.T., C.O., M.E.-G., J.-C.B.); Department of Neurology, the 2nd Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China (S.Y., M.L.); Department of Neurology and Center for Stroke Research,
| | - Marwan El-Koussy
- From the Stroke Research Centre, UCL Institute of Neurology, London, United Kingdom (A.C., D.W., D.J.W.); Hemorrhagic Stroke Research Group, Massachusetts General Hospital, Boston (A.C.); Departments of Neurology and Radiology, Hôpital Sainte-Anne, Université Paris Descartes, France (G.T., C.O., M.E.-G., J.-C.B.); Department of Neurology, the 2nd Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China (S.Y., M.L.); Department of Neurology and Center for Stroke Research,
| | - Wakoh Takahashi
- From the Stroke Research Centre, UCL Institute of Neurology, London, United Kingdom (A.C., D.W., D.J.W.); Hemorrhagic Stroke Research Group, Massachusetts General Hospital, Boston (A.C.); Departments of Neurology and Radiology, Hôpital Sainte-Anne, Université Paris Descartes, France (G.T., C.O., M.E.-G., J.-C.B.); Department of Neurology, the 2nd Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China (S.Y., M.L.); Department of Neurology and Center for Stroke Research,
| | - Yusuke Moriya
- From the Stroke Research Centre, UCL Institute of Neurology, London, United Kingdom (A.C., D.W., D.J.W.); Hemorrhagic Stroke Research Group, Massachusetts General Hospital, Boston (A.C.); Departments of Neurology and Radiology, Hôpital Sainte-Anne, Université Paris Descartes, France (G.T., C.O., M.E.-G., J.-C.B.); Department of Neurology, the 2nd Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China (S.Y., M.L.); Department of Neurology and Center for Stroke Research,
| | - Duncan Wilson
- From the Stroke Research Centre, UCL Institute of Neurology, London, United Kingdom (A.C., D.W., D.J.W.); Hemorrhagic Stroke Research Group, Massachusetts General Hospital, Boston (A.C.); Departments of Neurology and Radiology, Hôpital Sainte-Anne, Université Paris Descartes, France (G.T., C.O., M.E.-G., J.-C.B.); Department of Neurology, the 2nd Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China (S.Y., M.L.); Department of Neurology and Center for Stroke Research,
| | - Chelsea S. Kidwell
- From the Stroke Research Centre, UCL Institute of Neurology, London, United Kingdom (A.C., D.W., D.J.W.); Hemorrhagic Stroke Research Group, Massachusetts General Hospital, Boston (A.C.); Departments of Neurology and Radiology, Hôpital Sainte-Anne, Université Paris Descartes, France (G.T., C.O., M.E.-G., J.-C.B.); Department of Neurology, the 2nd Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China (S.Y., M.L.); Department of Neurology and Center for Stroke Research,
| | - Jeffrey L. Saver
- From the Stroke Research Centre, UCL Institute of Neurology, London, United Kingdom (A.C., D.W., D.J.W.); Hemorrhagic Stroke Research Group, Massachusetts General Hospital, Boston (A.C.); Departments of Neurology and Radiology, Hôpital Sainte-Anne, Université Paris Descartes, France (G.T., C.O., M.E.-G., J.-C.B.); Department of Neurology, the 2nd Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China (S.Y., M.L.); Department of Neurology and Center for Stroke Research,
| | - Asma Sallem
- From the Stroke Research Centre, UCL Institute of Neurology, London, United Kingdom (A.C., D.W., D.J.W.); Hemorrhagic Stroke Research Group, Massachusetts General Hospital, Boston (A.C.); Departments of Neurology and Radiology, Hôpital Sainte-Anne, Université Paris Descartes, France (G.T., C.O., M.E.-G., J.-C.B.); Department of Neurology, the 2nd Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China (S.Y., M.L.); Department of Neurology and Center for Stroke Research,
| | - Solene Moulin
- From the Stroke Research Centre, UCL Institute of Neurology, London, United Kingdom (A.C., D.W., D.J.W.); Hemorrhagic Stroke Research Group, Massachusetts General Hospital, Boston (A.C.); Departments of Neurology and Radiology, Hôpital Sainte-Anne, Université Paris Descartes, France (G.T., C.O., M.E.-G., J.-C.B.); Department of Neurology, the 2nd Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China (S.Y., M.L.); Department of Neurology and Center for Stroke Research,
| | - Myriam Edjlali-Goujon
- From the Stroke Research Centre, UCL Institute of Neurology, London, United Kingdom (A.C., D.W., D.J.W.); Hemorrhagic Stroke Research Group, Massachusetts General Hospital, Boston (A.C.); Departments of Neurology and Radiology, Hôpital Sainte-Anne, Université Paris Descartes, France (G.T., C.O., M.E.-G., J.-C.B.); Department of Neurology, the 2nd Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China (S.Y., M.L.); Department of Neurology and Center for Stroke Research,
| | - Vincent Thijs
- From the Stroke Research Centre, UCL Institute of Neurology, London, United Kingdom (A.C., D.W., D.J.W.); Hemorrhagic Stroke Research Group, Massachusetts General Hospital, Boston (A.C.); Departments of Neurology and Radiology, Hôpital Sainte-Anne, Université Paris Descartes, France (G.T., C.O., M.E.-G., J.-C.B.); Department of Neurology, the 2nd Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China (S.Y., M.L.); Department of Neurology and Center for Stroke Research,
| | - Zoe Fox
- From the Stroke Research Centre, UCL Institute of Neurology, London, United Kingdom (A.C., D.W., D.J.W.); Hemorrhagic Stroke Research Group, Massachusetts General Hospital, Boston (A.C.); Departments of Neurology and Radiology, Hôpital Sainte-Anne, Université Paris Descartes, France (G.T., C.O., M.E.-G., J.-C.B.); Department of Neurology, the 2nd Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China (S.Y., M.L.); Department of Neurology and Center for Stroke Research,
| | - Ashkan Shoamanesh
- From the Stroke Research Centre, UCL Institute of Neurology, London, United Kingdom (A.C., D.W., D.J.W.); Hemorrhagic Stroke Research Group, Massachusetts General Hospital, Boston (A.C.); Departments of Neurology and Radiology, Hôpital Sainte-Anne, Université Paris Descartes, France (G.T., C.O., M.E.-G., J.-C.B.); Department of Neurology, the 2nd Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China (S.Y., M.L.); Department of Neurology and Center for Stroke Research,
| | - Gregory W. Albers
- From the Stroke Research Centre, UCL Institute of Neurology, London, United Kingdom (A.C., D.W., D.J.W.); Hemorrhagic Stroke Research Group, Massachusetts General Hospital, Boston (A.C.); Departments of Neurology and Radiology, Hôpital Sainte-Anne, Université Paris Descartes, France (G.T., C.O., M.E.-G., J.-C.B.); Department of Neurology, the 2nd Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China (S.Y., M.L.); Department of Neurology and Center for Stroke Research,
| | - Heinrich P. Mattle
- From the Stroke Research Centre, UCL Institute of Neurology, London, United Kingdom (A.C., D.W., D.J.W.); Hemorrhagic Stroke Research Group, Massachusetts General Hospital, Boston (A.C.); Departments of Neurology and Radiology, Hôpital Sainte-Anne, Université Paris Descartes, France (G.T., C.O., M.E.-G., J.-C.B.); Department of Neurology, the 2nd Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China (S.Y., M.L.); Department of Neurology and Center for Stroke Research,
| | - Oscar R. Benavente
- From the Stroke Research Centre, UCL Institute of Neurology, London, United Kingdom (A.C., D.W., D.J.W.); Hemorrhagic Stroke Research Group, Massachusetts General Hospital, Boston (A.C.); Departments of Neurology and Radiology, Hôpital Sainte-Anne, Université Paris Descartes, France (G.T., C.O., M.E.-G., J.-C.B.); Department of Neurology, the 2nd Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China (S.Y., M.L.); Department of Neurology and Center for Stroke Research,
| | - H. Rolf Jäger
- From the Stroke Research Centre, UCL Institute of Neurology, London, United Kingdom (A.C., D.W., D.J.W.); Hemorrhagic Stroke Research Group, Massachusetts General Hospital, Boston (A.C.); Departments of Neurology and Radiology, Hôpital Sainte-Anne, Université Paris Descartes, France (G.T., C.O., M.E.-G., J.-C.B.); Department of Neurology, the 2nd Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China (S.Y., M.L.); Department of Neurology and Center for Stroke Research,
| | - Gareth Ambler
- From the Stroke Research Centre, UCL Institute of Neurology, London, United Kingdom (A.C., D.W., D.J.W.); Hemorrhagic Stroke Research Group, Massachusetts General Hospital, Boston (A.C.); Departments of Neurology and Radiology, Hôpital Sainte-Anne, Université Paris Descartes, France (G.T., C.O., M.E.-G., J.-C.B.); Department of Neurology, the 2nd Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China (S.Y., M.L.); Department of Neurology and Center for Stroke Research,
| | - Junya Aoki
- From the Stroke Research Centre, UCL Institute of Neurology, London, United Kingdom (A.C., D.W., D.J.W.); Hemorrhagic Stroke Research Group, Massachusetts General Hospital, Boston (A.C.); Departments of Neurology and Radiology, Hôpital Sainte-Anne, Université Paris Descartes, France (G.T., C.O., M.E.-G., J.-C.B.); Department of Neurology, the 2nd Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China (S.Y., M.L.); Department of Neurology and Center for Stroke Research,
| | - Jean-Claude Baron
- From the Stroke Research Centre, UCL Institute of Neurology, London, United Kingdom (A.C., D.W., D.J.W.); Hemorrhagic Stroke Research Group, Massachusetts General Hospital, Boston (A.C.); Departments of Neurology and Radiology, Hôpital Sainte-Anne, Université Paris Descartes, France (G.T., C.O., M.E.-G., J.-C.B.); Department of Neurology, the 2nd Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China (S.Y., M.L.); Department of Neurology and Center for Stroke Research,
| | - Kazumi Kimura
- From the Stroke Research Centre, UCL Institute of Neurology, London, United Kingdom (A.C., D.W., D.J.W.); Hemorrhagic Stroke Research Group, Massachusetts General Hospital, Boston (A.C.); Departments of Neurology and Radiology, Hôpital Sainte-Anne, Université Paris Descartes, France (G.T., C.O., M.E.-G., J.-C.B.); Department of Neurology, the 2nd Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China (S.Y., M.L.); Department of Neurology and Center for Stroke Research,
| | - Wataru Kakuda
- From the Stroke Research Centre, UCL Institute of Neurology, London, United Kingdom (A.C., D.W., D.J.W.); Hemorrhagic Stroke Research Group, Massachusetts General Hospital, Boston (A.C.); Departments of Neurology and Radiology, Hôpital Sainte-Anne, Université Paris Descartes, France (G.T., C.O., M.E.-G., J.-C.B.); Department of Neurology, the 2nd Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China (S.Y., M.L.); Department of Neurology and Center for Stroke Research,
| | - Shunya Takizawa
- From the Stroke Research Centre, UCL Institute of Neurology, London, United Kingdom (A.C., D.W., D.J.W.); Hemorrhagic Stroke Research Group, Massachusetts General Hospital, Boston (A.C.); Departments of Neurology and Radiology, Hôpital Sainte-Anne, Université Paris Descartes, France (G.T., C.O., M.E.-G., J.-C.B.); Department of Neurology, the 2nd Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China (S.Y., M.L.); Department of Neurology and Center for Stroke Research,
| | - Simon Jung
- From the Stroke Research Centre, UCL Institute of Neurology, London, United Kingdom (A.C., D.W., D.J.W.); Hemorrhagic Stroke Research Group, Massachusetts General Hospital, Boston (A.C.); Departments of Neurology and Radiology, Hôpital Sainte-Anne, Université Paris Descartes, France (G.T., C.O., M.E.-G., J.-C.B.); Department of Neurology, the 2nd Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China (S.Y., M.L.); Department of Neurology and Center for Stroke Research,
| | - Christian H. Nolte
- From the Stroke Research Centre, UCL Institute of Neurology, London, United Kingdom (A.C., D.W., D.J.W.); Hemorrhagic Stroke Research Group, Massachusetts General Hospital, Boston (A.C.); Departments of Neurology and Radiology, Hôpital Sainte-Anne, Université Paris Descartes, France (G.T., C.O., M.E.-G., J.-C.B.); Department of Neurology, the 2nd Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China (S.Y., M.L.); Department of Neurology and Center for Stroke Research,
| | - Min Lou
- From the Stroke Research Centre, UCL Institute of Neurology, London, United Kingdom (A.C., D.W., D.J.W.); Hemorrhagic Stroke Research Group, Massachusetts General Hospital, Boston (A.C.); Departments of Neurology and Radiology, Hôpital Sainte-Anne, Université Paris Descartes, France (G.T., C.O., M.E.-G., J.-C.B.); Department of Neurology, the 2nd Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China (S.Y., M.L.); Department of Neurology and Center for Stroke Research,
| | - Charlotte Cordonnier
- From the Stroke Research Centre, UCL Institute of Neurology, London, United Kingdom (A.C., D.W., D.J.W.); Hemorrhagic Stroke Research Group, Massachusetts General Hospital, Boston (A.C.); Departments of Neurology and Radiology, Hôpital Sainte-Anne, Université Paris Descartes, France (G.T., C.O., M.E.-G., J.-C.B.); Department of Neurology, the 2nd Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China (S.Y., M.L.); Department of Neurology and Center for Stroke Research,
| | - David J. Werring
- From the Stroke Research Centre, UCL Institute of Neurology, London, United Kingdom (A.C., D.W., D.J.W.); Hemorrhagic Stroke Research Group, Massachusetts General Hospital, Boston (A.C.); Departments of Neurology and Radiology, Hôpital Sainte-Anne, Université Paris Descartes, France (G.T., C.O., M.E.-G., J.-C.B.); Department of Neurology, the 2nd Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China (S.Y., M.L.); Department of Neurology and Center for Stroke Research,
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26
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Mueller L, Pult F, Meisterernst J, Heldner MR, Mono ML, Kurmann R, Buehlmann M, Fischer U, Mattle HP, Arnold M, Mordasini P, Gralla J, Schroth G, El-Koussy M, Jung S. Impact of intravenous thrombolysis on recanalization rates in patients with stroke treated with bridging therapy. Eur J Neurol 2017. [DOI: 10.1111/ene.13330] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- L. Mueller
- Department of Neurology; Inselspital; University Hospital Bern, Bern and University of Bern; Bern
| | - F. Pult
- Department of Diagnostic and Interventional Neuroradiology; Inselspital; University Hospital Bern and University of Bern; Bern Switzerland
| | - J. Meisterernst
- Department of Neurology; Inselspital; University Hospital Bern, Bern and University of Bern; Bern
| | - M. R. Heldner
- Department of Neurology; Inselspital; University Hospital Bern, Bern and University of Bern; Bern
| | - M.-L. Mono
- Department of Neurology; Inselspital; University Hospital Bern, Bern and University of Bern; Bern
| | - R. Kurmann
- Department of Neurology; Inselspital; University Hospital Bern, Bern and University of Bern; Bern
| | - M. Buehlmann
- Department of Neurology; Inselspital; University Hospital Bern, Bern and University of Bern; Bern
| | - U. Fischer
- Department of Neurology; Inselspital; University Hospital Bern, Bern and University of Bern; Bern
| | - H. P. Mattle
- Department of Neurology; Inselspital; University Hospital Bern, Bern and University of Bern; Bern
| | - M. Arnold
- Department of Neurology; Inselspital; University Hospital Bern, Bern and University of Bern; Bern
| | - P. Mordasini
- Department of Diagnostic and Interventional Neuroradiology; Inselspital; University Hospital Bern and University of Bern; Bern Switzerland
| | - J. Gralla
- Department of Diagnostic and Interventional Neuroradiology; Inselspital; University Hospital Bern and University of Bern; Bern Switzerland
| | - G. Schroth
- Department of Diagnostic and Interventional Neuroradiology; Inselspital; University Hospital Bern and University of Bern; Bern Switzerland
| | - M. El-Koussy
- Department of Diagnostic and Interventional Neuroradiology; Inselspital; University Hospital Bern and University of Bern; Bern Switzerland
| | - S. Jung
- Department of Neurology; Inselspital; University Hospital Bern, Bern and University of Bern; Bern
- Department of Diagnostic and Interventional Neuroradiology; Inselspital; University Hospital Bern and University of Bern; Bern Switzerland
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27
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Yang K, Feng Y, Mu J, Fu N, Chen S, Fu Y. The Presence of Previous Cerebral Microbleeds Has a Negative Effect on Hypertensive Intracerebral Hemorrhage Recovery. Front Aging Neurosci 2017; 9:49. [PMID: 28326034 PMCID: PMC5339337 DOI: 10.3389/fnagi.2017.00049] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2016] [Accepted: 02/20/2017] [Indexed: 11/13/2022] Open
Abstract
Background and Purpose: Cerebral microbleeds are an intracerebral microangiopathy with bleeding tendency found in intracerebral hemorrhage patients. However, studies about cerebral microbleed effects on the prognosis of hypertensive intracerebral hemorrhage patients are rare. We performed a prospective study to discuss not only the risk factors of cerebral microbleed incidence in hypertensive intracerebral hemorrhage patients but also the relevance of cerebral microbleeds with silent brain infarction, hemorrhage and prognosis. Methods: This study enrolled 100 patients diagnosed with hypertensive intracerebral hemorrhage within 3 days after onset. Magnetic resonance imaging including susceptibility-weighted imaging and diffusion-weighted imaging (DWI) were utilized to examine patients on the fifth day after onset. Regular follow-ups were performed to examine the following clinical cerebrovascular events and vascular deaths in 1 year. Results: Cerebral microbleeds were observed in 55 (55%) patients. Multiple logistic regression analysis showed that over-aging, elevation of serum creatinine, and leukoaraiosis were independently associated with cerebral microbleeds. In addition, higher silent brain infarction prevalence was observed in patients with cerebral microbleeds. In contrast, none of the cerebral microbleed patients exhibited cerebral microbleeds ≥5, which is an independent risk factor of poor 3-month neurological function recovery. During the 1-year follow-up, 14 subjects presented clinical cerebrovascular events or vascular death. The Cox proportional hazards model implicated that atrial fibrillation, cerebral microbleeds ≥5 and silent brain infarction were independent predictive factors for these events. Conclusions: Over-aging combined with an elevation of serum creatinine and leukoaraiosis were independent risk factors of cerebral microbleeds. Patients with cerebral microbleeds were more likely to exhibit silent brain infarction. Poor recovery of 3-month neurological function was observed in hypertensive intracerebral hemorrhage patients with cerebral microbleeds ≥5. Cerebral microbleeds ≥5 or silent brain infarction might also indicate an elevated risk of future cerebrovascular events and vascular death.
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Affiliation(s)
- Kang Yang
- Department of Neurology and Institute of Neurology, Rui Jin Hospital, School of Medicine, Shanghai Jiao Tong University Shanghai, China
| | - Yulan Feng
- Department of Neurology, Min Hang Hospital, Fudan University Shanghai, China
| | - JinJin Mu
- Department of Neurology and Institute of Neurology, Rui Jin Hospital, School of Medicine, Shanghai Jiao Tong University Shanghai, China
| | - Ningzhen Fu
- School of Medicine, Shanghai Jiao Tong University Shanghai, China
| | - Shufen Chen
- Department of Neurology and Institute of Neurology, Rui Jin Hospital, School of Medicine, Shanghai Jiao Tong University Shanghai, China
| | - Yi Fu
- Department of Neurology and Institute of Neurology, Rui Jin Hospital, School of Medicine, Shanghai Jiao Tong University Shanghai, China
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Zand R, Tsivgoulis G, Singh M, McCormack M, Goyal N, Ishfaq MF, Shahripour RB, Nearing K, Elijovich L, Alexandrov AW, Liebeskind DS, Alexandrov AV. Cerebral Microbleeds and Risk of Intracerebral Hemorrhage Post Intravenous Thrombolysis. J Stroke Cerebrovasc Dis 2017; 26:538-544. [DOI: 10.1016/j.jstrokecerebrovasdis.2016.11.127] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2016] [Revised: 10/17/2016] [Accepted: 11/29/2016] [Indexed: 11/27/2022] Open
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Evaluation of the role of susceptibility-weighted imaging in thrombolytic therapy for acute ischemic stroke. J Clin Neurosci 2017; 40:175-179. [PMID: 28228323 DOI: 10.1016/j.jocn.2017.01.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2016] [Accepted: 01/22/2017] [Indexed: 11/20/2022]
Abstract
We inspected low-intensity venous signals and microbleeds in patients with acute ischemic stroke (AIS) using susceptibility-weighted imaging (SWI) before and after administration of within-thrombolytic-time-window thrombolytic therapies, and observed their prognosis and safety, in order to guide individualized thrombolytic therapies. Patients with AIS were divided into groups A or B according to the presence of symmetric or asymmetric veins on SWI, and were re-inspected by SWI after intravenous thrombolysis using recombinant tissue plasminogen activator (rt-PA). The National Institutes of Health stroke scale (NIHSS) score before treatment and at 1-h and 24-h posttreatment in the two groups were 11.9, 7.3, and 7.1 in group A, 12.4, 8.2, and 7.9 in group B, significant difference was detected between the two groups after treatment. The 90-day mortality rate was 0, and the incidences of cerebral microbleeds (CMBs) and symptomatic cerebral hemorrhage (SCH) were 17.6%, and 0% in group A, 25.6% and 0% in group B, respectively. The incidences of CMBs and SCH in group A were lower than those in group B, but the intergroup differences were not statistically significant (P>0.05). The 90-day neurological improvement rates in the two groups were 70.2% and 58.1%, respectively, and group A showed a significantly better prognosis than group B (P<0.05). Thus, low-intensity venous signals in SWI can be used to evaluate a low level of perfusion, post-thrombolytic prognosis, and bleeding indexes, and can therefore be used to guide individualized thrombolytic therapies.
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于 永. Cerebral Microbleeds Screening with Original Image of 3D-TOF MRA Sequences Predicting Hemorrhagic Transformation in the Patients with Cerebral Infarction. ACTA ACUST UNITED AC 2017. [DOI: 10.12677/ijpn.2017.63004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Smith EE, Saposnik G, Biessels GJ, Doubal FN, Fornage M, Gorelick PB, Greenberg SM, Higashida RT, Kasner SE, Seshadri S. Prevention of Stroke in Patients With Silent Cerebrovascular Disease: A Scientific Statement for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke 2016; 48:e44-e71. [PMID: 27980126 DOI: 10.1161/str.0000000000000116] [Citation(s) in RCA: 227] [Impact Index Per Article: 28.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Two decades of epidemiological research shows that silent cerebrovascular disease is common and is associated with future risk for stroke and dementia. It is the most common incidental finding on brain scans. To summarize evidence on the diagnosis and management of silent cerebrovascular disease to prevent stroke, the Stroke Council of the American Heart Association convened a writing committee to evaluate existing evidence, to discuss clinical considerations, and to offer suggestions for future research on stroke prevention in patients with 3 cardinal manifestations of silent cerebrovascular disease: silent brain infarcts, magnetic resonance imaging white matter hyperintensities of presumed vascular origin, and cerebral microbleeds. The writing committee found strong evidence that silent cerebrovascular disease is a common problem of aging and that silent brain infarcts and white matter hyperintensities are associated with future symptomatic stroke risk independently of other vascular risk factors. In patients with cerebral microbleeds, there was evidence of a modestly increased risk of symptomatic intracranial hemorrhage in patients treated with thrombolysis for acute ischemic stroke but little prospective evidence on the risk of symptomatic hemorrhage in patients on anticoagulation. There were no randomized controlled trials targeted specifically to participants with silent cerebrovascular disease to prevent stroke. Primary stroke prevention is indicated in patients with silent brain infarcts, white matter hyperintensities, or microbleeds. Adoption of standard terms and definitions for silent cerebrovascular disease, as provided by prior American Heart Association/American Stroke Association statements and by a consensus group, may facilitate diagnosis and communication of findings from radiologists to clinicians.
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Wang S, Lv Y, Zheng X, Qiu J, Chen HS. The impact of cerebral microbleeds on intracerebral hemorrhage and poor functional outcome of acute ischemic stroke patients treated with intravenous thrombolysis: a systematic review and meta-analysis. J Neurol 2016; 264:1309-1319. [DOI: 10.1007/s00415-016-8339-1] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2016] [Revised: 11/07/2016] [Accepted: 11/08/2016] [Indexed: 11/28/2022]
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Liu J, Wang D, Xiong Y, Liu B, Wei C, Ma Z, Wu B, Tang H, Liu M. High-sensitivity cardiac troponin T levels and risk of cerebral microbleeds in acute ischemic stroke patients with atrial fibrillation and/or rheumatic heart disease. J Neurol Sci 2016; 369:15-18. [PMID: 27653858 DOI: 10.1016/j.jns.2016.08.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2016] [Revised: 08/01/2016] [Accepted: 08/01/2016] [Indexed: 02/05/2023]
Abstract
BACKGROUND AND OBJECTIVE Elevated high-sensitivity cardiac troponin T (hs-cTnT) levels are associated with coronary disease and small-vessel ischemic stroke through their associations with atherosclerosis. Considering the relationship between atherosclerosis and cerebral microbleeds (CMBs), the purpose of this study was to examine associations between serum hs-cTnT levels and risk of CMBs in acute ischemic stroke patients. METHODS This prospective study involved consecutively recruited acute ischemic stroke patients with atrial fibrillation and/or rheumatic heart disease treated at a large tertiary care hospital in southwestern China. Clinico-demographic data were collected and analyzed by logistic regression to identify the relationship between serum hs-cTnT levels and CMB occurrence and location. RESULTS In the final analysis, of 66 patients (27 males; mean age, 68.7years), 39 (59.1%) had CMBs. Hs-cTnT levels were not associated with risk of strictly lobar CMBs. However, after adjusting age, sex, current alcohol consumption, total cholesterol, hypertension, diabetes mellitus, prior antithrombotic therapy and NIHSS on admission, patients in the higher tertile were more likely to have CMBs and deep or infratentorial CMBs (P<0.05) compared with the lower hs-cTnT tertile. CONCLUSION Hs-cTnT may be an independent predictor for the occurrence of CMBs, particularly of deep or infratentorial CMBs. This finding justifies further research into how hs-cTnT levels may contribute to CMBs and potentially other subclinical small-vessel diseases.
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Affiliation(s)
- Junfeng Liu
- Stroke Clinical Research Unit, Department of Neurology, West China Hospital, Sichuan University, Chengdu, PR China
| | - Deren Wang
- Stroke Clinical Research Unit, Department of Neurology, West China Hospital, Sichuan University, Chengdu, PR China
| | - Yao Xiong
- Stroke Clinical Research Unit, Department of Neurology, West China Hospital, Sichuan University, Chengdu, PR China
| | - Bian Liu
- Stroke Clinical Research Unit, Department of Neurology, West China Hospital, Sichuan University, Chengdu, PR China
| | - Chenchen Wei
- Stroke Clinical Research Unit, Department of Neurology, West China Hospital, Sichuan University, Chengdu, PR China
| | - Zhenxing Ma
- Stroke Clinical Research Unit, Department of Neurology, West China Hospital, Sichuan University, Chengdu, PR China
| | - Bo Wu
- Stroke Clinical Research Unit, Department of Neurology, West China Hospital, Sichuan University, Chengdu, PR China
| | - Hehan Tang
- Department of Radiology, West China Hospital, Sichuan University, Chengdu, PR China
| | - Ming Liu
- Stroke Clinical Research Unit, Department of Neurology, West China Hospital, Sichuan University, Chengdu, PR China.
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Prats-Sánchez L, Camps-Renom P, Sotoca-Fernández J, Delgado-Mederos R, Martínez-Domeño A, Marín R, Almendrote M, Dorado L, Gomis M, Codas J, Llull L, Gómez González A, Roquer J, Purroy F, Gómez-Choco M, Cánovas D, Cocho D, Garces M, Abilleira S, Martí-Fàbregas J. Remote Intracerebral Hemorrhage After Intravenous Thrombolysis. Stroke 2016; 47:2003-9. [DOI: 10.1161/strokeaha.116.013952] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2016] [Accepted: 06/07/2016] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
Remote parenchymal hemorrhage (rPH) after intravenous thrombolysis with recombinant tissue-type plasminogen activator may be associated with cerebral amyloid angiopathy, although supportive data are limited. We aimed to investigate risk factors of rPH after intravenous thrombolysis with recombinant tissue-type plasminogen activator.
Methods—
This is an observational study of patients with ischemic stroke who were treated with intravenous thrombolysis with recombinant tissue-type plasminogen activator and were included in a multicenter prospective registry. rPH was defined as any extraischemic hemorrhage detected in the follow-up computed tomography. We collected demographic, clinical, laboratory, radiological, and outcome variables. In the subset of patients who underwent a magnetic resonance imaging examination, we evaluated the distribution and burden of cerebral microbleeds, cortical superficial siderosis, leukoaraiosis, and recent silent ischemia in regions anatomically unrelated to the ischemic lesion that caused the initial symptoms. We compared patients with rPH with those without rPH or parenchymal hemorrhage. Independent risk factors for rPH were obtained by multivariable logistic regression analyses.
Results—
We evaluated 992 patients (mean age, 74.0±12.6 years; 52.9% were men), and 408 (41%) of them underwent a magnetic resonance imaging. Twenty-six patients (2.6%) had a rPH, 8 (0.8%) had both rPH and PH, 58 (5.8%) had PH, and 900 (90.7%) had no bleeding complication. Lobar cerebral microbleeds (odds ratio, 8.0; 95% confidence interval, 2.3–27.2) and recent silent ischemia (odds ratio, 4.8; 95% confidence interval, 1.6–14.1) increased the risk of rPH.
Conclusions—
The occurrence of rPH after intravenous thrombolysis with recombinant tissue-type plasminogen activator in patients with ischemic stroke is associated with lobar cerebral microbleeds and multiple ischemic lesions in different regions.
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Affiliation(s)
- Luis Prats-Sánchez
- From the Department of Neurology, Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute, IIB-Sant Pau, Barcelona, Spain (L.P.-S., P.C.-R., J.S.-F., R.D.-M., A.M.-D., R.M., J.M.-F.); Hospital Universitari Germans Trias i Pujol, Badalona, Spain (M.A., L.D., M.G.); Hospital Clínic de Barcelona, Barcelona, Spain (J.C., L.L.); Hospital del Mar, Barcelona, Spain (A.G.G., J.R.); Hospital Universitari Arnau de Vilanova, Lleida, Spain (F.P.); Hospital Moisès Broggi, Sant Joan Despí, Spain (M.G
| | - Pol Camps-Renom
- From the Department of Neurology, Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute, IIB-Sant Pau, Barcelona, Spain (L.P.-S., P.C.-R., J.S.-F., R.D.-M., A.M.-D., R.M., J.M.-F.); Hospital Universitari Germans Trias i Pujol, Badalona, Spain (M.A., L.D., M.G.); Hospital Clínic de Barcelona, Barcelona, Spain (J.C., L.L.); Hospital del Mar, Barcelona, Spain (A.G.G., J.R.); Hospital Universitari Arnau de Vilanova, Lleida, Spain (F.P.); Hospital Moisès Broggi, Sant Joan Despí, Spain (M.G
| | - Javier Sotoca-Fernández
- From the Department of Neurology, Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute, IIB-Sant Pau, Barcelona, Spain (L.P.-S., P.C.-R., J.S.-F., R.D.-M., A.M.-D., R.M., J.M.-F.); Hospital Universitari Germans Trias i Pujol, Badalona, Spain (M.A., L.D., M.G.); Hospital Clínic de Barcelona, Barcelona, Spain (J.C., L.L.); Hospital del Mar, Barcelona, Spain (A.G.G., J.R.); Hospital Universitari Arnau de Vilanova, Lleida, Spain (F.P.); Hospital Moisès Broggi, Sant Joan Despí, Spain (M.G
| | - Raquel Delgado-Mederos
- From the Department of Neurology, Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute, IIB-Sant Pau, Barcelona, Spain (L.P.-S., P.C.-R., J.S.-F., R.D.-M., A.M.-D., R.M., J.M.-F.); Hospital Universitari Germans Trias i Pujol, Badalona, Spain (M.A., L.D., M.G.); Hospital Clínic de Barcelona, Barcelona, Spain (J.C., L.L.); Hospital del Mar, Barcelona, Spain (A.G.G., J.R.); Hospital Universitari Arnau de Vilanova, Lleida, Spain (F.P.); Hospital Moisès Broggi, Sant Joan Despí, Spain (M.G
| | - Alejandro Martínez-Domeño
- From the Department of Neurology, Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute, IIB-Sant Pau, Barcelona, Spain (L.P.-S., P.C.-R., J.S.-F., R.D.-M., A.M.-D., R.M., J.M.-F.); Hospital Universitari Germans Trias i Pujol, Badalona, Spain (M.A., L.D., M.G.); Hospital Clínic de Barcelona, Barcelona, Spain (J.C., L.L.); Hospital del Mar, Barcelona, Spain (A.G.G., J.R.); Hospital Universitari Arnau de Vilanova, Lleida, Spain (F.P.); Hospital Moisès Broggi, Sant Joan Despí, Spain (M.G
| | - Rebeca Marín
- From the Department of Neurology, Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute, IIB-Sant Pau, Barcelona, Spain (L.P.-S., P.C.-R., J.S.-F., R.D.-M., A.M.-D., R.M., J.M.-F.); Hospital Universitari Germans Trias i Pujol, Badalona, Spain (M.A., L.D., M.G.); Hospital Clínic de Barcelona, Barcelona, Spain (J.C., L.L.); Hospital del Mar, Barcelona, Spain (A.G.G., J.R.); Hospital Universitari Arnau de Vilanova, Lleida, Spain (F.P.); Hospital Moisès Broggi, Sant Joan Despí, Spain (M.G
| | - Miriam Almendrote
- From the Department of Neurology, Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute, IIB-Sant Pau, Barcelona, Spain (L.P.-S., P.C.-R., J.S.-F., R.D.-M., A.M.-D., R.M., J.M.-F.); Hospital Universitari Germans Trias i Pujol, Badalona, Spain (M.A., L.D., M.G.); Hospital Clínic de Barcelona, Barcelona, Spain (J.C., L.L.); Hospital del Mar, Barcelona, Spain (A.G.G., J.R.); Hospital Universitari Arnau de Vilanova, Lleida, Spain (F.P.); Hospital Moisès Broggi, Sant Joan Despí, Spain (M.G
| | - Laura Dorado
- From the Department of Neurology, Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute, IIB-Sant Pau, Barcelona, Spain (L.P.-S., P.C.-R., J.S.-F., R.D.-M., A.M.-D., R.M., J.M.-F.); Hospital Universitari Germans Trias i Pujol, Badalona, Spain (M.A., L.D., M.G.); Hospital Clínic de Barcelona, Barcelona, Spain (J.C., L.L.); Hospital del Mar, Barcelona, Spain (A.G.G., J.R.); Hospital Universitari Arnau de Vilanova, Lleida, Spain (F.P.); Hospital Moisès Broggi, Sant Joan Despí, Spain (M.G
| | - Meritxell Gomis
- From the Department of Neurology, Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute, IIB-Sant Pau, Barcelona, Spain (L.P.-S., P.C.-R., J.S.-F., R.D.-M., A.M.-D., R.M., J.M.-F.); Hospital Universitari Germans Trias i Pujol, Badalona, Spain (M.A., L.D., M.G.); Hospital Clínic de Barcelona, Barcelona, Spain (J.C., L.L.); Hospital del Mar, Barcelona, Spain (A.G.G., J.R.); Hospital Universitari Arnau de Vilanova, Lleida, Spain (F.P.); Hospital Moisès Broggi, Sant Joan Despí, Spain (M.G
| | - Javier Codas
- From the Department of Neurology, Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute, IIB-Sant Pau, Barcelona, Spain (L.P.-S., P.C.-R., J.S.-F., R.D.-M., A.M.-D., R.M., J.M.-F.); Hospital Universitari Germans Trias i Pujol, Badalona, Spain (M.A., L.D., M.G.); Hospital Clínic de Barcelona, Barcelona, Spain (J.C., L.L.); Hospital del Mar, Barcelona, Spain (A.G.G., J.R.); Hospital Universitari Arnau de Vilanova, Lleida, Spain (F.P.); Hospital Moisès Broggi, Sant Joan Despí, Spain (M.G
| | - Laura Llull
- From the Department of Neurology, Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute, IIB-Sant Pau, Barcelona, Spain (L.P.-S., P.C.-R., J.S.-F., R.D.-M., A.M.-D., R.M., J.M.-F.); Hospital Universitari Germans Trias i Pujol, Badalona, Spain (M.A., L.D., M.G.); Hospital Clínic de Barcelona, Barcelona, Spain (J.C., L.L.); Hospital del Mar, Barcelona, Spain (A.G.G., J.R.); Hospital Universitari Arnau de Vilanova, Lleida, Spain (F.P.); Hospital Moisès Broggi, Sant Joan Despí, Spain (M.G
| | - Alejandra Gómez González
- From the Department of Neurology, Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute, IIB-Sant Pau, Barcelona, Spain (L.P.-S., P.C.-R., J.S.-F., R.D.-M., A.M.-D., R.M., J.M.-F.); Hospital Universitari Germans Trias i Pujol, Badalona, Spain (M.A., L.D., M.G.); Hospital Clínic de Barcelona, Barcelona, Spain (J.C., L.L.); Hospital del Mar, Barcelona, Spain (A.G.G., J.R.); Hospital Universitari Arnau de Vilanova, Lleida, Spain (F.P.); Hospital Moisès Broggi, Sant Joan Despí, Spain (M.G
| | - Jaume Roquer
- From the Department of Neurology, Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute, IIB-Sant Pau, Barcelona, Spain (L.P.-S., P.C.-R., J.S.-F., R.D.-M., A.M.-D., R.M., J.M.-F.); Hospital Universitari Germans Trias i Pujol, Badalona, Spain (M.A., L.D., M.G.); Hospital Clínic de Barcelona, Barcelona, Spain (J.C., L.L.); Hospital del Mar, Barcelona, Spain (A.G.G., J.R.); Hospital Universitari Arnau de Vilanova, Lleida, Spain (F.P.); Hospital Moisès Broggi, Sant Joan Despí, Spain (M.G
| | - Francisco Purroy
- From the Department of Neurology, Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute, IIB-Sant Pau, Barcelona, Spain (L.P.-S., P.C.-R., J.S.-F., R.D.-M., A.M.-D., R.M., J.M.-F.); Hospital Universitari Germans Trias i Pujol, Badalona, Spain (M.A., L.D., M.G.); Hospital Clínic de Barcelona, Barcelona, Spain (J.C., L.L.); Hospital del Mar, Barcelona, Spain (A.G.G., J.R.); Hospital Universitari Arnau de Vilanova, Lleida, Spain (F.P.); Hospital Moisès Broggi, Sant Joan Despí, Spain (M.G
| | - Manuel Gómez-Choco
- From the Department of Neurology, Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute, IIB-Sant Pau, Barcelona, Spain (L.P.-S., P.C.-R., J.S.-F., R.D.-M., A.M.-D., R.M., J.M.-F.); Hospital Universitari Germans Trias i Pujol, Badalona, Spain (M.A., L.D., M.G.); Hospital Clínic de Barcelona, Barcelona, Spain (J.C., L.L.); Hospital del Mar, Barcelona, Spain (A.G.G., J.R.); Hospital Universitari Arnau de Vilanova, Lleida, Spain (F.P.); Hospital Moisès Broggi, Sant Joan Despí, Spain (M.G
| | - David Cánovas
- From the Department of Neurology, Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute, IIB-Sant Pau, Barcelona, Spain (L.P.-S., P.C.-R., J.S.-F., R.D.-M., A.M.-D., R.M., J.M.-F.); Hospital Universitari Germans Trias i Pujol, Badalona, Spain (M.A., L.D., M.G.); Hospital Clínic de Barcelona, Barcelona, Spain (J.C., L.L.); Hospital del Mar, Barcelona, Spain (A.G.G., J.R.); Hospital Universitari Arnau de Vilanova, Lleida, Spain (F.P.); Hospital Moisès Broggi, Sant Joan Despí, Spain (M.G
| | - Dolores Cocho
- From the Department of Neurology, Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute, IIB-Sant Pau, Barcelona, Spain (L.P.-S., P.C.-R., J.S.-F., R.D.-M., A.M.-D., R.M., J.M.-F.); Hospital Universitari Germans Trias i Pujol, Badalona, Spain (M.A., L.D., M.G.); Hospital Clínic de Barcelona, Barcelona, Spain (J.C., L.L.); Hospital del Mar, Barcelona, Spain (A.G.G., J.R.); Hospital Universitari Arnau de Vilanova, Lleida, Spain (F.P.); Hospital Moisès Broggi, Sant Joan Despí, Spain (M.G
| | - Moises Garces
- From the Department of Neurology, Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute, IIB-Sant Pau, Barcelona, Spain (L.P.-S., P.C.-R., J.S.-F., R.D.-M., A.M.-D., R.M., J.M.-F.); Hospital Universitari Germans Trias i Pujol, Badalona, Spain (M.A., L.D., M.G.); Hospital Clínic de Barcelona, Barcelona, Spain (J.C., L.L.); Hospital del Mar, Barcelona, Spain (A.G.G., J.R.); Hospital Universitari Arnau de Vilanova, Lleida, Spain (F.P.); Hospital Moisès Broggi, Sant Joan Despí, Spain (M.G
| | - Sonia Abilleira
- From the Department of Neurology, Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute, IIB-Sant Pau, Barcelona, Spain (L.P.-S., P.C.-R., J.S.-F., R.D.-M., A.M.-D., R.M., J.M.-F.); Hospital Universitari Germans Trias i Pujol, Badalona, Spain (M.A., L.D., M.G.); Hospital Clínic de Barcelona, Barcelona, Spain (J.C., L.L.); Hospital del Mar, Barcelona, Spain (A.G.G., J.R.); Hospital Universitari Arnau de Vilanova, Lleida, Spain (F.P.); Hospital Moisès Broggi, Sant Joan Despí, Spain (M.G
| | - Joan Martí-Fàbregas
- From the Department of Neurology, Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute, IIB-Sant Pau, Barcelona, Spain (L.P.-S., P.C.-R., J.S.-F., R.D.-M., A.M.-D., R.M., J.M.-F.); Hospital Universitari Germans Trias i Pujol, Badalona, Spain (M.A., L.D., M.G.); Hospital Clínic de Barcelona, Barcelona, Spain (J.C., L.L.); Hospital del Mar, Barcelona, Spain (A.G.G., J.R.); Hospital Universitari Arnau de Vilanova, Lleida, Spain (F.P.); Hospital Moisès Broggi, Sant Joan Despí, Spain (M.G
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Nighoghossian N, Abbas F, Cho TH, Geraldo AF, Cottaz V, Janecek E, Mechtouff L, Bischoff M, El Khoury C, Schott AM, Derex L, Hermier M, Tisserand LG, Amelie R, Chamard L, Berthezene Y. Impact of leukoaraiosis on parenchymal hemorrhage in elderly patients treated with thrombolysis. Neuroradiology 2016; 58:961-967. [PMID: 27447872 DOI: 10.1007/s00234-016-1725-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2016] [Accepted: 07/07/2016] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Severity of vascular damage of white matter may predict hemorrhagic transformation (HT). We assess the relationship between leukoaraiosis (LA) severity and the type of hemorrhagic transformation in elderly patients treated with thrombolysis. METHODS We retrospectively analyzed the clinical data and pretreatment magnetic resonance imaging (MRI) of 180 consecutive ischemic stroke patients aged over 75 years. LA severity was graded according to the Fazekas scale, and acute diffusion-weighted-imaging (DWI) lesion volumes were semi-automatically outlined. Predictors of hemorrhagic infarction (HI) and parenchymal hemorrhage (PH) were identified using logistic regression analysis and exact multinomial logistic analysis. RESULTS HT occurred in 31 patients (17 %). Baseline National Institute of Health Stroke Score (NIHSS; p = 0.008), severe LA (p = 0.02), and diffusion lesion volume (p = 0.02) were predictors of HT in univariable logistic regression. Adjusted to lesion volume and baseline NIHSS score, exact multinomial logistic analysis showed that severe LA was the only independent predictor of parenchymal hemorrhage (p = 0.03). CONCLUSION In elderly patients, LA severity better predicts parenchymal hemorrhage than infarct size.
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Affiliation(s)
| | - Fatima Abbas
- Pôle Information Médicale Evaluation Recherche, Hospices Civils de Lyon, Lyon, France
| | - Tae-Hee Cho
- Department of Stroke, Neurological Hospital, Université Lyon 1, Lyon, France
| | - Ana Filipa Geraldo
- Department of Neuroradiology, Neurological Hospital, Université Lyon 1, 59 Bd Pinel, 69677, Bron, Lyon, France
| | - Vincent Cottaz
- Department of Stroke, Neurological Hospital, Université Lyon 1, Lyon, France
| | - Elie Janecek
- Department of Neuroradiology, Neurological Hospital, Université Lyon 1, 59 Bd Pinel, 69677, Bron, Lyon, France
| | - Laura Mechtouff
- Department of Stroke, Neurological Hospital, Université Lyon 1, Lyon, France
| | | | | | - Anne Marie Schott
- Pôle Information Médicale Evaluation Recherche, Hospices Civils de Lyon, Lyon, France
| | - Laurent Derex
- Department of Stroke, Neurological Hospital, Université Lyon 1, Lyon, France
| | - Marc Hermier
- Department of Neuroradiology, Neurological Hospital, Université Lyon 1, 59 Bd Pinel, 69677, Bron, Lyon, France
| | - Louis Guy Tisserand
- Department of Neuroradiology, Neurological Hospital, Université Lyon 1, 59 Bd Pinel, 69677, Bron, Lyon, France
| | - Roxana Amelie
- Department of Neuroradiology, Neurological Hospital, Université Lyon 1, 59 Bd Pinel, 69677, Bron, Lyon, France
| | - Leila Chamard
- Department of Neuroradiology, Neurological Hospital, Université Lyon 1, 59 Bd Pinel, 69677, Bron, Lyon, France
| | - Yves Berthezene
- Department of Neuroradiology, Neurological Hospital, Université Lyon 1, 59 Bd Pinel, 69677, Bron, Lyon, France.
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Liu J, Wang D, Xiong Y, Liu B, Wei C, Ma Z, Wu B, Yuan R, Tang H, Liu M. A cohort study of relationship between serum calcium levels and cerebral microbleeds (CMBs) in ischemic stroke patients with AF and/or RHD. Medicine (Baltimore) 2016; 95:e4033. [PMID: 27368027 PMCID: PMC4937941 DOI: 10.1097/md.0000000000004033] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Calcium is an essential element for life and has cerebroprotective property in stroke patients. Low serum calcium levels were found to be related to large hematoma volumes in intracerebral hemorrhagic patients and hemorrhagic transformation in ischemic stroke patients after thrombolysis. However, their impact on hemorrhage-prone small vessel disease represented by cerebral microbleeds (CMBs) is uncertain. We aim to investigate whether low serum calcium levels are associated with presence and location of CMBs.Ischemic stroke patients with atrial fibrillation (AF) and/or rheumatic heart disease admitted to our hospital were consecutively and prospectively enrolled. Demographic and clinical information were collected and analyzed according to the occurrence and location of CMBs, and levels of serum calcium. We used logistic regression analysis to estimate the multivariable adjusted relationship between serum calcium levels and the presence or location of CMBs.Among the 67 patients (28 males; mean age, 67.3 years) in the final analysis, 39 (58.2%) were found to have CMBs. After adjustment for age, sex, smoking habits, drinking habits, and renal impairment, the presence of CMBs and deep CMBs was, respectively, 4.96- and 4.83-fold higher in patients with lower serum calcium levels (≤2.15 mmol/L) than in patients with higher serum calcium levels.Lower serum calcium levels (≤2.15 mmol/L) are independently associated with the presence of CMBs and deep CMBs in ischemic stroke patients with AF and/or rheumatic heart disease, which should be verified and extended in large cohorts, with other types of stroke patients and the general population.
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Affiliation(s)
- Junfeng Liu
- Stroke Clinical Research Unit, Department of Neurology, West China Hospital, Sichuan University, Chengdu, People's Republic of China
| | - Deren Wang
- Stroke Clinical Research Unit, Department of Neurology, West China Hospital, Sichuan University, Chengdu, People's Republic of China
| | - Yao Xiong
- Stroke Clinical Research Unit, Department of Neurology, West China Hospital, Sichuan University, Chengdu, People's Republic of China
| | - Bian Liu
- Stroke Clinical Research Unit, Department of Neurology, West China Hospital, Sichuan University, Chengdu, People's Republic of China
| | - Chenchen Wei
- Stroke Clinical Research Unit, Department of Neurology, West China Hospital, Sichuan University, Chengdu, People's Republic of China
| | - Zhenxing Ma
- Stroke Clinical Research Unit, Department of Neurology, West China Hospital, Sichuan University, Chengdu, People's Republic of China
| | - Bo Wu
- Stroke Clinical Research Unit, Department of Neurology, West China Hospital, Sichuan University, Chengdu, People's Republic of China
| | - Ruozhen Yuan
- Stroke Clinical Research Unit, Department of Neurology, West China Hospital, Sichuan University, Chengdu, People's Republic of China
| | - Hehan Tang
- Department of Radiology, West China Hospital, Sichuan University, Chengdu, People's Republic of China
| | - Ming Liu
- Stroke Clinical Research Unit, Department of Neurology, West China Hospital, Sichuan University, Chengdu, People's Republic of China
- Correspondence: Ming Liu, Stroke Clinical Research Unit, Department of Neurology, West China Hospital, Sichuan University, No. 37, GuoXue Xiang, Chengdu, 610041, Sichuan Province, People's Republic of China (e-mail: )
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Polyakova TA, Arablinsky AV, Levin OS. Do cerebral microbleeds increase the risk of hemorrhagic complications of thrombolytic therapy? Zh Nevrol Psikhiatr Im S S Korsakova 2016; 116:41-45. [DOI: 10.17116/jnevro20161166241-45] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Charidimou A, Shoamanesh A, Wilson D, Gang Q, Fox Z, Jäger HR, Benavente OR, Werring DJ. Cerebral microbleeds and postthrombolysis intracerebral hemorrhage risk Updated meta-analysis. Neurology 2015; 85:927-4. [PMID: 26296519 DOI: 10.1212/wnl.0000000000001923] [Citation(s) in RCA: 58] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE We performed a systematic review and meta-analysis to assess whether the presence of cerebral microbleeds (CMBs) on pretreatment MRI scans of patients with acute ischemic stroke treated with thrombolysis is associated with an increased risk of symptomatic intracerebral hemorrhage (ICH). METHODS We searched PubMed for relevant studies and calculated pooled odds ratios (ORs) for symptomatic ICH, using the Mantel–Haenszel fixed-effects method, among individuals with vs without CMBs on pretreatment MRI scans. To minimize potential bias, sensitivity analysis was performed including studies providing data on patients treated only with IV thrombolysis. RESULTS Ten eligible studies including 2,028 patients were pooled in meta-analysis. The overall prevalence of CMBs was 23.3%. Among patients with CMBs, 40 of 472 (8.5%; 95%confidence interval [CI]: 6.1%–11.4%) experienced a symptomatic ICH after thrombolysis compared with 61 of 1,556 patients (3.9%; 95% CI: 3%–5%) without CMBs. The pooled OR of ICH across all studies was 2.26 (95%CI: 1.46–3.49; p , 0.0001). Eight studies, including 1,704 patients (n 5 401 with CMBs), provided data on patients treated with IV thrombolysis only; OR for the presence of CMBs and the development of symptomatic ICH was 2.87 (95%CI: 1.76–4.69; p , 0.0001). CONCLUSIONS Our meta-analysis of the available published data demonstrates an increased risk of symptomatic ICH after thrombolysis for acute ischemic stroke in patients with CMBs. However, we cannot fully exclude bias or confounding, so our results should be considered hypothesis generating. Detecting CMBs should not prevent thrombolytic treatment based on present evidence. Further analyses, taking into account CMB number and location, as well as measures of functional outcome, are needed.
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Cai J, Fu J, Yan S, Hu H, Lin C. Clinical Outcome in Acute Ischemic Stroke Patients With Microbleeds After Thrombolytic Therapy: A Meta-Analysis. Medicine (Baltimore) 2015; 94:e2379. [PMID: 26717385 PMCID: PMC5291626 DOI: 10.1097/md.0000000000002379] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
It remains unclear whether preexisting cerebral microbleeds (CMBs) increase the risks of worse functional outcome after thrombolytic therapy. We performed a systematic review and meta-analysis to assess the risk of unfavorable outcome in patients with acute ischemic stroke and CMBs.We searched EMBASE, PubMed, and Web of Science for relevant studies assessing functional outcome in the patients with CMBs following thrombolytic therapy. Fixed-effects and random-effects models were performed.Five eligible studies including 1974 patients were pooled in meta-analysis. The prevalence of CMBs was 24.3%. The pooled analysis demonstrates odds ratio for preexisting CMBs and the achievement of favorable outcome to be 0.69 (95% CI 0.56-0.86; P = 0.001) with no evidence of statistical heterogeneity (I = 46.7%, P = 0.112).Our meta-analysis of available published data demonstrates an increased risk of worse functional outcome after thrombolytic therapy for acute ischemic stroke in patients with pre-existing CMBs. Future studies are needed to determine whether the risk outweigh the expected benefit of reperfusion therapies.
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Affiliation(s)
- Jing Cai
- From the Neurosurgerical Intensive Care Unit, the 2nd Affiliated Hospital of Zhejiang University (JC); Department of Neurology, the 4th Affiliated Hospital of Zhejiang University (JF); Department of Neurology (SY, HH); and Department of Surgical Oncology, the 2nd Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China (CL)
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Yan S, Jin X, Zhang X, Zhang S, Liebeskind DS, Lou M. Extensive cerebral microbleeds predict parenchymal haemorrhage and poor outcome after intravenous thrombolysis. J Neurol Neurosurg Psychiatry 2015; 86:1267-72. [PMID: 25632155 DOI: 10.1136/jnnp-2014-309857] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2014] [Accepted: 12/22/2014] [Indexed: 11/04/2022]
Abstract
PURPOSE Thrombolysis-related haemorrhagic transformation (HT) subtypes may have different prognostic implications. We aimed to analyse the impact of cerebral microbleeds (CMBs) burden on HT subtypes and outcome after intravenous thrombolysis. METHODS We retrospectively examined clinical and radiological data from 333 consecutive patients with acute ischaemic stroke who underwent susceptibility-weighted imaging before intravenous thrombolysis. Logistic regression analysis was used to determine the impact of CMBs on HT subtypes and neurological outcome. RESULTS We observed 596 CMBs in 119 (39.7%) patients on initial gradient-recalled echo scans. HT occurred in 88 (29.3%) patients, among which 62 were haemorrhagic infarction and 26 were parenchymal haemorrhage (PH). Logistic regression analysis indicated that the presence of extensive (≥ 3) CMBs was independently associated with PH (OR 6.704; 95% CI 2.054 to 21.883; p = 0.002) and poor clinical outcome (OR 2.281; 95% CI 1.022 to 5.093; p = 0.044). CONCLUSIONS The presence of extensive (≥ 3) CMBs increased the risk of PH 24 h after intravenous thrombolysis, and predicted poor clinical outcome independently.
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Affiliation(s)
- Shenqiang Yan
- Department of Neurology, The 2nd Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China
| | - Xinchun Jin
- Department of Neurology, The 2nd Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China
| | - Xuting Zhang
- Department of Neurology, The 2nd Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China
| | - Sheng Zhang
- Department of Neurology, The 2nd Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China
| | - David S Liebeskind
- University of California-Los Angeles Stroke Center, Los Angeles, California, USA
| | - Min Lou
- Department of Neurology, The 2nd Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China
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Turc G, Sallem A, Moulin S, Tisserand M, Machet A, Edjlali M, Baron JC, Leclerc X, Leys D, Mas JL, Cordonnier C, Oppenheim C. Microbleed Status and 3-Month Outcome After Intravenous Thrombolysis in 717 Patients With Acute Ischemic Stroke. Stroke 2015; 46:2458-63. [DOI: 10.1161/strokeaha.115.009290] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2015] [Accepted: 05/13/2015] [Indexed: 12/22/2022]
Abstract
Background and Purpose—
Whether cerebral microbleeds (CMBs) detected on pretreatment magnetic resonance imaging increase the risks of symptomatic intracranial hemorrhage (sICH) and, most importantly, poor outcome in patients treated by intravenous thrombolysis for acute ischemic stroke is still debated. We assessed the effect of CMB presence and burden on 3-month modified Rankin Scale and sICH in a multicentric cohort.
Methods—
We analyzed prospectively collected data of consecutive patients solely treated by intravenous thrombolysis for acute ischemic stroke, in 2 centers where magnetic resonance imaging is the first-line pretreatment imaging. Neuroradiologists blinded to clinical data rated CMBs on T2* sequence using a validated scale. Logistic regressions were used to assess relationships between CMBs and 3-month modified Rankin Scale or sICH.
Results—
Among 717 patients, 150 (20.9%) had ≥1 CMBs. CMB burden was associated with worse modified Rankin Scale in univariable shift analysis (odds ratio, 1.07; 95% confidence interval, 1.00–1.15 per 1-CMB increase;
P
=0.049), but significance was lost after adjustment for age, hypertension, and atrial fibrillation (odds ratio, 1.03; 95% confidence interval, 0.96–1.11 per 1-CMB increase;
P
=0.37). Results remained nonsignificant when taking into account CMB location or presumed underlying vasculopathy. The incidence of sICH ranged from 3.8% to 9.1%, depending on the definition. Neither CMB presence, burden, location, nor presumed underlying vasculopathy was independently associated with sICH.
Conclusions—
Poor outcome or sICH was not associated with CMB presence or burden on pre–intravenous thrombolysis magnetic resonance imaging after adjustment for confounding factors. An individual patient data meta-analysis is needed to determine whether a subgroup of patients with CMBs carries an independent risk of poor outcome that might outweigh the expected benefit of intravenous thrombolysis.
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Affiliation(s)
- Guillaume Turc
- From the Departments of Neurology (G.T., J.-C.B., J.-L.M.) and Radiology (M.T., A.M., C.O.), Hôpital Sainte-Anne, Université Paris Descartes, Sorbonne Paris Cité, INSERM UMR S894, DHU Neurovasc, Paris, France; and Departments of Neurology (S.M., D.L., C.C.) and Radiology (A.S., M.E., X.L.), Lille University Hospital and Université de Lille, UDSL, INSERM U1171, Lille, France
| | - Asmaa Sallem
- From the Departments of Neurology (G.T., J.-C.B., J.-L.M.) and Radiology (M.T., A.M., C.O.), Hôpital Sainte-Anne, Université Paris Descartes, Sorbonne Paris Cité, INSERM UMR S894, DHU Neurovasc, Paris, France; and Departments of Neurology (S.M., D.L., C.C.) and Radiology (A.S., M.E., X.L.), Lille University Hospital and Université de Lille, UDSL, INSERM U1171, Lille, France
| | - Solène Moulin
- From the Departments of Neurology (G.T., J.-C.B., J.-L.M.) and Radiology (M.T., A.M., C.O.), Hôpital Sainte-Anne, Université Paris Descartes, Sorbonne Paris Cité, INSERM UMR S894, DHU Neurovasc, Paris, France; and Departments of Neurology (S.M., D.L., C.C.) and Radiology (A.S., M.E., X.L.), Lille University Hospital and Université de Lille, UDSL, INSERM U1171, Lille, France
| | - Marie Tisserand
- From the Departments of Neurology (G.T., J.-C.B., J.-L.M.) and Radiology (M.T., A.M., C.O.), Hôpital Sainte-Anne, Université Paris Descartes, Sorbonne Paris Cité, INSERM UMR S894, DHU Neurovasc, Paris, France; and Departments of Neurology (S.M., D.L., C.C.) and Radiology (A.S., M.E., X.L.), Lille University Hospital and Université de Lille, UDSL, INSERM U1171, Lille, France
| | - Alexandre Machet
- From the Departments of Neurology (G.T., J.-C.B., J.-L.M.) and Radiology (M.T., A.M., C.O.), Hôpital Sainte-Anne, Université Paris Descartes, Sorbonne Paris Cité, INSERM UMR S894, DHU Neurovasc, Paris, France; and Departments of Neurology (S.M., D.L., C.C.) and Radiology (A.S., M.E., X.L.), Lille University Hospital and Université de Lille, UDSL, INSERM U1171, Lille, France
| | - Myriam Edjlali
- From the Departments of Neurology (G.T., J.-C.B., J.-L.M.) and Radiology (M.T., A.M., C.O.), Hôpital Sainte-Anne, Université Paris Descartes, Sorbonne Paris Cité, INSERM UMR S894, DHU Neurovasc, Paris, France; and Departments of Neurology (S.M., D.L., C.C.) and Radiology (A.S., M.E., X.L.), Lille University Hospital and Université de Lille, UDSL, INSERM U1171, Lille, France
| | - Jean-Claude Baron
- From the Departments of Neurology (G.T., J.-C.B., J.-L.M.) and Radiology (M.T., A.M., C.O.), Hôpital Sainte-Anne, Université Paris Descartes, Sorbonne Paris Cité, INSERM UMR S894, DHU Neurovasc, Paris, France; and Departments of Neurology (S.M., D.L., C.C.) and Radiology (A.S., M.E., X.L.), Lille University Hospital and Université de Lille, UDSL, INSERM U1171, Lille, France
| | - Xavier Leclerc
- From the Departments of Neurology (G.T., J.-C.B., J.-L.M.) and Radiology (M.T., A.M., C.O.), Hôpital Sainte-Anne, Université Paris Descartes, Sorbonne Paris Cité, INSERM UMR S894, DHU Neurovasc, Paris, France; and Departments of Neurology (S.M., D.L., C.C.) and Radiology (A.S., M.E., X.L.), Lille University Hospital and Université de Lille, UDSL, INSERM U1171, Lille, France
| | - Didier Leys
- From the Departments of Neurology (G.T., J.-C.B., J.-L.M.) and Radiology (M.T., A.M., C.O.), Hôpital Sainte-Anne, Université Paris Descartes, Sorbonne Paris Cité, INSERM UMR S894, DHU Neurovasc, Paris, France; and Departments of Neurology (S.M., D.L., C.C.) and Radiology (A.S., M.E., X.L.), Lille University Hospital and Université de Lille, UDSL, INSERM U1171, Lille, France
| | - Jean-Louis Mas
- From the Departments of Neurology (G.T., J.-C.B., J.-L.M.) and Radiology (M.T., A.M., C.O.), Hôpital Sainte-Anne, Université Paris Descartes, Sorbonne Paris Cité, INSERM UMR S894, DHU Neurovasc, Paris, France; and Departments of Neurology (S.M., D.L., C.C.) and Radiology (A.S., M.E., X.L.), Lille University Hospital and Université de Lille, UDSL, INSERM U1171, Lille, France
| | - Charlotte Cordonnier
- From the Departments of Neurology (G.T., J.-C.B., J.-L.M.) and Radiology (M.T., A.M., C.O.), Hôpital Sainte-Anne, Université Paris Descartes, Sorbonne Paris Cité, INSERM UMR S894, DHU Neurovasc, Paris, France; and Departments of Neurology (S.M., D.L., C.C.) and Radiology (A.S., M.E., X.L.), Lille University Hospital and Université de Lille, UDSL, INSERM U1171, Lille, France
| | - Catherine Oppenheim
- From the Departments of Neurology (G.T., J.-C.B., J.-L.M.) and Radiology (M.T., A.M., C.O.), Hôpital Sainte-Anne, Université Paris Descartes, Sorbonne Paris Cité, INSERM UMR S894, DHU Neurovasc, Paris, France; and Departments of Neurology (S.M., D.L., C.C.) and Radiology (A.S., M.E., X.L.), Lille University Hospital and Université de Lille, UDSL, INSERM U1171, Lille, France
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Klinger-Gratz PP, Schroth G, Gralla J, Jung S, Weisstanner C, Verma RK, Mordasini P, Kellner-Weldon F, Hsieh K, Heldner MR, Fischer U, Arnold M, Mattle HP, El-Koussy M. Protected stent retriever thrombectomy prevents iatrogenic emboli in new vascular territories. Neuroradiology 2015; 57:1045-54. [PMID: 26319999 PMCID: PMC4602059 DOI: 10.1007/s00234-015-1583-8] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2015] [Accepted: 08/19/2015] [Indexed: 01/19/2023]
Abstract
Introduction Diagnostic tools to show emboli reliably and protection techniques against embolization when employing stent retrievers are necessary to improve endovascular stroke therapy. The aim of the present study was to investigate iatrogenic emboli using susceptibility-weighted imaging (SWI) in an open series of patients who had been treated with stent retriever thrombectomy using emboli protection techniques. Methods Patients with anterior circulation stroke examined with MRI before and after stent retriever thrombectomy were assessed for iatrogenic embolic events. Thrombectomy was performed in flow arrest and under aspiration using a balloon-mounted guiding catheter, a distal access catheter, or both. Results In 13 of 57 patients (22.8 %) post-interventional SWI sequences detected 16 microemboli. Three of them were associated with small ischemic lesions on diffusion-weighted imaging (DWI). None of the microemboli were located in a new vascular territory, none showed clinical signs, and all 13 patients have been rated as Thrombolysis in Cerebral Infarction (TICI) 2b (n = 3) or 3 (n = 10). Retrospective reevaluation of the digital subtraction angiography (DSA) detected discrete flow stagnation nearby the iatrogenic microemboli in four patients with a positive persistent collateral sign in one. Conclusion Our study demonstrates two things: First, SWI seems to be more sensitive to detect emboli than DWI and DSA and, second, proximal or distal protected stent retriever thrombectomy seems to prevent iatrogenic embolization into new vascular territories during retraction of the thrombus, but not downstream during mobilization of the thrombus. Both techniques should be investigated and refined further.
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Affiliation(s)
- Pascal P Klinger-Gratz
- Department of Diagnostic and Interventional Neuroradiology, Inselspital, Freiburgstrasse 10, Bern University Hospital and University of Bern, 3010, Bern, Switzerland.,Department of Radiology, University of Basel, Basel, Switzerland
| | - Gerhard Schroth
- Department of Diagnostic and Interventional Neuroradiology, Inselspital, Freiburgstrasse 10, Bern University Hospital and University of Bern, 3010, Bern, Switzerland.
| | - Jan Gralla
- Department of Diagnostic and Interventional Neuroradiology, Inselspital, Freiburgstrasse 10, Bern University Hospital and University of Bern, 3010, Bern, Switzerland
| | - Simon Jung
- Department of Diagnostic and Interventional Neuroradiology, Inselspital, Freiburgstrasse 10, Bern University Hospital and University of Bern, 3010, Bern, Switzerland.,Department of Neurology, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Christian Weisstanner
- Department of Diagnostic and Interventional Neuroradiology, Inselspital, Freiburgstrasse 10, Bern University Hospital and University of Bern, 3010, Bern, Switzerland
| | - Rajeev K Verma
- Department of Diagnostic and Interventional Neuroradiology, Inselspital, Freiburgstrasse 10, Bern University Hospital and University of Bern, 3010, Bern, Switzerland
| | - Pasquale Mordasini
- Department of Diagnostic and Interventional Neuroradiology, Inselspital, Freiburgstrasse 10, Bern University Hospital and University of Bern, 3010, Bern, Switzerland
| | - Frauke Kellner-Weldon
- Department of Diagnostic and Interventional Neuroradiology, Inselspital, Freiburgstrasse 10, Bern University Hospital and University of Bern, 3010, Bern, Switzerland
| | - Kety Hsieh
- Department of Diagnostic and Interventional Neuroradiology, Inselspital, Freiburgstrasse 10, Bern University Hospital and University of Bern, 3010, Bern, Switzerland
| | - Mirjam R Heldner
- Department of Neurology, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Urs Fischer
- Department of Neurology, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Marcel Arnold
- Department of Neurology, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Heinrich P Mattle
- Department of Neurology, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Marwan El-Koussy
- Department of Diagnostic and Interventional Neuroradiology, Inselspital, Freiburgstrasse 10, Bern University Hospital and University of Bern, 3010, Bern, Switzerland
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Gilgen MD, Klimek D, Liesirova KT, Meisterernst J, Klinger-Gratz PP, Schroth G, Mordasini P, Hsieh K, Slotboom J, Heldner MR, Broeg-Morvay A, Mono ML, Fischer U, Mattle HP, Arnold M, Gralla J, El-Koussy M, Jung S. Younger Stroke Patients With Large Pretreatment Diffusion-Weighted Imaging Lesions May Benefit From Endovascular Treatment. Stroke 2015; 46:2510-6. [PMID: 26251252 DOI: 10.1161/strokeaha.115.010250] [Citation(s) in RCA: 71] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2015] [Accepted: 06/23/2015] [Indexed: 01/13/2023]
Abstract
BACKGROUND AND PURPOSE Lesion volume on diffusion-weighted magnetic resonance imaging (DWI) before acute stroke therapy is a predictor of outcome. Therefore, patients with large volumes are often excluded from therapy. The aim of this study was to analyze the impact of endovascular treatment in patients with large DWI lesion volumes (>70 mL). METHODS Three hundred seventy-two patients with middle cerebral or internal carotid artery occlusions examined with magnetic resonance imaging before treatment since 2004 were included. Baseline data and 3 months outcome were recorded prospectively. DWI lesion volumes were measured semiautomatically. RESULTS One hundred five patients had lesions >70 mL. Overall, the volume of DWI lesions was an independent predictor of unfavorable outcome, survival, and symptomatic intracerebral hemorrhage (P<0.001 each). In patients with DWI lesions >70 mL, 11 of 31 (35.5%) reached favorable outcome (modified Rankin scale score, 0-2) after thrombolysis in cerebral infarction 2b-3 reperfusion in contrast to 3 of 35 (8.6%) after thrombolysis in cerebral infarction 0-2a reperfusion (P=0.014). Reperfusion success, patient age, and DWI lesion volume were independent predictors of outcome in patients with DWI lesions >70 mL. Thirteen of 66 (19.7%) patients with lesions >70 mL had symptomatic intracerebral hemorrhage with a trend for reduced risk with avoidance of thrombolytic agents. CONCLUSIONS There was a growing risk for poor outcome and symptomatic intracerebral hemorrhage with increasing pretreatment DWI lesion volumes. Nevertheless, favorable outcome was achieved in every third patient with DWI lesions >70 mL after successful endovascular reperfusion, whereas after poor or failed reperfusion, outcome was favorable in only every 12th patient. Therefore, endovascular treatment might be considered in patients with large DWI lesions, especially in younger patients.
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Affiliation(s)
- Marc D Gilgen
- From the Department of Diagnostic and Interventional Neuroradiology (M.D.G., D.K., P.P.K.-G., G.S., P.M., K.H., J.S., J.G., M.E.-K., S.J.) and Department of Neurology, Inselspital (M.D.G., K.T.L., J.M., M.R.H., A.B.-M., M.-L.M., U.F., H.P.M., M.A., S.J.), University Hospital Bern and University of Bern, Bern, Switzerland; and Department of Radiology, University of Basel, Basel (P.P.K.-G.)
| | - Dariusz Klimek
- From the Department of Diagnostic and Interventional Neuroradiology (M.D.G., D.K., P.P.K.-G., G.S., P.M., K.H., J.S., J.G., M.E.-K., S.J.) and Department of Neurology, Inselspital (M.D.G., K.T.L., J.M., M.R.H., A.B.-M., M.-L.M., U.F., H.P.M., M.A., S.J.), University Hospital Bern and University of Bern, Bern, Switzerland; and Department of Radiology, University of Basel, Basel (P.P.K.-G.)
| | - Kai T Liesirova
- From the Department of Diagnostic and Interventional Neuroradiology (M.D.G., D.K., P.P.K.-G., G.S., P.M., K.H., J.S., J.G., M.E.-K., S.J.) and Department of Neurology, Inselspital (M.D.G., K.T.L., J.M., M.R.H., A.B.-M., M.-L.M., U.F., H.P.M., M.A., S.J.), University Hospital Bern and University of Bern, Bern, Switzerland; and Department of Radiology, University of Basel, Basel (P.P.K.-G.)
| | - Julia Meisterernst
- From the Department of Diagnostic and Interventional Neuroradiology (M.D.G., D.K., P.P.K.-G., G.S., P.M., K.H., J.S., J.G., M.E.-K., S.J.) and Department of Neurology, Inselspital (M.D.G., K.T.L., J.M., M.R.H., A.B.-M., M.-L.M., U.F., H.P.M., M.A., S.J.), University Hospital Bern and University of Bern, Bern, Switzerland; and Department of Radiology, University of Basel, Basel (P.P.K.-G.)
| | - Pascal P Klinger-Gratz
- From the Department of Diagnostic and Interventional Neuroradiology (M.D.G., D.K., P.P.K.-G., G.S., P.M., K.H., J.S., J.G., M.E.-K., S.J.) and Department of Neurology, Inselspital (M.D.G., K.T.L., J.M., M.R.H., A.B.-M., M.-L.M., U.F., H.P.M., M.A., S.J.), University Hospital Bern and University of Bern, Bern, Switzerland; and Department of Radiology, University of Basel, Basel (P.P.K.-G.)
| | - Gerhard Schroth
- From the Department of Diagnostic and Interventional Neuroradiology (M.D.G., D.K., P.P.K.-G., G.S., P.M., K.H., J.S., J.G., M.E.-K., S.J.) and Department of Neurology, Inselspital (M.D.G., K.T.L., J.M., M.R.H., A.B.-M., M.-L.M., U.F., H.P.M., M.A., S.J.), University Hospital Bern and University of Bern, Bern, Switzerland; and Department of Radiology, University of Basel, Basel (P.P.K.-G.).
| | - Pasquale Mordasini
- From the Department of Diagnostic and Interventional Neuroradiology (M.D.G., D.K., P.P.K.-G., G.S., P.M., K.H., J.S., J.G., M.E.-K., S.J.) and Department of Neurology, Inselspital (M.D.G., K.T.L., J.M., M.R.H., A.B.-M., M.-L.M., U.F., H.P.M., M.A., S.J.), University Hospital Bern and University of Bern, Bern, Switzerland; and Department of Radiology, University of Basel, Basel (P.P.K.-G.)
| | - Kety Hsieh
- From the Department of Diagnostic and Interventional Neuroradiology (M.D.G., D.K., P.P.K.-G., G.S., P.M., K.H., J.S., J.G., M.E.-K., S.J.) and Department of Neurology, Inselspital (M.D.G., K.T.L., J.M., M.R.H., A.B.-M., M.-L.M., U.F., H.P.M., M.A., S.J.), University Hospital Bern and University of Bern, Bern, Switzerland; and Department of Radiology, University of Basel, Basel (P.P.K.-G.)
| | - Johannes Slotboom
- From the Department of Diagnostic and Interventional Neuroradiology (M.D.G., D.K., P.P.K.-G., G.S., P.M., K.H., J.S., J.G., M.E.-K., S.J.) and Department of Neurology, Inselspital (M.D.G., K.T.L., J.M., M.R.H., A.B.-M., M.-L.M., U.F., H.P.M., M.A., S.J.), University Hospital Bern and University of Bern, Bern, Switzerland; and Department of Radiology, University of Basel, Basel (P.P.K.-G.)
| | - Mirjam R Heldner
- From the Department of Diagnostic and Interventional Neuroradiology (M.D.G., D.K., P.P.K.-G., G.S., P.M., K.H., J.S., J.G., M.E.-K., S.J.) and Department of Neurology, Inselspital (M.D.G., K.T.L., J.M., M.R.H., A.B.-M., M.-L.M., U.F., H.P.M., M.A., S.J.), University Hospital Bern and University of Bern, Bern, Switzerland; and Department of Radiology, University of Basel, Basel (P.P.K.-G.)
| | - Anne Broeg-Morvay
- From the Department of Diagnostic and Interventional Neuroradiology (M.D.G., D.K., P.P.K.-G., G.S., P.M., K.H., J.S., J.G., M.E.-K., S.J.) and Department of Neurology, Inselspital (M.D.G., K.T.L., J.M., M.R.H., A.B.-M., M.-L.M., U.F., H.P.M., M.A., S.J.), University Hospital Bern and University of Bern, Bern, Switzerland; and Department of Radiology, University of Basel, Basel (P.P.K.-G.)
| | - Marie-Luise Mono
- From the Department of Diagnostic and Interventional Neuroradiology (M.D.G., D.K., P.P.K.-G., G.S., P.M., K.H., J.S., J.G., M.E.-K., S.J.) and Department of Neurology, Inselspital (M.D.G., K.T.L., J.M., M.R.H., A.B.-M., M.-L.M., U.F., H.P.M., M.A., S.J.), University Hospital Bern and University of Bern, Bern, Switzerland; and Department of Radiology, University of Basel, Basel (P.P.K.-G.)
| | - Urs Fischer
- From the Department of Diagnostic and Interventional Neuroradiology (M.D.G., D.K., P.P.K.-G., G.S., P.M., K.H., J.S., J.G., M.E.-K., S.J.) and Department of Neurology, Inselspital (M.D.G., K.T.L., J.M., M.R.H., A.B.-M., M.-L.M., U.F., H.P.M., M.A., S.J.), University Hospital Bern and University of Bern, Bern, Switzerland; and Department of Radiology, University of Basel, Basel (P.P.K.-G.)
| | - Heinrich P Mattle
- From the Department of Diagnostic and Interventional Neuroradiology (M.D.G., D.K., P.P.K.-G., G.S., P.M., K.H., J.S., J.G., M.E.-K., S.J.) and Department of Neurology, Inselspital (M.D.G., K.T.L., J.M., M.R.H., A.B.-M., M.-L.M., U.F., H.P.M., M.A., S.J.), University Hospital Bern and University of Bern, Bern, Switzerland; and Department of Radiology, University of Basel, Basel (P.P.K.-G.)
| | - Marcel Arnold
- From the Department of Diagnostic and Interventional Neuroradiology (M.D.G., D.K., P.P.K.-G., G.S., P.M., K.H., J.S., J.G., M.E.-K., S.J.) and Department of Neurology, Inselspital (M.D.G., K.T.L., J.M., M.R.H., A.B.-M., M.-L.M., U.F., H.P.M., M.A., S.J.), University Hospital Bern and University of Bern, Bern, Switzerland; and Department of Radiology, University of Basel, Basel (P.P.K.-G.)
| | - Jan Gralla
- From the Department of Diagnostic and Interventional Neuroradiology (M.D.G., D.K., P.P.K.-G., G.S., P.M., K.H., J.S., J.G., M.E.-K., S.J.) and Department of Neurology, Inselspital (M.D.G., K.T.L., J.M., M.R.H., A.B.-M., M.-L.M., U.F., H.P.M., M.A., S.J.), University Hospital Bern and University of Bern, Bern, Switzerland; and Department of Radiology, University of Basel, Basel (P.P.K.-G.)
| | - Marwan El-Koussy
- From the Department of Diagnostic and Interventional Neuroradiology (M.D.G., D.K., P.P.K.-G., G.S., P.M., K.H., J.S., J.G., M.E.-K., S.J.) and Department of Neurology, Inselspital (M.D.G., K.T.L., J.M., M.R.H., A.B.-M., M.-L.M., U.F., H.P.M., M.A., S.J.), University Hospital Bern and University of Bern, Bern, Switzerland; and Department of Radiology, University of Basel, Basel (P.P.K.-G.)
| | - Simon Jung
- From the Department of Diagnostic and Interventional Neuroradiology (M.D.G., D.K., P.P.K.-G., G.S., P.M., K.H., J.S., J.G., M.E.-K., S.J.) and Department of Neurology, Inselspital (M.D.G., K.T.L., J.M., M.R.H., A.B.-M., M.-L.M., U.F., H.P.M., M.A., S.J.), University Hospital Bern and University of Bern, Bern, Switzerland; and Department of Radiology, University of Basel, Basel (P.P.K.-G.)
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Kim BJ, Lee SH. Prognostic Impact of Cerebral Small Vessel Disease on Stroke Outcome. J Stroke 2015; 17:101-10. [PMID: 26060797 PMCID: PMC4460329 DOI: 10.5853/jos.2015.17.2.101] [Citation(s) in RCA: 57] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2014] [Revised: 01/07/2015] [Accepted: 01/20/2015] [Indexed: 12/13/2022] Open
Abstract
Cerebral small vessel disease (SVD), which includes white matter hyperintensities (WMHs), silent brain infarction (SBI), and cerebral microbleeds (CMBs), develops in a conjunction of cumulated injuries to cerebral microvascular beds, increased permeability of blood-brain barriers, and chronic oligemia. SVD is easily detected by routine neuroimaging modalities such as brain computed tomography or magnetic resonance imaging. Research has revealed that the presence of SVD markers may increase the risk of future vascular events as well as deteriorate functional recovery and neurocognitive trajectories after stroke, and such an association could also be applied to hemorrhagic stroke survivors. Currently, the specific mechanistic processes leading to the development and manifestation of SVD risk factors are unknown, and further studies with novel methodological tools are warranted. In this review, recent studies regarding the prognostic impact of WMHs, SBI, and CMBs on stroke survivors and briefly summarize the pathophysiological concepts underlying the manifestation of cerebral SVD.
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Affiliation(s)
- Beom Joon Kim
- Department of Neurology and Cerebrovascular Center, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Seung-Hoon Lee
- Department of Neurology, Seoul National University Hospital, Seoul, Korea
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45
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Shi ZS, Duckwiler GR, Jahan R, Tateshima S, Gonzalez NR, Szeder V, Saver JL, Kim D, Ali LK, Starkman S, Vespa PM, Salamon N, Villablanca JP, Viñuela F, Feng L, Loh Y, Liebeskind DS. Mechanical thrombectomy for acute ischemic stroke with cerebral microbleeds. J Neurointerv Surg 2015; 8:563-7. [DOI: 10.1136/neurintsurg-2015-011765] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2015] [Accepted: 04/27/2015] [Indexed: 11/04/2022]
Abstract
BackgroundThe influence of cerebral microbleeds (CMBs) on post-thrombolytic hemorrhagic transformation (HT) in patients with acute ischemic stroke remains controversial.ObjectiveTo investigate the association of CMBs with HT and clinical outcomes among patients with large-vessel occlusion strokes treated with mechanical thrombectomy.MethodsWe analyzed patients with acute stroke treated with Merci Retriever, Penumbra system or stent-retriever devices. CMBs were identified on pretreatment T2-weighted, gradient-recall echo MRI. We analyzed the association of the presence, burden, and distribution of CMBs with HT, procedural complications, in-hospital mortality, and clinical outcome.ResultsCMBs were detected in 37 (18.0%) of 206 patients. Seventy-three foci of microbleeds were identified. Fourteen patients (6.8%) had ≥2 CMBs, only 1 patient had ≥5 CMBs. Strictly lobar CMBs were found in 12 patients, strictly deep CMBs in 12 patients, strictly infratentorial CMBs in 2 patients, and mixed CMBs in 11 patients. There were no significant differences between patients with CMBs and those without CMBs in the rates of overall HT (37.8% vs 45.6%), parenchymal hematoma (16.2% vs 19.5%), procedure-related vessel perforation (5.4% vs 7.1%), in-hospital mortality (16.2% vs 18.3%), and modified Rankin Scale score 0–3 at discharge. CMBs were not independently associated with HT or in-hospital mortality in patients treated with either thrombectomy or intravenous thrombolysis followed by thrombectomy.ConclusionsPatients with CMBs are not at increased risk for HT and mortality following mechanical thrombectomy for acute stroke. Excluding such patients from mechanical thrombectomy is unwarranted. The risk of HT in patients with ≥5 CMBs requires further study.
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46
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Marchidann A, Balucani C, Levine SR. Expansion of Intravenous Tissue Plasminogen Activator Eligibility Beyond National Institute of Neurological Disorders and Stroke and European Cooperative Acute Stroke Study III Criteria. Neurol Clin 2015; 33:381-400. [DOI: 10.1016/j.ncl.2015.01.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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47
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Liebeskind DS, Feldmann E. Imaging of cerebrovascular disorders: precision medicine and the collaterome. Ann N Y Acad Sci 2015; 1366:40-8. [PMID: 25922154 DOI: 10.1111/nyas.12765] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2015] [Revised: 03/16/2015] [Accepted: 03/18/2015] [Indexed: 12/29/2022]
Abstract
Imaging of stroke and neurovascular disorders has profoundly enhanced clinical practice and related research during the last 40 years since the introduction of computed tomography (CT) and magnetic resonance imaging (MRI) enabled mapping of the brain. We highlight recent advances in neurovascular imaging. We describe how the convergence of readily available data and new clinical trial paradigms will recast our methods for studying the neurovascular patient. The application of a precision medicine approach to the collaterome, a comprehensive synthesis of neurovascular pathophysiology, will entail novel methods for clinical trial randomization, collection of routine and clinical trial imaging results, data archiving, and analysis.
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Affiliation(s)
- David S Liebeskind
- Neurovascular Imaging Research Core and the University of California, Los Angeles Stroke Center, Los Angeles, California
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48
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Dannenberg S, Scheitz JF, Rozanski M, Erdur H, Brunecker P, Werring DJ, Fiebach JB, Nolte CH. Number of Cerebral Microbleeds and Risk of Intracerebral Hemorrhage After Intravenous Thrombolysis. Stroke 2014; 45:2900-5. [DOI: 10.1161/strokeaha.114.006448] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
Cerebral microbleeds (CMBs) are found in a substantial proportion of patients with ischemic stroke eligible for treatment with intravenous thrombolysis. Until now, there is limited data on the impact of multiple CMBs on occurrence of intracerebral hemorrhage (ICH) after intravenous thrombolysis.
Methods—
Between 2008 and 2013, all patients receiving MRI-based intravenous thrombolysis were identified within our prospective thrombolysis register. Number of CMBs was rated on pretreatment T2*-weighted MRI by a rater blinded to clinical data and follow-up. Outcomes of interest were occurrence of symptomatic ICH (sICH) and parenchymal hemorrhage (PH).
Results—
Among 326 included patients, 52 patients had a single CMB (16.0%), 19 had 2 to 4 CMBs (5.8%), and 10 had ≥5 CMBs (3.1%). Frequency of sICH/PH was 1.2%/5.7% in patients without CMBs, 3.8%/3.8% in patients with a single CMB, 10.5%/21.1% in patients with 2 to 4 CMBs, and 30.0%/30.0% in patients with ≥5 CMBs, respectively (each
P
for trend <0.01). The unadjusted odds ratio per additional CMB for sICH was 1.19 (95% confidence interval, 1.07–1.33;
P
<0.01) and for PH was 1.13 (95% confidence interval, 1.03–1.24;
P
=0.01). Compared with patients without CMBs, both patients with 2 to 4 CMBs (
P
=0.02/
P
=0.02) and patients with ≥5 CMBs (
P
<0.01/
P
<0.01) had significantly increased odds ratios for sICH and PH, whereas in patients with a single CMB, odds ratios were not significantly increased (
P
=0.21/
P
=0.59). The association of CMB burden with sICH/PH remained significant after adjustment for possible confounders (age, age-related white matter changes score, atrial fibrillation, onset-to-treatment time, prior statin use, and systolic blood pressure on admission).
Conclusions—
Our findings indicate a higher risk of sICH and PH after intravenous thrombolysis when multiple CMBs are present, with a graded relationship to increasing baseline CMB number.
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Affiliation(s)
- Steffen Dannenberg
- From the Klinik und Hochschulambulanz für Neurologie (S.D., J.F.S., M.R., H.E., C.H.N.), Center for Stroke Research (J.F.S., M.R., P.B., J.B.F., C.H.N.), and Excellence Cluster NeuroCure (J.F.S.), Charité–Universitätsmedizin Berlin, Berlin, Germany; Department of Brain Repair and Rehabilitation, UCL Institute of Neurology, London, United Kingdom (D.J.W.); and The National Hospital for Neurology and Neurosurgery, London, United Kingdom (D.J.W.)
| | - Jan F. Scheitz
- From the Klinik und Hochschulambulanz für Neurologie (S.D., J.F.S., M.R., H.E., C.H.N.), Center for Stroke Research (J.F.S., M.R., P.B., J.B.F., C.H.N.), and Excellence Cluster NeuroCure (J.F.S.), Charité–Universitätsmedizin Berlin, Berlin, Germany; Department of Brain Repair and Rehabilitation, UCL Institute of Neurology, London, United Kingdom (D.J.W.); and The National Hospital for Neurology and Neurosurgery, London, United Kingdom (D.J.W.)
| | - Michal Rozanski
- From the Klinik und Hochschulambulanz für Neurologie (S.D., J.F.S., M.R., H.E., C.H.N.), Center for Stroke Research (J.F.S., M.R., P.B., J.B.F., C.H.N.), and Excellence Cluster NeuroCure (J.F.S.), Charité–Universitätsmedizin Berlin, Berlin, Germany; Department of Brain Repair and Rehabilitation, UCL Institute of Neurology, London, United Kingdom (D.J.W.); and The National Hospital for Neurology and Neurosurgery, London, United Kingdom (D.J.W.)
| | - Hebun Erdur
- From the Klinik und Hochschulambulanz für Neurologie (S.D., J.F.S., M.R., H.E., C.H.N.), Center for Stroke Research (J.F.S., M.R., P.B., J.B.F., C.H.N.), and Excellence Cluster NeuroCure (J.F.S.), Charité–Universitätsmedizin Berlin, Berlin, Germany; Department of Brain Repair and Rehabilitation, UCL Institute of Neurology, London, United Kingdom (D.J.W.); and The National Hospital for Neurology and Neurosurgery, London, United Kingdom (D.J.W.)
| | - Peter Brunecker
- From the Klinik und Hochschulambulanz für Neurologie (S.D., J.F.S., M.R., H.E., C.H.N.), Center for Stroke Research (J.F.S., M.R., P.B., J.B.F., C.H.N.), and Excellence Cluster NeuroCure (J.F.S.), Charité–Universitätsmedizin Berlin, Berlin, Germany; Department of Brain Repair and Rehabilitation, UCL Institute of Neurology, London, United Kingdom (D.J.W.); and The National Hospital for Neurology and Neurosurgery, London, United Kingdom (D.J.W.)
| | - David J. Werring
- From the Klinik und Hochschulambulanz für Neurologie (S.D., J.F.S., M.R., H.E., C.H.N.), Center for Stroke Research (J.F.S., M.R., P.B., J.B.F., C.H.N.), and Excellence Cluster NeuroCure (J.F.S.), Charité–Universitätsmedizin Berlin, Berlin, Germany; Department of Brain Repair and Rehabilitation, UCL Institute of Neurology, London, United Kingdom (D.J.W.); and The National Hospital for Neurology and Neurosurgery, London, United Kingdom (D.J.W.)
| | - Jochen B. Fiebach
- From the Klinik und Hochschulambulanz für Neurologie (S.D., J.F.S., M.R., H.E., C.H.N.), Center for Stroke Research (J.F.S., M.R., P.B., J.B.F., C.H.N.), and Excellence Cluster NeuroCure (J.F.S.), Charité–Universitätsmedizin Berlin, Berlin, Germany; Department of Brain Repair and Rehabilitation, UCL Institute of Neurology, London, United Kingdom (D.J.W.); and The National Hospital for Neurology and Neurosurgery, London, United Kingdom (D.J.W.)
| | - Christian H. Nolte
- From the Klinik und Hochschulambulanz für Neurologie (S.D., J.F.S., M.R., H.E., C.H.N.), Center for Stroke Research (J.F.S., M.R., P.B., J.B.F., C.H.N.), and Excellence Cluster NeuroCure (J.F.S.), Charité–Universitätsmedizin Berlin, Berlin, Germany; Department of Brain Repair and Rehabilitation, UCL Institute of Neurology, London, United Kingdom (D.J.W.); and The National Hospital for Neurology and Neurosurgery, London, United Kingdom (D.J.W.)
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